Psychotherapy Part 37

_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 appet.i.te 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 quant.i.ty. 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 sub.u.mbilical region, it should be fastened up {309} 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 a.s.similating 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 appet.i.te 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.

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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.

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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 a.s.sociated 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 {312} 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 rea.s.surance of the patient of the harmless nature of the complaint goes a great way in curing him. The rea.s.surance 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.

Heart Remedies and Suggestion.--Probably the best evidence we have for the influence of the mind over the heart in diseased conditions, that is, when there is definite organic change in the heart valves or muscle, is to be found in the history of the many remedies that have come and gone in heart therapeutics during the past generation.

Strophanthus, for instance, was very popular a quarter of a century ago, and it seems as though in many cases it not only replaced, but was more efficient than digitalis. How few there are who use it now with confidence, and how general is the impression that it does not affect the heart to any extent! The confidence with which the remedy was given by the physician was conveyed to the patient and he "took heart," as the expression is, and proceeded to get better. Even more striking is the evidence afforded by other remedies. For a while it seemed that cactus provided a heart stimulant and regulator of value.

Convalaria also gained a reputation as a heart remedy. Both are now practically abandoned. Here, once more, the real remedy, when these substances were employed, was, undoubtedly, the suggestion to the patient in connection with the regulation of his habits of life, so that his heart got a chance to catch up with its work. There are other remedies with which we had similar experiences.

Even digitalis has had phases of confidence and distrust in it, that are interesting to study in the light of what we now know with regard to the influence of the psyche on the heart. One hears at medical society meetings reports of the favorable action of digitalis within a few hours of its administration. These are not examples of digitalis action, but of mental influence. {313} Any heart patient after the first visit of a physician in whom he has confidence is sure to brighten up at once, heart action is ever so much better and symptoms of mental depression, and even of circulatory disturbance, disappear.

It is this that has made the study of even the efficiency of digitalis so difficult. There were times when most physicians employed it in rather large quant.i.ties for all forms of heart disease. In some heart cases it is absolutely contra-indicated. Fortunately many of the preparations of digitalis used in the past were quite inert, and so no harm was done. The results obtained were psychotherapeutic.

Cardiac Inhibition.--The importance of the role of the nervous system and of the mental influences which control it in all functions is well ill.u.s.trated by what we have learned during the last half century with regard to inhibition in the animal organism. We used to think that while the nervous system sent down positive impulses--that is, nervous stimuli which brought about the accomplishment of certain activities--it had nothing to do with the stoppage of those activities. Such interference was supposed always to be due to external influences of various kinds, potent for the time, in the organism. We have learned, however, that inhibition is one of the important functions of the nervous system. The idea has now become so familiar that sometimes we are apt to forget how great is its significance. Lauder Brunton, in his article on "Inhibition," set forth its role as we have come to know it.

The recognition of the part inhibition plays in vital phenomena is undoubtedly one of the most important discoveries which have been made in physiology since Harvey discovered the circulation of the blood. It throws light upon an immense number of phenomena previously inexplicable and enables us to form theories of a satisfactory nature about many vital problems. It offers an explanation of the nature of hypnotic states, which is at least as satisfactory as that we have of the action of many drugs.

The nervous mechanism of the heart affords the best and most commonly cited example of inhibitory action, and here it was first studied by Weber and Claude Bernard in 1848. The cardiac ganglia derived from the sympathetic preside over the movements of the organ, and in response to the stimulus of the intra-ventricular blood-pressure cause rhythmical contraction of the cavities. Their action is, however, controlled by the pneumogastric nerve, through which impulses of an inhibitory nature are constantly traveling and acting as a restraining force.

As noted by Lauder Brunton, the late Professor Czermak had a small glandular tumor in close contact with the right pneumogastric nerve and he was able by pressure on this to compress the nerve to any extent he wished, and either "to completely stop the heart or simply r.e.t.a.r.d it." He often performed this experiment so that it is not nearly so dangerous as might be thought. We have some instances, apparently too well authenticated to be doubted, in which the power of the human will to inhibit heart action has been as strikingly manifested as this mechanical disturbance of Professor Czermak.

Sometimes these stories of cardiac inhibition through the will are dismissed as unworthy of credence, and doubtless many of them are mere fiction, or have been exaggerated for sensational purposes, but some of them are very suggestive examples of the power of the will over the heart. If only a modic.u.m of such power were to be employed, it would seriously hamper heart action, and it must be the aim of psychotherapy to prevent such inhibition.

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At least one instance of voluntary heart inhibition was observed by thoroughly trained and properly accredited scientists. A report of it has been published. As a bit of doc.u.mentary evidence, on a subject that is usually considered so vague as to be scarcely worth considering, Dr. Cheyne's description of the remarkable power of Colonel Tonshend over his heart should be in the hands of those who wish to influence hearts through minds and wills.

He could die or expire when he pleased, and yet by an effort, or somehow, he could come to life again. . . . We all three felt his pulse first: it was distinct, though small and thready, and his heart had its usual beating. He composed himself upon his back and lay in a still posture for some time. While I held his right hand.

Dr. Baynard laid his hand upon his heart, and Mr. Skrine held a clean looking-gla.s.s to his mouth. I found his pulse sink gradually till at last I could not feel any, by the most exact and nice touch; Dr. Baynard could not feel the least motion in the heart, nor Mr.

Skrine discern the least soil of breath on the bright mirror. Then each of us by turns examined his arm, heart and breath, but could not by the nicest scrutiny, discover the least symptom of life in him. We reasoned a long time about this odd appearance, and finding he still continued in that position, we began to conclude that he had indeed carried the experiment too far; and at last we were satisfied that he was already dead, and were just ready to leave him. This continued about half an hour. . . . As we were going away we perceived some motion about the body, and, upon examination, found his pulse and the motion of his heart gradually returning; he began to breathe heavily and speak softly.

Nor must it be thought that the inhibitory faculty can act only in slowing the heart. Normally a certain amount of inhibition is exercised over the heart's action. If by any chance this should be decreased then acceleration of cardiac activity may take place. Lauder Brunton called attention to that in discussing another phase of pneumogastric function. He said:

Paralysis of the pneumogastric, of course, does away with its action. And hence we have among other symptoms of this condition increased rapidity of the contractions of the heart from withdrawal of the inhibitory influence.

If slowing of the heart action can be produced through the mind by this mechanism of inhibition, so also under other circ.u.mstances may acceleration occur.

Shock and the Heart--How large a role emotion plays in disturbing the action of a heart that is already diseased, is ill.u.s.trated by the story told in serious histories, on what seems good authority, of the dwarf of the French king, who was frightened to death by what he thought were the arrangements for his execution. While we take great pains as a rule to impress upon sufferers from organic heart disease the necessity for their avoiding every kind of over-exertion, or sudden movement of any kind, we do not always impress upon them the even greater necessity for the avoidance of shock and fright, and profound emotions. It must not be thought that emotional shocks have a deleterious effect only in advanced cases of heart trouble. Almost any physician will readily recall examples where emotion had much to do with the break in compensation which indicates that the heart has for a time been overworked.

A case in my own experience ill.u.s.trates this: The patient, a student, had suffered from severe so-called growing pains, undoubtedly rheumatic, when he was about fourteen, and probably had acquired a heart lesion at that time. {315} It did not, however, disturb him in the slightest degree. The patient had never noticed any fatigue on running up stairs; he had no shortness of breath; there were no symptoms pointing to his heart. One summer while his family were in the country he came into town for the day, and missing the last train out, he went to the family home to sleep, though it had been closed up for the summer. He let himself in without difficulty and was preparing to go to bed when he resolved to get a gla.s.s of water. There being no tumbler nearer than the dining-room, he went there. As he entered the dining-room he struck a match. With the flash of the light he found himself looking into the barrel of a revolver and a hoa.r.s.e voice said, "Hands up!" His hands went up. The next minute he was in the hands of two "plain clothes" policemen who had been watching the neighborhood because of recent burglaries. Noticing the light upstairs, they had made their way in for the purpose of catching what they thought a burglar at work.

The young fellow, who had never before fainted, collapsed almost at once, and was unconscious for some minutes. The next day he was rather prostrated and tired on movement. By resting a good deal for the next week this pa.s.sed off to a considerable degree, but then his physician found that he was suffering from a serious heart lesion, with a decided break in compensation. I saw him several months later. His heart had never regained its old power, and his mitral valve was quite unable to fulfill its function. Just what the mechanism of the almost sudden break in compensation was after he had been for so long quite immune from any effects of the rheumatism, is hard to say, but the lesson of the case is easy to understand.

Place of Psychotherapy in Treatment.--The role of psychotherapy, then, in heart cases consists in the recognition of the part that the mind, the will and the emotions play in their influence over this important organ. These psychic factors may produce disturbed conditions of various kinds. The more experience the physician has with cardiac cases of all kinds, organic as well as functional, the more powerful does he recognize the influence of the mind over the heart to be. The expression that a man is living on his will is no mere figure of speech. Some cases we have cited seem to show that a favorable att.i.tude of mind keeps up heart action, where an unfavorable att.i.tude would almost surely allow the heart to fail. It is this very potent influence then that must be used to as great advantage as possible in the psychotherapy of cardiac patients.

Undoubtedly the most important phase of it is in prophylaxis. As far as possible we must save our heart patients from emotions. The effect of emotion on the heart is known. When that organ is already crippled, emotion may produce a serious strain on it. It is as important to save heart patients from joyful emotions as from those of contrary nature.

Many a son who, after years of absence, thought to surprise a dear old mother by suddenly presenting himself to her, has learned to his cost that an old heart may break from joy, almost as easily as from sorrow, and may be as unfavorably affected by the glad emotions as by terror or fright. We must also save heart patients from the unfavorable influence of a bad prognosis, and of too serious a diagnosis, both of which may be quite unjustified, for the rule is that the longer a man has been studying the heart, the less likely is he to be confident in his diagnosis, or unfavorable in his prognosis.