Psychotherapy Part 21

Probably even more important than details with regard to the early hours of the day, is detailed information as to the day's work, the kind and character of the occupation and the length of time spent at it, the interruptions that may occur, the habits with regard to luncheon, and, above all, the state of mind in which the occupation is pursued. The physician will only learn these details when he sets before himself a definite schedule of what he wants to know, and then proceeds to secure information with regard to it. With this sufficient can be learned in a short time to ascertain the source of the affection or the symptoms complained of. In some cases it is, however, only when the whole day's occupation is reviewed that proper suggestions can be made.

Getting to Work.--Many a man, especially if he has been accustomed to much exercise in younger years, craves muscular exercise, feels much better whenever he has the opportunity to take it, yet rides down to business every morning and back every evening. On his vacation in the summer time, he gets up early for the sake of a morning walk, but he scarcely has time to take his breakfast and ride to business at other times, though the main reason for his better feeling during his vacation is his exercise. There is usually the story of crowded cars in the busy hours, often with annoying thoughts pestering him that he may not be in time and with a constant call on nervous energy while he stands up in the train, jolted, pushed, crowded, or unable to read his paper with satisfaction, even if he has a seat. The discomfort experienced during a ride in crowded cars to business is about as bad a way to begin a day for a nervous person as could be imagined.

As a rule, it will take more than half an hour to get to business in this way. If an extra twenty minutes were taken, it would be possible to walk the distance. On at least two out of every three days in the year this would give a magnificent opportunity for exercise of the best kind, for fresh air, {172} for diversion of mind, for the route could be frequently changed, and, during the spring and fall, if there are parks on the way, these would provide occasion for pleasant thoughts to replace the annoyances which too intimate contact with over-strenuous humanity in overcrowded cars is likely to occasion.

This seems almost too trivial for a doctor to talk about, but it is on the care of trivialities that good health often depends. It is easy to a.s.sume that this amounts to little for health but tempt a dissatisfied patient, whose digestion and sleep are disturbed, to do it, especially in the spring and in the fall, and see what a difference it makes in all his physical functions. If he is not used to walking, he will have to begin by walking only a mile or two, but after a time he will do his four-mile walk in about an hour, with no waste of business time, and with a renewal of energy that will seem little short of marvelous.

Details of the Day's Work.--If patients are to be benefited through mental influence it is extremely important that details as to occupation be completely secured. This must include, especially in cases where there are objective but obscure symptoms, minute information that may seem trivial, and yet which often proves to be of great importance. In recent years there has been profound study of the dangers of trades and occupations. Anyone who wants to treat nervous patients, must know much about these occupations, for otherwise symptoms may be ascribed to old infections, to obscure rheumatic conditions, to intestinal auto-intoxication, or to nervous weakness or exhaustion, when they are really the result of occupation-conditions.

The various poisons must be carefully looked for, or affections will be wrongly treated. I have had a series of cases of lead poisoning [Footnote 22] under most unexpected conditions which have taught me much as to the possibilities of obscure plumbism. Lead poisoning from new lead pipes--with no one else in the household suffering from it, lead poisoning from frequent drinking of carbonated waters, the bottles of which had the old-fashioned lead stoppers, lead poisoning from the painting of a flat by a settlement worker who could not get a painter to do it, show how carefully such things must be looked for.

[Footnote 22: "Curiosities of Lead Poisoning,"

_International Clinics_, Eighth Series, Vol. II.]

_Dust and Respiratory Affections_.--Mechanical conditions connected with trades are especially important. Workers in dusty trades are almost sure to suffer severely from bronchitis at times, and to have the affection oftener than others, to have it "hang on longer," as they say, and eventually to have tuberculosis develop. There are some of the polishing trades in the metal industries in which it is impossible to maintain the ordinary death benefit fund that workmen have in other trades, because the men die so frequently and at such an early age from consumption that the drain on the treasury makes it impossible to maintain the fund. Practically all of the dusty occupations have this same tendency. This is true often in occupations where dust is sometimes not supposed to be much of a factor. Railroad trainmen suffer more frequently from colds than do those in other trades because of the dust to which they are exposed, and a trainman with incipient consumption will be greatly benefited by getting out of the dust during the summer months. Sweepers in large buildings, janitors and janitresses have colds that are often untractable because of the dust in their occupations. It is to be hoped that {173} the new vacuum cleaning system now becoming so popular will obviate these dangers, though like all improvements, it will probably bring its own dangers with it.

_Lack of Light_.--People who work at occupations that keep them from the light are likely to suffer from lung symptoms and to have quite intractable colds which will not clear up until they get more sunlight. Workers in theaters and like places who do their sweeping where sunlight does not penetrate, are in more danger than others from respiratory disease. Those who work in gloomy lower stories, especially in narrow but busy and dusty streets, suffer the same way.

Attendants at moving picture shows who work much in the dark where the frequently changing crowd brings in dust which cannot be well removed, and in quarters where the sun does not penetrate, are almost sure to have persistent repeated respiratory troubles.

_Habitual Movements_.--After the question of dust comes the mode of the occupation. Many occupations demand certain habitual and repeated movements. When people come complaining of pains in muscles in and around joints, or of achy conditions in the limbs, it is important to know every detail of their occupation movements, if the physician is to appreciate just what pathological causes are at work. It is not enough, for instance, to know that a man is a clerk, or a bookkeeper, but it should be asked whether he stands much at his occupation, or walks considerably, or whether he sits practically all the day. If he stands much, we can expect that he will have various painful conditions in his feet and legs, unless he takes care to change his position frequently, to wear the most comfortable shoes obtainable and, above all, to provide against any yielding of the arch of the foot. Often it will be found that people who complain of discomfort in the feet stand much on a cold, and sometimes damp and draughty floor, and this needs to be corrected or their symptoms, often carelessly called rheumatic, will not disappear. If he sits down always during his occupation, he will need exercise and air or he will suffer from many vague discomforts, over sensitiveness and irritability of nerves, as well as from physical conditions.

Most patients prefer to think that they are suffering from some const.i.tutional condition, rather than from a merely local manifestation due to their occupations. Those who have to stand much can often make such arrangements as will permit their sitting down from time to time. They may, if they are standing at a desk, have a high stool; they may during their hour of lunch sit down restfully, or even to recline for a time, so as to restore the circulation in the legs. For many people who suffer from the achy discomfort connected with varicose veins in the leg, a rest of half an hour in the middle of the day with the feet a little higher than the head, will do more than anything else to make them comfortable. This same thing is true for people with flat-foot, and there are many occupations with regard to which advice of this kind will be appreciated. The well known tendency of many men to sit with their feet higher than their head is not a mere caprice, but is due to the fact that this is an extremely restful posture and thoroughly hygienic for those who have been standing much.

Unfortunately, it is not so easy to secure such relief for working women, but occasionally the advice to lie down during the middle of the day on the couches of the retiring rooms may be the best medical prescription that can {174} be given. This will carry young women over trying periods of the month when everything seems to be going wrong.

In women particularly, if there are complaints of the pains in the lower limbs, footwear must be investigated. When the heels are too high those who have to stand much are thrown forward and there is a strain of the muscles of the thighs and on the muscles of the back.

Many young women suffer from backache supposed to be due to internal conditions usually of gynecological character, when it is only due to high heels or a combination of high heels and constipation. On the other hand, heels that are too low are not comfortable and women's shoes, in spite of the outcry against them, have been better adapted than men's to prevent them from developing flat foot. Fewer women than men suffer from this affection. Shoes that are too loose are almost as bad, sometimes it would seem worse, than those that are too tight.

_Habitual Motions and So-Called Rheumatism_.--The habitual movements of various trades are extremely important for the diagnosis of conditions that develop in the muscular system. Much of the so-called rheumatism of the working people is really due to the muscular over-activity demanded by their trades. This affects all kinds of working people. Men who have to work foot-lathes, or women who have to work sewing machines, or men or women who have to use their arms much in repeated vigorous movements, are likely to suffer from achy discomfort. The strong and healthy ones do not suffer, but the delicate do. The suffering is much more prevalent in rainy, damp weather; it is worse during the spring and fall than at other times.

It is particularly noticeable whenever the patient is run down physically, is worrying about many things, or, above all, is getting insufficient nutrition. The discomfort is particularly likely to recur in those who do not know how to use their muscles properly, who are naturally awkward, and who perhaps have from nature an insufficient control over opposing and coodinating muscles, so that they do not accomplish movements quite as readily as would be the case if they were normal. The personal element enters largely into these affections. Many patients, however, can be trained to do their habitual movements under the best possible mechanical conditions, whereas very often they are found accomplishing them under the worst possible mechanical conditions.

Men who have to do much writing may have to be taught the application of Gowers' rule, that the forearm should so move as a whole during writing that if a pen were fastened to the elbow it would execute exactly all the movements of a pen held in the hand. The writing must all be done from the shoulder. People who do typewriting may have to be instructed not to allow the machine to be too much above them, nor on the other hand, too much below them when they sit down. Young people particularly who, from long hours of practice on the piano, suffer from neurotic conditions, may have to be instructed to do this under good mechanical conditions.

Men who do much filing of metal will often suffer from painful conditions in the arms. These will be much worse in case the filing is done at a table or workbench so high that pressure has to be brought to bear upon the file by the arms instead of through the weight of the body. This same thing is true for women who iron much. If the ironing board is so high that the additional pressure applied is made by the arms, then painful conditions will {175} almost inevitably develop if the work is long continued. These details are discussed in the chapters on joint and muscular affections.

Night Work.--In a large city there are many workmen who are on night duty. They will be disturbed in many ways in health, unless they make special arrangements to live under conditions that enable them to have full eight hours of sleep every day and, above all, to have their meals regularly. When they come home in the morning they usually have a rather hearty meal. Most of them can sleep very well with this, but very few of them sleep the full eight hours, and all need this amount.

Usually they have another full meal about five in the evening. Very often it will be found that the third meal of the day consists of a sandwich, with a gla.s.s of milk or a gla.s.s of beer, and some cake or some crackers and cheese, or the inevitable pie. Every workman should have three full meals, and a man who is suffering from almost any symptoms will be improved at once if the third good meal is insisted upon. At one time I had occasion to see a number of men whose work began not later than seven in the evening and did not finish until six or seven in the morning. They were sufferers from all sorts of complaints. Most of them were under weight. Not a few were constipated. Some were suffering from severe headaches that came rather frequently, and a few from a headache that was severe but came only every two or four weeks. These patients alternated night and day work, and it was the week after they had been on day work, and first went on to night work, that they suffered from headache.

In every one of these cases instructions with regard to eating and sleeping proved to be the best remedy. Nearly all of them were not eating enough, and were skimping the third meal. Three of them were taking only between four and five hours of sleep. They stayed up after breakfast to read the paper, went to bed about nine and got up about two o'clock. Just as soon as two or three hours was added to their sleep, they began to feel better, and various symptoms, digestive, rheumatic and nervous, of which they complained, began to disappear.

Nearly always night workers are more p.r.o.ne than the ordinary run of workmen to some indulgence in spirituous liquors. Cold and shivery on the way home from work in the early morning, they take a nip of whiskey to brace them up. Alcoholic cirrhosis of the liver is a little more common among sea captains, policemen, printers and night workmen on the railroads than among the average of the population. The reason for it seems to be that undilute whiskey is thrown into the circulation by being taken into the stomach at a time when that viscus is empty and all the cells are craving food and drink. It is carried directly to the liver, and there either produces or predisposes to the bad effects upon liver cells which we know as cirrhosis.

It is usually useless to treat such men for the indigestion and other symptoms that are likely to develop as a consequence of their habits, without getting at their story completely. It is easy, as a rule, to relieve them of certain of their symptoms by ordinary drug therapeutics. Unless their habits are changed, this relief, however, is only temporary. It must not be forgotten that in recent years women have come to do a good deal of work at night that was not usual to them before. In the telephone service of certain cities, as cashiers in restaurants, as ticket sellers in various places of entertainment, {176} as office help at busy seasons of the year, women may be kept occupied either all night or at least until quite late. Not infrequently during times when rehearsals are on, chorus girls are kept until the wee small hours. They are particularly likely to suffer from such variations in normal habits, and no treatment is so effective with them as pointing out how they must live, if they want to preserve their appearance and continue in such exacting occupations. A healthy young woman can burn the candle of life at both ends with less protest from nature at the beginning than man, but she suffers more for it and the suffering begins sooner.

Positions During Occupations.--The question of position during occupation, especially as regards its influence upon digestive processes, has always seemed to me much more important than most people think. Our idea of digestion has been so largely one of digestive secretions, to the neglect of the motor side of the gastric and intestinal functions, that we have missed some important points.

If a person leans over a desk shortly after a meal, there is no doubt that the crowding of the abdominal viscera hinders peristalsis, at least to some degree, not of course in the robust and healthy, but in those who already have some irregularity or sluggishness in this region. The old high desks at which many clerks used to stand, at which even proprietors did not hesitate to take their position, had a reason in common sense that has been forgotten in the modern times, and the variation of position thus permitted seems to have been good for the workers.

A good deal of comfort may be obtained by having a suitable desk and chair for business hours. Not infrequently it happens that a desk is too high for comfortable writing. Any discomfort that is continuous and makes itself felt intrusively during occupation with other things, will have an unfortunate effect. Such things seem trivial by contrast with serious disease and may seem safely negligible. Trivial they are, but little things count both in themselves and as to the att.i.tude of mind which they occasion. It is the att.i.tude of mind that we try to modify by psychotherapy, and even the removal of little sources of annoyance help a patient materially to get through life more happily and through work more efficiently and without any more discomfort than is absolutely unavoidable.

_Positions After Meals_.--While we have talked thus of business people, what is said refers, also, to the positions a.s.sumed out of business hours, as, for instance, at home after dinner. A Morris chair that permits of a somewhat reclining position, or a rocking chair that temps one to sit back, pretty well distending the abdomen and giving all due play to the internal viscera, will be found not only much more comfortable than a straight-back chair which tempts a man to lean forward, but also there will be less interference with gastric motility, the most important digestive function of the stomach.

Arm-chairs which really support the arms, and therefore tend to keep the shoulders up, have something of the same effect. We naturally a.s.sume these positions, though occasionally social usage forbids them.

The tendency, for instance, for elbows to be put on the table, especially toward the end of a meal, represents a natural instinct to lift up the shoulders and keep the weight of the upper part of the trunk off the abdominal organs. Children's instincts often curiously guide their postures--as is ill.u.s.trated by the story of the little boy who, when asked by his grandmother if he could manage {177} another tart, said that he thought he could if he stood up. (See chapter on Position.)

Mental Conditions of Occupations.--While the details of manual occupations have to be learned with great care if we are to modify the conditions so as to prevent certain unfortunate effects, just as much care has to be exercised, with those not employed manually, in finding out details as to mental worries, and the various disturbances consequent upon business conditions. Many a man has not brain enough to run his business and his liver. This is the old English expression, and the liver, as the largest of the abdominal organs, is taken for the physical life generally. Many people have not vital energy enough to waste any of it on worries and then be able to complete their digestion and other physiological functions with success. The preceding mental condition is a predisposing cause of many a purely physical ailment. It used to be said that during a cabinet crisis in England, or rather just after it was over, attacks of gout were most frequent among prominent politicians. Mental influence usually kept the attacks off until the very end of the crisis. Merchants come down with pneumonia or digestive disturbances more frequently during periods of acute business depression. Physicians are attacked by pneumonia, or influenza in bad form, after they have been wearing themselves out in an epidemic and worrying about patients. Just after a mother has nursed a child through a severe ailment she herself is p.r.o.ne to suffer from some acute infection. Such common-place infections as boils, styes, abscesses and even the more serious osteomyelitis are likely to come at these times.

It is important, then, to know as much as possible about a business man's affairs. Any one who has had a series of tuberculous patients (who were getting along quite well in spite of latent or even active lesions) disturbed by anxieties of one kind or another, knows how much worries may mean. Men will lose weight and appet.i.te and weaken in their general condition as a consequence of some serious business incident, while all the time physical conditions are the same as they were when they were improving. And it must not be forgotten that even in those who do no physical labor, there may be physical conditions of their occupation that are important. Many a business man does his work cooped up in a small office, with insufficient ventilation, and sometimes, especially where his business is on the ground floor of a large building, with so little sunlight that his environment is quite unhygienic. The great air purifier is sunlight. Unless sunlight is admitted for hours every day to the rooms in which people live, the dust that is inevitably breathed will contain living germs, active and noxious, though had they been exposed to sunlight these germs would be harmless.

Especially then for people with respiratory defects of any kind, whether these be tuberculous or of chronic bronchitic character, the conditions surrounding the occupation should be carefully inquired into. Once the family physician knew such things as a matter of course. Now he is likely to know very little. The lack of such information may not be important for the more serious conditions that he has to treat at patients' homes, but they usually mean much for the submorbid conditions, so to say, the discomforts and chronic conditions, which come for office treatment. They mean much for comfort in life, and for the conservation of health and strength. They {178} represent that newer medicine which people are asking of us now so much more than before, which shall keep them in good health and prevent them, as much as possible, from suffering even from minor ills.

Business Habits.--The modern idea of having a flat-top business desk, instead of a roll-top desk, and having it thoroughly cleared off every evening, so that each day's work does not acc.u.mulate, is an important psychic factor in the strenuous life, which in recent years many corporations have been taking advantage of. It is well for those who are their own masters to realize the value of this principle. Nothing so disturbs the efficiency of work, nor adds so much to the incubus that work may become, as having a number of unfinished things which keep intruding themselves. It is not always possible to dispose of problems, but discipline is necessary to keep us from pushing business matters aside. Then they have to be done in a rush, very often at a moment when other things are also pressing. The result is poor work, but, above all, a waste of nerve force and energy that leads up to nervous symptoms and eventually nervous exhaustion. The orderly man, who has learned to settle things as they come up, or at definite times, can accomplish an immense amount of work. Some men are born orderly, but any one who wants to do much work must have order grafted on his makeup--a habit which can be made a second nature. It may seem that a physician is unwarranted in intruding on a man's business affairs thus to inquire about the ways he does things, but this is the difference between psychotherapy and the regulation of life as compared with cures by more material but less effective means.

Personal Hygiene.--Expert Advice.--For many men who are much occupied with business, the best possible safeguard for health, as well as the best guarantee against nervous or physical breakdown, would be a detailed consultation once a year with a physician regarding their habits of life and their business in relation to their health, present and future. In recent years many a business firm has found it not only expedient but profitable to turn to an expert accountant or auditing company and ask advice with regard to the management of its business.

It is often found that certain business customs are causing serious drains, and that there are newer ways of doing things that save time and money. Sometimes a reorganization of the accounting system, or of the method of dealing with credits and debits, or the receiving or shipping department, proves advantageous to the business. Sometimes it is found that the capital invested will not justify the extension of business that is proposed, and not infrequently it is shown that a proposed extension adds to business movement but does not add to profits. Sometimes there are departments that can be dropped to advantage, though they seem to be adding to both business and profit.

All of this may well be transferred to the question of health in its relation to business. Not infrequently it is found that the capital of strength of the business man is not sufficient to justify the extension that he is planning or has already attempted. Sometimes suggestions can be made with regard to the mode of doing business, the hours employed and the hours of relaxation, that will make business less of a drain on the system. Occasionally arrangements for sleep and exercise, as well as for afternoons or special times of diversion, may save a man from that concentration of attention on one thing {179} which frequently leads to nervous breakdown. Not infrequently business men who are of neurotic habit have customs of doing business which add to their nervous irritability, and these might be modified so as to lessen the call on nervous energy. There is need that the physician be looked to as an expert in personal health and its relation to business, just as the expert accountant or auditing firm is looked to for advice with regard to business methods.

CHAPTER IV

THE MIDDLE OP THE DAY

Information regarding the mid-day meal will be of value to the physician in many cases. In cities, luncheon, likely to be rather an apology for a meal, is taken rapidly, and immediately there is a return to work. As a medical student in Vienna, I was much interested in the mid-day meal of the bankers and merchants of the old Austrian capital. At that time--I hope they have not changed the good custom since--the banks closed at 12 o'clock and did not open again until 3 o'clock. This gave time for taking the mid-day meal in comfort, and for a proper interval for digestion. In all the southern countries of Europe, for seven or eight months in the year at least, little is done during the two or three hours in the middle of the day. The people get up earlier and rest at mid-day as a break between the afternoon and morning. It is quite beyond expectation that anything like this will ever again be possible in the great commercial cities. The fact that this was the custom of our European forefathers, however, shows how business has obtruded itself on the habits that man would naturally form for himself. Business men hurry to luncheon, or if they take any time over it, it is because they have invited some one to lunch with them with whom they wish to talk over important matters. This means of saving time recalls the well-known expression of James Jeffrey Roche: "Time is money. Every second saved from your dinner now is a sequin in your doctor's pocket later on in life!"

Hurried Lunch.--The seeds of our frequent American dyspepsia are sown partly at the hurried breakfast and then at the hurried mid-day lunch.

When a physician finds this to be the case, then the patient's habits must be reformed. Otherwise there is little prospect of relief from neurotic digestive symptoms, or from those uncomfortable feelings so often supposed to refer to the heart, or other important organ, when digestion is interfered with. There should be pleasant company at luncheon if possible; it should be preceded by fifteen or twenty minutes in the open air, with, as far as possible, complete seclusion from business thoughts so as to allow the stomach to secure its share of blood, and it should be followed by at least half an hour of pleasant occupation that does not call for serious mental work. This may not be possible for every one, and many will complain that this is asking too much in our busy time. We physicians are not here to make the nice customs of medicine courtesy to great kings of finance or to the busy tyrants of the professions, but to tell them what we think should be {180} done in order that nature may not be abused. Men should be advised to take their luncheon in some building different from that in which their offices are located, or, if they eat in the same building, to go out on the street for a while before the meal. In the old days men used to call on one another in order to transact business, and these little trips were often made just before or after luncheons.

Now the telephone and the messenger boy have done away with this, with a great saving of time, but with an increase of intensity of labor that makes for nervous exhaustion. Luncheon clubs are excellent things when men do not talk shop, but they have one fatal defect. Almost invariably they lack simplicity of menu, and, because of the variety supplied and the example of others, there is a tendency to eat to excess. A game of billiards after eating is often excellent, because, when standing, digestion is accomplished with more comfort than when seated. A walk after the lighter midday meal is a good thing, though the old saw said "after dinner sit a while," but that was in reference to the largest meal of the day, and may still hold good for the evening meal, which is likely to be the heaviest one.

Women's Lunch.--Women are very likely to take their mid-day meal, when it is their luncheon, very irregularly. If they have to get it for themselves they are likely to be satisfied with almost anything. If they get it outside the house they are likely to take it rather late, so that if they have breakfast before eight o'clock, this putting off of the next meal causes some disturbance of the economy. When the stomach gets to be empty, either there is a tendency to swallow air, or there is a rumbling sense of fullness that disturbs the appet.i.te, or the appet.i.te itself is capricious, and a headache develops. How many headaches are due to missed meals it would be hard to say, but this is one of the most fruitful causes of the ordinary pa.s.sing headache. Delicate women, and especially those who work, are likely not to eat enough luncheon. All the details with regard to this meal must be known or the physician will find it hard to get rid of many neurotic symptoms, particularly in working women. The same thing is true for the so-called society woman, since she is likely to have a late breakfast and then skip her mid-day meal. This is permissible if she is so stout as to be able to spare it, but it is all wrong if she is thin and needs every ounce of weight.

Nature of the Noon Meal.--During the last two generations fashion, custom and the increasing demands of business have pushed the hour of taking the princ.i.p.al meal farther and farther away from mid-day. There are, however, cases in which it seems better that the princ.i.p.al meal should be taken in accordance with the old custom, about noon time.

For tuberculous patients this is especially important. They often have fever in the afternoon that seriously disturbs appet.i.te. They may eat with comfort and relish a couple of hours before the fever is due. For delicate persons, especially those who have not much appet.i.te for breakfast and who can not be persuaded to eat a sufficient amount early in the morning, a hearty meal at noon is almost a necessity.

They should be shown how low their nutrition is during working hours.

Their princ.i.p.al meal of the day before was taken between six and seven o'clock. They have had a light breakfast, a meager lunch, and naturally have little reserve force during the afternoon hours. As a consequence they become overtired, this lessens the appet.i.te, they do not eat properly, and, {181} above all, they do not digest as well as they would if their last good meal were not so far away. They are suffering from inanition, and, as is well known, starving people cannot be allowed to eat heartily, because their stomachs have not enough vitality to digest well.