Psychotherapy Part 36

Eating Enough.--It is very difficult to persuade some people to eat enough! They have all sorts of excuses. They rather pride themselves on the fact that they do not eat much. Persons who are twenty pounds under weight will calmly tell you that they do not need more than they eat. They are actually in debt to that extent to their tissues, yet they are persuaded that they are paying nature's claims in full.

Sometimes the excuse is that they have heard, or read, of how much harm is done by overeating; they have taken to heart the phrase that people are digging their graves with their teeth, and so they are actually cultivating the habit of undereating instead of allowing their instinct for food to manifest itself. Many are found to be following the good old saw of getting up from the table hungry. The inventor of it is not known, but quite unlike the inventor of sleep, it would have been a great blessing if he had kept it to himself by patent right.

After a time habit for these people becomes second nature, and it is hard to get them to eat enough. When people undereat it is the digestive organs that, in my experience, always suffer the most. As a consequence, the appet.i.te decreases because of gradually acquired lack of vitality in the digestive system, its nutrition having been lowered by drafts upon it from other portions of the body. Quite contrary to what is told in the old fable, the stomach apparently is not selfish and does not keep the lion's share for itself. The decrease in the amount of food brings on a decrease in digestive power.

Weight for Height.--The physician who wants to help patients by suggestion must keep before him weight tables for height, as they have been determined by statistics. When people are under weight, it matters not what they may be suffering from, improvement will come if they are made to gain in weight. To be able to show them that they are considerably below the normal and to point out what this probably means in lack of surplus energy, suffices of itself to make many people understand the necessity for {300} effort in the matter and to give them a strong suggestion as to probable relief of their symptoms.

The following tables are the best-known averages for men and women:

ADJUSTED TABLE OF WEIGHTS FOR INSURED WOMEN, BASED ON 58,855 ACCEPTED LIVES

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Combined Ages 4' 11" 111 113 115 117 119 119 122 125 128 126 118 5' 0" 113 114 117 119 122 122 125 128 130 129 120 5' 1" 115 116 118 121 124 124 128 131 133 132 122 5' 2" 117 118 120 123 127 127 132 134 137 136 125 5' 3" 120 122 124 127 131 131 135 138 141 140 128 5' 4" 123 125 127 130 134 134 138 142 145 144 131 5' 5" 125 128 131 135 139 139 143 147 149 148 135 5' 6" 128 132 135 139 143 143 146 151 153 152 139 5' 7" 132 135 139 143 147 147 150 154 157 155 143 5' 8" 136 140 143 147 151 151 155 158 161 160 147 5' 9" 140 144 147 151 155 155 159 163 166 165 151 5' 10" 144 147 151 155 159 159 163 167 170 169 155 Combined 123 126 129 132 136 136 139 142 145 142 133 Heights

The average shoes of the average woman will raise her about 1-1/2 to 1-3/4 inches.

DR. SHEPHERD'S TABLE OF HEIGHT AND WEIGHT FOR MEN AT DIFFERENT AGES

15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

5' 0' 120 125 128 131 133 134 134 134 131 5' 1' 122 126 129 131 134 136 136 136 134 5' 2' 124 128 131 133 136 138 138 138 137 5' 3' 127 131 134 136 139 141 141 141 140 140 5' 4' 131 135 138 140 143 144 145 145 144 143 5' 5' 134 138 141 143 146 147 149 149 148 147 5' 6' 138 142 145 147 150 151 153 153 153 151 5' 7' 142 147 150 152 155 156 158 158 158 156 5' 8' 146 151 154 157 160 161 163 163 163 162 5' 9' 150 155 159 162 165 166 167 168 168 168 5' 10' 154 159 164 167 170 171 172 173 174 174 5' 11' 159 164 169 173 175 177 177 178 180 180 6' 0' 165 170 175 179 180 183 182 183 185 185 6' 1' 170 177 181 185 186 189 188 189 189 189 6' 2' 176 184 188 192 194 196 194 194 192 192 6' 3' 181 190 195 200 203 204 201 198

Correction of Underweight.--Underweight is undesirable for many reasons, and gain in weight is often the solution of many problems in ill feeling. It is well to bear in mind that most patients who are under weight can be made to gain in weight by an appeal to their reason and by proper directions and care in seeing that those directions are carried out. Patients have told me that they could not eat more and yet I have been able to persuade them that they must eat more, and they have done so. Anyone who has much to do with tuberculous patients knows that utter repugnance for food can be overcome by will-power, when it is once made clear to the patient that they {301} must eat if they want to live. The most interesting event in the process is that with the increase in the amount of food taken, instead of the appet.i.te becoming more and more satiated, as patients are likely to antic.i.p.ate, and instead of the repugnance for food growing, the appet.i.te grows stronger, and the repugnance gradually disappears. There is only one way to gain in weight; that is by eating more than one has been accustomed to eat. Persons who are twenty pounds under weight ought easily to gain three pounds a week, half a pound a day, if seriously intent on doing so, but in order to do this they will probably have to increase the amount they eat by double this quant.i.ty. That means that a solid additional pound of food, quite apart from the watery elements of the food, must be taken every day.

In the correction of under-weight details are all-important. Patients must be given specific directions as to what and how much of the various foods they should take. With regard to supposed idiosyncrasies against such nutritious substances as eggs, milk and b.u.t.ter, enough is said elsewhere to make it clear that, as a rule, these are merely pet notions, beginning in some unfortunate incident and cherished until they have become a mental persuasion strong enough to disturb the digestion of these substances. What is true for quality of food is true also for quant.i.ty. People must be made to understand that the amount of food is to be increased. The results attained by this method are well worth the efforts required for it. Of course, the bitter tonics, especially strychnin and cinchona, will do much to help. Just as soon as patients begin to gain in weight many of their neurotic symptoms leave them. Their tired feelings are no longer complained of and when they are up to normal weight they are quite other individuals, both in good humor and efficiency.

If for years patients have been eating less than they should, then they will have discomfort when they begin to eat more. They will have no more discomfort, however, than would be occasioned if they took more exercise than they had been accustomed to. The stomach and intestines must be gradually accustomed to the new task of disposing of more food. Unfortunately, the usual impression among these patients is that discomfort in the abdominal region, by which they mean any sense of fullness, proceeds from indigestion, and indigestion signifies developing dyspepsia with all the horrors that are supposed to go with it. In reality the slight discomfort which comes from increased eating is usually not manifest whenever the patients are occupied with something reasonably interesting. After a time the organs will become accustomed to it, and then the discomfort will cease.

_Nervous Patients_.--One of the strongest suggestions that we have in our power for thin nervous patients, suffering from many and various ills, is to have them gain in weight. Many of them will be found to be distinctly under weight for their height. They insist that they cannot eat more, that they are eating as much as they care to, and that they have no appet.i.te, that when they eat more they have discomfort, etc.

It must be made clear to them that their one easy road to health is to gain in weight. If they are under weight this makes a very definite purpose to put before their minds. The objection so often urged, that they come from a thin family, must not be listened to. The unalterable purpose to make them gain in weight must be insisted upon. If they can be made to eat more than they have been {302} eating before, they will surely gain in weight. To see themselves gaining in weight is a daily renewal of the suggestion that they will be better when they get up to their normal weight. It is much better than electricity or the rest cure, or anything else that I know; it is perfectly natural and, above all, because it may be made an auto-suggestion, it does not leave the patient after a time dependent on anyone else.

CHAPTER X

VAGUE ABDOMINAL DISCOMFORTS--LOOSE KIDNEY

After the vague pains around joints so commonly called rheumatic, and which occur so frequently that probably there is no one over forty who is quite ready to confess that he has not had rheumatism, the most important source of vague discomfort is the abdominal region. This occurs particularly in people who are engaged in a sedentary occupation which prevents much exercise, keeps them indoors, and gives them abundant opportunity as a rule for introspection and dwelling upon their sensations. There are few people who live the intellectual life who have not suffered from some of this abdominal discomfort, which they presumed must mean some definite lesion, or portend some serious development, and yet, as a rule, they have lived for years afterward without any of their fears proving true.

Physicians are not spared from this source of worry and discomfort.

They suffer from it even a little more than others. Their knowledge of the possibilities of serious pathological developments within the abdomen, especially after the age of forty, makes them a little more concerned as to the significance of these vague discomforts.

At least half a dozen times a year, for the last ten years, I have heard physicians say that they were sure that some organ or other within was not performing its function properly, and that there was probably some organic lesion. The thought has usually been in their minds for months, sometimes for years, and they have come to be thoroughly examined. Sometimes they rather expect to be told that they should go to a surgeon. They are usually half concealing a question as to how soon they should set about putting their affairs to rights and how serious the outlook is. As a rule, I am able to dismiss them without any further treatment than the injunction not to think so persistently about certain obscure feelings which they are allowing to occupy their consciousness. Sometimes I know they take the advice--even oftener, perhaps, I know they do not. Once it has got hold of us, it is hard to get away from morbid introspection, and I sometimes hear of them consulting others. All of these patients are improved for a time after their consultation by the rea.s.surance that so long as they have a good appet.i.te--which is the case with all of them--and their bowels are regular--which unfortunately is not the case with most of them--and so long as they sleep well and have no acute pain, there is little likelihood of any serious latent abdominal condition.

Such rea.s.surance cannot be given until the abdominal region is carefully palpated, and especially the right side explored as thoroughly as possible. {303} Here lies the appendix, the head of the colon, which is sometimes the seat of trouble not necessarily originating in the appendix. Just above them one may find a loose kidney, for the right kidney is more likely to be movable than the left, because of the overhanging liver, and finally the gall-bladder, and the bile pa.s.sages, so likely to be the seat of serious trouble. If none of these organs are tender on deep palpation, if the kidney does not come down when the patient is examined in the standing position, if there are no serious derangements of digestion, except such as can be attributed to nervous indigestion, and if there is no dilatation of the stomach, and no enlargement of the spleen, there is no reason why one should do anything but try to get the patient's mind off himself.

There is always the danger of overlooking an abdominal cancer, in these eases, though with the care in diagnosis I have suggested this is minimal. The best therapeutic test that I know to determine this, if there should be any doubt, is to put the patient on an increased diet and watch the scales. If he is able to digest the added food well, and without trouble, and if he proceeds promptly to gain in weight, there is much less than one chance in a hundred that he is the subject of latent cancer in the abdominal region. The old farmer's maxim is: "A sick hog don't get fat." When human beings properly respond to increased feeding, it is probable, not only that there is nothing serious the matter with them, but that the symptoms of which they complained before may very likely have been due to lack of nutrition. The digestive organs not having enough to occupy them, were tempted to digest themselves, or at least to have their function disturbed by the short circuiting of nervous energy looking for something to do.

I have seen a number of these cases that had been operated on for vague discomfort--some whose appendices had been removed, some whose kidneys had been fastened up because they were slightly movable, some whose gall pa.s.sages had been examined for adhesions that were supposed to exist, or perhaps for a stone that it was thought might be found there, and except where some actual organic lesion was found and relieved, none of them was materially improved when seen several years after operation. I have heard reports of cures of these cases by surgeons who felt that the removal of an appendix presumed to show a catarrhal process, or a hyperemia, or an adhesion at its tip, had meant the cure of vague abdominal discomfort which had continued for many years and made the patient profoundly miserable. But these reports were founded on the patient's condition at the end of convalescence after the operation, and not on the condition that established itself some months, or perhaps a year, later. Operations on the abdomen, except for very definite indications, have, in my experience, always done more harm than good, and I have seen serious conditions--hernia, displacement of organs and disturbance of the peristalsis of the intestines--develop subsequent to them.

I have in mind two typical cases. One was a physician whom I had seen on a number of occasions, and who complained of vague discomfort, mainly in the right side of the abdomen, though never acute, never accompanied by fever, nor even by any disturbance of pulse when he was not in an excitable mood. His bowels were not always regular, and he had had some disturbance of circulation as the result of thrombosis of veins on that side after an {304} attack of typhoid fever. My opinion was that his discomfort was entirely due to the disturbance of circulation. There was probably some interference with the normal full circulation to the large intestine, in its ascending portion, that gave him a feeling of uneasiness, or of consciousness of its function.

Eventually he became convinced that he was suffering from a chronic form of appendicitis. After considerable persuasion he convinced a surgeon friend that his appendix should be removed, and the operation was done. I saw his appendix afterwards. It was supposed to be thickened, but considering the normal limits of size of the appendix, I could not think that it was beyond them in any marked way. At most there was but a slight catarrhal inflammation.

For a time after operation he was much improved. He felt confident that all his trouble has disappeared, and he took some pains to impress me with the supposed fact that in these vague cases of discomfort there was always some underlying organic lesion that needed surgical treatment. During convalescence he had gained in weight, and was looking very well. When I met him a year and a half later he said that some of his discomfort had returned. He had grown thinner and was feeling discouraged. Six months later he was about to submit to another operation, this time for the breaking up of adhesions in the neighborhood of his gall-bladder. He had become convinced that this must be the seat of the difficulty. After this operation he was sure, beyond peradventure, that his trouble was gone never to return. Two years later I found him preparing to have his right kidney sewed up. I had known that his right kidney was slightly movable, but it did not move sufficiently to cause any disturbance of kidney function, and certainly not enough to justify serious surgical intervention.

After this operation I met him once casually and he a.s.sured me that now everything was surely all right. I have since heard that he submitted to an operation either for the breaking up of some adhesions around his stomach or in order to tuck up that organ for ptosis. It had not been quite decided whether an adhesion caused a slight hour-gla.s.s constriction of the stomach, with some dilatation of the splenic end of the fundus, or whether there had been some actual sagging. I am sure that after this operation, as after preceding ones, with the strong suggestion that he ought to be better and an increase of weight during convalescence, he lost his vague abdominal discomfort for a time, though I have no doubt that it either has or will return.

When he gets something to so occupy his mind that he does not dwell too much on his discomfort, he will not increase it to the extent that makes it intolerable. Then he will remember that most people have some discomfort, and he will learn to distract his mind, rather than allow it to dwell on the thought of his particular ailment until it becomes intolerable.

It has taken twelve years or more to develop this case to the point where it is as instructive as it now is, and it is a typical example of what may happen even to a physician. There are other cases in my notes that are quite as instructive, two of them occurring in thoroughly educated men, clergymen who were of good intellectual capacity, but who became too much occupied with themselves. One of these had more operations done on him than my friend the physician. He first had his appendix removed, and was better for a time. Then his kidney was fastened up, and improvement once more took place. After this he lost in weight considerably and suffered so much {305} from headaches that a friendly surgeon suggested that there must be adhesions between his dura and his brain. Accordingly a trephining was done, and these adhesions, real or supposed, were broken up. For a time he seemed to be better. Then he had some urinary trouble. A long prepuce, though one that was never tight or adherent, and only required a little attention to cleanliness to keep it from giving bother, was removed. Some disturbance of his appet.i.te led him to limit his eating for a time, and then he suffered from constipation. This was diagnosed by a specialist in rectal troubles as due to abnormally developed valves in his r.e.c.t.u.m, and these were cut. He still complained very much of abdominal discomfort at times. This was diagnosed as ptosis of his organs, and an operation was done to tuck these up. After this he developed a large ventral hernia, which had to be relieved by a subsequent operation.

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 circ.u.mcision, 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 appet.i.te 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 {306} 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 pa.s.s 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 pa.s.s on this quant.i.ty 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 pa.s.sage of food, gas acc.u.mulates 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 a.s.sociated 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.

{307}

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, {308} 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 appet.i.te, 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.