Our muscular system is our principal heat-making apparatus. It is easy to understand. If we have larger heat-making organs than are necessary for the maintenance of the temperature of the body, and if we have no mode of dissipating our heat by muscular energy, as through exercise, then there will be a constant tendency for our temperature to rise, which must be overcome, at considerable expense of energy, by the heat-regulating mechanism of the body. This heat-regulating mechanism is extremely delicate, yet does not seem to be easily disturbed. With the external temperature at 120° F. or—10°, human temperature is constant. With a heating apparatus entirely too large for its purpose, it is no wonder that irritability of the nervous system ensues because of the constant over-exercise of a function called for from it. It is this state of affairs which seems to me to account for the marked tendency to nervous unrest, and to the presence of many heart and digestive symptoms that often characterize athletes who develop a magnificent muscular system when they are young, and later have no use for it. They must learn the lesson and keep up the practice of using their muscles sufficiently to dissipate surplus heat, so as to prevent this energy from being used up in various ways within the body, with a resulting disturbance of many delicate nervous mechanisms.

Useless Muscles.—Whatever a human being has to carry round as useless can only be expressed by the telling Roman word for the baggage of an army, impedimenta. Prof. James, in his "Principles of Psychology," sums up the law very well:

The great thing in all education is to make our nervous system our ally instead of our enemy. It is to fund and capitalize our acquisitions and live at ease upon the interest of the fund. For this we must make automatic and habitual as early as possible as many useful actions as can be and guard against the growing into ways that may be disadvantageous to us as we should guard against the plague.

An over-developed muscular system, with its tendency to manufacture heat and its craving to be used, and the consciousness it is so apt to produce of ability to stand various dangerous efforts, is a disadvantage rather than an advantage.

Useless Fat.—This reminds us very much of the attitude with regard to children in the acquisition of fat. Chubby babies with rolls of fat all over them and deep creases near their joints are considered to be "perfectly lovely." Mothers are proud to exhibit them. They are supposed to be typical examples of abounding good health. Neighborly mothers come in to coo over them and, in general, the main aim of existence for children in their early years would seem to be to make them as fat as possible. Such children, as is brought out in the discussion of the subject in the chapter on obesity, are not healthy in the true sense of the word, are well known to be of lower resistive vitality than thinner infants, and easily succumb to diseases.

Resistive Vitality.—One reason for the early deaths of many athletes is the fact that, confident of their strength, they allow themselves to become so overwhelmed by an infection, before they confess that they are sick and take to bed, that often the cure of their affection is hopeless. Ordinarily neither pneumonia nor typhoid are likely to be fatal diseases for men between twenty and fifty. If a man's heart and kidneys are in good condition during this {202} period, an attack of either of these diseases, while a serious incident, is likely to be only a passing loss of time. Rather frequently, however, strong and healthy men without any organic defect that may be considered responsible for the fatal termination, succumb to these diseases. The reason for the fatality is that they are not willing to admit that they are ill enough to be in bed, they have a large reserve force of strength on which they call and which enables them, for a good while, to resist the weakening influence of disease. Doctors know and dread these cases. A young man in the flower of youth, with magnificent muscular development, comes into the office breathing very rapidly and with a laboring pulse. Almost exhausted, he sinks into a chair, confesses that he is nearly "all in," and wonders what is the matter. At times the physician will find practically a whole lung solidified by pneumonia, and at times both lungs are seriously affected. The wonder is how the young man succeeded in holding out so long. Sometimes the doctor is summoned to see him because he has fainted in his home, or in his office, and his friends are alarmed. These cases are almost invariably fatal. Any one who continues to be up and around until the third or fourth day of pneumonia will have so exhausted his vitality, no matter how great that may be, that he will have no reserve force for the life-struggle that must come before the crisis is reached.

Nearly the same thing is true for typhoid fever in the same class of persons. A young athlete, who considers it babyish to confess to illness, complains of feeling out of sorts but nothing more, until some morning he is literally unable to leave his bed, or has a fainting fit after going up-stairs. He is found by the physician with a temperature of 104°, or near it, and with evident signs of being in the middle of the second week of typhoid fever. The termination of such a case is generally fatal.

The ordinary man knows his limitations better; he recognizes the fact that he may be ill, and gives in quietly and rests, so that nature may employ all her energies in conquering the infection. Most of the long-lived people of history have been rather delicate and have learned young the precious lesson of caring for themselves. This care has not been exaggerated, but it has consisted in avoiding danger, in resting when tired, in not overdoing things, and above all in yielding to the symptoms of disease before these become serious.

Regulation of Exercise.—Each man must be a law unto himself as to the amount of exercise that is necessary for him. He must take enough to use up the energy supplied by the food he eats, just as, on the other hand, he must eat enough food to make up for whatever waste there is in his body. There are many men who eat over-heartily and then have to take exercise to use up this material or else suffer for it. This is one of the compensations that the hearty eater must pay: he overfeeds and becomes obese, or, if he succeeds in keeping down his weight to the normal, it is only by the expenditure of time in securing such muscular action as will use up surplus energy. Many men find it difficult to control their appetites, and prefer to take exercise rather than to deny the appetite which they created during their days of indulgence in athletics. It is for such men to decide just what seems preferable. If the fuel is supplied to the heat engine, which all human beings are, it must be used for the production of energy or else it will exert {203} itself in accumulating certain waste in the tissues, just as over-abundant fuel serves merely to clog up the fire-box of an engine without doing any work.

Air and Exercise.—It is easy to deceive one's self in the matter of exercise. With regard to air such a mistake is almost impossible. As a rule, it is air rather than exercise that people need when they have the restlessness and nervousness which comes from over-abundant nutrition. Fresh, pure air enables the individual to burn up nutritive material to the best advantage by the encouragement of oxidation. It is a surprise to those who are not accustomed to it, to see how tuberculosis patients who come to sanatoria with very little appetite, soon acquire an appetite and are able to consume large quantities of food, to sleep well and become restful—all as the result of living constantly in the open air during the day, and also having an abundance of fresh air at night. This is particularly true if the air in which they live is rather cold, and, above all, if it has a large difference of temperature every day, so that there is an upward and downward swing of the thermometer of from thirty to forty degrees. This varying temperature seems to use up nutritive material, and keeps all the natural processes going.

Gymnastics.—The very opposite to this plan of open air life is that followed by those who take gymnastic exercises for health's sake, with the idea that the use of certain muscles is necessary to keep the bodily economy in equilibrium. Such gymnastics are usually undertaken indoors, sometimes in stuffy quarters, and the movements are commonly repeated with such continued routine that absolutely all interest is lost. That there are many who advocate this form of exercise, it has nearly always seemed to commonsense physicians an entirely wrong solution of the important question of the encouragement of oxidation. It is like running an engine, not for the purpose of having it do something, but simply in order to have it oil itself, and consume the fuel that has been put into its boiler and that must be used up because more will be put in to-morrow. It would be much better, either to limit the amount of fuel or to give the muscular exercise some useful purpose, above all connect it with some interest that furnishes diversion of mind at the same time that the muscles are used. This last is the most important consideration, for, after a time, gymnastics pall in spite of artificial incentive.

Dr. Saleeby, in "Health, Strength and Happiness," has expressed very forcibly what has come to be the feeling of many physicians with regard to gymnastics, especially indoor gymnastics:

The natural spontaneous exercise having been forbidden, and the bad consequences of no exercise having become conspicuous, there has been adopted a system of factitious exercise—gymnastics. That this is better than nothing, we admit; but that it is an adequate substitute for play we deny. . . . The common assumption that, so long as the amount of bodily action is the same, it matters not whether it be pleasurable or otherwise, is a grave mistake. . . . The truth is that happiness is the most powerful of tonics. . . Hence the intrinsic superiority of play to gymnastics. The extreme interest felt by children in their games and the riotous glee with which they carry on their rougher frolics, are of as much importance as the accompanying exertion. And as not supplying these mental stimuli, gymnastics must be radically defective.

Granting, then, as we do, that formal exercises of the limbs are better than nothing—granting further that they may be used with advantage as supplementary aids, we yet contend that they can never serve in place of the exercises prompted by nature. For girls, as well as boys, the sportive activities to which the instincts {204} impel, are essential to bodily welfare. Whoever forbids them, forbids the divinely appointed means to physical development.

Play and Exercise.—There has been a distinct tendency in modern times to think that gymnastic exercise can be a substitute for play for growing young folks. When certain of the instruments and methods of the modern systems of gymnastics which have been introduced into schools, and are supposed to be so wonderfully beneficial, are put to the test of the psychology of exercise, the conclusions are likely to be very different from the theories under which they were introduced. Dr. Saleeby has expressed these differences rather strikingly:

Anyone who will consider for a moment the natural constitution of man and the principles of natural education, must agree that the deplorable thing called a dumb-bell offers an exquisite parody of what exercise should really be. The cat, as she exercises her kittens along the lines of their natural proclivities and needs, never telling them that this is exercise for the sake of exercise, and certainly prepared, if she could, to turn up her nose at any artificial implement we might offer her—should be our model in this respect. It may be imagined that some unfortunate girl, brought up on early Victorian lines, having never been permitted to wear comfortable garments, or to stretch her arms, would welcome and enjoy the dumb-bells when first introduced to them. But any one who has had a natural childhood and who has been taught to play, and who has taken his or her exercise naturally, or incidentally in the course of pursuing some mental interest—any such person may be excused for saying that a pair of dumb-bells should be deposited in our museums as indications of what was understood by exercise even as late as the earlier years of the twentieth century. All exercise for the sake of exercise is a mistake—or, at any rate, a second best. You may do your mind—and body, too—more harm by sheer boredom than you may gain good from the exercise you go through. The dumb-bell symbolizes the fact that the most elementary and obvious truths of psychology are still unrecognized, though the play and games of every natural child—if you object to be instructed by kittens—should be perfectly sufficient to teach us what indeed nature taught us ages ago, if only we would listen to her.

Indoor Sport.—Indoor sport is another thing. In wintry weather it is impossible to play outside conveniently, and indoor games have their place. Unfortunately they are usually associated with dust, and when played before crowds of spectators, the participants suffer also from the disadvantage of rebreathed air containing, too, the emanations of those who are looking on. It must not be forgotten that these two factors are the most prominent predisposing causes of tuberculosis. Those who have any tendency to tuberculosis, by which is meant specifically all those who are associating with tuberculosis patients, whether those patients are related to them or not, or who are more than 20 per cent. under the weight that they should have for their height, should not be allowed to take part in indoor sports where these drawbacks are sure to be encountered.

Sport, because of the diversion of mind involved, is an ideal form of exercise. An exercise that becomes a mere routine and that can be eventually gone through with so mechanically as to leave abundant room for thoughts of business or study or worries of other kinds, loses sight of one of the principal purposes of exercise as nature demands it.

Horseback Biding.—It is because of the complete diversion of mind that is necessarily involved in it, that horseback riding makes such a magnificent exercise for the busy man. The old expression "the outside of a horse is the {205} best thing for the inside of a man" is founded even more on the mental influence of horseback riding than its physical quality. The same amount of exercise in the open air, taken otherwise, often does not accomplish so much good, because a man's thoughts may continue to run on his business or be occupied with his worries, or he may not be able to divert his thoughts from himself and his digestion or his ills. A horseback rider must pay attention to the other animal, rather than himself, and that represents the complete diversion of mind so necessary for the health of most people. Just as soon as man rides an old favorite animal on whose back he can throw down the reins, allowing it to saunter on as it will, while he occupies himself with other things, then horseback riding loses its efficacy and falls back into the class of bicycle riding or carriage riding or walking in the open air unless there is diversion of mind in the scenes, or the necessity for care at street crossings, to banish preoccupation of mind. Unless business troubles and worries are necessarily excluded by its conditions, or are deliberately eliminated from the mind during the course of any exercise, it may even become a renewed source of worrisome thoughts, rather than a renewal of energy, mental and physical.

It is doubtful whether horseback riding should ever be recommended for those who have not been accustomed to it from their youth. To ask a man past forty to learn to ride horseback for the sake of exercise is nearly always a mistake. It becomes a trial rather than a recreation, and may thus do harm rather than good. On the other hand, horseback riding is one of the things that may be, and indeed often is, much abused. The old English fox-hunting squire would never have lived out his life even as long as he did, consuming the amount of proteid material that was his custom, and drinking his three or more quarts of port at dinner every day, but that the excessive drain upon his system by long days of hard riding in the hunting field made calls upon his nutrition which kept even this amount of food and stimulant from doing immediate harm. Just as soon, however, as long spells of severe exercise become excuses for the consumption of big dinners, and exercise is used as a factor to enable one to overeat with more comfort than would otherwise be the case, a vicious circle is formed, and one serious abuse is counterbalanced by another. What many well-to-do people of leisure need is not so much more exercise as less eating.

Walking.—Perhaps the best and most readily available form of exercise for most people is walking. It has one disadvantage. As soon as the walk becomes too much of a routine, and the ground gone over has lost its interest, or is even of such a nature as to permit or, indeed, tempt introspection and occupation with other things, rather than with the surroundings, then walking loses most of its efficacy as a form of exercise. Walking in the country, for instance, becomes monotonous, though at first it is a great source of pleasure. Walking in a large city, however, has little of this objection and as large city life has grown more and more strenuous in recent years, the good effect of walking to and from the office or walking in the busy parts of the city has been increased. Between the trolley and the automobile, and the hustling commercial traffic of the streets, it is impossible for a man to walk through the busier portions of any large American city without keeping his wits thoroughly intent on what he is doing, nor without requiring all of his {206} attention for his transportation. An abstracted man will in the course of a half hour have so many narrow escapes from being run down in a busy quarter that he will either eschew walking in that particular neighborhood, or give up his habits of mental abstraction, or else he will come to himself some day in a hospital.

Besides, the passing show in city life is itself of surpassing interest. It is not things but men that interest us most. There are so many phases of human life to be seen on busy city streets, so many things happen in the course of even a short walk to bring out prominently traits of human nature that, if a man is at all sympathetic, he finds much to occupy his attention, to distract him from his own worries and take him away from his business cares. The long walk to and from the office may thus become an efficacious source of thoughts that are different and of profound pleasure. All depends on the man and his mood. Men who try it whole-heartedly soon find a renewed interest in life. An hour of daily walking in the open air with the distractions of city life all around, provided the walking is done briskly and faithfully, is of infinitely more hygienic value than an hour of gymnasium work. There is only one thing that hampers this form of exercise—there are so many excuses to tempt one not to keep it up. If one gets to a gymnasium there is an instructor or director who keeps tabs on one's hours and so helps a weak human will, and excuses are easier made to one's self than to others.

Massage as Exercise.—This curious tendency of men to take their exercise far more regularly, provided some other is concerned in their taking it so that it cannot be neglected without explanation, is illustrated in many of the experiences of the doctor in modern life. A number of forms of massage have come into vogue as wonderful cure-alls. It is comparatively easy for some men, and above all for many women, to take their exercise by means of massage rather than in some more vigorous way that requires their own initiative. A man who is working hard, and who feels the need of exercise, will not take the easy natural way of getting up half an hour earlier, having his breakfast half an hour sooner and then walking down to his office four or five miles, but he hears of someone who gives vigorous massage and he engages him to come every morning and exercise him for half an hour or an hour. In order to do so, he has to get up an hour earlier, but the fact that he has the engagement with someone else, rather than with himself, makes it more difficult for him to make excuses, and so morning after morning, in spite of the fact that he may have been up late the night before, perhaps to a big dinner, he gets up to be given his exercise. If he is a heavy eater he will, of course, at the end of a week or ten days feel ever so much better for he has been using up material that was clogging his circulation and irritating his nervous system.

At the end of a month he will probably feel so much better that he will conclude that he has found the root of all evil in life, or of all disease, in a failure of circulation that can be removed by means of massage, manipulation and passive movements. When he gets well enough to give it up, he drops straight back into his old troubles, because what he needs is a radical change of life that will adapt his eating to the amount of exercise that he takes, and his exercise to the amount that he eats. If this fails to come, he has had only a temporary benefit that has probably tempted him rather to increase {207} the amount that he eats normally than otherwise and will probably do him harm in the end. This massage brings about a distinct reduction in the weight of women, and as most of them are very desirous of this, the remedy becomes even more precious to them than to men. Here, too, however, it is only a temporary expedient. They are tempted to eat more than before, or at least not to reduce their diet, and the good that is accomplished is only for the moment, while no habits, either of restraint of eating, or of more exercise in the open air which so many of them need, have been formed.

Passive Movements.—The success of osteopathy has been largely founded on this curious peculiarity of human nature. People are not satisfied to regulate their eating and exercise in a sensible way. They prefer to submit to various methods of exercise, manipulations and passive movements which make up for the muscular exertion that should help the circulation within the body, but do not accomplish the purpose nearly so well as the voluntary exercise of muscles. It requires little exercise of will to submit to this treatment, while for many people it requires considerable exertion of will power to exercise their muscles for themselves. The old particularly, who are likely to suffer from achy conditions around joints, always worse on rainy days, which would be expelled by enough exercise to stimulate the circulation in these structures, find the new remedial measures of vicarious exercise of great service to them and consequently osteopathy has gained many votaries. Old members of many a state legislature who have been accustomed to ride for so long that exercise is almost an unknown quantity in their lives, are treated by the osteopath and lose so many vague pains and aches and discomforts of various kinds that it has not been difficult to persuade them that it is a great new discovery in medicine, and so in many of the states the osteopaths have secured legal recognition.

Summary.—Exercise, as exercise, often does harm rather than good. Thin people seldom need exercise, stout people seldom take enough of it. No one should be encouraged to exercise merely that he may be able to use up material that he has eaten, when it is evident that he is eating more than is required for his ordinary occupation. The question can never be settled without taking into consideration all these individual peculiarities of each case. Properly used, exercise is one of the most important therapeutic aids. But it is liable to as many abuses as are drugs, and the patient's attitude of mind toward any particular exercise is always an extremely important factor. If the exercise produces fatigue and disgust, then it will do no good, in spite of all that is hoped from it. If it creates true diversion of mind, it will surely be precious, even though it may, for other reasons, seem unsuitable.

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 assumed, 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 massage 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 massage 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 illustrated 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 assumption 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 accumulation 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 recumbent position. Whenever there is difficulty of breathing in connection with an affection of the heart, the recumbent position is extremely uncomfortable. This is nature's safeguard against the accumulation 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 assume. 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 accumulations 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 assumed. Restlessness, in the recumbent 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 assume 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 assume 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 prone 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 testicles 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.

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 illustrate 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 illustrated 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.