Kitabı oku: «Psychotherapy», sayfa 37

Physical Basis .—Whenever the patients are run down in weight there is a distinct exaggeration of the condition. Whether the loss of weight, by removing fat from within the abdomen, does not tend to make the intestines more ready to take up air and to produce these manifestations is a question worth considering. The most annoying cases that I have seen were in people who had lost considerable weight and though there had been some tendency to the condition before they lost weight, it was doubtful whether the symptoms were greater than those often seen and which are not productive of special annoyance except in very sensitive people. In three of these cases that have been under my observation in recent years, improvement came promptly when weight was put on. The presence of an abundance of fat in the abdominal cavity seemed properly to balance the intestines and to dampen peristalsis.

Reassurance, absence of worry, occupation of mind with interests that keep it from putting such surveillance on the intestinal tract as will surely be resented, must be the chief care of the physician. Without these any relief afforded will be only temporary. With psychotherapy relapses will occur, for these individuals are in a state of unstable intestinal equilibrium, but practically all the successful remedies of the past have been founded on it and its effect may be renewed over and over again under various forms.

CHAPTER VII
MUCO-MEMBRANOUS COLITIS

Probably the severest, certainly the most interesting of the neurotic conditions of the intestines, is muco-membranous colitis. The only lesions discovered are those which point to a functionally increased secretion of tenacious mucus from the lower bowel. No definite pathological changes are known. The colic seems to be due to nothing more than the effort of the large intestine to push off the thick mucus which has been secreted, and which in many cases clings to the bowel walls. This may be of such consistency that it is passed from the bowel in the shape of tubular casts. These casts have often been seen in place in the lower bowel. While the word membranous used in connection with the disease has produced the impression that this might be a form of diphtheritic affection, it is now known that it is only due to an abnormally increased function, and not to any structural pathological condition or infection of the lower bowel. The membranous material is often gelatinous, and so the casts may hang together in long pieces.

Neurotic Etiology.—It might be thought that such a cast could not be formed, remain in situ in the lower bowel for a considerable period, and then be passed as a whole, or in quite long portions, without causing serious tissue disturbance in the mucous membrane. As Sir William Osier says, in spite of the apparent improbability, the separation may and usually does take place without any lesion even of the surface of the mucous membrane. The epithelium seems to be left intact. Owing to the curious nature of the stools, the disease has been recognized for a long time and the descriptions of this disease by the older authors are very interesting. Muco-membranous colitis occurs mainly in nervous individuals, and is much more frequent in women than in men, but it is not limited to women. Some of the severest cases have occurred in men, and Woodward, in the second volume of "The Medical and Surgical Reports of the Civil War," has an exhaustive description of the disease as it occurred among soldiers. It is particularly those who are worried and run down from overwork and excitement who are likely to suffer from it, but it occurs typically in people who, faute de mieux, worry about themselves. Most of its victims are self-centered, though not hysterical.

Recent Increase in Number of Cases.—According to all the authorities, there has been a considerable increase in the number of cases in recent years. At one watering place in France, Plombiêres, which has acquired the reputation for relieving, or even curing the disease, about 400 cases had been under treatment during the course of about two years. This increase was attributed by Boas of Berlin to two causes. First the struggle for life has become much more intense in our day, and the nervous conditions which are practically always the basis of muco-membranous colitis, have as a consequence become more frequent. Not only this, but mild cases that were not called to the attention of physicians in the past, have become so emphasized by the nervous worries of the strenuous life that now they seldom escape the physician's attention. Besides our generation is getting away from the old-fashioned idea of patiently standing many pains and aches, and refusing to call in a physician unless the condition persists or seems to be producing serious results. There are more cases of the disease, but physicians also see more of the cases than formerly because patients come for treatment for slighter causes.

Dr. Boas considered that, besides the strenuous life, there was another prominent factor in the increase of the disease. This is the abuse of laxatives and purgatives. Many of these have their principal effect on the lower bowel. In consequence the nervous mechanism of this structure has been irritated to a point where occasionally explosions of nerve force take place. This causes an increase of the secretion, and a tendency to cramp-like contractions. While there is undoubtedly much of truth in this, there is no doubt that the most important factor in the disease is the patient's nervous condition. Only those who are inclined to be introspective, to worry much about themselves, and who are constantly examining their stools for the presence of mucus, suffer severely from the affection.

Very few cases have been seen among the working classes. Most of the cases have hypochondriacal symptoms that sometimes go to the extent of real melancholia and the full persuasion that they have an incurable disease, a visitation on them for some real or fancied lapse from the laws of health in earlier years. The affection usually lasts a long time, or has been in existence for some years when the physician is asked to see it, and patients are made most miserable by it.

Unfavorable Suggestion and Over-attention.—The pathological physiology of this disease, for, as has been said, it has no pathology in the proper sense of the word, is in many cases a problem of mental influence. For some reason, the patient gets his or her lower bowel on his or her mind. There is so much talk of constipation and its evil effects in the newspapers, in advertisements and by suggestion from bill-boards and in the magazines as well as, sad to relate, in parlors, drawing-rooms and even dining-rooms, that it is easy for those who are introspective and nervous about themselves, and who have some little tendency to constipation already, to become much worried about it. If, then, as was suggested by Boas, they take laxatives in profusion, the irritation set up further fixes the attention on this portion of the body. After a while, in these people, a goodly portion of the waking hours are spent in thoughts with regard to the lower bowel. The morning thought is the possibility of a stool to-day, followed by conjecture as to its character. After the stool has taken place, if there seems anything abnormal about it, comes a morbid dread of the consequences of having such stools.

This constant attention sends down a lot of impulses to the lower bowel. Anyone who has studied the psychology of attention knows how much influence can be exerted on the skin, or on the mucous surface by mental influence. Hyperemia is produced, and this leads to over-action of the glands of the large intestine. These glands secrete a glairy mucus which is necessary to protect the bowel from the offensive material that is always present, and from the hardened material that is so often there when there is a tendency to constipation. This mucus is secreted in large quantities, while at the same time a hyperemia of the colon tends to interfere with peristalsis and consequently to delay the passage of contents and to keep the mucus in place. An accumulation goes on for some time, until irritation is set up by the presence of such a large quantity of material in the intestine, and then colicky efforts for its removal are occasioned. All of this process is accompanied by suggestive reactions upon the mind that further complicate the case. This story of the affection points out the indications for treatment. Unless the patient's mind can be diverted from its constant attention to the lower bowel, the possibility of cure is distant, and even after such diversion any return of attention is likely to bring on a relapse.

Treatment.—The treatment of this affection emphasizes its neurotic origin. We have had any number of cures for it and each one has actually relieved many patients. The more trouble the cure involves, and the greater the impression produced on the patient's mind the more likely is there to be a relief of symptoms. All sorts of drugs have been employed. Many of them have for a time been heralded as more or less specific. The important thing, however, was that the patients should come predisposed to believe that they were going to be improved, and then that suggestion should be made at frequent intervals—a combination of auto-suggestion through the administration at regular intervals for a long period of simple remedies with the confident suggestion of the physician that the patient will get better. Local treatment of various kinds has been reported to bring about improvement. The more difficult this is, and the longer it takes, as well as the more bother it involves for the patient and the attendant, the better the response to it is likely to be. Long rectal tubes were found beneficial in many cases, though they failed in many others, and most physicians have seen relapses occur in spite of the continuance of the treatment that at first did much good. High injections of water containing various drugs, and of olive oil sometimes bring improvement though they afford no guarantee against a relapse. Mineral waters do good only in the suggestive environment of the spring.

Surgery and Suggestion .—The symptoms have sometimes been so severe and the complaints of the patients have been so great that even surgery of serious character has been recommended and tried in some of these cases. The making of an artificial anus in the right inguinal region, so that for a time the feces are not allowed to pass over the colon mucous membrane has been tried. This gives decided relief from the symptoms, but when the artificial anus is allowed to close, recurrences often take place. It has been suggested, therefore, that the artificial anus should be allowed to stay open for months, but even this seems to afford no guarantee against a relapse. In recent years the appendix has been taken out through the opening in the right inguinal region, and a portion of it allowed to remain through which, when fastened to the abdominal wall, injections might be made into the colon. In these cases ice-water has been found probably of more effect than any drug solutions. This rather serious surgical procedure is, however, as yet on trial, and we do not know enough about the after-course of the cases to be sure that it has any permanent effect.

A strong suggestion is involved in the removal of the appendix, and the use of the stump of it as an irrigating tube. When the treatment consists of something that is so strongly excitant of feeling as ice-water, applied directly to the colon, it is easy to understand that suggestion reaches the limit of its possibilities. No wonder these cases improve, though we are not sure as yet what happens after the appendix opening is allowed to close, or is deliberately sutured. I should expect a recurrence of symptoms, if ever a time came when the patient was run down in weight and worried by external conditions, introspection, and above all by concentration of attention on the intestines.

Direct Suggestion .—The question is whether suggestion can be used to advantage in these cases without employing any of the radical measures that have been suggested. There is no doubt that at certain watering places where a specialty is made of this disease, and to which patients go, sure that they are going to be much better than before, and where they see patients all round them who are improving, they often get complete relief. This is only what might be expected. Whether a similar effect can be produced by simple suggestion when the patient is thoroughly convinced that the physician understands the case, and that if they will respond he can cure it, remains to be seen. I know that mild cases improve rapidly under simple hygienic measures, with a renewal of confidence in the possibility of relief, and with the diversion of the patient's mind from the intestinal difficulty. This is the most important factor in the treatment, as it is the most important factor in pathology. If the patient's nerve centers can be kept from sending down impulses causing exaggerated action of the glands, then there is some hope of relief. A habit has been formed in the matter, and a habit can only be broken by a series of acts, just as it was formed. It is not effort for a few days nor a week that counts in these cases, but diversion of mind for long periods, until normal function is restored. It is usually quite impossible to keep up this improvement constantly in nervous patients. There are setbacks, but then this is true in every form of nervous affection. It is, then, that the renewed suggestion of the physician is needed.

Resort Cures and Suggestion .—Physicians often tell patients that muco-membranous colitis is incurable, or at least emphasize strongly that it is very refractory to treatment, and that it is prone to relapse even after improvement. After a certain number of physicians have insisted on these points, it is inevitable that patients should not respond readily to treatment, and that they should be solicitous about themselves, even when improvement does come.

It is most important then to bring about the neutralization of these unfavorable suggestions. This is what is particularly accomplished at the health resorts where muco-membranous colitis is successfully treated. At these the patients see other sufferers from the disease who proclaim how much better they are and some at least who are entirely cured. The waters used at these health resorts are not nearly so efficient when used at a distance because of this lack of additional suggestion.

The most efficacious treatment of muco-membranous colitis then is to bring the patient up to normal weight, for they are often thin people, quiet their solicitude about themselves, give them a bland and irritating diet and get them away from worries or anxieties about themselves or others. I know cases in physicians where the effect of worry of any kind can be traced very clearly in the increased symptoms of their colitis and the greater frequency of attacks. It is particularly important not to give habit-forming drugs in these cases for they always do harm. Where the pain is much complained of the coal-tar anodynes are useful, but ice in the rectum or even suppositories of gluten, or of cocoa butter without any medication often prove useful. Most of these patients watch prescriptions that are given them rather carefully and make up their mind beforehand whether they are likely to do them good or not and the event usually follows their premonition. They often have habits of self-drugging which must be stopped and always carefully inquired into for they will sometimes continue to take things for themselves in spite of being under the doctor's care. If they have heard of surgical treatment for their affection they are likely to think that they will have to come to it eventually and this prevents a favorable attitude of mind towards their affection. Unless this is secured no treatment will prove efficient. With it almost anything that keeps up the suggestion will greatly relieve and often will actually cure the condition.

CHAPTER VIII
OBESITY

Obesity, popularly considered to be an over-accumulation of fat, is sometimes thought to exist only when there is the large development of abdomen which is more properly designated corpulency. In its strictly scientific sense it represents excessive over-weight, that is, above twenty per cent. more of weight than is normal for the height of the particular individual. (See table of weight for height in chapter Weight and Good Feeling.) The Latin derivation of the word gives also its etiology. Ob-ese means having eaten too much. It is a question of failure of due proportion between the taking of nutrition and the oxidation processes within the body. More food being taken than is needed, there is an accumulation of it in the form of fat, and this is deposited by natural preference in certain places, such as the abdomen, the breasts and in the panniculus adiposus beneath the skin. The fats and starches are most readily converted into this fat, but under certain circumstances proteid material may be turned into fat, and then a true pathological condition develops resembling diabetes in certain ways.

The metabolism of fat is rather simple, but this may be disturbed by bad habits. When such large quantities of sugar-making materials are taken that they are beyond the power of the normal metabolism to dispose of, they are excreted in the urine with the production of what is known as physiological glycosuria. In the same way, the eating of a superabundance of fat-forming food leads to the deposition of fat in the tissues where, when in excess, it is just as much wasted as if it were excreted. Physiological glycosuria is, however, usually considered to be dangerous, inasmuch as its frequent occurrence may disturb the normal metabolism of sugar, and lead to diabetes. In the same way, the over-consumption of fat-forming materials may disturb the fatty metabolism, and lead even to the changing of proteid materials into fat. This represents a real disease requiring careful management, while ordinary obesity needs only the exercise of the patient's will to secure such proportion between the amount of food taken, and the amount of exercise and fresh air, as will not only prevent accumulation of fat but will lead to the reduction of any accumulation that may, through neglect of this care, already have taken place.

Over-eating.—The putting on of weight depends on the individual's craving for food, and his satisfaction of his appetite. While it is not ordinarily looked at from this standpoint, this craving for food and the habit of satisfying it which is developed, is not very different from the craving for stimulants and the habit that forms with regard to them. People insist that they can not eat less—that their appetite simply requires them to eat. We have all heard this story over and over again from the man who craves alcoholic stimulation. Usually the obese can be persuaded more easily than the inebriate to break off their habit, but they relapse into it even more easily than he does. It is comparatively easy to limit the appetite, or rather to forego the satisfaction of eating abundantly, for a week or two weeks or even a month, but the effort finally becomes appalling and the consequence is a relapse. If the patient really wants to lose weight, in nine cases out of ten it is a comparatively simple matter. The trouble is that they want to lose in weight without giving up the satisfaction of eating.

Under Exercise.—The second factor in obesity—lack of sufficient exercise, is even more important than the habit of over-eating. This is illustrated very well by the cases of certain animals who, without any tendency to fat accumulation by nature, but rather the contrary, acquire fat to a marked degree, owing to the habits that are forced on them by their relations to human beings. A typical example is the pet dog. Dogs living their natural active lives, have little tendency to put on superfluous flesh. Kept in the house in cities, they practically always put on weight until, after some years, many of them are quite incapable of moving except in an awkward waddle, often comically symbolizing their mistresses in this respect. Besides the inactivity, the dog is subject to the influence of the other cause of obesity, the over-eating of fat producing material. Another typical example, and one that provides evidence of the pathological tendency to fat accumulation, is found in the Strasburg geese from whom the fatty goose livers for pates de foie gras are obtained. Geese are placed in a warm underground room, in a mass of cement that gradually hardens round their feet keeping them almost completely inactive, and then they are fed abundantly with fat-forming materials. The absence of light and air, and the immobility, leads to the production of the fatty changes, eventually producing the enlarged fatty livers, which delight the gourmet's palate.

What is true of the dog and the goose is exemplified in the lives of all other animals. The fattening process is well understood by butchers—keep the animal inactive and supply an abundance of fattening food. The inactivity is even more important than the food.

Prophylaxsis.—Of course, if obesity is to be successfully treated, cases must be seen early and before there has been a large accumulation of fat. When people are more than 10 per cent. over weight they are in the danger zone, and with 20 per cent. above the normal, decrease must come or the condition becomes inveterate. It is between these two points and not when they are forty or fifty pounds over weight that they need the advice of a physician and the careful institution of regular life to prevent further fat accumulation. After the body has carried thirty or forty pounds over weight for some time, it has acquired the habit of accumulating fat, rather than using it, and this, once acquired, is hard to break. Every additional pound tempts to the formation of lazy or sluggish habits because of the additional weight that has to be carried around. Everyone knows how hard it is to walk a few blocks a little briskly carrying a suit case that weighs thirty pounds. Even twenty pounds soon proves to be a burden. Fat in the tissues, though it seems to be a portion of the individual, is really quite outside of him and consists of extra food material that the body is carrying round, having accumulated it for the purpose, apparently, of using it at some time when it should be necessary. While carrying this burden, people have little inclination to an active life. Inactivity lowers oxidation processes and leaves them with an additional tendency to fat accumulation because of lack of oxidation. In a word, a vicious circle of cause and effect is formed. Accumulation of fat prevents the taking of proper exercise, and lack of exercise leads to further accumulation of fat!

Not only should the treatment of obesity begin early in a particular case, but, in families where there is a recognized tendency to take on fat, it should begin early in life.

Children should not be so fed that they become mere specimens, illustrative of how early fat accumulation may occur, and to what a degree it may go. Just as soon as baby shows signs of an accumulation of fat above its normal weight for age and size, there should be just such a regulation of its diet as would be considered necessary if it were an older person, and showed the same unfortunate tendency. This is particularly important if the parental relatives on either or both sides of the house show tendencies to fat accumulation. We are sure that in diabetes the over-eating of starchy and sugary substances produces what is, at the beginning, an alimentary or so-called physiological glycosuria, though it is doubtful whether any glycosuria is ever absolutely physiological. This may lead to a pathological glycosuria and the production of a true diabetes. So, also, the tendency to accumulation of fat, as the result of what might be called alimentary obesity, may lead eventually to the production of an essential obesity in which even the proteid materials of the food may be changed into fats, just as in the case of diabetes they are changed to sugar. This fat is then stored up in the tissues though there is no need at all for such an accumulation, and the food stuff is wasted quite as much as in diabetes.

The Will in Treatment.—The important element in the treatment of obesity is the readiness of the patient to follow directions. Nine out of every ten stout people are thoroughly able to control the accumulation of fat and even to bring themselves down to about normal weight, if only they will to do so. This is no easy matter. It is not an affair of a few weeks, or even a few months. Just as in the case of over-indulgence in alcohol, it will probably be a life struggle. It is well worth the while, however, for life is longer and is larger without the accumulation of fat, which is not only so uncosmetic, but is so preventive of real enjoyment of life. Unfortunately, the cosmetic side of it, that is, the absurdity of going round among one's friends with a very prominent abdomen, or with noticeable protuberances, is the particular motive that appeals to most people. While women may be quite ready to stand many discomforts for cosmetic effect when dictated by fashion, they are not ordinarily persistent enough in their efforts to prevent fat accumulation to be successful in this much more important purpose.

Such patients make the rounds from physician to physician, and from quack to quack, and go from patent medicine to patent medicine, to find something that will enable them to lose weight without the necessity for their taking any trouble. It is the old, old story that the nerve specialist who is known occasionally to treat his patients by hypnotism has so often presented to him. Patients who are sufferers from alcoholism, or drug addiction, or some other vicious habit, present themselves and ask if they cannot be hypnotized and then lose their tendency to fall back into the old habit. There is no possibility of this. If they are willing to cooperate, all of these habits may be overcome, but a constant effort will be required and, even after the habit is broken, there always remains a distinct danger of relapse. Patients suffering from obesity want to transfer the burden of working it off to someone else's shoulders, or they want some specific remedy that will bring about reduction in weight yet permit them to indulge in all the pleasures of their artificially excited appetite. They follow directions for a few weeks, often half-heartedly, and then give up the struggle.

Food Temptations .—With obesity, as with indulgence in alcohol, the main difficulty is the occasion. Most of these fat people are placed in circumstances in which tempting food passes them three times a day, and it is hard to refuse it. If a hot punch or a fragrant cocktail were several times every day passed under the nose of a man with a tendency to inebriety it would be beyond the bounds of reason to hope that he should withstand his craving. Just as soon as those who want to reduce in weight are put in conditions in which only simple food, though there may be a reasonably good variety of it, is presented to them, the difficulty of limiting the amount they eat is comparatively easy. This necessitates, as a rule, refusing invitations to dinner at friends' houses, especially at the beginning of a reduction cure, avoiding hotel menus and giving up various social functions. It may even involve changing home customs from those of luxury back to simplicity. The question is whether this is worth while or not. When a husband is likely to indulge over much in alcoholic liquors a wife is apt to consider it easy to deny herself the privilege of such liquors on her table and of avoiding places where he is likely to be tempted. The rest of the family are usually quite satisfied to stand some self-denial so that unfortunate results may not follow.

Where father or mother are suffering from obesity this same thing may be necessary with regard to rich and highly seasoned foods. This would be a hardship to inflict on the family were it not for the fact that the health of all the members will be distinctly benefited and a return to simple food, nutritious and with a variety that makes it eminently wholesome, will be good for them as a prophylactic measure.

Motives for Self-Control .—The task of keeping the weight down is so difficult that very few people with a tendency to over-weight are equal to it. They need the help of every motive possible for encouragement. It is well to make these persons realize that over-weight, according to the statistics carefully gathered and collated by the large insurance companies in recent years, is a serious bar to great expectancy of life. In a large series of cases it was found that not a single individual recorded as being more than twenty per cent. over the normal weight that he should have for height, died of old age. Furthermore no one of over-weight attained the age of eighty years, though 44 under-weights passed this age, and two of them even reached the age of ninety. Death from nearly every known cause is more frequent among the over-weights than in the normal population, except in the single instance of tuberculosis.

What was thus demonstrated from statistics, carefully gathered in modern times, has been a commonplace in medicine since the earliest days. Hippocrates summed up Greek experience in the aphorism "persons who are naturally very fat are apt to die earlier than those who are slender." Practically all the commentators since his time have agreed with him. In early years thinness may be quite as dangerous.