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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 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 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 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 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 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.





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