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Prostatism





It may seem impossible to include prostatic hypertrophy, or the train
of symptoms connected with it, among those affections likely to be
benefited by mental treatment. The history of this affection, however,
and especially of its treatment in recent years since it has come to
be the subject of special study, has furnished many examples of the
value of suggestion in the relief of many of its symptoms. Many forms
of treatment have been exploited for a time, attracting attention
because of the cures attributed to them, and have then been relegated
to the limbo of unsuccessful remedial measures. A striking example of
the place of suggestion came with the development of organo-therapy
some fifteen years ago. The succession of events illustrated well how
much persuasion and a favorable attitude of mind might mean even in so
purely physical an affection as interference with urination by
enlargement of the prostate.

It was at a time when thyroid medication for myxedema having proved
successful the medical journals were full of reports of other
successful phases of organo-therapy. The spleen and the bone marrow
were being used in the anemias, the ductless glands in various
nutritional diseases and even extract of heart for heart disease. Just
on what general principle it was assumed by some German investigator
that possibly extract of prostate from animals might be of benefit in
the treatment of prostatic hypertrophy is hard to understand. The
German physician, however, gave an order to the butcher to send him
prostates and as furnished they were administered to the patients. A
number of patients began at once to improve on the treatment. They
were able to empty their bladders much better than before, the
residual urine was decreased, the tendency to fermentation was
diminished and, above all, the patients' general symptoms were much
improved.

The success was so marked that the German investigator published his
cases and, with the public mind interested in organotherapy, they
attracted wide-spread attention. He was asked how to obtain the
material and only then did he take the trouble to investigate just
what the butcher had been sending him. The description furnished the
butcher by the doctor was that he wanted an organ lying below and
somewhat in front of the bladder of the bull. It was found on careful
inquiry that the abattoir attendants following these directions had
supplied not prostates but seminal vesicles. As soon as this was found
out some of the therapeutic suggestions failed. A number of cases,
however, continued to improve. German medical journals made fun
of the whole proceeding and most people will consider the ridicule
deserved.

Shortly before this time, however, we had had a very similar
experience with another pair of organs. In spite of the fact that
whatever we know about Graves' disease would seem to indicate that
that affection is due to an increased thyroid secretion in the system,
at the time of the organo-therapeutic fads, thyroid extract was
reported as having been used successfully in the treatment of this
affection. The name signed to the report was that of a trustworthy
English clinical observer. A few practitioners of medicine got similar
results, but most of them failed entirely to get his successes and
some of them were sure that their patients were rather harmed than
helped by the new medication. An investigation of just what material
was being employed in the English cases showed that the butcher was
supplying thymus and not thyroid glands. Suggestion did the rest, for
thymus has proved to be quite ineffective, and the treatment was
entirely expectant but acted on a favorable state of mind. Anyone who
has had much experience with Graves' disease knows how amenable to
suggestion the patients are. It would seem evident from the foregoing
story of organo-therapy for prostatic hypertrophy that sufferers from
prostatism are probably as prone to suggestion as patients with
Graves' disease. This is all the more surprising as the two affections
are so different in their etiology. Graves' disease being undoubtedly
a ductless gland disease, while prostatism is due entirely to
mechanical obstruction.

We have abundant additional evidence of the role of psychotherapy in
prostatism. Some years ago a well-known American surgeon suggested
that removal of the testicles would reduce the enlarged prostates. And
much improvement was seen after castration in those who previously
suffered from prostatism. The subject was carefully studied.
Experiments were made on animals and the results seemed to prove that
castration in them constantly produced prostatic atrophy. The fallacy
probably came from the fact that at the time so little was known about
the prostate in comparative anatomy and, above all, with regard to the
prostate in dogs, that it was impossible to come to any sure
conclusion as to reduction in weight and size after removal of the
testicles. A number of prostatic cases were treated by different
surgeons and with excellent results. Then after a time the number of
supposed successes dwindled or proved to be failures and now no one
does the operation. The only explanation that is at all satisfactory
in these cases, is that the rest in the hospital, the favorable
suggestion of reported cures and of an experimental demonstration on
animals led many patients, some of them even physicians, to secure a
better control over their bladders.

It took a good deal of persuasion as a rule to bring men, even men
well beyond seventy, to consent to the sacrifice of their testicles,
but once they did, the sacrifice brought a favorable suggestion to
work and so it was not long before they were able to make their
bladder act much more efficiently against the obstacles presented to
its contraction. Some could be persuaded more easily to sacrifice a
single testicle, but in these cases the mental influence was less and
the reported cures fewer. After a time the operation of vasectomy was
suggested as a substitute for the removal of the testicles. For a time
even this in the hands of certain operators gave excellent results.
Almost any other operation in the genito-urinary tract performed with
the definite persuasion on the part of the patient that he would
be better after it would probably have acted just as favorably. The
whole story of these series of incidents in the surgery of the last
decade of the nineteenth century ought to be a clear demonstration of
how valuable for therapeutic purposes is mental influence oven in
prostatism, and how much we should try to secure its favorable
effects.


Unfavorable Suggestion.--Since enlargement of the prostate has become
a familiar subject of discussion and men know and hear much about it
every now and then, one has to reassure a man but little beyond fifty
that he is not suffering from this affection. Just as soon as a man
begins to urinate frequently during the day and to have to got up once
at night he begins to wonder how soon he will be likely to suffer from
further symptoms of enlarged prostate. If he is of the nervous kind
his worrying will soon give him additional symptoms that will confirm
his suspicions. Probably one of the most familiar of phenomena, even
to the non-medical man, is the ease with which worry and excitement
causes frequent urination. Probably no system of organs in the body is
so likely to be disturbed by the mind as the urinary system with the
exception, of course, of the allied tract, the genital system, but the
two are so one in union and sympathy that they cannot be separated in
practice. The prostate is rather a genital than a urinary organ.


Urinary Worries.--When a man begins to worry about the possibility
of bother from enlarged prostate and recalls that frequent urination
is one of the symptoms of it, it will not be long before this symptom
develops. Occasionally his first wakings to urinate at night or in the
early morning are only due to passing conditions, either he drank
freely shortly before bedtime or perhaps he did not drink enough. In
the one case the bladder is rather full; in the other a concentrated
urine, especially with the patient lying on his back, makes itself
felt over the sensitive area at the base of the bladder, waking him
up. The rest of the symptoms may develop as a consequence of
solicitude over a few such incidents.

Practically all men who reach sixty have some tendency to more
frequent urination than before. Their bladder does not hold as much
fluid with comfort and they are likely to have to get up in the early
morning. This does not necessarily mean any enlargement of the
prostate nor any pathological change. The physiological change that
takes place seems to be rather conservative than otherwise. Old
muscles are less capable of extension and thorough reaction than they
were earlier in life and in order that the bladder may not be
over-distended nature makes it more sensitive than before.


Emptying the Bladder.--In the study of these cases individual
peculiarities in the emptying of the bladder must be remembered. There
are some men who cannot urinate if anyone is near them, and who even
have to step into a closed toilet if they are to succeed in emptying
their bladders when others are in the room. Some who find no
difficulty in the presence of others in open urinals find it difficult
or impossible to urinate when it is expected of them. Under worry and
excitement urination may become urgent or imperative, but on the other
hand some men find it very difficult to empty their bladders under an
emotional strain. Now that much more is written publicly with regard
to symptoms from enlarged prostate and much more is heard of the
affection, many old men got worried and lose some of the power that
they had over their bladder before, not so much because of their
enlarged prostate as from the psychic loss of control over their
bladder. The viscus consists of a series of muscles, the fibres of
which must be rather nicely coordinated and controlled in order to
secure that complete contraction necessary for thorough emptying. A
certain amount of residual urine occurs occasionally at least in many
other persons besides those who have prostatic obstruction.


The Question of Operation.--In recent years there has been a
tendency to suggest operation even on comparatively small prostates
when symptoms referable to them are noted. Operations on the prostate
have become much more easy and successful, and there has been the same
sort of feeling about them among surgeons as there was when operations
for affections, real or supposed, of the ovaries came into general
vogue twenty years ago. I have seen patients in whom an operation for
the removal of the prostate had been suggested, though the only
symptoms were somewhat increased frequency of urination during the day
and the necessity for rising two or three times at night. Such a
suggestion, by calling the patient's attention strongly to his
condition, emphasizes the irritability of the vesical tissues and is
almost sure to bring about a considerable increase in the symptoms.
The first principle of any treatment of irritability of the bladder
should be the setting of the patient's mind as free as possible from
solicitude. Any over-attention is sure to lead to reflexes and often
to what seems to be even imperative urination, though with a little
care and discipline much can be done for the relief of such symptoms.

The necessity for operation must be judged entirely from the symptoms
of the individual patient and not from any hard and fast rule with
regard to the size of the prostate. Prostates are eminently individual
organs, at least as individual as the human nose, and their projection
into the rectum is dependent on the relations of other tissues in the
neighborhood as well as on mere size. Men have been known to live with
comparatively few or no symptoms for many years, though at autopsy
they proved to have what would ordinarily be considered a
pathologically enlarged prostate.

Operations upon the prostate are valuable and indeed often afford the
only avenue of relief from an intolerable condition. The results are
not so encouraging in all cases, however, as to make recourse to
operation advisable until a thorough trial of palliative measures has
been made. It is surprising how often the confident suggestion of
assured relief when accompanied by the same amount of rest in bed and
the special care that is required for an operation, brings about a
disappearance of symptoms that seemed inevitably to demand surgical
intervention. There may be much residual urine, there may even be, as
a consequence of this, some fermentation with cystitis, and yet a
course of rather simple remedial measures may serve to bring about a
period of prolonged freedom from vesical symptoms. If these patients,
however, have heard much of the trials and sufferings of a catheter
life, the solicitude aroused with regard to their condition is
sufficient of itself to disturb their urination to a marked degree.
Unfavorable suggestion is particularly serious in its effects in these
cases, while favorable suggestion frequently repeated will enable the
patient very often to regain bladder control when the developments
present might seem to put that almost out of the question.


Position Suggestions.--An important suggestion for treatment in
prostatism with residual urine seems to be to teach the patient to
urinate lying down, especially with the hips somewhat elevated.
This seems to be the element that proved capable of making many
different operations, castration, the removal of one testicle,
vasectomy, and other suggestions appear curative. My own experience is
too limited to make my opinion of much weight; but I have seen certain
patients greatly relieved of prostatic symptoms and their residual
urine much diminished by the advice to urinate leaning well out of
bed, lying prone with the head lower than the body. A small stool is
brought to the side of the bed, a pillow placed on it and the patient
leans over face down on this with the shoulders considerably lower
than the pelvis. This allows gravity to assist rather than hamper the
emptying of the bladder and after men have become a little used to it
they are quite satisfied to take the trouble. Personally I feel sure
that more generally applied this would put off the necessity for using
a catheter a good deal and even save some cases from operation that
now seem to need it. The principle is exactly the same as that by
which patients suffering from bronchiectasis avail themselves of the
help of gravity and get rid of the nocturnal accumulation of material
in their dilated bronchi. They can thus be saved much trouble and
exhausting effort.

So much, as we have said, is written in recent years with regard to
prostatic symptoms that a body of unfavorable suggestion has been
created. This must be neutralized as far as possible by calling the
attention of patients who have initial symptoms of vesical disturbance
to the ease with which mental influences act upon the urinary
functions. Solicitude and anxiety will add to symptoms and may even
bring about their continuance when the original, local and passing
condition which has caused them has ceased. Very often if the
patient's mind can be properly disposed a marked relief of symptoms
will follow, especially if, at the same time, remedial measures of
other kinds are employed to lessen the irritation that is being set
up. While prostatism seems to be due to such purely mechanical
difficulties that mental influences can mean very little, the history
of the therapeutics of the condition for the last twenty years shows
us clearly that if strong mental influences are aroused they bring so
much relief that many patients consider themselves cured. This
psychotherapy will not do away with the necessity for operation in
many cases, but it will cure many of the sufferers from milder
symptoms and will in not a few cases bring such relief as will prepare
the patients to undergo operation, if it should be necessary, with
more assurance of favorable results.





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