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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