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 trea ment 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.