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Problems of convalescence
The American Journal VOL.
v
AUGUST,
1948
of Medicine No. 2
Editorial Problems
A
of Convalescence
to Stedman’s Medical Dictionary the word convalescence (growing strong) refers to the time that elapses between the termination of a disease and the patient’s complete restoration to health. The simple finality of that statement invites discussion. Its implied supposition that “a disease” is something a man “gets” or “has” maintains the primitive concept that he himself is a victim of Olympian wrath. That he may be an important causal factor in his own malady the statement completely overlooks. One might as well ask when does a disease actually begin as to judge when it terminates. The pathologic events which occur between two successive states of health form a continuum. The course or curve in recovery from the onset of disease to the stated cure varies greatly with different persons. In some cases the curves of disease from onset to peak and through the descent are rapidly described. In others every variation in form and speed appears. Those who dally in regaining health and in the ability to return to their previous life-setting deserve special scrutiny. No doubt various facts and motives determine why slow recoverers are slow. Of course, many subjects with early deterioration of tissues such as liver, kidney or arteries, as well as those with rheumatoid arthritis and similar disabilities, should hardly be classed as convalescents. They clearly belong in the growing ranks of victims of chronic disease whose chances for ultimate recovery are what they may be. A good deal can often be done to make resumption of work fairly successful for CCORDING
shorter or longer periods of time. This type of fixed tissue disease rarely moves in the direction of biologic recovery. But even with great physical handicaps certain persons may achieve superb capacity for work. Deaver, Rusk and others have shown that the patients’ effectiveness may be maintained for remarkably long periods by proper, diet training and point of view. In many convalescent homes the most satisfactory patients, as far as recovery is concerned, are those whose maladies arise in the organs equipped with smooth muscle which is motivated by the autonomic nervous system. These include the whole field of the neuroses, for example, peptic ulcer, thyroid disease, asthma, enteritis and essential hypertension. In Homeric times the Greeks used to speak of two varieties of medicine---profane and sacred. The former dealt with sewing up the wounds of a warrior, setting broken bones and treating any ailment caused by explainable physical forces. Sacred medicine or magic, on the other hand, had to be called upon for maladies whose concealed inner mechanism could not be perceived or directly dealt with by tangible methods. The former has come down the ages to end in modern surgery and physiotherapy for physical rehabilitation. Sacred medicine or magic has turned into contemporary psychotherapy. Today the combined technics are expressed in that presently overworked word, “psychosomatic.” And this brings us to the specific problems of convalescence and convalescent care. The question has often been raised
Editorial as to what sort of regimen should be provided at convalescent homes. In the first place, the term “home” carries a maternal connotation of “being taken care of,” a continuation of the protective nursing just terminated in the general hospital. If the patient is well enough to leave that phase of his illness, he should be weaned as promptly as possible. A better name for the modern convalescent home would be “Recovery Training Institute.” The effort of all concerned with the patient’s ultimate recovery should be to help him as little and as indirectly as possible within the limits of good sense. One of the remarkable achievements at the Bellevue Clinic has been the education of patients to help themselves and to become independent of their former aids. They are taught selfsufficiency in the face of handicaps. There are times, too, when patients flee from apparently insoluble family troubles “just to get away from it all.” Such cases derive scant benefit from the three weeks of sunlit and well fed loneliness among strangers, agoraphobia and anticipated terror at the idea of returning to their unsolved problems. These individuals might better have settled the home conflict first. It probably led to the acute illness or general collapse which called for a convalescent period. After such a settlement the healing virtues of fresh air, sunshine, good food and rest might have produced more rapid and complete rehabilitation. The recovering patient is in a tough spot indeed, one which often defies a first-class social service worker. A large number of patients who avoid the guidance of a well trained and wise physician use a Recovery Hospital as an escape from the intolerable family situation. Many others are without funds and have nowhere to go when they leave the institution, which therefore is often forced to act as a hostel for lost and stranded wayfarers. And so
the medical problems for which the patients seek final relief become submerged beneath waves of personal and social relationships and world economics. Medical men have always realized that when a new remedy like penicillin appears, which “cures” a definite disease in the mass, the intimate relationship between patient and doctor, which Jung calls “le participatends to diminish. Moretion mystique,” over, the shortened period of illness, which often results from new drugs, hardly permits more than a “how-do-you-do, good-bye” relationship. In preventive medicine there is not much personal interchange between the Board of Health doctor and his 5,000 vaccinees. Treatment of the acute phase of disease in a general hospital, where tangible ills are handled in heroic fashion, has much in common with the Greek concept of profane medicine. In sharp contrast, the recovery phase of disease should call forth the special technics which have now been developed to perform the work of sacred medicine. The patient, exhausted by his bout of acute sickness, feels unlike his former self; he is a strange and unaccustomed pilot in his own conning tower. He finds himself doubtfully suspended between what went before and what lies ahead. He reaches for a guiding hand and should find one whose sensitive and powerful grasp provides exactly the correct proportions of direct help and insistence upon the achievement of self-help. In the recovery phase of disease, therefore, the physician should encompass all the skills of sacred and profane medicine with which to restore the patient to his original wholeness; short of that the patient will have learned to accept his residual handicap and find a way to carry on in spite of it.
GEORGE DRAPER, M.D. Burke Foundation, White Planes, N. Y.
AMERICAN
JOURNAL
OF
MEDICINE
v
AUGUST,
1948
of Medicine No. 2
Editorial Problems
A
of Convalescence
to Stedman’s Medical Dictionary the word convalescence (growing strong) refers to the time that elapses between the termination of a disease and the patient’s complete restoration to health. The simple finality of that statement invites discussion. Its implied supposition that “a disease” is something a man “gets” or “has” maintains the primitive concept that he himself is a victim of Olympian wrath. That he may be an important causal factor in his own malady the statement completely overlooks. One might as well ask when does a disease actually begin as to judge when it terminates. The pathologic events which occur between two successive states of health form a continuum. The course or curve in recovery from the onset of disease to the stated cure varies greatly with different persons. In some cases the curves of disease from onset to peak and through the descent are rapidly described. In others every variation in form and speed appears. Those who dally in regaining health and in the ability to return to their previous life-setting deserve special scrutiny. No doubt various facts and motives determine why slow recoverers are slow. Of course, many subjects with early deterioration of tissues such as liver, kidney or arteries, as well as those with rheumatoid arthritis and similar disabilities, should hardly be classed as convalescents. They clearly belong in the growing ranks of victims of chronic disease whose chances for ultimate recovery are what they may be. A good deal can often be done to make resumption of work fairly successful for CCORDING
shorter or longer periods of time. This type of fixed tissue disease rarely moves in the direction of biologic recovery. But even with great physical handicaps certain persons may achieve superb capacity for work. Deaver, Rusk and others have shown that the patients’ effectiveness may be maintained for remarkably long periods by proper, diet training and point of view. In many convalescent homes the most satisfactory patients, as far as recovery is concerned, are those whose maladies arise in the organs equipped with smooth muscle which is motivated by the autonomic nervous system. These include the whole field of the neuroses, for example, peptic ulcer, thyroid disease, asthma, enteritis and essential hypertension. In Homeric times the Greeks used to speak of two varieties of medicine---profane and sacred. The former dealt with sewing up the wounds of a warrior, setting broken bones and treating any ailment caused by explainable physical forces. Sacred medicine or magic, on the other hand, had to be called upon for maladies whose concealed inner mechanism could not be perceived or directly dealt with by tangible methods. The former has come down the ages to end in modern surgery and physiotherapy for physical rehabilitation. Sacred medicine or magic has turned into contemporary psychotherapy. Today the combined technics are expressed in that presently overworked word, “psychosomatic.” And this brings us to the specific problems of convalescence and convalescent care. The question has often been raised
Editorial as to what sort of regimen should be provided at convalescent homes. In the first place, the term “home” carries a maternal connotation of “being taken care of,” a continuation of the protective nursing just terminated in the general hospital. If the patient is well enough to leave that phase of his illness, he should be weaned as promptly as possible. A better name for the modern convalescent home would be “Recovery Training Institute.” The effort of all concerned with the patient’s ultimate recovery should be to help him as little and as indirectly as possible within the limits of good sense. One of the remarkable achievements at the Bellevue Clinic has been the education of patients to help themselves and to become independent of their former aids. They are taught selfsufficiency in the face of handicaps. There are times, too, when patients flee from apparently insoluble family troubles “just to get away from it all.” Such cases derive scant benefit from the three weeks of sunlit and well fed loneliness among strangers, agoraphobia and anticipated terror at the idea of returning to their unsolved problems. These individuals might better have settled the home conflict first. It probably led to the acute illness or general collapse which called for a convalescent period. After such a settlement the healing virtues of fresh air, sunshine, good food and rest might have produced more rapid and complete rehabilitation. The recovering patient is in a tough spot indeed, one which often defies a first-class social service worker. A large number of patients who avoid the guidance of a well trained and wise physician use a Recovery Hospital as an escape from the intolerable family situation. Many others are without funds and have nowhere to go when they leave the institution, which therefore is often forced to act as a hostel for lost and stranded wayfarers. And so
the medical problems for which the patients seek final relief become submerged beneath waves of personal and social relationships and world economics. Medical men have always realized that when a new remedy like penicillin appears, which “cures” a definite disease in the mass, the intimate relationship between patient and doctor, which Jung calls “le participatends to diminish. Moretion mystique,” over, the shortened period of illness, which often results from new drugs, hardly permits more than a “how-do-you-do, good-bye” relationship. In preventive medicine there is not much personal interchange between the Board of Health doctor and his 5,000 vaccinees. Treatment of the acute phase of disease in a general hospital, where tangible ills are handled in heroic fashion, has much in common with the Greek concept of profane medicine. In sharp contrast, the recovery phase of disease should call forth the special technics which have now been developed to perform the work of sacred medicine. The patient, exhausted by his bout of acute sickness, feels unlike his former self; he is a strange and unaccustomed pilot in his own conning tower. He finds himself doubtfully suspended between what went before and what lies ahead. He reaches for a guiding hand and should find one whose sensitive and powerful grasp provides exactly the correct proportions of direct help and insistence upon the achievement of self-help. In the recovery phase of disease, therefore, the physician should encompass all the skills of sacred and profane medicine with which to restore the patient to his original wholeness; short of that the patient will have learned to accept his residual handicap and find a way to carry on in spite of it.
GEORGE DRAPER, M.D. Burke Foundation, White Planes, N. Y.
AMERICAN
JOURNAL
OF
MEDICINE