A Doctor's Journal
Adapt or Be Ill
By MILES HOWARD AREADER from Kingston asks : 'As many of the underlying causes of stress are such as cannot easily be altered, how should one adapt oneself to the presenting situation, so that the stress-effects can be neutralised before they pro- duce mental or physical symptoms?' A fair ques- tion, and one that has exercised my mind often enough.
To begin with, some definitions. The best defi- nition of stress, as the term is used in medicine, is Harold Wolff's: the internal or resisting force brought into being in the human organism by interaction with the environment. In Western society in time of peace much the most important form of such interaction, in the production of disease, is that between man and his fellow- beings : husband and wife, mother and child, employer and employee. The law of survival, in the animal kingdom, is 'Adapt or perish'; in the human world, the law is 'Adapt or be ill.' The man in a fix has thus two alternatives, if he is to remain well : (1) Alter his circumstances, or (2) Adapt himself to them.
Let us suppose that (I) is not possible (say, mother-in-law living in the same house, with nowhere else to go); then he must try (2). He doesn't want to make scenes—that would upset his wife. So he keeps quiet, and swallows his rage. At first, the bodily disturbances that follow on rage-swallowing are transient—discomfort in the midriff, fullness, some nausea : a nuisance, but not disabling. As time goes on, however, if he cannot accept the situation, and the 'charge' of hostile feeling inside continues to build up, he will start to vomit. Very probably he is not con- sciously aware of the intensity of the feeling- charge : it is, I believe, the rule in stress disorder that the emotional drive underlying symptom- production, that is denied outlet in action, is out- side consciousness. He knows well enough that he is fretted by the old lady fussing about the kitchen, and advising everyone, but the full force of his feeling is held back, and appears only as sickness. Situations with this kind of structure are to be seen all around us every day. It is plain that to comprehend the meaning of this man's vomiting it is not enough to scrutinise only the patient—his being sick is one symptom of a family-illness, so to say : a disorder of human relations.
How then. shall he act? He looks ahead, and sees that new quarters for his persecutor won't be available for perhaps three years. He can just go on. being sick, the illness having of course some protest-value in the family. Presuming that no organic changes occur in his gut, as they may not, no permanent harm will be done. Or he can make some attempt to deal with the emotional dishar- mony in himself, from which his symptoms spring.
To do this he will need to seek help from some- one outside the family, unless he is an excep- tional person with enough insight and self-discip- line to handle it himself. In the ordinary way he will go first to his doctor, who is really the most appropriate 'catalyst.' The family doctor who can give time, patience and privacy to his patients with stress disorders will do more good in the long run than anyone else. More and more nowadays the practitioner is undertaking this kind of work him- self, and with experience he will soon acquire a skill that brings great benefits to his flock and satisfaction to himself.
Or our patient can 'work through' his problem with someone other than a doctor—a close friend, a lay therapist, a priest, and in fact anyone who can listen with detachment, and avoid giving advice. Where the main symptom is a bodily dysfunction, like vomiting, however, he is much better advised to consult his doctor first. In the 'working-through' he may, and probably will, come to see that the sources of disharmony and tension lie as much in himself as in the situation: for instance, that he has (unconsciously) identified his mother-in-law with a persecutory mother- -figure, or nanny, from his earlier life; that he came out of childhood with an unfinished revengeful need for this person, and now has found a target for it.
My reader makes an important point in the question : `. . . before they produce symptoms.' Prevention is always better than cure. Where asthmatic attacks, for instance, are linked to mental tension (as they so often are), how much better to reduce tension and forestall the attack than to wait until it happens. Once the attack has begun it is much more difficult to deal with.
How many appendices are taken out because of abdominal pain which has its origin in the nervous system? I doubt if any surgeon could answer that one. Two years ago a surgeon wrote a paper on appendicitis in which he reported the `conservative treatment' (that is, leaving out the operation) of 137 patients; only one died. `1 sometimes wonder,' he said cautiously, 'whether it would not be a sound procedure to treat all cases of acute appendicitis conservatively. They seem to settle down quite nicely and some never seem to have any further trouble.' On the other side of the fence, two Scottish surgeons this year recounted their experiences with 549 patients; they operated on all of these, and six died. `Appendicitis,' they say firmly, 'must be suspected in all patients, irrespective of age, who present with abdominal pain.'
Two comments. (1) Far and away the most common cause of recurrent abdominal pain in children is agitation, and I suspect that 'tension pain' of this kind is also pretty common in adultqf though no survey of a random sample of patients has been published. (2) Many patients who loge their appendix to the surgeon later come bacK to the family doctor with a bellyache and this ache is often in the same quadrant of the abdomen as the original pain. How many of these does ' the surgeon see? And on what data does the surgeon who believes in operation base his. judgment?
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