initial commit of ebook 36450HEADmain

1 files changed, 50324 insertions, 0 deletions

diff --git a/36450-8.txt b/36450-8.txt
new file mode 100644
index 0000000..b5aa888
--- /dev/null
+++ b/36450-8.txt
@@ -0,0 +1,50324 @@
+The Project Gutenberg EBook of Psychotherapy, by James J. Walsh
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Psychotherapy
+
+Author: James J. Walsh
+
+Release Date: June 17, 2011 [EBook #36450]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK PSYCHOTHERAPY ***
+
+
+
+
+Produced by Don Kostuch
+
+
+
+
+
+[Transcriber's Notes]
+  This book is derived from a copy on the Internet Archive:
+    psychotherapy00walsgoog/psychotherapy00walsgoog_djvu.txt>
+
+  A publication contemporary to this book is "Mother's Remedies"
+  by Thomas Jefferson Ritter. It contains hundreds of suggestions
+  that hindsight shows to be purely "mental" in their effect.
+    http://www.gutenberg.org/ebooks/17439
+
+  One of the author's favorite terms is "over-solicitous". The patient
+  literally "worrys themselves sick" over trivial symptoms and makes
+  serious cases worse than necessary. Most of his use of psychotherapy
+  consists of informing, diverting and cheering the patient so that
+  worry and its consequences are not piled on top of real or imagined
+  disease.
+
+  This book illustrates the general state of medicine in 1910.
+  Psychotherapy was more important to medical care because so little
+  was known of the complex physical mechanisms of the body. I
+  particularly reacted to the discussion of hay fever because it
+  plagued me for thirty years until experimental desensitization
+  therapy successfully cured my case. Nonetheless, much of value has
+  been lost with the decline of psychotherapy by the family physician.
+  A personal relationship with the physician is often replaced with
+  expensive impersonal technology that mostly tells what is not wrong.
+
+  Many paragraphs have bold or italic titles. These are rendered
+  by a extra blank line--a total of two blank lines.
+
+  Obvious spelling or typographical errors have been corrected.
+  Inconsistent spelling of names and inventive and alternative
+  spelling is left as printed.
+
+  The outline format of the book uses these conventions:
+    Major Topics, [Upper Case title]
+      Sections, [Upper Case, italic title]
+        Chapters,
+          Minor topics, denoted by bold face and an em-dash
+            Topic subheads denoted by italics and and em-dash
+
+  for example:
+    SPECIAL PSYCHOTHERAPY
+      SECTION VII. _Cardiotherapy_
+        Chapter III. Cardiac Neuroses
+          Varieties.-- [Bold]
+           _Palpitation_.-- [italic]
+
+
+  During the transcription of this book Dr. Michael Stewart of the
+  Mayo Clinic, Jacksonville, FL., diagnosed me with a retinal
+  condition that had deprived me of the ability to read with my left
+  eye. His skilled surgery corrected the condition. I dedicate this
+  transcription to Dr. Stewart and the skilled and thoughtful staff of
+  Mayo.
+[End Transcriber's Notes]
+
+
+PSYCHOTHERAPY
+
+
+
+PSYCHOTHERAPY
+
+
+
+INCLUDING THE HISTORY OF THE USE OF MENTAL INFLUENCE,
+DIRECTLY AND INDIRECTLY, IN HEALING AND THE
+PRINCIPLES FOR THE APPLICATION OF ENERGIES
+DERIVED FROM THE MIND TO THE
+TREATMENT OF DISEASE.
+
+
+
+BY
+
+JAMES J. WALSH, M.D.. Ph.D.
+
+DEAN AND PROFESSOR OF FUNCTIONAL NERVOUS DISEASE AND OF THE HISTORY
+OF MEDICINE AT FORDHAM UNIVERSITY SCHOOL OF MEDICINE, AND OF PHYSIOLOGICAL
+PSYCHOLOGY AT CATHEDRAL COLLEGE, NEW YORK; FELLOW OF NEW YORK ACADEMY OF
+MEDICINE; MEMBER A.M.A., A.A.A.S., NEW YORK STATE MEDICAL SOCIETY,
+GERMAN SOCIETY FOR THE HISTORY OF MEDICINE AND THE PHYSICAL SCIENCES,
+NEW ORLEANS PARISH MEDICAL SOCIETY, ST. LOUIS MEDICAL HISTORY
+CLUB, ETC.
+
+
+
+
+
+
+
+  NEW YORK AND LONDON
+  D. APPLETON AND COMPANY
+
+  1912
+
+
+
+
+
+COPYRIGHT, 1912, BY
+
+D. APPLETON AND COMPANY
+
+
+
+Printed in
+New York, U. S. A.
+
+
+
+
+TO THE JESUITS
+
+TO WHOM THE AUTHOR OWES A HAPPY INTRODUCTION TO THE INTELLECTUAL LIFE
+AND CONSTANTLY RENEWED INSPIRATION IN HIS WORK
+THIS BOOK IS RESPECTFULLY AND AFFECTIONATELY DEDICATED
+
+
+
+{vii}
+
+
+PREFACE
+
+"Prefaces are a great waste of time," said Francis Bacon, "and, though
+they seem to proceed of modesty, they are bravery." In spite of this
+deterring expression of the Lord Chancellor, the author ventures to
+write a short _apologia pro libro suo_. Five years ago he began at
+Fordham University School of Medicine a series of lectures on
+Psychotherapy. This book consists of material gathered for these
+lectures. It will be found in many ways to partake more of the nature
+of a course of lectures than a true text-book. In this it follows
+French rather than English or American precedent. Its relation to
+lectures makes it more diffuse than the author would have wished, but
+this is offered as an explanation, not an excuse. Addressed to medical
+students and not specialists the language employed is as untechnical
+as possible, and, indeed, was meant as a rule to be such as young
+physicians might use to their patients for suggestion purposes.
+
+The historical portion is probably longer than some may deem
+necessary. The place of psychotherapy in the past seemed so important,
+however, and psychotherapeutics masqueraded under so many forms that
+an historical résumé of its many phases appeared the best kind of an
+introduction to a book which pleads for more extensive and more
+deliberate use of psychotherapy in our time. The historical portion
+was developed for the lectures on the history of medicine at Fordham
+and perhaps that fact helps to account for the space allotted to this
+section of the book.
+
+So far as the author knows, this is the first time in the history of
+medicine that an attempt has been made to write a text-book of the
+whole subject of psychotherapy. We have had many applications of
+psychotherapeutics to functional and organic nervous and mental
+disease and also indirectly to nutritional diseases; but no one
+apparently has attempted to systematize the application of
+psychotherapeutic principles, not only to functional diseases, but
+specifically to all the organic diseases. A chapter on the use of
+mental influence in anesthesia was, during the course of the
+preparation of this volume, written for Dr. Taylor Gwathmey's
+text-book on Anesthesia, which is to appear shortly (Appletons).
+
+No one knows better than the author how difficult is the subject and
+how liable to misunderstanding and abuse. He appreciates well, too,
+how almost hopeless it would be to make a perfectly satisfactory
+text-book of so large a subject at the first attempt. The present
+volume is founded, however, on considerable experience, on wide
+reading in the subject, and on much reflection on its problems. It is
+offered to those who are interested in the old new department of
+psychotherapy until a better one is available. The author's principal
+idea in the book has been to help students and practitioners of {viii}
+medicine to care for (_curare_) suffering men and women and not cases,
+to treat individual human beings, not compounds in which various
+chemical, physical and biological qualities have been observed,
+diligently enough and with noteworthy success, but incompletely as
+yet, and quite without the satisfying adequacy which it is to be hoped
+will result from future investigations.
+
+  James J. Walsh.
+  110 West Seventy-fourth Street,
+  New York City.
+
+
+{ix}
+
+CONTENTS
+
+                                                    PAGE
+Introduction                                          1
+
+
+HISTORY OF PSYCHOTHERAPEUTICS
+
+SECTION I
+
+      _Psychotherapy in the History of Medicine_
+
+   I. Great Physicians in Psychotherapy                  7
+
+  II. Unconscious Psychotherapeutics                    19
+
+ III. Genuine Remedies and Suggestive Exaggeration      25
+
+  IV. Signatures And Psychotherapy                      35
+
+   V. Pseudo-science and Mental Healing                 38
+
+  VI. Quackery and Mind Cures                           46
+
+ VII. Nostrums and the Healing Power of Suggestion      53
+
+VIII. Amulets, Talismans, Charms                        60
+
+  IX. Deterrent Therapeutics                            63
+
+   X. Influence of the Personality in Therapeutics      69
+
+  XI. Faith Cures                                       77
+
+
+
+GENERAL PSYCHOTHERAPEUTICS
+
+SECTION II
+
+_General Considerations_
+
+   I. Influence of Mind on Body                         84
+
+  II. Unfavorable Mental Influence                      93
+
+ III. The Influence of Body on Mind                    100
+
+  IV. The Mechanism of the Influence of Mind on Body   108
+
+   V. Brain Cells and Mental Operations                124
+
+  VI. Unconscious Cerebration                          134
+
+ VII. Distant Mental Influence                         140
+
+VIII. Secondary Personality                            147
+
+  IX. Hypnotism                                        151
+
+
+
+SECTION III
+
+_The Individual Patient_
+
+   I. Psychotherapy and the Individual Patient         163
+
+  II. The Morning Hours                                165
+
+ III. The Day's Work                                   171
+
+  IV. The Middle of the Day                            179
+
+   V. The Leisure Hours                                181
+
+{x}
+
+SECTION IV
+
+_General Psychotherapeutics_
+
+   I. General Principles of Psychotherapy              186
+
+SECTION V
+
+_Adjuvants and Disturbing Factors_
+
+   I. Suggestion                                       194
+
+  II. Exercise                                         198
+
+ III. Position                                         207
+
+  IV. Training                                         213
+
+   V. Occupation of Mind                               218
+
+  VI. Diversion of Mind--Hobbies                       224
+
+ VII. Habit                                            229
+
+VIII. Pain                                             235
+
+
+SPECIAL PSYCHOTHERAPY
+
+SECTION VI
+
+_The Digestive Tract_
+
+   I. Influence of Mind on Food Digestion              242
+
+  II. Indigestion and Unfavorable States of Mind       250
+
+ III. Psychic Treatment of Digestive Conditions        254
+
+  IV. Appetite                                         262
+
+   V. Constipation                                     268
+
+  VI. Neurotic Intestinal Affections                   278
+
+ VII. Muco-Membranous Colitis                          286
+
+VIII. Obesity                                          290
+
+  IX. Weight and Good Feeling                          297
+
+   X. Vague Abdominal Discomforts--Loose Kidney       302
+
+
+SECTION VII
+
+_Cardiotherapy_
+
+   I. The Heart and Mental Influence                   310
+
+  II. Diagnosis and Prognosis in Heart Disease         316
+
+ III. Cardiac Neuroses                                 321
+
+  IV. Cardiac Palpitation and
+      Gastro-Intestinal Disturbance                    328
+
+   V. Angina Pectoris                                  335
+
+  VI. Tachycardia                                      340
+
+ VII. Bradycardia                                      342
+
+
+SECTION VIII
+
+_Respiratory Diseases_
+
+   I. Coughs and Colds                                 345
+
+  II. Tuberculosis                                     350
+
+ III. Neurotic Asthma and Cognate Conditions           364
+
+  IV. Dust Asthma--Seasonal Catarrh, Hay Fever         368
+
+   V. Dyspnea--Cat and Horse Asthma                    373
+
+{xi}
+
+CONTENTS xi
+
+SECTION IX
+
+_Psychotherapy in the Joint and Muscular System_
+
+   I. Painful Joint Conditions--Pseudo-Rheumatism      379
+
+  II. Old Injuries and So-called Rheumatism            387
+
+ III. Muscular Pains and Aches                         389
+
+  IV. Occupation Muscle and Joint Pains                395
+
+   V. Painful Arm and Trunk Conditions                 400
+
+  VI. Lumbago and Sciatica                             402
+
+ VII. Painful Knee Conditions                          409
+
+VIII. Foot Troubles                                    413
+
+  IX. Arthritis Deformans                              421
+
+   X. Coccygodynia                                     428
+
+
+SECTION X
+
+_Gynecological Psychotherapy_
+
+   I. Mental Healing in Gynecology                     430
+
+  II. Psychic States in Menstruation                   434
+
+ III. Amenorrhea                                       437
+
+  IV. Dysmenorrhea                                     440
+
+   V. Menorrhagia                                      447
+
+  VI. The Menopause                                    450
+
+
+SECTION XI
+
+_Psychotherapy in Obstetrics_
+
+   I. Suggestion in Obstetrics                         453
+
+  II. Maternal Impressions                             461
+
+
+SECTION XII
+
+_Genito-Urinary Diseases_
+
+   I. Prostatism                                       468
+
+  II. Sexual Neuroses                                  472
+
+ III. Sexual Habits                                    482
+
+
+SECTION XIII
+
+_Skin Diseases_
+
+   I. Psychotherapy in Skin Diseases                   491
+
+
+SECTION XIV
+
+_Diseases of Ductless Glands_
+
+   I. Diabetes                                         496
+
+  II. Graves' Disease                                  500
+
+
+{xii}
+
+xii CONTENTS
+
+SECTION XV
+
+_Organic Nervous Diseases_
+
+   I. Psychotherapy of Organic Nervous Diseases        508
+
+  II. Cerebral Apoplexy                                513
+
+ III. Locomotor Ataxia                                 524
+
+  IV. Paresis                                          530
+
+   V. Epilepsy and Pseudo-Epilepsy                     534
+
+  VI. Paralysis Agitans                                542
+
+ VII. Headache                                         546
+
+
+SECTION XVI
+
+_Neuroses_
+
+   I. Nervous Weakness (Neurasthenia)                  555
+
+  II. Chorea                                           561
+
+ III. Tics                                             564
+
+  IV. Stuttering, Ataxia in Talking,
+      Walking, Writing, Etc.                           570
+
+   V. Tremors                                          580
+
+
+DISORDERS OF THE PSYCHE
+
+SECTION XVII
+
+_Psycho-Neuroses_
+
+   I. Psycho-Neuroses (Hysteria)                       585
+
+
+SECTION XVIII
+
+_Disorders of Mind_
+
+   I. Mental Incapacity (Psychasthenia)                597
+
+  II. Hallucinations                                   603
+
+ III. Dreads                                           612
+
+  IV. Heredity                                         627
+
+   V. Premonitions                                     634
+
+ VI. Periodical Depression                             641
+
+ VII. Insomnia                                         651
+
+VIII. Some Troubles of Sleep                           663
+
+  IX. Dreams                                           669
+
+   X. Disorders of Memory                              678
+
+  XI. Psychic Contagion                                688
+
+
+SECTION XIX
+
+_Disorders of Will_
+
+   I. Alcoholism                                      694
+
+  II. Drug Addictions                                  707
+
+ III. Suicide                                          713
+
+  IV. Grief                                            727
+
+   V. Doubting                                         732
+
+  VI. Responsibility and Will Power                    738
+
+
+{xiii}
+
+SECTION XX
+
+_Psychotherapy in Surgery_
+
+   I. Psychotherapy in Old-Time Surgery                746
+
+  II. Mental Influence Before Operation                749
+
+ III. Mental Influence and Anesthesia                  753
+
+  IV. Mental Influence After Operation                 759
+
+
+APPENDICES
+
+   I. Illusions                                        766
+
+  II. Religion and Psychotherapy                       776
+
+
+INDEX                                                  781
+
+{xiv}
+
+{xv}
+
+LIST OF ILLUSTRATIONS
+
+FIG.                                                   PAGE
+
+The Temple of Epidaurus as a health resort    Facing page 9
+
+ 1.--Expressions of the mouth                           102
+
+ 2.--Cortex of human brain illustrating complexity
+     of the systems and plexuses of nerve fibers        109
+
+ 3.--Small and medium-sized pyramidal cells of the
+     visual cortex of a child twenty days old           110
+
+ 4.--Series of sections showing the fine nerve
+     endings and branchings of the first and second
+     layer of the visual cortex of a child
+     fifteen days old.                                  111
+
+ 5.--First, second and third layer of the anterior
+     central convolution of the brain of a child
+     one month old                                      112
+
+ 6.--Layers of the posterior central or ascending
+     parietal convolution of a new-born child           112
+
+ 7.--Diagram of cells of cerebral cortex                113
+
+ 8.--Scheme of lower motor neuron                       114
+
+ 9.--Scheme of the visual conduction paths              115
+
+10.--Schematic frontal section through the occipital
+     lobe illustrating manifold connections in a
+     single lobe                                        116
+
+11.--Isolated cell from human spinal cord               117
+
+12.--Neuron from the optic lobe of the embryo chick     118
+
+13.--Deep layer of giant pyramidal cells of the
+     posterior central or ascending parietal
+     convolution of a child thirty days old             119
+
+14.--Pyramidal cell of cerebral cortex of mouse         119
+
+15.--Neuroglia cells of the fascia dentata, in the
+     new-born rabbit                                    121
+
+16.--Neuroglia cell from the subcortical layer of
+     the cerebrum from which two processes go to a
+     blood vessel                                       122
+
+17.--Neuroglia cells from the spinal cord               122
+
+18.--An artery from the cerebral cortex                 125
+
+19.--Neuroglia cells of the superficial layers of
+     the brain from an infant aged two months           126
+
+20.--Complexity of cell of the central nervous system   131
+
+21.--Section through the cortex of the
+     gyrus occipitalis superior                         132
+
+22.--Motor cell of ventral horn of spinal cord from
+     the human fetus                                    133
+
+23.--Normal diaphragm curve in normal breathing         577
+
+24.--Curve in diaphragm before and during talking
+     by a stutterer                                     577
+
+25.--Illusion of dual vision                            615
+
+26.--Illusion of dual vision                            767
+
+27.--Binocular vision                                   767
+
+28.--Binocular vision                                   767
+
+29.--The Müller-Lyer lines                              768
+
+30.--Illusions of size                                  769
+
+31.--Illusion of filled space (interrupted vision)      769
+
+32.--Illusions of size and linear continuity            770
+
+33.--Poggendorf's displacement of oblique lines         771
+
+34.--Zöllner's distortion of parallel lines             772
+
+
+
+{1}
+
+
+PSYCHOTHERAPY
+
+
+INTRODUCTION
+
+To physicians who are students not alone of the manifestations of
+disease but also of the workings of human nature, there are few
+chapters in the history of medicine more interesting than those which
+record the welcome by each generation of the supposed advances in the
+treatment of disease. Each generation announced its cures for
+diseases, provided its remedies to relieve symptoms, and invented
+methods of treatment that seemed to put off the inevitable tendency
+toward dissolution. Yet few of these inventions and discoveries
+maintain their early reputations, and succeeding generations
+invariably abandon most of this supposed medical progress in favor of
+ideas of their own, which later suffer a like fate. Plausible theories
+have not been lacking to support the successive remedies and methods
+of treatment, but the general acceptance of them was always founded
+far less upon theory than upon actual observation of their supposed
+efficacy. Certain remedies were given and the patients began to
+improve. Patients who did not have the remedies continued to suffer,
+and sometimes the course of their disease led to a fatal termination.
+Even with the best remedies death sometimes took place, but that was
+easily accounted for on the ground that the disease had secured so
+firm a hold that it could not be dislodged, even by a good remedy. The
+connection of cause and effect between the administration of the
+remedy and the improvement and eventual cure of the patient seemed to
+be demonstrated.
+
+The archives of old-time medicine disprove the notion that clinical
+learning and teaching--that is, observation and demonstration at the
+bedside--were not part of medical education until quite modern times.
+The medical books of the thirteenth, fourteenth and fifteenth
+centuries are full of descriptions of actual cases, while, over a
+millenium before, one of Martial's epigrams tells of a patient who
+dreaded the coming of his physician because he brought with him so
+many students, whose cold hands gave chills to the poor victim.
+
+
+
+Coincidence and Consequence.--In spite of the opportunities for
+careful observation thus afforded and the facilities for training
+clinical observers in medicine, many remedies came into vogue, were
+enthusiastically applied, and then, after a time, went out of use and
+were heard of no more. Sometimes they were subsequently revived and
+had even a greater vogue than when originally brought out. But most of
+these remedies eventually went forever into the lumber room of disused
+treatments. Of the many thousands of remedies which had the approval
+and the praise of past generations, two score at most hold a place in
+the pharmacopeia of to-day.
+
+There are many reasons for this initial success and eventual failure;
+but the most important explanation lies not so much in reason as in
+coincidence. In the majority of human ills there is a definite
+tendency to get better, and almost anything that is given to the
+patient will be followed by relief and {2} improvement. The recovery
+is not, however, on account of the remedy, but occurs only after a
+definite succession of events that would have taken place either with
+or without the remedy.
+
+
+Mental Influence.--What the old physicians did not, as a rule,
+appreciate, or at least failed to value at its true significance, was
+the effect upon the patient's mind of the taking of a remedy. Because
+of the confidence with which it was given, the patient, having full
+faith in the physician who gave it, became impressed with the idea
+that now he must get well. The very presence of the physician and his
+assurance that the illness was not serious and that many symptoms that
+were sources of dread to the patient were only concomitant conditions
+of the ailment, naturally to be expected under the circumstances,
+relieved the patient from worry, and so gave his nervous energy a
+chance to exert itself in bringing about improvement. In other words,
+the suggestive elements of the presence of the physician and the
+taking of his remedy were important therapeutic factors which enabled
+what was an absolutely inefficient remedy, as the event proved when
+closer observations of it had been made, to relieve even serious
+symptoms, or helped a weak remedy to accomplish good results by
+strengthening the patient's resistive vitality.
+
+In recent years we have come to study much more closely this
+suggestive element and to appreciate better its true value. Suggestion
+has always been an important factor in therapeutics, but has been used
+indeliberately and indirectly rather than with careful forethought.
+Not that the great thinkers in medicine have not known its value and
+have not used it deliberately on appropriate occasions, but that the
+profession generally has been so much occupied with the merely
+material means of curing that practitioners have not realized the
+influence for good of the psychotherapeutic factors they were
+unconsciously employing.
+
+The history of the phases of psychotherapy brings out clearly how much
+it has always meant in the curing of human ills.
+
+
+Constancy of Psychotherapy in Medicine.--Though we are prone to think
+of it as coming to attention in our time, psychotherapy has played an
+important role in every phase of the history of medicine. It has
+always been at work, though usually under other names, and has been
+effectively used without conscious direction. Germs and their
+pernicious activity were not recognized before our time, yet many
+definite precautions against them, such as cooking of food and the
+keeping of perishable goods on ice, which now seem to be the direct
+result of our knowledge of bacteriology, were commonly practiced. The
+influence of the mind on the body exerted itself quite apart from
+man's recognition of its place or appreciation of its power. When
+employed unconsciously it was in many ways even more effective than it
+will be when a consciousness of the means by which it is applied
+becomes more general. For most people are unwilling to confess that
+their minds exercise as much influence as now proves to be the case,
+and that over-solicitude means so much in inhibiting the curative
+powers of nature, and that it is this which is favorably affected by
+psychotherapy.
+
+The great physicians employed psychotherapy very commonly, and on that
+account many of their disciples were inclined to think that they were
+neglectful of medication and other remedial measures. At all times
+physicians have had to be large-minded and have had to recognize the
+limitations of medicine in {3} their own time, to turn to other agents
+and to appreciate how much their own influence on the patient and that
+of the patient on himself meant for the relief of symptoms and the
+increase of resistive vitality.
+
+Some of the phases of indeliberate psychotherapy, however, are even
+more interesting than this chapter of the history of genuine and
+deliberate psycho-therapeutics. Not a few of the remedies recommended,
+even by distinguished physicians, were utterly inert, yet accomplished
+good through their effect upon the patient's mind. If we were to omit
+all reference to certain favorite prescriptions that passed down from
+generation to generation, sometimes for centuries, yet eventually
+proved to be quite inefficient for the purpose for which they were
+employed, what a large lacuna would be left in the history of medical
+treatment! Galen's _theriac_ is a typical example of this. Still more
+strikingly the role of psychotherapy is seen in the many remedies that
+were recommended at various times for such self-limited diseases as
+erysipelas, ordinary coughs and colds, pneumonia and typhoid fever.
+Anything that was administered just before the change for the better
+came in these diseases, or that was persistently taken until that
+change came, was proclaimed as curative.
+
+An even more interesting chapter in the positive history of
+psychotherapy is that which shows how the value of genuine remedies
+was exaggerated by suggestion, and how these remedies became
+therapeutic fads, and sometimes almost seemed to be cure-alls. What a
+large place antimony holds in medical history, though it is now
+entirely discredited! How beneficent has venesection seemed, though it
+is now frankly confessed that it has but a narrow usefulness for a
+very circumscribed set of ills! Calomel in large doses has a history
+very like that of antimony. Alcohol in various forms, now so
+strikingly losing its hold in therapeutics, must also be placed in
+this category.
+
+Psychotherapy has perhaps had its most fruitful field of potency in
+connection with discoveries in the physical sciences. Whenever a
+discovery has been made in any science, an application of it to
+medicine has been mooted by some fertile mind, though as a rule it
+eventually proved to have no place in medicine. One might ordinarily
+expect that the suggestion would be latent only when the discovery was
+in one of the sciences allied to medicine, but this relation has not
+been necessary. Discoveries in astronomy even, in light, in
+electricity, in every department of physical science, have each been
+given their opportunity to affect patients' minds favorably, and have
+succeeded.
+
+
+Irregular Phases of Psychotherapy.--The quack has always been a
+psycho-therapeutist _par excellence_. His main stock in trade has been
+his knowledge of men and his power to convince them that he was able
+to do them good, so that he could tap all the sources of energy that
+were in the patient, some of them quite latent, yet of great
+efficiency. Often what the quack and the nostrum vender did for their
+patients was calculated to do harm rather than good, yet the mental
+energy aroused by the appeal to the patients' minds was sufficient not
+only to neutralize the evil, but to release curative powers that
+otherwise would not have been called out. The advertisements of the
+nostrum maker have proved especially effective, and printer's ink,
+properly administered, has been a most potent remedy.
+
+
+Drug Therapeutics.--Many of the newer phases of mental healing pretend
+to do away with drugs. Nothing is farther from my purpose than to
+condemn drugs: I am simply pointing out how much supposed drug
+efficacy has been {4} due to the mental influence on the patient of
+the suggestion that went with the drugs. There has been no thought at
+all of pushing drugs out of the extremely valuable place they occupy
+in medicine, for I yield to no one in my thorough conviction of their
+usefulness. But the efficacious element in the administration of many
+drugs has been entirely the confidence of the physician in them, which
+confidence was communicated to the patient's mind. Undoubtedly many
+highly recommended drugs have in themselves tended to do harm rather
+than good, and have been useful only because of this
+psycho-therapeutic element. Dr. Oliver Wendell Holmes' famous
+expression, that if all the drugs that had ever been used had been
+thrown into the sea instead of put into patients' bodies the human
+race might have been the better for it, should not be taken to mean
+that a great many drugs are not efficacious. Above all, it leaves out
+the most important consideration, that patients, while taking drugs
+that are either inert or at times even slightly harmful, have had
+their mental attitude towards themselves and their ills so favorably
+modified by the repeated suggestion that the result has been
+distinctly beneficial.
+
+There are probably two score of drugs that are simply
+invaluable--magnificent auxiliaries in times of physical and mental
+distress. To realize and appreciate the place of these drugs, their
+limitations, how they should be administered, and what they can do
+under varying circumstances, has taken us centuries. When to these
+drugs there is intelligently attached the influence that psychotherapy
+has over the patient, their efficacy is probably doubled. Without that
+influence nature often works against the drug and lowers its
+efficiency. That is the reason why physicians, when themselves
+patients, do not respond well to drugs. Familiarity has bred contempt
+for some of the old-fashioned remedies, but the contempt that comes
+from familiarity is often quite undeserved, and many of the things
+that we thus undervalue because of accustomedness have a power that
+should be respected. People in a dynamite factory become so familiar
+with danger as to despise it at times, but that does not lessen the
+energy of the dynamite when occasion arises. When the physician
+himself is ill he is likely to remember his failures with drugs rather
+than his successes. That is, however, only the tendency of human
+nature to a certain pessimistic outlook where we ourselves are
+concerned.
+
+There is another class in whom familiarity with drugs has become a
+serious matter. They are the patients who have made the rounds of
+physicians, have learned to read prescriptions, have looked up the
+significance of the various remedies that they have seen prescribed,
+have heard doctors talk about them, and remember only what is
+depreciatory, and who critically examine a prescription and conclude
+that the remedies recommended are not likely to do them good. Every
+physician knows the hopeless condition such patients are in. Mental
+attitude will greatly help drugs, and it can utterly undo the effect
+of all drugs except those which have certain drastic mechanical
+effects. Drug failure in these cases is another illustration of how
+much psychotherapy means in connection with drug treatment.
+
+Not only is there no intent, then, to lessen respect for drugs in this
+textbook of psychotherapeutics, but the one thing that the author
+would like to emphasize is the necessity for giving drugs in
+sufficient doses. Recommendations in text-books of medicine are often
+vague in their indications as to dosage, and surprisingly small doses
+are, in consequence, sometimes prescribed. {5} Practically the only
+remedial element of such small doses is the mental effect on the
+patient, whereas a combination of pharmaceutic and psychotherapeutic
+factors would be much more efficacious. It is not unusual to find that
+the patient who is supposed to be taking nux vomica as an appetizer or
+a muscle tonic, or in order to produce heart equilibrium in the
+cardiac neuroses, is getting five drops, two and a half minims, three
+times a day, when he should be getting at least twenty drops with the
+same frequency. I have known a physician to prescribe ten grains of
+bromid where thirty to sixty grains should have been prescribed, and
+such valuable pharmaceutic materials as bismuth and pepsin are often
+given in doses so small that they preclude all possibility of benefit
+except by mental influence.
+
+With therapeutic nihilism or skepticism of the power of drugs I have
+no sympathy. As a teacher of medicine I have for years emphasized the
+necessity of the use not of conventional doses of drugs for every
+patient, but of doses proportioned to the body weight. It seems to me
+quite absurd to give the same amount of a drug to a woman who weighs a
+hundred pounds and to a man who weighs two hundred and fifty pounds of
+solid muscular tissue. I believe in using drugs well up to their
+physiological effects if the drugs are really indicated.
+
+With regard to other modes of treatment the same thing is true. Where
+they are indicated, balneo-therapy, hydro-therapy, mechano-therapy,
+electro-therapy, massage, and all the forms of external treatment,
+should be used rationally and not merely conventionally. The
+individual and not his affection must be treated. In all of these
+methods there is a psychotherapeutic element, and for the benefit of
+the patient this, too, must be recognized and used to its fullest
+extent.
+
+
+Supposed Novelties in Mind Healing.--We hear much of mental healing,
+of absent treatment, of various phases of suggestion, and of the
+marvelous therapeutic efficiency of complete denial of the existence
+of evil, and sometimes we wonder whether all these things are not
+offshoots of our recent growth in the knowledge of psychology. It is
+possible, however, to find, masquerading under the head of the
+efficacy of nostrums in the past, the equivalents for all the
+activities of mental healing of the present. It all depends on what is
+the scientific fad of the hour. If it is electricity, then some mode
+of electrical treatment serves the purpose of suggesting cure, and
+relief of symptoms follows. If drug treatment of any particular kind
+is attracting much attention, then the suggestion is most effective
+that is founded on this basis. Perkins' tractors or the Leyden jar are
+effective at one time, radium or the X-rays at another, sarsaparilla
+or dilute alcohol at another, while a generation that is much
+interested in psychology may find, as ours does to a noteworthy
+degree, quite sufficient favorable suggestion for the cure of many
+ills in purely psychic influences, either direct or indirect,
+deliberate or unconscious.
+
+Men and women do not change, their ills are about the same, and except
+for certain definite scientific remedies it is only the superficial
+mode of treatment that differs very much. Psychotherapy has always
+been an important element in most of the therapeutics of history. With
+so much accomplished in the past by indirection, there can be no doubt
+but that important advances in psychotherapeutics must result from the
+extension of its deliberate use.
+
+We have not yet reached a point in our knowledge of the mode of the
+{6} influence of the mind on the body that will enable us to treat
+this large subject in a scientific manner. What has been written is
+set down rather as suggestive than conclusive. There is almost nothing
+that the human mind cannot do, its power ranging from the ability to
+delay death for hours or even days to causing sudden or unlooked for
+death under strong emotional strain. But we are as yet without
+definite data as to the possibilities of the immense power for good,
+and also for ill, that lie unrevealed in this domain. Anything that
+makes for observations by a large body of trained observers in a large
+number of cases will almost surely serve to bring about a development
+of this subject of valuable practical application.
+
+Psychotherapy is open to large abuse. It will happen that men who are
+not trained in diagnosis will occasionally try to use
+psychotherapeutic means when what is needed is the knife, the actual
+cautery, a good purge, some strong drug, or other efficient remedy
+whose value has been demonstrated and which any trained physician can
+use. It will also happen that men who lack tact will occasionally
+disturb patients' minds still further by what they say to them in a
+mistaken attempt at psychotherapy, and will sometimes suggest other
+symptoms and make sufferers worse by their clumsy attempts to remove
+symptoms that are already present. Every good thing, however, is open
+to the same objection. Even good food is abused. The use of drugs has
+been so abused that the abuse has done much to discredit medicine at
+many periods. There is a Latin proverb which says: "From the abuse of
+a thing no argument against its use can be drawn." We cannot prevent
+liability to abuse, and psychotherapy is sure to meet that fate. It
+has been abused in the past, and is abused now, and always will be
+abused, but formal study of psychotherapy and its deliberate
+employment will do more than anything else to limit the inevitable
+abuse.
+
+If its place in history and in medicine is definitely set forth, its
+problems squarely faced and their solutions definitely suggested, it
+is much less likely to be misused. At least, then, the whole subject
+is open for free and frank discussion and for such additions and
+subtractions as may make this department of therapeutics as important,
+or at least in a measure as valuable, as climato-therapy or
+balneo-therapy or mechano-therapy or electro-therapy. The development
+of each of these subjects has proved helpful. It is true that each
+specialist has, in the eyes of his colleagues in general practice,
+exaggerated the significance of his own department. This is true in
+all specialties, however, and psychotherapy deserves quite as much as
+any of the subjects we have mentioned to have a place among the
+text-books of medicine; and so this one is committed to the judgment
+of clinical observers. Long ago Horace said:
+
+  Si quid novisti rectius his candidus imperti
+  Si non his utere mecum.
+
+
+{7}
+
+HISTORY OF PSYCHOTHERAPEUTICS
+
+SECTION I
+
+_PSYCHOTHERAPY IN THE HISTORY OP MEDICINE_
+
+
+CHAPTER I
+
+GREAT PHYSICIANS IN PSYCHOTHERAPY
+
+
+"The real physician is the one who cures: the observation which does
+not touch the art of healing is not that of a physician, it is that of
+a naturalist."
+
+
+Psychotherapy is as old as the history of medicine and may be traced
+to the earliest ages. The great physicians of all time have recognized
+its value, have used it themselves and commended its use to their
+disciples, though realizing its mysterious side and appreciating its
+limitations.
+
+
+FIRST PHYSICIAN
+
+The first physician of whom we have any record was I-em-Hetep, who
+lived in the reign of King Tcsher of the third dynasty of Egypt,
+probably before 4000 B. C. Among his titles, besides that of Master of
+Secrets, was Bringer of Peace. He was looked up to as one who, when
+not able to cure physical ailments, did succeed in consoling and
+reassuring patients so as to make their condition much more bearable.
+Like others of the great early physicians, he was after his death
+worshiped as a god, a tribute which probably signifies that those who
+had been benefited by his ministrations felt that he must have been
+more than mortal.
+
+The extent of the Egyptians' admiration for him will be appreciated
+from the fact that the step pyramid at Sakkara is said to have been
+built in his honor, though, as a rule, pyramids were erected only to
+honor kings or the very highest nobility. The extant statue of
+I-em-Hetep shows a placid-looking man with an air of beneficent
+wisdom, seated with a scroll on his knees. It produces the distinct
+impression, as may be seen from the illustration, that his patients
+must have trusted him thoroughly, since this is the memory of his
+personality that was transmitted to posterity. While he came to be
+looked upon as the medical divinity of the Egyptians, he was never
+represented with a beard, which is the token of the gods, or of
+mortals who have been really apotheosized. Evidently his devotees felt
+that it was the divine in his humanity which was the most prominent
+feature that they wished to honor. Among the Greeks AEsculapius, who
+had been merely a successful physician, came to be honored as a deity.
+When we recall the condition of therapeutics at that {8} time, it is
+evident that man's appreciation of his power to console, even though
+he might not be able to heal, of his influence over men's minds in the
+midst of their sufferings, and the confidence that his presence
+inspired, were the real sources of their grateful recognition.
+
+
+PSYCHOTHERAPY IN EGYPT
+
+Among the Egyptians the first great development of medicine came among
+the priests. The two professions, the medical and priesthood, were
+one, and the temples were the hospitals of the time. We have stories
+of people traveling long distances to certain temples in the early
+days of Egypt and also of Greece. Often the sick slept in the temples
+and dreamed of ways by which they would be cured. The stories make one
+feel that somehow the sleep which came over them was not entirely
+natural and spontaneous, but must have been something like hypnotic
+sleep. As for the dreams, the suggestions of modern time given in the
+hypnotic condition seem to be the best indication that we have of what
+happened in those old days. Certain it is that the persuasion of the
+patient that he would get better, the influence of the diversion of
+mind consequent upon his journey and the regulation of life under new
+circumstances in the temple, with the repeated suggestions of the
+priests and of their various remedial measures, as well as those due
+to the fact that other patients around him were improving, all plainly
+show the place of psychotherapy at this time.
+
+Much of the old-time therapy was in association with dreams supposed
+to have been in some way inspired. This was true at Epidaurus, at Kos,
+at Rome, at Lebene, at Athens, and at every place we know of where
+cures were worked in the olden times. To the modern mind it seems
+impossible that dreams should come so apropos unless they were in some
+way directed. The only explanation seems to be the use of suggestion,
+with the probable production of sleep resembling our modern hypnotic
+trance. Apparently the patient's attention was little directed to the
+origin of the suggestions received, but he remembered and benefited by
+them.
+
+The most explicit testimony that we have to the antiquity of
+psychotherapeutics and to the employment of the influence of the minds
+of patients over their ailments in the olden time is in Pinel's
+"Nosographie philosophique" and in his "Traité médico-philosophique
+sur l'alienation mentale."
+
+Pinel himself will be remembered as the great French psychiatrist who,
+confident that he could control most of them by mental influence,
+first dared to strike the chains from the insane in the asylums of
+Paris, at the end of the eighteenth century, when for more than a
+century they had been treated more barbarously than ever before in
+history. The passage makes clear that the writer himself, over a
+hundred years ago, was persuaded of the significance of the patient's
+mental attitude and of the value of mental treatment for many nervous
+and mental diseases:
+
+  An intimate acquaintance with human nature and with the character in
+  general of melancholics must always point out the urgent necessity  of
+  forcibly agitating the system, of interrupting the chain of their
+  gloomy ideas, and of engaging their interest by powerful and
+  continuous impressions on their external senses. Wise regulations of
+  this nature are considered as having constituted in part the
+  celebrity and utility of the priesthood of ancient Egypt. Efforts of
+  industry and of art, scenes of magnificence and of grandeur, the
+  varied pleasures of sense, and
+{9}
+the imposing influences of a pompous and mysterious superstition, were
+perhaps never devoted to a more laudable purpose. At both extremities
+of ancient Egypt, a country which was at that time exceedingly
+populous and flourishing, were temples dedicated to Saturn, whither
+melancholics resorted in crowds in quest of relief. The priests,
+taking advantage of their credulous confidence, ascribed to miraculous
+powers the effects of natural means exclusively. Games and recreations
+of all kinds were instituted in these temples. Beautiful paintings and
+images were everywhere exposed to public view. The most enchanting
+songs, and sounds the most melodious "took prisoner the captive
+sense." Flowery gardens and groves, disposed with taste and art,
+invited them to refreshment and salubrious exercise. Gaily decorated
+boats sometimes transported them to breathe, amidst rural concerts,
+the pure breezes of the Nile. Sometimes they were conveyed to its
+verdant Isles, where, under the symbols of some guardian deity, new
+and ingeniously contrived entertainments were prepared for their
+reception. Every moment was devoted to some pleasurable occupation, or
+rather a system of diversified amusements, enhanced and sanctioned by
+superstition. An appropriate and scrupulously observed regimen,
+repeated excursions to the holy places, preconcerted fêtes at
+different stages to excite and keep up their interest on the road,
+with every other advantage of a similar nature that the experienced
+priesthood could invent or command, were, in no small degree,
+calculated to suspend the influence of pain, to calm the inquietudes
+of a morbid mind, and to operate salutary changes in the various
+functions of the system.
+
+  [Illustration: The Temple at Epidaurus as a Health Resort]
+
+  This gives some slight idea of the magnificent arrangement of this
+  famous health resort of the Greeks in which every possible care was
+  taken to influence the mind of the patient favorably and bring about
+  his cure. The buildings of the Hieron or medical institution of
+  Epidaurus were beautifully situated about six miles from the town of
+  Epidaurus in picturesque scenery and the most healthful
+  surroundings. There were a series of bathing houses for hydropathy.
+  The abatons, lofty and airy sleeping chambers with their southern
+  sides and open colonnade, are singularly like the open balconies of
+  our tuberculosis sanatoria. Every occupation of mind was provided.
+  There was a theatre that would seat over 10,000 people. Here the
+  great classic Greek plays were given with fullest effect. There was
+  a stadium seating about 12,000 people in which athletic events were
+  witnessed, finally there was a hippodrome for alt sorts of
+  amusements in which animals shared. Then there were the walks
+  through the country, sheltered paths around the grounds for
+  inclement weather, even tunnels for passage from one building to
+  another and all the influence of religion, of suggestion, of contact
+  with cultured priests thoroughly accustomed to dealing with all
+  manner of patients. No wonder the place was popular and many cures
+  effected.
+
+  A, South Propylaea; B, Gymnasium; C, Temple of Esculapius; DD, East
+  and West Abatons (temple enclosures); E, Pholos;  F, Temple of
+  Artemis; G, Grove; H, Small Altar; I, Large Alter; J, South
+  Boundary; K, Square (building); L, Baths of Esculapius; M, Gymnasium
+  and Hostel; N, Four Quadrangles (for promenade and exercise); O,
+  Roman Building; P, Roman Bath; Q, Portico of Cotys; R, Northeastern
+  Colonnade; S, Northeastern Quadrangle; T, Temple of Aphrodite (?);
+  U, Northern Propylaea, on the Road to Epidaurus; V, Roman Building;
+  W, Northern Boundary; X, Stadium; Y, Goal or Starting Line; Z, Tunnel
+  between Temple and Stadium. (Caton.)
+
+  [End Illustration]
+
+
+There are other phases of Egyptian medicine which serve to show us how
+early many of the psychological ideas that we now are trying to adopt
+and adapt in medicine had come to the thinkers in medicine of long
+ago. There is, for instance, now in the Berlin museum an interesting
+papyrus of the Middle Kingdom, the date of which is about 2500 B. C,
+in which there are many modern ideas. It is a dialogue which attempts
+the justification of suicide. The principal speaker, a man weary of
+life, has made up his mind to suicide, but is hesitant. The others who
+speak in the dialogue are his _secondary personalities_. The Egyptians
+considered that there were several of these interior persons with whom
+the man himself might have communication. A man could play draughts
+with his _ba_ somewhat as we play solitaire. He could talk to and
+exchange gifts with his _ka_. He could argue and remain at variance,
+but more often come to an agreement, with his _khou_. This last was
+his luminous immortal _ego_, which, according to the then generally
+received Egyptian conception, formed a complete and independent
+personality. The whole scene thus outlined is typically modern in
+certain phases of its psychology, and presents the only known
+treatment for the tendency to suicide. While we have but this
+instance, there seems no doubt that the same system of persuasion must
+have been employed for the cure of other mental conditions than that
+which predisposes to suicide.
+
+What is described in our quotation from Pinel as the most ancient form
+of psychotherapy has all down the centuries been the rule of life for
+patients at institutions similar to those of Egypt. We know more of
+Greece than of other countries; there the shrines of AEsculapius were
+in many ways what we now call sanatoria. They were spacious buildings
+pleasantly situated, the hours of rising and of rest were definitely
+regulated, the patients' minds were occupied with the details of the
+cure, they met pleasant companions from distant places, they had all
+the advantages of diversion of mind, simple diet, long hours in the
+open air and abundance of rest away from the ordinary worries of life.
+Besides, there had usually been some weeks or months of {10}
+preparation during a lengthy journey and all the diversion of mind
+which that implies. No wonder that these institutions acquired a
+reputation for cures of symptoms which the physician had been unable
+to accomplish while the patient was at home in the midst of his daily
+cares and worries of life.
+
+The temples in Egypt, in Assyria, in Greece, were much like the health
+institutions--"cure houses," as the expressive German phrase calls
+them--of our day. Pictures of the temple of AEsculapius at Epidaurus
+show a magnificent building with beautiful grounds, ample bathing
+facilities, and evidently many opportunities for a quiet, easy life
+far from the worries and bustle of the world and with everything that
+would suggest to the patient that he must get well. This phase of
+psychotherapy in the olden time is not only interesting in itself, but
+furnishes a valuable commentary on corresponding modern institutions,
+since it shows that it is not so much the physical influences, which
+have differed markedly at different periods, as the mental attitude so
+constantly influenced at these institutions which was the real
+therapeutic factor.
+
+Now our sanatoria are nearly all founded on some special principle of
+therapeutics. Some of them have dietetic fads and no food out of which
+the life has been cooked is eaten. Some of them are absolutely
+vegetarian. Some of them depend on wonderful springs in their
+neighborhoods, others on certain forms of exercise, still others give
+the rest cure. All succeed in relieving many symptoms. No one who has
+analyzed the cures effected will think for a moment that it is the
+special therapeutic fad of the institution that accomplishes all the
+good done for patients suffering from so many different complaints.
+Similar ills often are affected quite differently, and, while some are
+relieved, others are not. Those who fail to be cured at one will,
+however, often be relieved at another. It depends on how much
+influence of mind is secured over the patient and how much diversion
+from thoughts of self is provided.
+
+
+MIND HEALING IN GREECE
+
+When Greece awoke to the great literary and scientific discussion of
+human thought that gave us such philosophic and scientific thinkers as
+Hippocrates, Plato and Aristotle, then psychotherapy, in the formal
+sense of caring for the mind of the patient as well as for his body,
+came to be explicitly recognized as having therapeutic value.
+Hippocrates insisted that medicine was an art rather than a science,
+that personality had much to do with it, and that the patient must be
+optimistically influenced in every way. The first of his aphorisms is
+well known, but few realize all of its significance. Hippocrates
+declares that "life is short and art long, the occasion fleeting,
+experience fallacious and judgment difficult. The physician must not
+only be prepared to do what is right himself, _but also to make the
+patient, the attendants and externals coöperate."_ No one emphasized
+more than he the necessity for differentiating the individual patient,
+and to him we owe, in foundation at least, the aphorism that it is
+more important to know what sort of an individual has a disease than
+what sort of a disease the individual has, for the chances of cure
+greatly depend on favorable individuality.
+
+Perhaps Hippocrates' most striking direct contribution to
+psychotherapy is his aphorism with regard to pain. He said: "Of two
+pains occurring together in different parts of the body, the stronger
+weakens the other." When {11} the attention is distracted from pain,
+then it is lessened. Of two pains, then, only the one that attracts
+the most attention is much felt, and, if a slight pain is succeeded by
+a severe pain in another part of the body, the lesser pain will
+apparently become trivial, or, indeed, not be felt at all.
+
+In Plato we find the direct philosophic expression of the value of
+psychotherapy. There had been during the preceding century a great
+increase in information with regard to the facts of physical nature,
+and especially the sciences relating to the human body, and so men had
+come, as they are prone to at such eras--our own, for instance--to
+think too much of the body and too little of the mind that rules it.
+Accordingly, we have from Plato a deliberate, emphatic assertion of
+this great truth under circumstances which make us realize how keenly
+he appreciated its significance for the art of medicine and for
+humanity.
+
+Professor Osier, in his address, "Physic and Physicians as Depicted in
+Plato," [Footnote 1] tells a story which shows clearly how much the
+great Greek philosopher appreciated the place of psychotherapy.
+
+  [Footnote 1: "AEquanimitas and Other Addresses."]
+
+  Charmides had been complaining of a headache, and Critias had asked
+  Socrates to make believe that he could cure him of it. Socrates said
+  that he had a charm which he had learnt, when serving with the army,
+  of one of the physicians of the Thracian king. Zamolxis. This
+  physician had told Socrates that the cure of a part should not be
+  attempted without treatment of the whole, and, also, that no attempt
+  should be made to cure the body without the soul, "and, therefore, if
+  the head and body are to be well, you must begin by curing the mind;
+  that is the first thing. And he who taught me the cure and the charm
+  added a special direction. 'Let no one,' he said, 'persuade you to
+  cure the head until he has first given you his soul to be cured. _For
+  this,'_ he said, _'is the great error of our day in the treatment of
+  the human body, that physicians separate the soul from the body._'"
+
+Because it anticipates so much that is thought to be recent in the
+treatment of certain affections this paragraph is interesting from
+many standpoints. Headache is typically one of the ills that in the
+modern time has often been cured by suggestion. Critias knew how much
+confidence Charmides had in Socrates, whom he looked upon as his
+master, and that, therefore, Socrates' declaration of his power to
+cure would probably be sufficient to relieve his disciple. Critias
+shrewdly suggests, however, that Socrates possessed a charm which he
+had learned from a distinguished royal physician. Cures in the modern
+time of any kind are likely to be much more effective if they come
+from a distance and, above all, if they have some connection with
+royalty, or have been tried with favorable results upon distinguished
+personages.
+
+
+ALEXANDRIAN PSYCHOTHERAPY
+
+When the center of interest in Greek medicine was transferred from
+Greece itself to Egypt, and the Alexandrian school represented what
+was best in medical thinking and investigation, we find evidence once
+more of wise physicians realizing the influence of the mind on the
+body and of what seemed to physicians of lesser experience the cure of
+physical ills by mental means. One of the most distinguished
+physicians of all time is Erasistratos, who, with Herophilus, made the
+fame of the great medical school at Alexandria, {12} the first
+university medical school in the world's history. Both practiced
+dissection with assiduity, and, while it is Herophilus' name that is
+associated with the _torcular_ within the skull, and it was he who
+gave the name _calamus scriptorius_ to certain appearances in the
+fourth ventricle, and otherwise stamped his personality on the study
+of the brain, it is to Erasistratos that we have to turn for a typical
+example of the mental physician. Erasistratos, about 300 B. C,
+recognized the valves of the heart, gave them the names tricuspid and
+sigmoid, and, like his great colleague, studied particularly the
+nervous system. He seems to have distinguished the nerves of motion
+from those of sensation, recognized their different functions and the
+different directions in which they carried impulses, and thought the
+brain the most important organ in the body.
+
+The story is told that he was summoned in consultation to see the son
+of Seleukos, surnamed Nikator, the Macedonian general of Alexander the
+Great, who became ruler of Babylonia. The illness of this son,
+Antiochos, had baffled the skill of the court physicians. While
+Erasistratos was feeling his patient's pulse, the stepmother of the
+young prince entered the room. She, the second wife of his father, was
+young and handsome, and Erasistratos noted that there was great
+perturbation of the pulse as soon as the stepmother came in. He
+correctly surmised that the young man was in love with the lady and
+that his illness had been occasioned by the feeling that his love was
+hopeless. The very sharing of his secret seems to have started the
+young man's cure, and Erasistratos' wisdom and medical skill became a
+proverb throughout the East.
+
+
+PSYCHOTHERAPY AT ROME
+
+Galen.--Galen, whom we are prone to think of as a Latin because so
+much of his work was done at Rome, but whose works have come to us in
+Greek, and who was a disciple of the Greek school of medicine, brought
+up under Greek influence in his native town of Pergamos, re-echoed
+Hippocrates' expressions as to the necessity for securing the
+patient's confidence and setting his mind at ease. The story in the
+"Arabian Nights" of his experience with the quack, which is known to
+most people, shows clearly how the place of mental influence in the
+relief of human ills must have been brought home to him. For nearly
+fifteen centuries his works continued to be the most read of medical
+documents. Nine tenths of all the physicians of education and
+influence, confidently looking to him as their master, kept copies of
+his works constantly near them, and turned to them for medical
+guidance as they would to the Bible for spiritual aid.
+
+The book of Galen which is usually placed first among his collected
+works shows how much more important is the mind than the body for
+human happiness, and insists on mental interests as making life worth
+while. In it he describes the good physician, and says that to be a
+good physician a man must also be a good philosopher. When he comes to
+talk of the different sects in medicine--for even in his time there
+were groups of men who founded their medical practice on very
+different principles--he points out that the members of the different
+medical sects, while all employing practically the same remedies, do
+so on quite different principles, and yet get about the same {13}
+results. This concept comes as near to being a conscious reflection as
+to the place that the patient's mental reaction had in therapeutics as
+might well be expected at that early date.
+
+
+Alexander of Tralles.--After Galen, medicine suffered an eclipse
+because the Romans became too devoted to luxury to permit of its
+development, and later the descent of the barbarians from the North
+disturbed silence and culture. In spite of the disturbance, however,
+there is evidence during the succeeding centuries of the deliberate
+use of mental influence and even of direct suggestion in the cure of
+disease.
+
+Alexander of Tralles (sixth century A. D.) was not judiciously
+critical in his selection of remedies. Often he has quite ridiculous
+therapeutic suggestions, and yet we have at least two stories with
+regard to him which clearly indicate his employment of mental
+influence. One of his patients is said to have been suffering from the
+delusion that his head had been cut off by order of the tyrant, but he
+was cured as soon as the doctor hit on the interesting expedient of
+making him wear a leaden hat, which eradicated his delusion and made
+him think his head had been restored.
+
+It is also in Alexander Trallianus, as he is sometimes called, that we
+have the original of the story which has been often told, many writers
+giving it as an experience of their own. A woman was sure that she had
+swallowed a snake, and that it continued to exist in her stomach,
+devouring much of her food and causing acute pain whenever large
+quantities of food were not provided for it. All sorts of remedies had
+been tried without result. At last Alexander gave her an emetic and
+then slipped into the basin into which she was vomiting a snake
+resembling as closely as possible that which she thought she had
+swallowed. The ruse effected a complete cure. Usually in latter-day
+variants of this story the cure is only temporary, for the patient
+after a time has the same symptoms as before and then is sure that
+during the time of its residence in the stomach the snake has given
+birth to young.
+
+
+Paul of AEgina.--In the seventh century Paul of AEgina collected all
+that had been written on insanity by physicians of olden times, and
+many of his directions and prescriptions for treatment show that he
+appreciated the value of mental influence. He recommends that those
+who are suffering from mental disease should be placed in a quiet
+institution, should be given baths, and that an important portion of
+the treatment should consist of mental recreations.
+
+
+ARABIAN MENTAL MEDICINE
+
+The Arabian physicians who succeeded to the traditions of Greek
+medicine preserved also those relating to psychotherapy. Rhazes, the
+first of the great Arabian physicians, has a number of aphorisms that
+show his interest in and recognition of the value of mental healing.
+He insisted that "doctors ought to console their patients even though
+the signs of death are impending. For the bodies of men follow their
+spirits." He believed that the most important function of the
+physician was "to strengthen the natural vitality for, if you add to
+that you will remove a great many ills, but if you lessen it by the
+drugs which you employ you add to the patient's danger." "Truth in
+medicine," he said, "is a goal which cannot be absolutely reached, and
+the art of {14} healing, as it is described in books, is far beneath
+the practical experience of a skillful, thoughtful physician."
+Manifestly he realized the importance of the influence of the
+physician over the individual patient.
+
+His greatest successor among the Arab physicians, Avicenna (eleventh
+century), "the Hippocrates and the Galen of the Arabians," as Whewell
+called him, has some striking tributes to what he recognized as the
+influence of the mind on the body. He appreciated that not only might
+the mind heal or injure its own body, but that it might influence
+other bodies, through their minds, for weal or woe. He says: "The
+imagination of man can act not only on his own body, but even on other
+and very distinct bodies. It can fascinate and modify them, make them
+ill or restore them to health." In this, of course, he is yielding to
+the dominant mystical belief that man can work harm to others, which
+subsequently, under the name of witchcraft, came to occupy so
+prominent a place for ill in European history. But at the same time it
+is evident that his opinions are founded on his knowledge of the
+influence of mind on body, as he had seen its action in medicine. From
+him we have the expression: "At times the confidence of the patient in
+the physician has more influence over the disease than the medicine
+given for it."
+
+
+MEDIEVAL MIND-HEALING
+
+During the Middle Ages faith was one of the things most frequently
+appealed to, and even the physicians made use of religious belief to
+secure a favorable attitude of the patient's mind toward the remedies.
+One of the men who particularly realized the importance of this was
+Mondeville, the great French surgeon.
+
+Pagel has called attention to Mondeville's insistence on preparing the
+patient's mind properly for venesection. The patient should be made to
+feel that this procedure was sure to do him good, and various reasons
+should be given him why the removal of a certain amount of blood
+carried with it poisons from the body, and so gave a better
+opportunity to nature to conquer the disease. If the patients were
+unfavorably disposed towards venesection, Mondeville thought that it
+should not be performed, as it was not likely to do good. It was not
+that he felt that the mental influence was the more important of the
+two therapeutic factors, but that a combination of the remedial force
+of blood-letting with a favorable state of the patient's mind meant so
+much more than could be accomplished by venesection alone that it was
+worth while to take pains to have the combination of the two. We in
+modern times realize that in most cases blood-letting rather did
+physical harm than good. It continued to hold a place in medicine
+because patients were so much impressed by it that they were given
+renewed vigor after its use.
+
+
+MENTAL HEALING IN THE RENAISSANCE
+
+What is exemplified in medieval medicine in this matter remains true
+during the Renaissance. In the fifteenth century Petrus Pomponatius,
+well known as a thinker and writer on borderland subjects related to
+medicine, came to the conclusion that men might very well be cured of
+certain ailments {15} by influence from the minds of others, and that
+such treatment, undertaken by physicians appropriately endowed,
+produced wonderful effects. He said:
+
+  Some men are specially endowed with eminently curative faculties;
+  the effects produced by their touch are wonderful: but even touch is
+  not always necessary; their glances, their mere intention of doing
+  good are efficient for the restoration of health. The results,
+  however, are due to natural causes.
+
+
+PSYCHOTHERAPY AND MODERN MEDICINE
+
+Paracelsus.--Paracelsus, the great physician of the first half of the
+sixteenth century, who may well be considered the father of modern
+pharmaceutics, had no illusions with regard to the exclusive power of
+drugs over disease. He recognized that mental influence was extremely
+important, and often lent a power not otherwise possessed to many
+remedies. He said:
+
+  Imagination and faith can cause and remove diseases. Confidence in
+  the virtue of amulets is the whole secret of their efficacy. It is
+  from faith that imagination draws its power. Anyone who believes in
+  the secret resources of Nature receives from Nature according to his
+  own faith; let the object of your faith be real or imaginary, you
+  will in an equal degree obtain the same results.
+
+Personal magnetism, in the sense in which we now use it, a
+transference of the idea from the science of magnetics as related to
+the phenomena of the magnet, seems to have originated with Paracelsus.
+He was sure that the influence exerted over certain patients by
+certain physicians was due to a force very like that exerted by the
+magnet over iron. He was even inclined to think that magnets
+themselves might exert a strong potency over diseased conditions, and
+he found them to be useful in epilepsy. Doubtless in many cases of
+supposed epilepsy successfully treated the ailment was really of an
+hysterical nature. In these cases the strong suggestion which the use
+of the magnets gave for many centuries acted favorably.
+
+
+Agrippa.--The writings of Cornelius Agrippa, a contemporary of
+Paracelsus, and, like him, a student of alchemy and of the secrets of
+nature, contain corresponding passages which serve to show how much of
+interest there was in mental influence during the Renaissance. All of
+these men were, of course, a little outside of the ordinary medical
+tradition, intent on getting to realities, not being satisfied either
+with words or assumptions, refusing to accept many thing that the
+physicians of their time completely credited. Agrippa in a
+characteristic passage said:
+
+  Our mind doth effect divers things by faith (which is a firm
+  adhesion, a fixed intention, and a vehement application of the
+  worker or receiver) in him that coöperates in anything, and gives
+  power to the work which we intend to do. So that there is made in
+  us, as it were, the image of the virtue to be received, and the
+  thing to be done in us, or by us. We must, therefore, in every work
+  and application of things, affect vehemently, imagine, hope and
+  believe strongly, for that will be a great help.
+
+
+Van Helmont.--At the end of the sixteenth century Van Helmont, who
+carried on the work in pharmaceutics begun by Paracelsus, and to whom
+we owe the discovery of a number of substances commonly used, as well
+as the invention of the word "gas," was a thorough believer in the
+influence of mind over body and, indeed, in the existence in human
+beings of storehouses {16} of latent energy ordinarily unemployed, but
+that might under special circumstances be tapped to produce wonderful
+effects. Indeed, some passages remind us of Prof. James' expressions
+in his discussion of the law of human energy. Van Helmont said:
+
+  All magical power lies dormant in man, and requires to be excited.
+  (Compare Prof. James's "Law of Mental Energy" in the chapter on
+  Mental Influence). This (need for excitation) is particularly the
+  case if the subject upon whom we wish to operate is not in the
+  most favorable disposition; if his internal imagination does not
+  abandon itself entirely to the impression we wish to make upon him;
+  or if he towards whom the action is directed possesses more energy
+  than he who operates. But when the patient is well disposed or
+  weak, he readily yields to the magnetic influence of him who
+  operates upon him through the medium of his imagination. In order to
+  operate powerfully, it is necessary to employ some medium; but this
+  medium is nothing unless accompanied by internal action.
+
+
+Sydenham.--In the more modern period the deliberate use of the
+influence of the mind on the body is quite as clear. Undoubtedly the
+greatest of modern physicians, who well deserves the name of the
+English Hippocrates, is Sydenham. How much Sydenham realized that many
+of his patients' ailments could only be cured by occupying their minds
+with other things is seen in his writings. There is a characteristic
+story told by Dr. Paris in his "Pharmacologia" which illustrates this
+well and is a striking anticipation of what we are prone to think of
+as very modern views in these matters:
+
+  This great physician, Sydenham, having long attended a gentleman of
+  fortune with little or no advantage, frankly avowed his inability to
+  render him any further service, at the same time adding, that there
+  was a physician of the name of Robertson, at Inverness, who had
+  distinguished himself by the performance of many remarkable cures of
+  the same complaint as that under which his patient labored, and
+  expressing a conviction that, if he applied to him, he would come
+  back cured. This was too encouraging a proposal to be rejected; the
+  gentleman received from Sydenham a statement of his case, with the
+  necessary letter of introduction, and proceeded without delay to the
+  place in question. On arriving at Inverness, and anxiously inquiring
+  for the residence of Dr. Robertson, he found, to his utter dismay
+  and disappointment, that there was no physician of that name, nor
+  ever had been in the memory of any person there. The gentleman
+  returned, vowing eternal hostility to the peace of Sydenham, and on
+  his arrival, at home indignantly expressed his indignation at having
+  been sent on a journey of so many hundred miles for no purpose.
+  "Well," replied Sydenham, "are you better in health?" "Yes, I am now
+  quite well; but no thanks to you." "No," says Sydenham, "but you may
+  thank Dr. Robertson for curing you. I wished to send you on a
+  journey with some object of interest in view; I knew it would be of
+  service to you: in going, you had Dr. Robertson and his wonderful
+  cures in contemplation; and in returning, you were equally engaged
+  in thinking of scolding me."
+
+
+Morgagni.--In the century following Sydenham we have a number of
+examples cited by Morgagni, the father of pathology, in which his
+recognition of the value of the mind as a curative agent and of the
+harm that may be done by over-occupation of the mind is set forth at
+its proper value. Benjamin Ward Richardson in his "Disciples of
+AEsculapius" [Footnote 2] tells of two incidents in which this phase
+of Morgagni's very practical application of knowledge to medical
+practice is exemplified:
+
+  [Footnote 2: London, 1901]
+
+{17}
+
+  In other examples, where the symptoms are due to mental oppression,
+  he pursued a course of treatment that was of soothing nature. A
+  distinguished professor of physic at Bologna happened to discover
+  that his pulse was intermittent, and being extremely anxious about
+  it was incessantly feeling his pulse, to discover that the evil was
+  daily increasing. Morgagni's advice to his patient was to take his
+  finger off his wrist and not to inquire too anxiously about his
+  condition. The advice was followed, and the result was a complete
+  removal of the disturbance.
+
+  It is a very singular truth that in describing the action of the
+  nervous system on the circulation Morgagni shows that he was
+  cognizant of the fact that the circulation may be disturbed by two
+  sets of nervous irritations, one inflicted through the
+  pneumogastrics, the other "through those nerves which are
+  subservient to the arteries"--the vaso-motor system which is readily
+  disturbed by the mind. In one patient he observed great
+  perturbations of the pulse in both wrists as the result of mental
+  anxiety. But a day or two later the pulse derangement was confined
+  to the left side altogether. The pulse of the right arm was quite
+  regular, while that of the left arm still showed the inequality.
+  When the mental distress was relieved, this pulse also became equal.
+
+Morgagni cites Sydenham's contemporary, Lancisi, the great Italian
+physician, as recognizing the influence of the emotions on the heart.
+Examples of similar convictions as to mental influence in medicine are
+also found in the works of Morgagni's great contemporaries, Boerhaave
+and Van Swieten, and the great physicians of the seventeenth and
+eighteenth centuries were closely imitated in their recognition of the
+value of the influence of mind over body in medicine by their
+successors in the profession.
+
+
+John Hunter.--Wise old John Hunter recognized the influence of the
+mind on the body very clearly. He said, for instance, "There is not a
+natural action in the body, whether voluntary or involuntary, that may
+not be influenced by the peculiar state of mind at the time." He lays
+it down as a law that "every part of the body sympathizes with the
+mind, for whatever affects the mind, the body is affected in
+proportion." He said further, "as a state of the mind is capable of
+producing a disease, another state of it may affect a cure." He called
+attention to the fact that the touch of a corpse produced wonderful
+effects upon the minds of patients. He said, "Even tumors have yielded
+to the stroke of a dead man's hand." He observes that "while we should
+naturally expect that diseases connected with the nerves--and those in
+which their alteration is in the action of parts not in their
+structure--would be most affected by the imagination, we find that
+there are other diseases in which they appear to have little
+connection that are much affected by the state of mind."
+
+
+German Mind Healing.--In his monograph on "Psychotherapy in Its
+Scientific Aspects" [Footnote 3] Dr. Berthold Kern calls attention to
+a forgotten book of the German physician Scheidemantel, published in
+1787. Its title was "The Emotions as Remedies." It seems to be very
+rare since even our Surgeon General's Library has no copy of it. The
+author treated psychotherapy systematically. He insisted that man was
+a unit in which body and soul mutually influenced each other.
+Scheidemantel blamed the moralists for considering the soul
+exclusively and the physicians for thinking only of the body. He
+thought that this was a serious mistake for both sides and he seems to
+have anticipated much of our recent discussion on the influence of the
+body and {18} of things physical generally in what is called crime and
+various divagations from law. On the other hand, he thought that the
+influence of the mind on the body was one of the most important
+elements in therapeutics.
+
+  [Footnote 3: "Die Psychische Krankenbehandlung im Ihren
+  Wissenschaftlichen Grundlagen." Berlin 1910.]
+
+Reil, after whom the Island of Reil is named, and who taught us much
+with regard to brain anatomy, was also interested in the influence of
+mind on body. He was the professor of anatomy at Berlin in the early
+part of the nineteenth century and had great influence over the
+medical science of the time. He insisted on the recognition and
+development of psychotherapy and hoped to give it a place beside the
+medical and surgical treatment of human ills. He did much to create a
+current of thought in German medicine which culminated in Johann
+Müller's very definite expressions with regard to the power of the
+mind over the body.
+
+Very probably the most striking expression of the influence of mind
+upon body is in that wonderful old book, Johann Müller's text-book of
+physiology, issued in an English edition (London, 1842) under the
+title "Elements of Physiology." The subject, a favorite study, is set
+forth very clearly, and evidently from personal knowledge. He
+recognized that the mind might influence every organ and function of
+the body. The influence of expectancy he emphasized particularly:
+
+  The influence of ideas upon the body gives rise to a very great
+  variety of phenomena which border on the marvelous. It may be stated
+  as a general fact that any state of the body, which is conceived to
+  be approaching and which is expected with perfect confidence and
+  certainty of its occurrence, will be very prone to ensue as the mere
+  result of that idea, if it do not lie without the bounds of
+  possibility. The case mentioned by Pictet, in his observations on
+  nitrous oxide, may be adduced as an illustration of such phenomena.
+  A young lady, Miss B., wished to inspire this intoxicating gas; but
+  in order to test the power of the imagination, common atmospheric
+  air was given to her, instead of the nitrous oxide. She had scarcely
+  taken two or three inspirations of it, when she fell into a state of
+  syncope, which she had never suffered previously; she soon
+  recovered. The influence of the ideas, when they are combined with a
+  state of emotion, generally extends in all directions, affecting the
+  senses, motions and secretions. But even simple ideas, unattended
+  with a disturbed state of the passions, produce most marked organic
+  effects in the body.
+
+With regard to the influence of the mind over the body in the matter
+of fatigue Müller is especially emphatic. He states just as clearly
+two generations ago the Law of Reserve Energy as James stated it in
+recent years. Of course, Müller was far beyond his time in everything,
+but then men who really think always are, and even Müller's accurate
+expression only represents what had been in the minds of thinking men
+in many previous generations. He says:
+
+  The idea of our own strength gives added strength to our movements.
+  A person who is confident of effecting anything by muscular efforts,
+  will do it more easily than one not so confident in his own power.
+  The idea that a change is certainly about to take place in the
+  actions of the nervous system, may produce such a change in the
+  nervous energy, that exertions hitherto impossible become possible.
+  This is still more likely to be the case, if the individual is at
+  the time in a state of mental emotion.
+
+Even this necessarily fragmentary and rather disjointed sketch of the
+main features of psychotherapeutics, as we see them recognized by the
+great {19} physicians of the past, serve to show that mental influence
+has always been appreciated as an important element in the care of the
+individual patient.
+
+The times when special attention has been paid to psychotherapy have
+certain special characteristics. Usually the periods have come just
+after a signal advance in medicine made through devotion to physical
+science. Great attention is given to the advances and for a time the
+individual patient is forgotten in the hope that at last physical
+science is going to solve the problems of the physical man. With the
+disappointment that always follows there is a reversion of feeling and
+men realize once more how important is the mental state of the
+patient, even in physical diseases. Then there comes an emphatic
+expression of the value of psychotherapy. We are at present in the
+midst of one of these periods, hence the widespread interest in the
+subject.
+
+
+CHAPTER II
+
+UNCONSCIOUS PSYCHOTHERAPEUTICS
+
+The great authorities in medicine, the men whose thought counted for
+most in the development of not only the science but the art of
+medicine, the men to whom we look back as having been great practicing
+physicians, have always used this remedial measure deliberately and
+have suggested to others that it should be so used. But the smaller
+minds have been satisfied to think that their drugs, their external
+remedies and applications, have been the sole sources of the benefit
+that accrued to the patient. Such smaller men are prone to think that
+they have specifics for disease, while the larger men hesitate and
+recognize that coincidence plays a large role and that the suggestive
+factors in therapeutics often deceive us as to the real efficacy of
+drugs and remedies.
+
+All physicians have at all times used, though often unconsciously, the
+suggestive factor in therapeutics, and mental influence has had
+everywhere a large role in the treatment of disease. Only in recent
+years have we come to appreciate how many diseases are self-limited.
+In the treatment of these self-limited diseases all sorts of drugs and
+therapeutic methods achieved a reputation. Some of them were looked
+upon by generations as specifics, though we know now that they are
+almost, if not completely, useless so far as any direct influence upon
+the disease is concerned. Indeed, at times they were, _per se_,
+harmful rather than beneficial, and the patient literally got well in
+spite of the treatment, though the repeated suggestion of betterment
+often more than overcame the ill effect and helped in recovery.
+
+
+REMEDIES PLUS SUGGESTION
+
+Prof. Richet, the head of the department of physiology, University of
+Paris, quotes the expression of a French critic of medicine: "Hurry up
+and take the new remedy while it still cures. After a time it will
+lose its power." The power that is lost as remedies grow familiar is
+the suggestive element that accompanied them at the beginning. They
+were announced with a flourish of trumpets as a discovery in
+therapeutics, a number of cases treated with them {20} were much
+benefited (because of the feeling that they must do good), and it was
+only after a great many cases had been treated, many of them under
+circumstances where patients knew nothing of the claims made for the
+remedies, and where physicians had little or no previous confidence in
+them, that their true place in therapeutics was revealed. Every
+physician of experience has seen the popularity of remedies wax and
+wane as a consequence of the attention called to them. We have new
+therapeutic discoveries every week. Enthusiastic articles are written
+about them, many of them in perfect good faith, and then after a time
+no more is heard of them, or they sink back into the long list of
+dubious remedies that may be tried when others have failed, but have
+no special claim upon us, in spite of the fact that some physicians
+continue to think them wonder-working.
+
+"Time is short and art is long, the occasion is fleeting, experience
+fallacious and judgment difficult," as Hippocrates bemoaned 2400 years
+ago, and conditions in medicine continue the same. With suggestions
+and coincidence ever at work, it is still practically impossible to
+determine the intrinsic value of any remedy until after a prolonged
+trial. In the olden time it was still more difficult because there had
+been no such accumulation of experience as we have to guide us, and so
+it is not surprising to find striking examples of even great
+physicians recommending remedies whose main therapeutic influence must
+have been the element of suggestion.
+
+
+Galen's Theriac.--Perhaps the most striking instance of suggestive
+therapeutics is Galen's famous _theriac_, various prescriptions for
+which have come down to us, some of them much more complex than
+others, so Galen is probably not responsible for all its absurdities.
+This remedy contained a host of ingredients, some of which neutralized
+others, and all of which taken together could have had but little
+effect save by a strong suggestion to the patient that as he was
+taking so many drugs he surely must be benefited.
+
+
+Bernard's Theriac.--Almost in our own time another _theriac_ came
+prominently before the public. In his younger years Claude Bernard,
+the French physiologist, worked in a little drug store in a country
+place not far from the farm on which he was born. There he found that
+the most called for remedy was a _theriac_. It was good for most of
+the ills that flesh is heir to and was bought in quantities by the old
+women of the neighborhood, who administered it on every occasion. The
+remedy was made in large quantities, but the secret of its composition
+in this particular pharmacy was what interested Bernard. Whenever any
+compound was for any reason spoiled in the drug store, the rule was,
+"Put that aside for the _theriac_." This much sold remedy then
+consisted of the most heterogeneous drugs. It was so diluted that it
+could do no harm, though it had quite sufficient taste and odor to
+make every one who took it realize that without doubt they were taking
+a strong medicine.
+
+The effect of the knowledge of the composition of this wonderful
+remedy on Claude Bernard was the best that could have been
+anticipated. He resolved to study the physiological effects of drugs
+so that they could be given scientifically, and not in the hit or miss
+fashion that made possible the success of the _theriac_.
+
+The custom of Bernard's country drug store, however, was not different
+from that of most country drug stores of the time. Unconscious
+psychotherapeutics we may well call it, because the main therapeutic
+factor was {21} suggestion, renewed as often as the mixture was taken,
+that the patient ought to feel better, until finally whatever symptoms
+were due to over-attention and to concentration of mind on feelings of
+discomfort were diverted. Just as soon as the inhibition exercised by
+this over-attention ceased its hampering effect nature completed the
+cure.
+
+
+Suggestion in Colds.--Many remedies acquired a reputation for breaking
+up coughs and colds. It is, however, extremely doubtful whether any
+one has ever aborted a cold, or any other infection, that had gained a
+hold on the patient. We now know that this common affliction is not
+due to cold but to absorption of infectious material. Nansen spent two
+winters near the North Pole without catching any cold, and his men
+were as healthy as himself. He had been back in civilization scarcely
+a week before he and his men were confined to bed with a grippy cold.
+In the far north, and high on mountains where the temperature is low,
+colds are not as common as they are in crowded cities and especially
+among those who are much in crowds. Cold weather only predisposes to
+the infection, and after it has occurred it is sure to run its course.
+That course may be longer or shorter. The cold is usually preceded by
+chilly feelings. Every one knows it is possible to have chilly
+feelings that seem to portend a cold, yet be well the next day. If in
+the meantime any remedy is taken, credit will be given to the remedy.
+When a cold was supposed to be merely a disturbance of circulation or
+a congestion, one might expect to break it up. Now that we know that
+it is a microbic infection, and know further that microbic diseases
+are usually cured by a definite reaction on the part of the body, we
+are not so likely to think of breaking them up. There are still
+physicians who think they can abort a threatened pneumonia or
+abbreviate typhoid fever, but they are not those who know most about
+the science of medicine.
+
+We have the story, then, of a series of remedies used with great
+confidence in coughs and colds, some of them physically beneficial,
+many of them, especially those containing opium, often physically
+harmful, yet taken with such confidence that undoubtedly the patient
+was helped through his mind if not otherwise. What is thus true for
+this class of diseases can also be said of other minor affections.
+Many internal remedies have been used for boils and styes and other
+external infections and have often had wide vogue. The reason for
+their acceptance as remedies has been that the giving of anything
+produces a more hopeful attitude in the mind of the patient and this,
+by bettering the general health, sometimes overcomes the tendency that
+may exist to a repetition of such infectious processes.
+
+
+Erysipelas.--The medical history of erysipelas is just a succession of
+remedies recommended, each claimed to be almost infallible, yet
+abandoned after a time for another for which like exaggerated claims
+were made. The doctrine of signatures played a large rôle in the
+treatment of erysipelas, and, strange as it may seem, still survives.
+According to the doctrine of signatures, erysipelas, being a disease
+involving intense redness of the skin, red things in nature would be
+likely to do it good. Red pepper, for instance, was suggested for it
+over and over again, both internally and externally. Various red
+remedies have been favorites at different times in history. At
+present, in many country places, a poultice made of cranberries is
+supposed to be most efficacious. For many years I lived in a small
+town where one of the grocers {22} put in a large stock of cranberries
+each fall, though the people of the neighborhood used them but little
+on the table, because during the winter there were many calls for them
+for the making of poultices for erysipelas. People who have had
+erysipelas, especially if it has occurred on unexposed portions of the
+body, are supposed to be protected against its recurrence--for there
+is a distinct liability to its recurrence--by the wearing of red
+flannels!
+
+There is scarcely any drug that has not at some time been recommended
+as almost a specific for erysipelas. Anything that was given on the
+third or fourth day, and it was only at this time as a rule that
+patients came to physicians to be treated, seemed to bring about the
+alleviation of symptoms that occurred on the fifth or sixth day.
+
+Erysipelas, because of the sudden irruption of fever which accompanies
+it, the intense redness which characterizes it, and the discomfort
+which is often present, is an affection that disturbs patients very
+much. For them, then, the presence of the physician and his assurance
+that their affection is not likely to be severe, and his prompt relief
+of certain conditions, all act by suggestion on the patient's mind and
+strengthen the natural curative reaction.
+
+In country places where physicians were not near, erysipelas was one
+of the affections that continued almost down to our own day to be
+treated by incantations. I have known in a little American country
+town of a woman making a "charm," as it was called, for erysipelas.
+
+
+Pneumonia.--Pneumonia is another of these sharply self-limited
+diseases that give opportunity to many remedies for the acquisition of
+a reputation as cures. Croupous pneumonia is so disturbing in its
+onset, so rapid in its progress, yet so strictly self-limited in the
+previously strong and healthy, that in the old days there were many
+remedies that were supposed to bring about the crisis. The old
+text-books contain so many cures that it is surprising pneumonia
+should have continued to be the fatal disease it has been at all
+times. Almost any remedy that is used for three or four days in
+pneumonia will be followed by the crisis with, in most cases, a
+favorable termination. The crisis takes place some time from the
+seventh to the tenth or eleventh day, and often we do not see a
+pneumonia patient until the second or third day of the disease. Just
+before the crisis the patient runs into a series of acute and more or
+less alarming symptoms. Often there is much restlessness, difficulty
+of breathing with complaint of heaviness, and perhaps prostration. The
+pulse and temperature are high, the skin hot and dry. Then in the
+midst of this the patient sleeps, there is a critical sweat, the
+temperature drops, the patient wakes up feeling quite well, there is
+little difficulty in breathing, and he feels that recovery is sure to
+come. The change is so great that it is natural that it should have
+been attributed to all sorts of remedies which had been used
+immediately preceding the crisis.
+
+I once heard an old physician declare at a meeting of a large and
+important medical society that calomel in divided doses was
+practically a specific for pneumonia. He said he waited forty-eight
+hours to be sure that the affection was pneumonia, and also that it
+had reached that diffusion in the lungs beyond which it was not likely
+to go, then he gave the calomel. He said that, almost as a rule,
+during the next forty-eight hours the crisis came--and he attributed
+it to the calomel. We have had other remedies just as curious as this
+recommended and taken quite seriously. Some years ago a {23} Russian
+physician, who had been treating soldiers in the Russian army for the
+pneumonia which occurs so commonly after exposure on the Steppes,
+announced that he had found in digitalis almost a specific. He pushed
+the tincture up to twenty drops three times a day, beginning it just
+as soon as the pneumonia was detected, and the rate of mortality among
+his patients was about one per cent. According to his theory, it was
+the failure of the heart in pneumonia that made the disease fatal.
+
+Apparently the character of the patients in whom his pneumonias
+occurred was forgotten. They were absolutely the most favorable cases
+that could be selected. Most of them were young men between twenty and
+twenty-five. At this age no one who is given a reasonable amount of
+fresh air should die of pneumonia. If the patient had a serious heart
+lesion, or a crippled kidney from nephritis after scarlet fever, or
+crippled lungs because of a previous attack of tuberculosis, then the
+pneumonia might be fatal--indeed, almost inevitably would be, or, in
+the last-mentioned case, would end by lysis and not crisis. It really
+matters little what remedy is given to young, otherwise healthy,
+adults; they will get better, barring serious complications. The use
+of digitalis lessened the chances of recovery by stimulating too early
+in the case the heart that later had to bear one of the most serious
+strains that the organ can stand. But doubtless this harm was more
+than overcome by the patient's knowledge that he was taking a new and
+powerful remedy, supposed to be particularly calculated to cure him.
+
+Moreover, the special interest of the physician in these cases, and
+his administration of a remedy with confidence which inspired the
+patient, undoubtedly did much good. Pneumonia is one of those diseases
+in which the patient is likely to be greatly depressed unless he is
+surrounded by favorable mental influences, and is encouraged to
+believe that he is going to get well. Every physician has probably had
+cases in which patients died, not because of the severity of the
+disease, but because they gave up the struggle in fright. If several
+of a man's friends have died of pneumonia during the year or two
+before he gets it, he is likely to conclude, especially if he is of
+the worrying kind, that his doom is sealed as soon as the diagnosis of
+pneumonia is made. If this thought persists hardly anything will save
+him. He must be assured that pneumonia is not necessarily serious,
+that there are remedies that influence it, and that his own case is
+particularly likely to respond favorably to them.
+
+We now realize that nursing is the most important element in the
+treatment of pneumonia. Such attention to the patient as will treat
+symptoms so as to prevent them from disturbing him, will secure him
+against discouragement, will arouse his resistive vitality by assuring
+him of a favorable termination. This will above all prevent the
+patient from feeling that he is attacked by a fatal disease. The
+presence of the doctor and his general directions make the patient
+realize how thoroughly the course of the disease is understood and
+therefore how likely it is that a favorable termination will be
+brought about. We know how much the mind may interfere with the
+breathing if allowed to dwell on it, and therefore if the patient
+becomes over-solicitous about the condition of his lungs he seriously
+hampers his recovery. In pneumonia the physician has always brought
+relief, and he has usually attributed his success to his drugs, though
+he has felt, too, that the confidence inspired {24} by him meant much
+for his patient. It would have been better had he exaggerated the
+mental influence rather than the drug power.
+
+
+Typhoid Fever.--Typhoid fever is another affection for which we have
+many therapeutic suggestions, with wide vogue, that are nevertheless
+almost directly opposed to what we know about the pathology and
+etiology of the disease. Typhoid fever runs its course in from between
+twenty to thirty days. The majority of people who take the affection
+and who give in to it early enough, so as not to wear themselves out,
+come through successfully. Complications may carry them off, but we
+expect uncomplicated cases to recover. The longer course of typhoid
+has made the action of drugs appear less striking than in pneumonia
+and erysipelas, but a number of remedies have been proclaimed to
+shorten its course, to make it less dangerous, to cure, and sometimes
+actually to abort it. So often have these come and gone that the
+physician who knows the history of therapeutics is likely to be
+suspicious of them. Even at present there are certain remedies
+supposed to have this effect, but one does not find them used in
+hospitals where large numbers of cases are seen and where there are
+opportunities for comparative observation. They are used only by
+physicians who see a few cases every year, and to whom coincidences
+may mean much more than they are likely to when extensive statistics
+of the disease are made.
+
+As a rule, these remedies are founded on some real or supposed
+scientific principle. The antiseptic treatment of typhoid, for
+instance, was based on the supposition that if one can kill the
+microbes in the intestine the disease will run a shorter course. The
+principle apparently fails to note that any remedy likely to kill
+microbes is still more likely to kill cells of other kinds, and above
+all human cells lessened in their resistive vitality by disease. The
+advocates of this remedy also forget that typhoid is now recognized as
+a general disease with only a local manifestation in the intestines,
+and that the treatment of this local manifestation is no more likely
+to affect the course of the disease than the treatment of the symptoms
+of typhoid would be likely to do. But the giving of remedies with the
+thoroughgoing confidence that awakens trust is in itself an excellent
+therapeutic agent, and patients thus treated are sure to be benefited
+in so far as they share the physician's confidence. Just the same
+effect, however, can be produced by careful nursing and by making the
+patient realize that even though typhoid fever runs a definite course,
+which we cannot abbreviate nor probably influence, we can by nursing
+so prevent complications as to make a fatal termination almost
+impossible.
+
+
+Whooping Cough.--Perhaps none of the common affections illustrate the
+influence of psychotherapy better than it is exemplified in the
+history of the therapeutics of whooping cough. We have had all sorts
+of remedies suggested for it, and most of them have been introduced by
+those who had found them of great service in shortening the course of
+the disease, and in making the "whoop" disappear much sooner than
+would otherwise be the case. There have been internal and external
+remedies, inhalations and inunctions, as well as many less likely
+methods of treatment. Practically none has maintained itself. Whooping
+cough is likely to run a rather long course. We know now that as a
+consequence of the strain upon the lungs tuberculosis not infrequently
+develops. Whenever this is true the tendency to cough is likely to be
+{25} prolonged far beyond the natural period, and from habit ingrained
+upon the nervous system the "whoop" is likely to continue, though
+there is no necessity for it. It is this secondary period of the
+affection that the remedies have succeeded in shortening either
+apparently or in fact.
+
+Practically anything that is done for children is likely to instil the
+persuasion that the "whoop" should disappear. Anything impressive will
+arouse this favorable attitude of mind toward the affection, and hence
+the remedies have obtained a reputation. In the interior of many
+countries draughts of sea water are a popular remedy for whooping
+cough. Sea water, it is said, loses its efficacy if carried long
+distances from the shore, so the children must be brought to the
+seaside. In mining regions children are taken down into the mines. The
+experience is enough of itself, especially when talked over a good
+deal in the family, and when the occasion is often the first outing
+that the child has had for months, to bring with it such improvement
+in health as will enable it to suppress the whoop. If the exposure to
+the mine air does not bring improvement, it is said to be either
+because the child was not taken deep enough, or because there was no
+gas in the air, or the wrong sort of mine was chosen, or some other
+plausible excuse is advanced.
+
+The development of scientific medicine, or at least what we are
+pleased to think of as more scientific therapeutics than they had in
+the past, has not kept us from having many and varied remedies for
+whooping cough, which, after being introduced on apparently good
+authority and apparently accomplishing many good results, have
+eventually been allowed to drop into innocuous desuetude. Whenever the
+administration of any such remedy was accompanied by strong
+suggestion--when the internal remedies were particularly distasteful,
+or the inhalations rather trying or at least sure to attract the
+attention of the sufferers--then good results followed. But the cures
+were due to the mental influences at work. In recent years various
+serums, including diphtheria serum, have been tried with reported good
+results. The giving of the injection is one of those little operations
+that is likely to impress itself forcibly upon the child's mind, and
+when given in connection with the promise, implied or explicit, of
+improvement it is easy to understand that there will be a tendency to
+lessening the frequency of the whoop, at least during the secondary
+periods of the disease.
+
+
+
+CHAPTER III
+
+GENUINE REMEDIES AND SUGGESTIVE EXAGGERATION
+
+The story of the suggestive use of drugs shows us many suggestions
+employed even by distinguished physicians, men whose work is eminently
+rational and has lived long after their time. In fact, very few, even
+of the most distinguished physicians, have failed to extol remedies
+which later proved to be quite ineffectual. Hippocrates felt quite
+sure that an external application of snake skin was a cure for all
+forms of that chronic skin manifestation, lichen. Pythagoras declared
+that anise seed held in the hand was an excellent remedy for epilepsy.
+These are only examples which serve to show how much suggestion has
+been used unconsciously by the medical profession. The sensation {26}
+produced by the touch of the viper's skin was sufficient in some
+patients to bring about a change in the circulation in the skin, or
+perhaps a distinct modification of the nerve impulses on which trophic
+conditions in the skin depend, and this may have produced some cures
+on which Hippocrates founded his recommendation. We know that the skin
+can be unfavorably affected directly through the nervous system, and
+there is no good reason for thinking that it may not also be affected
+favorably. In our own day we have seen the suggestive influence of an
+operation act as a remedy in epilepsy and have lauded it for a time.
+It is, therefore, not surprising that Pythagoras saw, as he thought,
+the strong scent of the anise seed act favorably. Both of these
+conclusions as to the causative agency at work were wrong, because it
+was suggestion and not the operation in most cases, nor the anise in
+any case, which caused the improvement.
+
+
+THERAPEUTIC PERSUASION
+
+It is not only in the distant past, however, but also in quite modern
+times that these therapeutic persuasions have existed among
+physicians, and as a result physicians have frequently recommended and
+employed remedies that we now know not only to have been quite
+useless, but sometimes even harmful. A typical example of this is the
+use of antimony, originally discovered and studied by Basil Valentine,
+an alchemist who had busied himself much with the nature of
+substances, vegetable and mineral, and with their action as remedies
+for disease. Sir Michael Foster hailed him as the first of
+pharmacologists, and said: "The old monk did not care for the problem
+of the body; all he sought to understand was how the constituents of
+the soil and of plants might be treated so as to be available for
+healing the sick and how they produced their effect."
+
+
+Suggestion and Antimony.--This was an eminently scientific research.
+It brought the father of pharmacology to certain supposed discoveries
+which continued to occupy men's minds for centuries, yet ultimately
+proved to be utter misunderstandings of drug action, because
+suggestion played so large a role that it vitiated all the
+conclusions. The best known of Basil Valentine's books is the
+"Triumphal Chariot of Antimony," which contains many interesting
+scientific observations that were probably new at the time and which
+show their author's investigating spirit and his interest in
+scientific research.
+
+In spite of his scientific advances, however, Valentine was wholly
+mistaken with regard to antimony. He used it in various diseases, and,
+of course, it always produced very definite effects on the bowels.
+These effects the physician could easily foretell. It was for the
+patient a proof that the physician knew much, both about his disease
+and his remedies, since he could prophesy the results. After the
+antimony had exerted its influence the patient was much more ready to
+think that he must get better, and the influence of this suggestion
+worked strongly in all cases where the affection was not serious, and
+undoubtedly helped the patient's resistive vitality to throw off
+disease. In weak patients its physical effect was lamentable. It still
+further reduced vitality, and when used by thoughtless physicians must
+have done great harm. In spite of this, however, antimony continued to
+be used for centuries. Shortly {27} after the middle of the
+seventeenth century, when it was beginning to be neglected, antimony
+received a new lease of life as a consequence of its employment in a
+lingering illness of Louis XIV. The French king was attacked by what
+has since been recognized as typhoid fever. Many remedies were tried,
+but all in vain; the fever continued. When the fever had nearly run
+its course and the physicians were on the point of acknowledging that
+they could do nothing, and when a fatal termination seemed near, it
+was decided at a consultation to follow the advice of an old
+practitioner and use the old-fashioned remedy, antimony. Almost
+immediately the king began to get better. His improvement was quite
+naturally attributed to the last drug that he had taken, and antimony
+regained and held its remedial reputation for the next two centuries.
+
+Such stories have always worked wonders in producing popular faith and
+even professional confidence in drugs. When great personages seem to
+be cured by certain remedies, ordinary logic ceases to act, and the
+strong power of suggestion comes in to strengthen whatever remedial
+influence there may be.
+
+
+Calomel and Suggestion.--Such mistaken notions as to therapeutic
+efficiency are not confined to centuries before our own. During much
+of the nineteenth century calomel was employed as extensively as
+antimony had been in preceding centuries. Calomel was often given in
+doses which produced effects resembling those of antimony. Even in the
+small doses we now employ, it is apt to be a thorough purgative. In
+the twenty and forty grain doses, commonly administered by the country
+doctors of two generations ago at the beginning of practically every
+ailment, it was purgative--and worse. Its effects could, of course, be
+very strikingly seen, and what patients wanted were just such visible
+results of the doctor's prescription. Undoubtedly, then, the calomel
+did good, but not by its effect upon the patients' bodies, but upon
+their minds. Calomel is still used in ways that partake more of the
+old-fashioned ideas than we care to confess. Some of its supposed
+effects in stimulating the flow of bile have been placed in doubt by
+modern investigation, but we still use it empirically, and undoubtedly
+its effectiveness is partly due to the fact that many patients see the
+results in the purgation in dark coloration of the stools and are
+confident that improvement must follow--and it does. Perhaps at a
+subsequent operation we find the bile ducts effectively blocked and
+then learn for certain that the stool coloration observed was not
+biliary but due to a chemical reaction of the calomel itself.
+
+
+Venesection and Its Suggestiveness.--Between the periods of antimony
+and calomel popularity venesection was the favorite remedy of
+physicians. It is hard to understand now the extent to which this
+practice was carried by the medical profession. People were bled for
+nearly every combination of symptoms. In severe cases the amount of
+bleeding practiced was almost incredible. Mirabeau, the great French
+orator, suffering from angina pectoris, was bled some eighty ounces in
+the course of forty-eight hours. In spite of this heroic treatment,
+which his physicians thought ought to have cured him, he died. We find
+it hard to understand how he lived so long. This, of course, was an
+exceptional case at the very height of the venesection furor, but it
+helps us to realize how convinced physicians were of the curative
+power of the practice.
+
+{28}
+
+Thoughtful physicians like Morgagni did not accredit it, or at least
+refused to allow it to be practiced on themselves, but its acceptance
+was practically universal. Probably no remedial measure ever generally
+used was calculated to be so effective as bleeding in producing a
+strong mental influence. The rather sacrificial preparations for it,
+the sight and the prick of the lancet, then the sight of the blood,
+the languor that followed, the reaction on nature's part to reproduce
+the lost material, all united to impress the patient's mind so deeply
+that it is easy to understand that all the reserve of mental force was
+now directed toward helping nature in the cure of whatever disease was
+present. Venesection itself in nine out of ten cases probably did more
+physical harm than good, but all the good came from its suggestion.
+
+We are now apt to think of venesection as consisting only in the
+removal of some blood from a favorably situated vein, but we must not
+forget that in the olden time they bled from many veins, and that a
+particular vein was picked out because it was supposed to be connected
+in some way with the seat of the special trouble under treatment, and
+as a result there was a particular appeal to mental influence. A vein
+on the forehead was opened for the treatment of migraine and diseases
+of the eyes, on the nose in case of discharge from the eyes, back of
+the ears in chronic headache and in stuporous conditions, or beneath
+the chin when there was pain in the eyes, or in the nose, or in the
+jaws. The cephalic vein was opened for headache and for certain
+affections of the eyes and ears. Altogether there were thirty
+different veins opened for as many maladies. It was thought extremely
+important in the drawing of blood from the arm that that arm should be
+chosen which, for some anatomical or other reason, was supposed to be
+the more intimately connected with the affected part of the trunk or
+head. The psychotherapeutic factors at work in these cases are easy to
+understand, and their beneficial effects gave the practice a firm
+foothold in medicine.
+
+
+Quinine and Suggestion.--Whenever any drug has secured a reputation
+its use has always been extended to many other diseases besides that
+for which it was definitely indicated. Quinine is a typical example.
+It is a specific for malaria and, properly administered in suitable
+doses, breaks up the fever--not because of any action upon the febrile
+condition itself, but because it kills the _Plasmodium malariae_ whose
+reproduction in the blood brings about the paroxysms of fever. It was
+argued, however, that since quinine was good for one kind of fever it
+would probably be good in others, and all sorts of theories were
+invented and supported by supposed observations of the effect of
+quinine on various organs and tissues, even on the white blood cells,
+by which its efficacy in fever was supposed to be explained. Quinine
+was used in all sorts and conditions of fever, and acquired a
+reputation as a remedy that had the power even to abort conditions
+leading to all fevers. It was used in large doses for such conditions
+as cold, incipient pneumonia, or indeed any disease with a chill at
+the beginning, and was supposed to be a powerful prophylactic.
+
+Now it is settled that while quinine in small doses is an excellent
+tonic, it has no effect at all upon fevers in themselves nor upon
+fever-producing conditions. Yet it is still administered by many who
+have not quite abandoned the old teachings as if it were a general
+febrifuge. In the meantime, the use of quinine as a prophylactic of
+colds and other minor febrile conditions has {29} spread so that many
+people make themselves very uncomfortable by taking a large dose of
+quinine and whiskey whenever they fear they are going to have a cold.
+As a consequence they feel dull and heavy the next day, but assume
+that they would have been much worse than they are had they not taken
+the potent remedy the night before. Undoubtedly some of them are
+enabled by the suggestive value of the remedy and the continued
+suggestion of its unpleasant effects to throw off the lassitude that
+comes from some minor infection and are encouraged to get out into the
+air, when they might otherwise have stayed in the house. This enables
+them to get rid of their colds sooner than would be the case if they
+allowed themselves to be confined. Most of them, however, are harmed
+rather than benefited, and the cold runs its course, unaffected except
+that the patient is more miserable and depressed for the first day or
+two than he would otherwise have been. There are physicians who still
+use quinine as a febrifuge in typhoid and other essential fevers, and
+doubtless its bitter taste helps their patients because of the
+suggestive value of an unpleasant medicine.
+
+
+St. John Long's Liniment.--An interesting exemplification of the power
+of mystery in adding to the curative value of a commonplace remedy is
+found in the story of the famous St. John Long liniment. St. John Long
+was a well-known quack in London in the early part of the nineteenth
+century. Like all quacks at all times, his specialty was chronic
+diseases. He claimed to be able by means of external applications to
+cure the pains and aches to which the old are so likely to be subject.
+St. John soon acquired an immense reputation. He gave a liniment with
+a secret formula that was literally a miracle worker. People who used
+it found after a few times that they were free from, or at least
+greatly relieved of, aches that had bothered them for years. It was
+good for sprains and for internal pains of all kinds, as well as for
+the so-called chronic rheumatisms, which have as their principal
+symptom pains and aches around joints. So great a reputation, indeed,
+was acquired by the remedy that an agitation was begun to have
+Parliament buy the secret from its inventor in order to present it to
+the British nation. The proposition was actually carried through the
+legislative chambers and a considerable amount of money, still larger
+in those days because of the comparatively greater value of money, was
+voted to St. John Long.
+
+His liniment had a place in the British Pharmacopeia under his name
+for many years afterwards. It proved to be only a simple old-fashioned
+remedy, the basis of which was turpentine, and one of the principal
+ingredients was the white of egg. Just as soon as the secret was known
+the power of the remedy began to decline. So long as it remained
+mysterious and unknown, discovered by a man who supposedly had made a
+special study for many years of these conditions, and had finally
+worked out the external applications necessary for them, it
+accomplished wonders. Just as soon as it was known to be a combination
+of familiar turpentine and egg it lost its power. The remedy is, of
+course, an excellent counter-irritant, and the gentle rubbing
+undoubtedly did much good. The most important element, however, was
+the mental influence, the feeling that now things must be better,
+which thought distracted attention from the aches and pains and caused
+the unfavorable influence of over-concentration of mind on the part to
+cease, for the vaso-motor system is particularly under mental
+influence. Every now and then since that time some {30} liniment or
+oil containing nearly the same ingredients as that of St. John Long's
+acquires a reputation as a consequence of a campaign of advertising.
+It is the printers ink that counts, however, and just as soon as the
+advertising ceases to attract attention the remedy fails in
+efficiency.
+
+
+Alcohol Plus Suggestion.--Alcohol has been employed in medicine with
+the persuasion that it is a remedy for many states of exhaustion,
+though we have gradually gotten away from its use to a great extent,
+because we realize that subsequent physical ill consequences outweigh,
+in most cases, the physical good it may do. Its use was undoubtedly
+due to the confidence of physicians communicated to patients, and the
+sense of good feeling which it gives and which proves a further strong
+suggestion to the patient. This sense of well-being is illusory, for
+it is sure to be followed by a longer period of dejection, which more
+than counteracts it unless the dose of alcohol can be maintained for
+some time.
+
+A generation ago few physicians would have cared to treat exhausting
+diseases, the continued fevers for instance, without liberal doses of
+alcohol. Practically the only treatment for pyemia and septicemia on
+which any stress was laid, and in which there was any general
+confidence, was the administration of alcohol in large quantities. In
+the septicemia consequent upon puerperal infection it was the common
+teaching to give alcohol by the tablespoonful or more every hour, or
+oftener, until its effects began to be noticed, and ordinarily large
+quantities were required, so that sometimes nearly a quart was taken
+in the twenty-four hours. Undoubtedly these septic conditions were
+accompanied by great mental prostration, and this was emphasized by
+the knowledge that they are often fatal. So patients were usually
+depressed into a state of mind in which their resistive vitality was
+much lowered. Alcohol, then, by producing a sense of well-being as
+well as by stimulating hope in other ways and suggesting possibilities
+of recovery, undoubtedly exerted a powerful and favorable influence on
+the mind. Its use in these cases nearly always did good, in spite of
+its inevitable depressive reaction, for the course of these infections
+was rapid and the dosage of alcohol could be maintained until there
+was a change for the better or the fatal termination was in sight.
+
+Alcohol was frequently used in many other conditions of a similar
+nature, and above all in the septic conditions so common in hospitals
+before the days of antisepsis and asepsis. When it is recalled that
+amputations yielded a mortality from sepsis of at least one in four,
+the extensive use of alcohol in hospital practice two generations ago
+will be readily understood. We have changed that, however, and Sir
+Frederick Treves, at a meeting of the British Medical Association at
+Toronto, five years ago, called particular attention to the statistics
+of the use of alcohol in British hospitals. During the last forty
+years milk and alcohol have exactly changed places in the London
+hospitals. Between 1860 and 1870 about four times as much was spent
+for alcohol as for milk in these hospitals; during the last decade
+about four times as much was spent for milk as for alcohol.
+
+A corresponding change has taken place in many other phases of
+treatment in which alcohol was commonly used. The physician of fifty
+years ago would have thought that one of his most efficient remedies
+had been taken from him if he could not use alcohol freely in
+tuberculosis. There are practically no well-known specialists in
+tuberculosis now who recommend the use {31} of alcohol. On the
+contrary, most of them point out the dangers from its use and consider
+that the depression which follows even a moderate dose is likely to do
+much more harm than the temporary and fleeting stimulation which it
+gives can do good. In the treatment of phthisis in recent years milk
+has done much more than take the place of alcohol: it has displaced it
+entirely. The medical profession realizes now that what the
+consumptive needs is not more stimulation--for more of that than is
+good for him is forced upon him by the toxins of the disease--but more
+nutrition to enable him to resist the progress of the disease and
+raise his resistive vitality against its toxemia. The one stimulant
+that is of service in the affection is oxygen, and even that should be
+given in nature's dosage rather than by artificial means.
+
+
+_Alcohol in Pneumonia_.--A corresponding change has taken place in the
+professional attitude towards the use of alcohol in pneumonia. There
+was a time not so very long ago when alcohol was considered the sheet
+anchor of our therapeutics for pneumonic conditions, especially those
+in which from the beginning a fatal termination seemed inevitable,
+because of the age of the patient or some complication. There were
+physicians who said that if they had to choose between all the drugs
+of the pharmacopeia on the one hand without whiskey and whiskey
+without all drugs whatsoever, for the treatment of pneumonia, they
+would make the latter choice. We are not as yet entirely away from the
+point of view that attributes a certain value to alcohol in pneumonia,
+though even those who still employ alcohol are less emphatic in their
+advocacy of it. Any one who has seen the result of the fresh air for
+pneumonia patients will think less and less of alcohol. One well-known
+clinical authority declares that the very best place to treat
+pneumonia in our cities would be beneath the trees in the parks. Our
+patients are being treated at the ends of wards with the windows up,
+on the balconies, and on the roofs, and the death rate is much reduced
+and the necessity for any other than oxygen stimulation seems much
+less.
+
+
+_Alcohol in Vague Affections_.--The suggestive influence of the effect
+of alcohol is unconsciously obtained in a number of vague and rather
+chronic affections. Among these the most noteworthy are women's
+diseases. Various alcoholic home remedies, gin and whiskey, usually
+disguised by some bitter, used to be popular. But the known presence
+of alcohol in these discredited them. Then the nostrum vendors
+proceeded to supply something just as good. They were, in fact, the
+same things under another name. Many of the much-advertised remedies
+that are supposed to cure the ills the weaker sex is liable to, have
+been found to be little more than dilute whiskey, for in alcoholic
+strength they were about equal to whiskey diluted once with water, and
+the other substances were added only to disguise the taste and the
+odor of this principal ingredient. Many of these remedies have
+elicited innumerable flattering testimonials and not all of these were
+fraudulent or obtained by questionable means, but many of them were
+given because of results secured through the remedies. The alcohol
+gave the well-known sense of well-being, and the suggestive influence
+of this increased the appetite, tempted the patient to move around
+more, and to get more into the air than before, and the consequence
+was an improvement in the general health, in the midst of which many
+symptoms that seemed to the excited imaginations of run-down
+individuals to be serious were relieved. In a great many cases,
+however, the result was the {32} formation of a whiskey habit; hence
+the crusade which has discredited these remedies.
+
+Other patent medicines, and, indeed, some of the proprietary
+preparations, commonly recommended as nutrients and the like, and
+supposed to be ethical, are found to owe whatever efficiency they have
+to their alcoholic content. Here once more the suggestive elements
+were the more important, and enabled substances of little physical
+efficiency to produce effects that seemed to indicate the presence of
+powerful energizing materials.
+
+
+_Whiskey in Snake-Bites_.--A typical example of a remedy which owes
+its efficacy to mental influence over the patient is the use of
+whiskey for snake-bites. It is generally recognized that whiskey is
+not only of no special beneficial effect for snake-bite, but that when
+taken in the large quantities usual in such cases it probably produces
+an ill effect by disturbing the patient's general condition and
+lowering his resistive vitality. I have no doubt, however, that its
+use in considerable quantities has in these cases proved of value
+because of the mental effect upon the patient. Ordinarily a snake-bite
+is followed by a sense of extreme terror and prostration that lowers
+the resistive vitality. This is overcome by the temporary stimulation
+of the alcohol. The generally accepted idea that whiskey is almost a
+specific remedy for snake-bite takes away from most people this dread
+and consequent depression, and does this especially at a time when the
+acuter symptoms of the venom are making themselves felt. Only about
+one in six even of those bitten by large rattlesnakes are likely to
+die. Many circumstances are in their favor. The bite is not likely to
+be fatal unless the full contents of the poison sac is injected--which
+will not be done if the sac has been emptied in the preceding
+twenty-four hours--and if there are any obstacles, such as clothing or
+even hair, on the part struck by the snake. Most people, however,
+would almost die from fright, and such a thing is quite possible, if
+they thought there was no remedy. The fact that they understand that
+alcohol is an almost infallible remedy gives them courage, and as soon
+as they receive some whiskey and it begins to take effect this intense
+depression is relieved.
+
+It would be better if the knowledge we now have as to snake-bites were
+more generally used, and if people understood that only rarely is such
+an accident fatal. In this way there would be no necessity for an
+appeal to mental influence through whiskey. It is probable, however,
+that alcohol will still be used for many years, at least in the
+country districts, because the supposed knowledge is too widely
+diffused for a correction to come soon, and then other modes of
+treatment have not that persuasive mental influence which whiskey has
+as the result of the long tradition. There are many other popular
+remedies for snake-bite not quite so inefficient as whiskey, but that
+will continue to enjoy a reputation and really have a certain
+efficacious result as a consequence of the expectant attitude evoked
+by the fact that for as long as the patient has heard anything about
+these things this particular remedy has been mentioned always as the
+one thing sure to do good.
+
+
+Other Cures.--Fontana, toward the end of the eighteenth century, was
+sure that he had discovered in caustic potash an absolute specific for
+snake poisoning. He had had a series of cases, and felt that he had
+actually observed this substance following the snake poison into the
+system and neutralizing it. Its active effect on the external tissues
+proved eminently suggestive for {33} the patient and good results
+followed. We have had many specifics since, and yet we are not quite
+sure how much any of them avail unless recent biological remedies
+prove lasting in their effects and are really of therapeutic
+efficiency.
+
+
+Antidotes and Suggestion.--For many other poisons beside snake venom
+there have been announced supposed antidotes of all kinds. The
+literature of the antidotes used for opium is extremely interesting
+and even in recent times contains many disillusions. Twenty years ago
+our medical journals contained any number of cases in which a solution
+of potassium permanganate seemed to have proved effective in
+neutralizing not only opium itself but its alkaloids and derivatives.
+Not only was it efficacious, then, if taken while the opium was still
+in the stomach but, just as with Fontana's caustic potash and the
+snake venom, it followed the opium into the tissues and at least
+blunted its action. Numbers of cases were reported in which potassium
+permanganate was supposed to have had this desirable effect. The
+effect of alcohol in neutralizing carbolic acid attracted as much
+attention as did potassium permanganate for opium. Here there was no
+doubt that alcohol immediately after the external application of
+carbolic acid did prevent its corrosive action. It was supposed to do
+the same thing in the stomach and even, as some enthusiastic observers
+thought, followed the carbolic acid into the tissues. Here once more
+the claim is not proven and it is evident that the influence on
+patients' minds when small doses of carbolic acid were taken, was the
+real therapeutic factor at work.
+
+
+Poultices in Suggestive Therapeutics.--Poultices represent another
+phase of the value of suggestion in medicine and surgery, though for
+many centuries those who used them were sure that the reasons for
+their employment were entirely physical and not psychic. All sorts of
+poultices have been used and each was supposed to do specific curative
+work. New forms of poultice material have been introduced, and
+physicians and patients have been certain that each worked wonders of
+its own. The drawing power of the poultice was extolled until patients
+dwelt on the idea that this external application was literally engaged
+in extracting from them, even from distant portions of their anatomy,
+virulent material that would do harm if allowed to remain in them.
+Poultices in suitable cases, because they represent moist heat, do
+good by counter irritation, by bringing about the expulsion of gas, by
+diverting internal hyperemia to external tissues, but most of their
+supposed efficacy has been really due to the bother required to
+prepare and apply them, the discomfort of having them on, and the
+feeling that now something had been done and the aches and pains must
+get better. They are still used, but to a much less degree than
+before. Now the ordinary teaching is that a hot water bag wrapped in
+dry flannel, if dry heat is the agent desired, and in moist flannel,
+if moist heat is the desideratum, is much more efficient. It takes but
+a few minutes for a poultice, no matter how hot when applied--and
+occasionally in the olden time they were applied so warm as to burn or
+scald--to decrease in temperature to that of the body. After that they
+represent only a moist compress.
+
+It is easy to understand that the suggestive influence of poultices
+might serve for an age that knew less about the realities of the
+efficacy of external applications than ours. As a matter of fact, we
+have, nevertheless, shown ourselves to be quite as credulous and ready
+to receive analogous remedies as the past generation. With the waning
+of the popularity of the poultice, not {34} only among the profession,
+but also among the people generally, there came into use various
+plasters which were supposed to have even more wonderful efficacy than
+the poultice of the olden time. These required a good deal of trouble
+to apply and once applied remained on for hours, and so continued to
+produce a definite curative effect on patients' minds. When first
+introduced, exaggerated claims were made for their therapeutic value
+and a regular crusade to diffuse correct information regarding them
+had to be made, in order to set them in their proper place as mere wet
+compresses, without any therapeutic efficiency beyond that of cloths
+wrung out in water and kept in touch with the skin.
+
+
+_Poultices and the Doctrine of Signatures_.--There was a general
+impression in the past that the indication of the ailment for which
+substances are medically useful has been set on them by nature, either
+through the color, or the form of the plant, or other qualities. In
+general, the law of similars is supposed to hold in the doctrine of
+signatures--like cures like. Hence the cornmeal poultice for light
+jaundice, the flax-seed meal poultice for darker jaundiced conditions
+and for tendencies to gangrene. The charcoal poultice was employed for
+this same purpose with no better reason, though some of its efficacy
+may have been due to oxygen present in the pores of the charcoal. I
+have already spoken of the appeal to the patient's mind in the use of
+the cranberry for erysipelas, and various other berries were used in
+like manner on the doctrine of signatures.
+
+
+_Deterrent Materials and Suggestion_.--Another basic principle in the
+making of poultices was the use of deterrent, repulsive materials,
+because these were more effective on the patient's mind. All the
+ordures were so employed. Goose and chicken excrement was supposed to
+be particularly efficacious for many of the purposes for which we now
+use iodine. It was applied over sprains and bruises on the unbroken
+skin. Cow-dung was employed as a poultice for sprains of the larger
+joints, especially on the feet and legs, but to be efficacious it had
+to be applied fresh. I have known, within twenty years, of physicians
+in two so supposedly cultured parts of the country as Pennsylvania and
+Maryland, to employ such ordure poultices for the cure of sprains and
+dislocations, and these physicians had a great reputation among the
+people of their countryside. They were known especially as good bone
+doctors, and their use of such deterrent materials instead of
+decreasing their practices rather added to them.
+
+
+Ointments.--In the Middle Ages ointments made of the most far-fetched
+materials were employed even by distinguished surgeons. That, indeed,
+is the one serious flaw in the surgery of the thirteenth and
+fourteenth centuries, when they did everything else so well. These
+ointments contained all manner of materials that were likely to
+impress patients and make them feel that something wonderful was being
+done for them. Crushed insects of all kinds were employed for external
+lesions. Here the doctrine of similars seems once more to have been in
+play. Insects gave creepy feelings, and whenever such feelings, or the
+paresthesiae generally, were complained of, a poultice or ointment
+made of insects seemed to be the natural remedy. The more repellent
+the materials, the more efficient they were likely to be. Many of the
+paresthesiae are due to neurotic conditions and it is not surprising
+that when an ointment of crushed lice--these insects being collected
+from barnyard {35} fowls or from hogs--was used, the suggestive
+influence was strong. Another important ingredient in ointments were
+portions of dead bodies. A bit of a mummy from the East was supposed
+to be particularly efficacious. Portions of the bodies of men who had
+been hanged, or of the moss that grew on the skulls of malefactors
+whose bodies had been long exposed in chains to the air, were also
+favorite ingredients. Plants and shrubs gathered in graveyards,
+especially in the dark of the moon, because on account of the terror
+of the place they were then harder to get, also had a great
+reputation.
+
+
+
+CHAPTER IV
+
+SIGNATURES AND PSYCHOTHERAPY
+
+_Similia similibus curantur_, like is cured by like, is a very old
+idea. According to the doctrine of signatures nature had put an
+external natural marking or a symbolical appearance or characteristic
+upon a plant, mineral or other object, to indicate its special
+usefulness for the treatment of certain diseases or for affections of
+certain organs. Sir Robert Boyle, sometimes spoken of as the father of
+chemistry, said, "Chymists observe in the book of nature that those
+simples that wear the figure or resemblance, by them termed signature,
+of a distempered part, are medicinal for that part or that infirmity
+whose signature they bear." On this principle yellow flowered plants
+were good for jaundice, because they resembled it in color. The blood
+stone was good for hemorrhage, and plants of certain forms were good
+for the organs or parts of man which they resembled. Certain plants
+were named with this idea. Kidneywort, liverwort, are typical
+examples. Scorpion grass, our familiar forget-me-not of the _genus
+myosotis_, was so-called because its spike resembled a scorpion's tail
+and was, therefore, good against the scorpion's sting, or against
+pains similar to that produced by such a sting. Some of the
+resemblances were extremely far-fetched, but in spite of the defect of
+nature's signature on them, they seem to have been effective in
+therapeutics. The plant, sometimes called Jew's ear, which can by an
+effort of the imagination be made to bear resemblance to the human
+ear, was, for instance, supposed to be a successful cure for diseases
+of that organ.
+
+We know now that there is no significance in this doctrine of
+signatures. It represented one phase of pseudo-science. But the idea
+of itself was enough to help people to throw off many symptoms, to
+relieve discouragement, to encourage them with the thought that they
+ought to get better; accordingly they took new heart, ate better, went
+out more, and as a result naturally slept better, and then nature did
+the rest. Signatures are an exquisite example of pure psychotherapy,
+as the initial agent and natural curative methods accomplishing the
+cure.
+
+
+Signature Details.--Some of the details of the doctrine of signatures
+are amusing. For a considerable period nuts were supposed to be a good
+brain food, and some traces of this idea are still extant, although
+there does not seem to be any better reason for it than the fact that
+many nuts have an arrangement of their lobes which resembles the
+conformation of the brain. On the same principle the Chinese use
+ginseng-root as a general tonic. The extract is not {36} of any
+special significance in medicine, though it has come to be much
+advertised in recent years, and the Chinese continue to pay high
+prices for it. The reason is that the root of the ginseng plant often
+resembles the human body. The more nearly this resemblance can be
+traced, the more virtue there is for the Chinese in the particular
+specimen of ginseng. The signature is on the roots. It is good for man
+because it looks like man, just as the nuts are good for the brain
+because they look like the brain. In modern times we are likely to
+think that we are far away from any such self-deception. But our
+deceptions have a more appealing pseudo scientific element in them.
+Fish was for some time considered a good brain food because fish has
+phosphorus in it and so has the brain. The two reasons have as much
+connection as that between nuts and the brain; or ginseng and man.
+
+Astrological ideas came in to help out ignorance and foster supposed
+knowledge. The sun and the stars were favorable planets and the moon
+unfavorable. If anything about a plant reminded the gatherer of the
+sun or the stars, then that plant was sure to be beneficial,
+especially in chronic diseases. If anything reminded him of the moon,
+however, then it could be expected to be maleficent in influence.
+Though childish, this had yet its power to help.
+
+The use of nitrate of silver, which in the old days was called lunar
+caustic, because it had, in a fresh state, a silvery, moon-like sheen,
+was largely a matter of signatures. The signature went both by
+similitude and by contrary. Since the lunar caustic supposedly had a
+moon quantity, therefore it would be good for moon-struck people--the
+lunatics of the old time and of our own time. As a consequence nitrate
+of silver was used in many obscure nervous and mental diseases. In
+epilepsy it was commonly employed. Even in our own times, entirely on
+empiric grounds, it was used for such severe organic nervous diseases
+as locomotor ataxia and sometimes to such an extent as to produce
+argyria. Undoubtedly, its use, with confidence on the part of the
+physician and suggestion and persuasion on the part of the patient,
+did much to relieve sufferers from discouragement and from such
+psychic disturbance of their general health as would have made their
+condition seem worse.
+
+
+Wines as Remedies.--How much suggestibility means in the choice of
+remedies that of themselves are more or less indifferent, may be well
+judged from the recommendations with regard to various wines that have
+been made by physicians. At one time and place it is red wine, at
+another it is white wine that is particularly effective. For certain
+nations the stronger wines, as Port or some of the Hungarian wines,
+have appeared to exercise specific effects. Except for the tastiness
+of these various brands or for other trivial accessories, it is
+probable that the therapeutic efficacy of the wine depends entirely on
+the alcohol and the effect of this upon the patient. In his "Memories
+of My Life," Francis Galton relates that Robert Frere, one of his
+fellow pupils with Prof. Partridge, who became through marriage in
+later years a managing partner in a very old and eminent firm of wine
+merchants, told him that the books of the firm for one hundred and
+fifty years showed that every class of wine had in its turn been
+favored by the doctors.
+
+In prescribing wine the doctrine of signatures probably had more to do
+with the special choice than anything else. Red wines were recommended
+for anemic people, because somehow the coloring was supposed to affect
+the {37} patient in such a way as to make up for the lack of coloring
+in the blood. On the other hand, the light, and especially the
+straw-colored wines, were recommended for liver troubles, because of
+their relation in color to the yellow of bile. Light wines were best
+for people who had more color than normal. Some wines are much
+stronger than others, and the alcohol, as in so many of our patent
+medicines, had a stimulating tonic effect, but in olden times this was
+supposed to constitute only the smallest portion of the efficiency of
+the wine, while the ingredients that made its color and taste were
+extremely important. The taking of red wine by anemic patients often
+proved suggestively valuable, and the alcoholic stimulation led them
+to eat more freely and look at things more hopefully and,
+consequently, to improve in health more rapidly than would have been
+the case had they not had the feeling that somehow they were actually
+consuming elements that would make their blood red.
+
+
+Precious Stones.--The doctrine of signatures applied particularly to
+precious stones, and many of the popular medical superstitions with
+regard to precious stones were founded on it. The blood stone was said
+to be efficient as a tonic: it stimulated people: it made the anemic
+stronger and ruddier if it were worn on the fingers. The torquise
+turned pale when its owner was in poor health. It was the stone that
+was an index of what has been called "the blues" or what one modern
+writer has dignified by the title "splanchnic neurasthenia." Dr. Donne
+wrote of:
+
+  A compassionate turquoise that doth tell
+  By looking pale, the owner is not well.
+
+It is probable that the pallor of the patient's hands as the
+background to the stone made the difference in its appearance thus
+noted. It became deeper in hue, as it were, when people were in ruddy
+health. The suggestive influence of such beliefs is easy to
+understand. It is even possible that the wearing of an amethyst did
+help to keep people from indulging in liquor to excess, for that is
+the traditional effect of the wearing of this stone, though its virtue
+seems to be founded on nothing better than the supposed derivation of
+the name from the Greek _a_ privative and _methuo_, "I get drunk,"
+suggesting strongly to the wearer that he should not get drunk.
+
+The jacinth superinduced sleep and doubtless the strong suggestion of
+this supposed influence helped many sufferers from so-called insomnia
+to get sleep. The single fixed idea that now they must get to sleep
+would greatly help them. Pillows in the olden time were occasionally
+set with bits of jacinth, and there is even the record of bed-linen
+embroidered with it. This would probably be quite as effective as are
+hop-pillows in the modern time, for their main influence, as is also
+true of pine pillows, seems to be through suggestion. Some other
+traditions with regard to precious stones are harder to understand,
+yet may be explained. The owner of a diamond was supposed to be
+invincible. Diamonds represented money and money meant power. It is
+harder to explain the tradition that the possession of an agate made a
+man able and eloquent.
+
+The wide acceptance of the doctrine of signatures, and of allied
+ideas, as to the effect of precious stones and metal and jewelry upon
+disease, makes {38} it clear that the acceptance of a mental
+persuasion with the changes in habits that follow, may serve as the
+basis of a successful system of therapeutics. The materials associated
+with the idea had absolutely no more physical influence than does the
+carrying of a horse chestnut or a potato in the pocket serve to keep
+off rheumatism.
+
+
+
+CHAPTER V
+
+PSEUDO-SCIENCE AND MENTAL HEALING
+
+An interesting phase of psychotherapy is found in the history of the
+applications of new scientific discoveries to medicine. The
+development of every physical science has been followed by an attempt
+to apply its new principles and discoveries to the treatment of
+disease. Such applications have nearly always been followed by
+excellent results at the beginning. But almost without exception, the
+medical significance of these discoveries has, after a time, been
+found to be _nil_. When these discoveries were made they became the
+center of public attention. The announcement of their application to
+medicine then seemed natural and produced a feeling that another great
+therapeutic principle had been discovered. Sometimes wonderful
+therapeutic effects were noted. The chronic diseases particularly were
+helped for some time, at least, and practically all the affections
+that have mainly subjective symptoms were greatly relieved, or
+actually cured. After a time, however, when the novelty of the
+discovery wore off, its suggestive power was lessened and then the
+remedy lost its therapeutic power.
+
+
+ASTROLOGY
+
+Astrology is the typical example of pseudo-science in medicine. The
+stars, and particularly the planets and the moon, were supposed to
+have great influence on human destiny, human health, and human
+constitutions. Astrology was an organized body of knowledge over 3,000
+years ago. Mr. Campbell Thompson has recently translated a series of
+300 inscriptions from the cuneiform tablets in the British Museum, and
+Professor Südhoff of Leipzig has compiled all the references to
+medicine in these. The latter's studies show the extent which star
+influence was supposed to have over human health. A halo round the
+moon, an obscuration of the constellation of Cancer, the pallor of a
+planet in opposition to the moon, the conjunction of Mars and Jupiter,
+and other movements and phenomena of heavenly bodies were supposed to
+foretell the approach of disease for man and beast.
+
+As a consequence of this application of astrological knowledge to
+medicine, operations were performed only on certain favorable days or
+under favorable conjunctions of planets. An ailment that occurred at
+an unfavorable time, because of an unpropitious state of the heavens,
+would not be relieved until the motions of the stars brought a more
+benign conjunction. Observations seemed clearly to indicate that the
+stars actually had such influences. Even Hippocrates, though he
+insisted that "the medical art requires no basis of vain presumption,
+such as the existence of distant and doubtful factors, the {39}
+discussion of which, if it should be attempted, necessitates a
+hypothetic science of supra-terrestrial of subterrestrial belief,"
+could not entirely get away from astrology. In his treatise on "Air,
+Water and Locality" he writes: "Attention must be paid to the rise of
+the stars, especially to that of Sirus as well as the rise of
+Arcturus, and after these to the setting of the Pleiades, for most
+diseases in which crises occur develop during these periods." In the
+second chapter he writes: "If anyone would be of the opinion that
+these questions belong solely in the realm of astrology, he will soon
+change his opinion as he learns that astrology is not of slight, but
+of very essential importance in medical art." (Personally I doubt the
+Hippocratean authorship of these passages, but they are surely very
+old.)
+
+The influence of the suggestions derived from astrology on human
+patients continued until almost the nineteenth century. There were
+many protests, especially from the Doctors of the Church, that the
+applications of astrology to medicine were false, but the practice
+continued. Both Kepler and Galileo drew horoscopes for patrons, and
+while Kepler doubted their value, he felt that in making them he was
+justified by custom. Galileo drew up the horoscope of the Grand Duke
+of Tuscany during an illness, and declared that the stars foretold a
+long life, but the Duke died two weeks later. But incidents of this
+kind did not disturb either popular faith or medical confidence in
+astrology as helpful, in prognosis, at least, if not also in
+diagnosis. Even so late as 1766 Mesmer was graduated at the University
+of Vienna, when it was doing the best medical work in Europe, with a
+thesis on "The Influence of the Stars on Human Constitutions."
+
+
+Later Astrology.--Few now realize that the curious figure printed at
+the beginning of most of our almanacs down to the present day is a
+relic of the time when physicians believed in the influence of the
+constellations over the various portions of the body. Even yet this
+idea has not entirely gone out of the popular mind, and hence its
+retention as something more than a symbol in our little weather books.
+Man was considered as a little world, a microcosm, and the universe,
+as men knew it--the sun, the moon and the planets
+together--constituted a macrocosm. It was observed that the bodies
+constituting the universe were circumscribed in their movements and
+never went out of a particular zone in the heavens which was called
+the zodiac. This zodiac was divided into twelve equal parts called
+signs or constellations. Similarly man's body was divided into twelve
+parts, of which each one was governed by a sign of the zodiac or by
+the corresponding constellation. The ram governed the head; the bull
+the neck; the twins the paired portions, shoulders, arms and hands;
+the crab the chest; the lion the stomach, and so on. The old surgical
+rule, as quoted by Nicaise in his edition of Guy de Chauliac's "Grande
+Chururgie," was that the surgeon ought not make an incision, or even a
+cauterization, of a part of the body governed by a particular sign or
+constellation on the day when the moon was in that particular portion
+of the heavens, for the moon was supposed to be the bringer of
+ill-luck and to have untoward influences. The incision should not be
+made at these unfavorable periods for fear of too great effusion of
+blood which might then ensue. Neither should an incision be made when
+the sun was in the constellation governing a particular member,
+because of the danger and peril that might be occasioned thereby.
+
+{40}
+
+Such rules were supposed to be founded on observation. Patients were
+influenced by them mainly because they were assured that the surgical
+treatment was undertaken under the most favorable influence of the
+stars and that all unfavorable influences had been carefully observed
+and eliminated. It is hard for us to understand how such ideas could
+have been maintained for so long in the minds of men whose other
+attainments clearly show how thorough they were in observing and how
+profoundly intelligent in reaching conclusions. We should, however,
+have very little censure for them, since from some other standpoint we
+find every generation, down to and including our own, jumping at
+conclusions just as absurd and just as inconsequential. And the
+practice of astrology was not without its value, for the reassurance
+given patients by the consciousness that the stars were favorable did
+much to relieve their anxiety as to the consequences of surgery,
+lessened shocks, hastened convalescence, and favored recovery.
+
+
+HERBAL MEDICINE
+
+What is thus exemplified in astronomy and astrology can be found in
+the story of every other science. After the knowledge of the stars,
+the next organized branch of information that might deserve the name
+of science related to plants. This, too, was introduced into medicine,
+and with more justification than astrology. Most of what was
+accomplished by early herbal medicine was, however, due to the
+influence produced on the mind rather than to any physical influence
+tending to correct pathological conditions. The shape and color of
+plants, their form, the appearance of their leaves, were all supposed
+to indicate medical applications for human ailments. The reason for
+their acceptance was entirely the ideas associated with the plants and
+not any definite therapeutic effect. Whatever good nine-tenths of all
+the herbal medication accomplished certainly was by means of the
+influence on the mind. We have abandoned the use of most herbal
+remedies in recent years, even many that are still retained in the
+pharmacopeia, because we have realized their physical incapacity for
+good.
+
+
+
+ALCHEMY
+
+When chemistry, under the old name of alchemy, began to develop, its
+first study was of minerals, and just as soon as a body of knowledge
+was acquired chemistry was applied to medicine. All the investigators
+were engaged in searching for the philosopher's stone, the substance
+by means of which it was hoped to change base metals into precious. It
+was generally believed that when this substance was found, it would
+have wonderful applications to human diseases and would transmute
+diseased tissues into healthy tissues in the same way that it
+transformed metals. It was felt that the philosopher's stone would be
+an elixir of life as well as a master of secrets for wealth. This
+would seem amusingly childish to us were it not for the fact that in
+radium we, too, seem to have discovered a philosopher's stone--a
+substance that transmutes elements. For some years after its discovery
+{41} we were inclined to think that it must have some wonderful
+application in medicine and in surgery, and we actually secured many
+good results until its suggestive value wore off.
+
+The fact that much had been learned about chemicals persuaded men that
+they must be beneficial to human beings. Thus they were taken with
+confidence and produced good results. When our modern chemistry
+developed out of alchemy a great variety of drugs began to be used,
+and long, complex, many-ingrediented prescriptions were written.
+Polypharmacy became such an abuse that the time was ripe for
+Hahnemann, whose principles, if carried to their legitimate
+conclusions, would require his disciples to give practically nothing
+to patients and treat them entirely by suggestion.
+
+
+
+MATHEMATICAL MEDICINE
+
+When mathematics developed, applications of that science were made to
+physiology and to medicine. Under the influence of Borelli, the school
+of Iatro-Mathematical medicine developed and it flourished long after
+him. Foster, in his "History of Physiology," says:
+
+  Borelli was so successful in his mechanical solutions of
+  physiological problems that many coming after him readily rushed to
+  the conclusion that all such problems could be solved by the same
+  methods. Some of his disciples proposed to explain all physiological
+  phenomena by mathematical formulas and hypotheses concerning forces
+  and the shapes and sizes of particles.
+
+
+
+MAGNETISM
+
+Magnetism occupied a large place in the minds of the great thinkers of
+the sixteenth and seventeenth centuries. There is no doubt that
+Paracelsus accepted, quite literally, what we embody in figurative
+expressions with regard to magnetism. To him the attraction of sex was
+magnetic. People had personal magnetism because they possessed
+physical powers by which they attracted others. He considered that
+these powers of attraction were expressions in human beings of the
+power of the magnet in the physical world, and that the two were
+literally equivalents. Kepler, one of the deepest thinkers of his
+time, evidently entertained the idea that the magnet represented the
+soul of the physical world, and that the planets were held in
+connection with the sun and their satellites with the planets, by
+magnetic attraction. We now call it the attraction of gravitation. We
+understand the force no better than before, but have changed the
+terms. Descartes theorized much along magnetic lines, and felt that by
+the use of certain expressions he was adding to knowledge, though he
+was really only multiplying terms.
+
+
+Human Magnetism.--How seriously the question of human magnetism was
+taken will perhaps be best appreciated from one old fallacy. For a
+long period it was supposed that human beings were so highly magnetic
+that if a man were exposed in an open boat, in perfectly calm weather,
+in the open sea, where no currents would disturb him, his face would
+turn to the north, under the same magnetic influences as caused the
+needle to point to the north! Many studies of magnetism were made at
+this time, so that the subject {42} attracted widespread attention.
+Columbus had made some rather startling observations on his voyage to
+America with regard to the declination of the magnetic needle, and,
+during the century following, Norman and Gilbert made interesting
+studies in the same subject. Father Kircher wrote two books on
+magnetism and there were a number of others written by university
+professors. Advantage was taken of this thoroughly scientific interest
+in magnetism to erect a whole body of pseudo-scientific medicine
+supposed to be founded on magnetic principles. The same theories were
+also applied to supposed explanations of various psychological
+phenomena.
+
+During the sixteenth and seventeenth centuries the application of
+magnets was a favorite treatment for a great many diseases. Especially
+were they useful in the treatment of muscular pains and aches and the
+chronic diseases which so disturbed men's minds. Many of the joint
+troubles of the aged, the muscular pains and aches that develop from
+the wrong use of muscles, and the vague internal discomforts which
+often disturb men so seriously, were cured by the application of
+magnets. Perkins' success with his tractors shows how much can be
+accomplished in this way.
+
+
+
+ELECTROTHERAPY
+
+The great development of pseudo-science in medicine remained for the
+era following the scientific investigation of electricity. With the
+discovery of the Leyden jar and its startling spark, a new and
+marvelous healing agent seemed to be at hand. It is quite amusing to
+read the accounts of the influence of the spark of the Leyden jar on
+the well and on the ailing. In my "Catholic Churchmen in Science"
+(Dolphin Press, Phila., 1909) I summed up the situation.
+
+  Winckler of Leipzig said that the first time he tried the jar, he
+  found great convulsions by it in his body; it put his blood into
+  great agitation; he was afraid of an ardent fever, and was obliged
+  to use refrigerating medicines. He felt a heaviness in his head as
+  if a stone lay upon it. Twice it gave him a bleeding at the nose.
+  After the second shock his wife could scarcely walk, and, though a
+  week later, her curiosity stronger than her fears, she tried it once
+  more, it caused her to bleed at the nose after taking it only once.
+  Many men were terrified by it, and even serious professors describe
+  entirely imaginary symptoms. The jar was taken around Europe for
+  exhibition purposes, and did more to awaken popular interest than
+  all the publications of the learned with regard to electricity, in
+  all the preceding centuries.
+
+The extent to which the curative power of electric sparks from the
+Leyden jar was supposed to go is best appreciated from a list of the
+affections that one distinguished electro-therapeutist claimed could
+be not only benefited, but absolutely cured by its employment. It
+included pulmonic fever, under which title practically all the more or
+less acute diseases of the chest were included, and some at least of
+the sub acute; dropsy, by which was meant every effusion into the
+abdominal cavity no matter what its cause; dysentery, under which was
+included at that time not only the specific dysenteries but many of
+the summer complaints and some typhoid fevers; diarrhea, including all
+the intestinal diseases not already grouped under dysentery; putrid
+and bilious fever, under which category were assembled the worst cases
+of typhoid; typhus {43} fever, and all the other continued fevers, and
+any febrile condition reasonably severe for which no other term could
+be used; epidemic diseases, pest, anthrax, small-pox, cancer, gravel,
+diseases of the bladder and of the brain and spinal cord. The Leyden
+jar had no real effect on any of these affections, but doubtless the
+mental effect of this new remedy was quite sufficient to be of
+distinct therapeutic value in the milder forms of many of them.
+
+With Galvani's discovery of the twitching of the muscles of the frog
+there came a new impetus to the exploitation of electricity in
+medicine. Many felt that now it was beyond doubt that electrical
+energy bore some definite relation to vital energy--that one might be
+made to replace the other if indeed they were not more or less the
+same thing. This led to many applications of electricity in medicine.
+Students of physiology were convinced that they were getting close to
+the solution of the mystery of life, and their persuasion was readily
+carried over to the people of the time, so that electricity literally
+worked wonders on them.
+
+When the various electrical machines were invented and their use
+popularized, pseudo-science proceeded to exploit them, and succeeded,
+because the mechanical shock of the electric current proved a
+suggestive therapeutic stimulant. Gordon in the eighteenth century
+made the first practical frictional electrical machine, and soon some
+men were observing wonderful effects with it, though the charge was so
+small that it could actually accomplish little. Just after the
+invention of the voltaic pile in 1800 it came to be used in medicine
+with wonderful results. We are prone to think that electrotherapy is
+modern, but when electrical machines were quite crude, current
+strength small and potential low, old-time electro-therapeutists were
+recording their wonderful results and were getting just as marvelous
+effects as are reported now by enthusiasts. Considerable
+electro-medical literature existed a century ago when next to nothing
+was known of electricity. When, later, high potency currents came in
+and the Wimshurst and other powerful machines were invented, there was
+revealed at each novel invention a new horizon in electro-therapy and
+wondrous cures were reported. These continue to occur in the practice
+of a few favored individuals, though the general profession secures
+only some ordinary mechanico-muscular effects, which demand much time
+for real good to be accomplished and have nothing at all of the
+marvelous about them.
+
+The power of the pseudo-scientific aspect of electricity to influence
+patients, far from being lost in our time, has rather been increased.
+Our newspapers make their readers eminently suggestible because they
+constantly furnish suggestions, and nothing so strengthens a function
+of any kind as exercise of it. All sorts of electrical contrivances
+and apparatuses are advertised to cure various pains and aches. Many
+of them actually seem to relieve long-standing discomfort, though it
+is not through any electrical power that they do so, but entirely
+through their influence on the patient's mind. A museum of the
+electrical contrivances of various kinds for which absurdly high
+prices are paid at the present time and which people recommend to
+others because of having been benefited by them would be interesting.
+There are belts of many kinds, and rings, and medallions, and plates
+to be worn on the back and on the chest, and curiously shaped poles or
+"polar plates" resembling various organs, and pendants and armlets and
+anklets and insoles of many, many kinds, usually {44} going in pairs,
+one made in zinc and the other in copper, and worth exactly as much as
+the weight of copper and zinc in them, yet curing chronic ailments by
+suggestion, or at least bringing relief from many pains and aches
+complained of.
+
+
+
+LIGHT AND PSYCHOTHERAPY
+
+Just as electricity has always been therapeutically abused by those
+who have taken advantage of the suggestive influence of its marvelous
+energy, so each new discovery in light has been the source of
+pseudo-scientific applications to medicine. When the explanation of
+photography was first made, shortly after the middle of the nineteenth
+century, and it was demonstrated that it was the blue light, or at
+least that end of the spectrum, and even some of the rays beyond the
+visible violet, which were the most active in this regard,
+applications of this fact to popular medicine became the order of the
+day. We had a wave of "blue light therapy" that wandered over this
+country and sold tons of blue glass. People simply sat beneath the
+blue glass as the sun shone through it and were supposed to absorb the
+actinic rays and acquire new life. According to many who had tried
+them, the ultra-violet rays were quite equal in their power to heal
+and restore new vigor to old frames to the fabled elixir of life of
+the olden time. "Rheumatism (that universal ill of the unthinking) in
+all its hydra-headed forms disappeared," as one enthusiast declared,
+"before the blue light, like the mists of the morning before the sun."
+All this, though it is said that the movement had no more serious
+foundation than the desire of a manager of a glass factory, who found
+himself stocked up with blue glass through a mistake, to dispose of
+his surplus stock. He not only did so, but many other manufacturers
+turned special attention to the new product because of the demand for
+it. The newspaper advertising was through the reading columns. The
+results were heard of on every side.
+
+
+
+THE X-RAY
+
+That happened two generations ago, and it might be supposed that in
+the meantime there had been so much advance in popular education, and
+particularly in the diffusion of scientific knowledge, that such a
+self-deception on the part of scientists, and blind following by the
+people, could not take place in our time. Just as soon as Roentgen
+discovered the X-ray, however, we began to have applications of that
+wonderful agent to curative purposes. About 1900, scarcely five years
+after Roentgen's discovery, there was hardly an ailment that some one
+did not claim to have seen treated successfully by the X-rays.
+Especially was this true for the chronic and hitherto supposedly
+incurable diseases. All the forms of malignant disease were treated by
+the new agent, and some supposedly marvelous cures were reported.
+Everything chronic was favorably affected--lupus, rodent ulcer,
+eczema, acne rosacea, even tuberculosis of the lungs. At the time I
+was on the staff of a medical journal, and the favorable reports came
+in so thick and fast that it really looked for a time as though the
+surgery of the future was to be much simplified. It took but a year or
+two to show us how little of lasting therapeutic benefit there was
+{45} in the X-ray, in spite of the fact that it is a marvelous agent
+in its action upon living tissues. At the present moment it is used
+comparatively little, and its use is gradually diminishing, except for
+very special limited affections.
+
+
+
+RADIUM AND RADIO-ACTIVITY
+
+When radium was discovered, though it came so soon after the discovery
+of the X-ray and our disappointment with it, the old story of another
+pseudo-scientific medical application was told. For a time it looked
+as though radium might accomplish all that had been promised for the
+X-ray, though that promise had been so lamentably broken. Then,
+besides radium, we had brought home to us the whole class of
+radio-active substances, and their possibilities. The internal
+administration of radio-active liquids was one of the hopes of
+therapeutics. We had found it difficult to explain how many of the
+mineral waters produced the beneficial action credited to them when
+taken at the spring. We knew that artificially made waters of exactly
+the same chemical composition, so far as we could determine, did not
+have the same effect, nor even the waters themselves when taken at a
+distance from the spring.
+
+With the discovery of the radio-active principle there came the
+suggestion that possibly the main virtue of mineral waters at the
+spring was due to radio-activity. This would not be present in
+artificial water and would disappear from the natural water during
+shipment. This new idea was alluring, and it captured many. Radium
+seemed to be the new panacea. But we are discovering its limitations.
+It is of little avail in surgery; it is probably of less avail in
+medicine. As yet, however, we cannot say absolutely and must wait
+until results are determined. In the mean time many zealous advocates
+of the marvelous power of radio-activity to cure are exploiting it,
+apparently getting results and certainly making money. In the case of
+the mineral waters, also, the most important therapeutic element is
+probably the mental influence, which is strongest at the spring
+itself, where the suggestion of efficiency is repeated many times a
+day, and where the very atmosphere breathes confidence in the results
+to be obtained.
+
+
+
+SUGGESTION AND PSEUDO-SCIENCE
+
+These applications of science, or rather of supposed science,
+illustrate the influence of suggestion. The succession of events in
+each case is about as follows: The definite attitude of mental
+expectancy is created in the popular mind. As a consequence, with the
+application of the new scientific principle, patients cease inhibiting
+the recovery that would have come spontaneously before, only that they
+were self-centered and had their nervous energies short-circuited.
+Some are benefited by the habits of life that are established as a
+consequence of the belief that they are about to be cured, while
+before this they had been largely confining themselves to their
+houses, and had been refusing to take recreation or get diversion
+because of the conviction that they were ill. Finally, many of them
+had no real physical ills, but were suffering from mental ailments
+brought on by dreads and by a concentration {46} of attention on
+certain portions of the body which interfered with the normal
+physiologic action of those parts. Whenever strong mental impressions
+are produced, from any cause, results will surely follow, some of them
+marvelous. The supposed causes of these results will seem quite absurd
+to those who study them afterwards, but they were living realities to
+the sufferers. Nothing is more calculated to produce a strong mental
+impression than a newly discovered scientific fact with some
+supposedly wonderful application to humanity. The subsequent history
+of the application of scientific discoveries to medicine has been as
+invariably the same as the primary enthusiasm over each new
+therapeutic agent. After a time some people were not benefited.
+Physicians lost confidence in the power of the new remedial measure,
+whatever it might be. Patients were no longer impressed by the
+assurance that they would be benefited, and then the new application
+has either completely disappeared from our list of remedies, or has
+remained only to be used by a few, who still report good results from
+it. In spite of the constancy of this succession of events, we are
+still quite ready to take up with enthusiasm new discoveries in
+science and their applications to medicine. We have not yet lost the
+feeling, common in earlier centuries, that all science was meant for
+man and that every new scientific development must have some special
+reference to him.
+
+
+
+CHAPTER VI
+
+QUACKERY AND MIND CURES
+
+Not less interesting than the therapeutic results obtained by men who
+in good faith were using inert remedies that they thought effective,
+are the cures obtained by men who had good reason to know that the
+therapeutic methods they were using were quite inefficient. Their good
+results, often loudly proclaimed by healed patients, are obtained
+entirely through the patients' minds. Usually these men are supposed
+to possess some wonderful therapeutic secret, which they have obtained
+by a fortunate discovery, or by long years of study, though usually
+their discovery is a myth and their long years of study a fable. So
+long as people can be brought to believe in their powers many cures
+are sure to follow their ministrations. The real secret is their
+knowledge of human nature. They induce people to tap new sources of
+vital energy in themselves, and somehow they succeed in bringing to
+their aid this law of reserve energy. Besides, in many cases the real
+reasons why patients continue to have certain symptoms once they have
+been initiated, is that their worry about themselves inhibits their
+natural curative power. This inhibition is prevented or obliterated by
+the change of mind produced by the quack, and then the _vis medicatrix
+naturae_ brings about a cure.
+
+Probably the oldest story that we have of a quack in our modern sense
+of the word is found in the Arabian Nights, some of the stories of
+which were old even in the time of Herodotus. One day Galen, famous
+for his work at Rome in the second century after Christ, found a
+wandering healer pursuing his avocation in his front yard. He found
+also that this man succeeded in relieving certain patients for whom he
+had been unable to do anything. He {47} found that the medicines
+prescribed were likely to do harm rather than good, yet many of the
+patients were benefited.
+
+Galen succeeded in winning the man's confidence, who told him his
+story. He had been a weaver, but his wife thought he was not making
+money enough to support her properly, so she had advised him to become
+a leech. After taking lessons from a wandering quack, he set up for
+himself. When Galen inquired as to his method of making a diagnosis,
+he found that he did it entirely by his knowledge of human nature. He
+was even able to tell what was the matter with patients at a distance
+when friends came to demand medicine for them.
+
+We think that such ready deception was possible only in earlier times,
+when education was not widely diffused and when belief in
+superstitions was fostered. Any such idea completely ignores the
+modern status of the quack and the success that he meets among even
+the more intelligent members of the community. Indeed, with the
+diffusion of information in modern times the quack has secured a wider
+audience. Superficial ideas of science are disseminated by the
+newspapers and by the magazines, people think that they understand all
+about it, and then these ideas are turned to their own advantage by
+the irregular practitioners of medicine. We have quacks by the score
+in all the centers of population, making a livelihood by exploiting
+the ailing, and serving to no small extent to create a feeling of
+popular discontent towards the physician, because that serves the
+purpose of quackery. Indeed, it is during the past century or a little
+more that some of the most striking examples of quackery have
+occurred.
+
+
+Cagliostro.--Cagliostro, whose story is told in Dumas' "Memoirs of a
+Physician," and an excellent account of whose life may be found in
+Carlyle's "Miscellanies," is one of the great quacks and humbugs of
+history. He began his supposed medical work at Strasburg by the modest
+claim that during his travels in the East he had found a series of
+remedies which made old people young. In proof of his power to do this
+he exhibited his wife. She was a handsome young woman of very shady
+reputation whom he had married on his travels. She professed to be
+sixty years of age, though she was really under thirty and looked it,
+but she claimed that she had a son who had served for many years in
+the Dutch army. This imposition was so effective that in Strasburg,
+and subsequently in Paris, the charming pair collected large sums from
+wealthy old persons, especially from women on whom the marks of time
+had begun to show, and who expected, as the result of the treatment,
+to be shortly as young and as handsome-looking as Madame Cagliostro
+herself.
+
+We might think that it is quite impossible for any such a deception as
+this supposed renewal of youth to be practiced in our more enlightened
+day when popular education is so widely diffused. We must not forget,
+however, that the newspapers bring us evidence every month of some old
+person who is quite sure that something that was being done for him
+was, if not renewing his youth, at least giving him back much of his
+pristine vigor, healing his aches and pains, and enabling him to take
+up his work once more. In treating the ravages of old age, which would
+seem to be altogether beyond any influence of psychotherapy, some of
+the most striking results are obtained. New therapeutic methods for
+the old come into vogue every year. As they grow older, {48} people
+become discouraged and so do not exert even the natural energy that
+they have for the maintenance of health and the keeping up of
+strength. Their discouragement keeps them from exercising enough, and
+this decreases appetite and sleep, and as a consequence there are many
+disturbances of function. All of this disappears as soon as they feel
+encouraged. Brown Sequard and his extract of testicular tissues is a
+typical example of how strong suggestion may influence the old and
+make them think that they are renewing their vigor and strength, and
+even their youth.
+
+
+Perkins, Prince of Quacks.--Shortly after Cagliostro an American
+succeeded in using a very simple idea to gain world fame and at the
+same time to make an immense amount of money. He was a Connecticut
+Yankee with the typical name, Elisha Perkins. Dr. Perkins must have
+been born under a lucky star; at least he lived in fortunate
+circumstances for his purposes. Galvani's discovery of the twitchings
+that occur in the frog's legs when a nerve-muscle preparation or its
+equivalent was touched by metals in contact, had aroused world-wide
+discussion as to the place of electricity and magnetism in biology.
+Volta's brilliant experiments, which led to the invention of the
+Voltaic Pile, still further increased men's interest in this subject.
+It was then that Dr. Perkins came to exploit these electrical and
+magnetic ideas in medicine by means of a very simple invention. It was
+indeed the simplicity of his apparatus that made its appeal even more
+wide than would otherwise have been the case, and, be it said, left a
+larger measure of profit for the inventor.
+
+Oliver Wendell Holmes in his "Medical Essays" [Footnote 4] has told
+the story of what may be called the rise and fall of tractoration. Any
+physician who wants to appreciate the real significance of cured cases
+should read Holmes' essay. We quote:
+
+    [Footnote 4: Houghton, Mifflin Co., Boston.]
+
+  Dr. Elisha Perkins was born at Norwich, Connecticut, in the year
+  1740. He had practiced his profession with a good local reputation
+  for many years, when he fell upon a course of experiments, as it is
+  related, which led to his great discovery. He conceived the idea
+  that metallic substances might have the effect of removing diseases,
+  if applied in a certain manner; a notion probably suggested by the
+  then recent experiments of Galvani, in which muscular contractions
+  were found to be produced by the contact of two metals with the
+  living fiber. It was in 1796 that Perkins' discovery was promulgated
+  in the shape of the Metallic Tractors, two pieces of metal, one
+  apparently iron and the other brass, about three inches long, blunt
+  at one end and pointed at the other. These instruments were applied
+  for the cure of different complaints, such as rheumatism, local
+  pains, inflammations, and even tumors, by drawing them over the
+  affected parts very lightly for about twenty minutes. Dr. Perkins
+  took out a patent for his discovery, and traveled about the country
+  to diffuse the new practice.
+
+    [Footnote 5: (Transcriber: This footnote is not numbered in the
+    text but appears to refer to the preceding paragraph.): In one of
+    Plautus' plays there is a curiously interesting expression that is
+    recalled by this subject. The dramatist described one of his
+    characters, Sosia, as thrown into a sleep by the manipulations of
+    Mercury. These manipulations are described as _tractim
+    tangere_--that is, to touch strokingly. It would remind one very
+    much of Perkins' Tractors, and in this regard the fact that
+    Mercury was to the Romans, besides being the messenger of the
+    gods, the divinity of thieves, seems not without interest.]
+
+Just what the tractors were composed of may be found in the
+description of them filed with an application for a patent in the
+Rolls Chapel Office in London. They were not simply two different
+metals, but a combination of many metals, with even a little of the
+precious metals in them, partly because {49} of the appeal that this
+would make to the multitude, as chloride of gold did to our own
+generation, but doubtless mainly because the claim of precious metals
+entering into the composition enabled the inventor to sell his
+tractors at a better price.
+
+Dr. Holmes continues:
+
+  Perkins soon found numerous advocates of his discovery, many of them
+  of high standing and influence. In 1798 the tractors had crossed the
+  Atlantic, and were publicly employed in the Royal Hospital at
+  Copenhagen. About the same time the son of the inventor, Mr.
+  Benjamin Douglass Perkins, carried them to London where they soon
+  attracted attention. The Danish physicians published an account of
+  their cases in a respectable octavo volume, containing numerous
+  instances of alleged success. In 1804 an establishment, honored with
+  the name of the Perkinean Institution, was founded in London. The
+  transactions of this institution were published in pamphlets, the
+  Perkinean Society had public dinners at the Crown and Anchor, and a
+  poet celebrated their medical triumphs. [Footnote 6]
+
+    [Footnote 6:
+      "See pointed metals, blest with power t' appease
+       The ruthless rage of merciless disease,
+       O'er the frail part a subtle fluid pour,
+       Drenched with the invisible galvanic shower,
+       Till the arthritic staff and crutch forego
+       And leap exulting like the bounding roe!"]
+
+Miss Watterson [Footnote 7] tells how he attracted attention. Like all
+successful quacks, he had an inborn genius for advertising.
+
+    [Footnote 7: "Mesmer and Perkins's Tractors,"
+      _International Clinics_, Vol. III, Series 19. 1909.]
+
+  He lived in the house once occupied by John Hunter [how
+  characteristic this is--the first quack we mentioned in this
+  chapter, took up his work in Galen's front yard], and in 1804 the
+  Perkinean Institute was opened, but by the end of 1802, 5,000 cases
+  had already been treated. Lord Rivers was president. Sir William
+  Barker, Vice-President [Prominent legislators, lawyers, bankers
+  always lend their names.] Twenty-one physicians, nineteen surgeons,
+  and the leading veterinaries succumbed to the influence of the magic
+  tractors. One "eminent physician" who had had 30 guineas from a
+  country patient and had done him no good was very angry when the
+  sick man took to Perkinism.
+
+  "Why, I could have cured you in the same way with my old brick-bat
+  or tobacco pipe, or even my fingers."
+
+  "Then why, sir," answered the patient in a stern voice (Perkins
+  quotes this), "did you dishonorably pick my pocket when you had the
+  means of restoring me to health?"
+
+  In some 176 pages young Perkins gives us the pick of 2,000 cases who
+  had, of course, been foolish enough at first to put faith in the
+  ordinary physician and his drugs.
+
+  In Bath, particularly, where aristocratic London went, as they do
+  to-day, to repair the damage wrought by a season in town, the
+  Tractor Cure was the talk of the place. But an enemy dwelt there, a
+  Dr. Haygarth, an unbeliever. He, with a certain Dr. Falconer,
+  fabricated a pair of false tractors. Five cases of gout and
+  rheumatism were operated on by the conspirators, who discussed in a
+  light tone the wonders of magnetism as they described circles,
+  squares and triangles with the sham tractors. "We were almost afraid
+  to look each other in the face lest an involuntary smile should
+  remove the mask from our faces," says Haygarth, but the two
+  assistant doctors, unaware of what was being done, were almost
+  converted to Perkinism when they saw the five patients slowly
+  mending under the treatment. One man experienced such burning pain
+  that he begged to wait till the next day. [Footnote 8]
+
+    [Footnote 8: Compare the first effects of the Leyden Jar, related
+    in the chapter on Pseudo-Science.]
+
+  So rapid, and so many were the hospital cures wrought by these two
+  doctors, that patients crowded to them and they could hardly spare
+  five minutes to eat. They amused themselves inventing other
+  instruments made of common nails and sealing wax, and effected with
+  them cures, while they sent a pair of false tractors {50} to Sir
+  William Watson in London and Dr. Moncriffe in Bristol, who operated
+  with them with wonderful results.
+
+It must not, however, be thought that the uneducated, or the
+unskilled, or even merely unoccupied, were the only ones taken in by
+the supposed power of Perkins' Tractors. As we have seen, many
+physicians did not hesitate to avow themselves publicly as believers
+in this new and marvelous application of magnetism to human healing.
+It is true that the only thing we know about the men who became
+advocates of this new instrumental therapeusis, is their connection
+with it. The attention of the scientific world was rather cleverly
+managed. Dr. Perkins presented a pair of his tractors and the book
+that he had written about their use to the Royal Society. The custom
+of that learned body was to accept such presentations by a formal
+letter of thanks and place the objects and books on their shelves. No
+formal investigation of the claims to scientific consideration of such
+presentations was made. All possible advantage was taken of the fact
+that the Royal Society had accepted the new invention and had publicly
+thanked the discoverer for it.
+
+How characteristically recent this old story is; it is renewed on
+every possible occasion and wears all the familiar aspect of modern
+devices for securing recognition and obtaining the apparent
+approbation or recommendation of some scientific society or
+institution. We had an example of it a few years ago when a nostrum
+exploiter signed the register of an International Congress immediately
+after a great medical investigator and then used a photograph of the
+names for advertising purposes.
+
+How did the tractors secure the vogue they enjoyed? Those who believed
+in them did so not because of the scientific theory that animal
+magnetism or magnetic influence was behind them, nor because of the
+plausible ways of the Connecticut Yankee, but because of the
+unquestioned and unquestionable facts of actual healing that they saw
+in connection with the use of the tractors. Every one of these
+applications of science to medicine that has proved to be
+pseudo-scientific after enthusiasm subsides has made its appeal
+through the cures effected by it. Cures are what Eddyism advances to
+support its claims, cured patients are presented as their most
+effective argument by the osteopaths, cured symptoms are the proofs
+for Hahnemannism, but none of these systems of treatment ever cured as
+many cases in a corresponding time as did Perkins' tractors. They
+cured all sorts of physical ills, but their only effect was exerted
+through the mind.
+
+Holmes wrote:
+
+  Let us now look at the general tenor of the arguments addressed by
+  believers to sceptics and opponents. Foremost of all, blazoned at
+  the head of every column, loudest shouted by every triumphant
+  disputant, held up as paramount to all other considerations,
+  stretched like an impenetrable shield to protect the weakest advocate
+  of the great cause against the weapons of the adversary, was
+  that omnipotent monosyllable which has been the patrimony of cheats
+  and the currency of dupes from time Immemorial--Facts! Facts! FACTS!
+  First came the published cases of the American clergymen,
+  brigadier-generals, almshouse governors, representatives,
+  attorneys and esquires. Then came the published cases of the
+  surgeons of Copenhagen. Then followed reports of about one hundred
+  and fifty cases, published in England, "demonstrating the efficacy
+  of the metallic practice" in a variety of complaints, both upon
+  the human body and on horses, etc. But the progress of facts in
+  Great Britain did not stop here. Let those who rely upon the numbers
+  {51} of their testimonials, as being alone sufficient to prove the
+  soundness and stability of a medical novelty digest the following
+  from the report of the Perkinistic Committee. "The cases published
+  (in Great Britain) amounted, in March last, the date of Mr. Perkins'
+  last publication, to about five thousand. Supposing that not more
+  than one cure in three hundred, which the tractors have performed,
+  has been published, and the proportion is probably much greater,
+  it will be seen that the number, to March last, will have exceeded
+  one million five hundred thousand!"
+
+It is not surprising that with such "facts" behind them the tractors
+attracted deep and wide attention. A contemporary tells of it and the
+fate of the inventor:
+
+  A gentleman in Virginia sold a plantation and took the pay for it in
+  tractors. Nothing was more common than to sell horses and carriages
+  to buy them. But the worst (or the best) of it was, yellow fever was
+  raging in New York, and Perkins thought he could cure the fever with
+  the tractors and fell a victim to the fever himself.
+
+
+Success of Quackery.--Always in the history of quackery and, indeed,
+in the history of all therapeutics, the appeal is to the cures that
+have been effected. This is the only evidence, of course, that can be
+adduced for the development of therapeutics, and yet the history of
+medicine makes it clear how carefully supposed cures must be analyzed
+if they are really to mean anything. Mesmer could adduce thousands of
+cured cases. Perkins could do the same. Every quack in history, from
+Galen's weaver, who became a leech, down to the last street corner
+nostrum vendor, does the same thing. When on the strength of supposed
+cures, then, a new system of therapeutics is introduced, it is much
+more likely than not that there is no foundation for the claims made.
+We have had ever so many more experiences of disappointment after the
+introduction of remedies which cured at the beginning of their
+history, than we have had of remedies that maintain themselves after
+prolonged experience. It is the attitude of scepticism and suspended
+judgment until after a remedy or method of treatment has been tried on
+many different kinds of cases in varying circumstances that
+constitutes the only efficient safeguard against repeating the
+unfortunate errors of old times in the matter of drugs and remedial
+measures. If the public could be made to realize this, they would be
+much less easily taken in.
+
+What the quacks cure are not always imaginary ills, but often ills
+that are very real, at least to the patients, and the symptoms of
+which are relieved by the confidence aroused in the new remedy and the
+representations of the supposed discoverer, who, in spite of the
+exaggerated claims which he makes, somehow succeeds in catching the
+trust of patients. Very often this process initiated by the quack is
+really only the beginning of the cure.
+
+In most people a vicious circle of pathological subsidiary causes is
+formed when anything becomes the matter. Patients are persuaded that a
+serious illness is ahead of them. This keeps them from exercising as
+much as before. Becoming overcareful of their diet, they reduce it
+below the normal limit for healthy activity. This causes them to have
+less energy for work and disturbs their sleep. Then a host of minor
+symptoms, supposed to be due to the disease, whatever it is or they
+think it is, but really consequent upon the unhealthy habits that have
+formed, begin to develop. Just as soon as confidence in their power to
+regain health is restored to these people, a virtuous circle, {52} to
+use the Latin word virtue in its etymological sense, of strength and
+courage, is formed. Everything conspires to stimulate the patients;
+they live more naturally, the subsidiary symptoms consequent upon
+their bad habits disappear and the disappearance of each one of them
+means for the patients a new assurance of triumph over disease. They
+attribute every improvement to the remedy they happen to be taking,
+though most of them are due to the changes in their habits, their
+diversion of mind, and the new energy released by their sense of
+encouragement.
+
+An excellent example of how some of these mental persuasions in
+quackery act, and of how the cure is often really due to the physician
+who previously treated the case, though it is credited to the quack,
+may be found in the story that Hilton tells in his "Rest and Pain":
+
+  When this patient was first seen by a surgeon, he was thought to be
+  laboring under some disease of the bladder and kidneys, for he had
+  severe lumbago, pain over the bladder, and offensive urine. There
+  had been no suspicion of anything wrong as regards the spine. He was
+  a master painter and a house decorator, and was monstrously
+  conceited, thinking himself right and everybody else wrong. When I
+  explained to him, after careful examination, that the spine was the
+  cause of the symptoms, he was not satisfied with my opinion and
+  without my knowledge consulted Sir Benjamin Brodie, who also assured
+  him that his spine was diseased and told him that he must rest it by
+  lying down. To this he then assented. As he could not be controlled
+  in his own house, I persuaded him to go to Guy's Hospital, where he
+  had got nearly well; but he was very impatient, and would not remain
+  long enough under my care to be quite cured. He returned home,
+  gradually improved, and was getting quite well when some pseudo
+  friend advised hydropathy and homeopathy--it did not matter which
+  of the two--as "the thing" to cure him. After a few months he was
+  perfectly restored, not by either hydropathy or homeopathy, but,
+  no doubt, by nature. The man, however, feels convinced that
+  hydropathy and homeopathy cured him. It so happens, gentlemen, that
+  sometimes we do not get the degree of credit which perhaps belongs
+  to us.
+
+To Mr. Hilton's reflections one is tempted to add that many of these
+patients, after having been seriously ill, cannot bring themselves to
+think that they will gradually get well by the forces of nature. Even
+after they have improved very much they are still inclined to think
+that that improvement is illusory or will relapse because they have
+not been "cured," that is, actively treated, in some way so that a
+"cure" should result. When they are nearly well, because of properly
+directed rest and nursing, someone recommends some irregular form of
+treatment. They take it up and this gives them confidence that they
+are being cured. This state of mind makes the ultimate steps of their
+recovery more rapid than it otherwise would be. As a consequence, the
+irregular gets the credit. Immediately after this case Mr. Hilton
+tells the story of another case in which a "rubber" got all the credit
+for the cure. It is evident that the modern osteopath has only
+somewhat systematized what had been in existence generations ago.
+
+All this tendency of human nature to respond to anything that is done
+for it, provided the promise of cure goes with it, is taken advantage
+of by the quack, sometimes unconsciously, for his own purposes.
+Results, as a rule, are secured, in spite of the remedies that he
+suggests, which in most cases do harm rather than good. Of the
+thousands of remedies that have been introduced by quacks, not one now
+remains, though every one of them produced {53} wonderful cures on a
+great many patients at some time or other. It is the duty of the
+physician to secure just as good results honestly. He must influence
+the patient's mind favorably so as to bring about a modification of
+habits and a hopeful outlook on life, in spite of whatever ailment
+there may be. If he can do so he will have in his hands the best
+therapeutic measure that has been employed in all the history of
+medicine. It is the most universally applicable. It will cure, that is
+help, all forms of disease. It will relieve many of the symptoms of
+even incurable diseases. It will occasionally arouse the resistive
+vitality of the patient to such an extent that even apparently
+incurable diseases will be overcome. This is the lesson that the
+modern student of medicine must draw from the history of quackery.
+
+
+
+CHAPTER VII
+
+NOSTRUMS AND THE HEALING POWER OF SUGGESTION
+
+A striking illustration of the power of the mind to bring about the
+cure of ailments and symptoms of every sort is found in the history of
+the many nostrums and remedies that have worked wonders for a time and
+later proved to be inert or even harmful. The ordinary definition of a
+nostrum includes the idea of secrecy. At all times in the world's
+history fortunes have been made out of such remedies. They appeal not
+only to the uneducated, but also to those who are supposed to be well
+informed, and this in spite of the fact that generally the remedies
+are claimed to do good for nearly every form of disease, and it must
+be evident to anyone, after a moment's serious thought, that the one
+idea of their inventor is not to benefit patients, but to make money.
+
+With the multiplication of newspapers and magazines, there has been a
+great increase in these secret remedies and of their users. Apparently
+all that is needed for many people who are ailing, or think they are
+ailing, is to be told in a more or less impressive way that some
+remedy will cure, and then it proceeds to do them good. There is a
+general impression abroad that some of these remedies represent great
+discoveries in medicine, and the feeling of most of those who take
+them is that the inventor has found a new and wonderful remedy. During
+all the centuries such secret remedies have come and gone, and not one
+of them has proved to be of lasting value. Just as soon as its
+composition is no longer a secret it begins to fail. It is, therefore,
+evident that its effect was entirely due to influence on the mind and
+not at all to any influence on the body.
+
+The stories of the origin of these remedies bear a striking
+similarity. There are two variants on the theme: either the inventor
+is supposed to be an earnest student of science, devoting himself to
+profound research for many years and finally finding some wonderful
+secret of nature hitherto hidden from men; or else the remedy has been
+discovered by happy accident, and some chronic sufferer pronounced by
+the most eminent physicians to be hopelessly incurable has in despair
+turned to the now method, caring little really, so discouraged is he,
+whether it does good or ill, and wakes up to find that he is on the
+high road to recovery, apparently having been directed by Providence
+in the use of the remedy in question. Overflowing with gratitude, he
+{54} wants to share the heaven-sent blessing with all mankind--for a
+valuable consideration.
+
+
+The Weapon Ointment.--Among the most famous nostrums, and a striking
+example of the great rôle played in therapeutics by mental influence
+and coincidence, is the Unguentum Armariam or Weapon Ointment. This
+famous remedy would cure any wound made by a weapon, if it could only
+be employed before the fatal effects were absolutely manifest. There
+was an abundance of evidence that it stopped the pain, checked the
+bleeding and initiated the restoration of the patient to health. We
+know the remedy not from traditions of its use among the uneducated,
+but from descriptions that we have by men who were among the best
+educated of their time, and that by no means an era of dullards. The
+story of this infallible remedy is all the more surprising because it
+was not applied to the wound itself, nor indeed to the sufferer at
+all, but _to the weapon which inflicted the wound_. Nay, it was well
+authenticated that, where the weapon could not be secured for
+inunction, if the ointment were applied to a wooden model of the
+weapon, the cure followed with almost, though, it was confessed by
+some, not quite so much assurance as in the fortunate case of the
+weapon being available.
+
+The story has been so well told by Oliver Wendell Holmes in his
+"Medical Essays" [Footnote 9] that it seems best to retell it in
+abstracts from his "Homeopathy and Its Kindred Delusions." He says:
+
+    [Footnote 9: Houghton Mifflin Co., Boston.]
+
+  Fabricius Hildanus, whose name is familiar to every surgical
+  scholar, and Lord Bacon, who frequently dipped a little into
+  medicine, are my principal authorities for the few circumstances I
+  shall mention regarding it. The Weapon Ointment was a preparation
+  used for the healing of wounds, but instead of its being applied to
+  them, the injured part was washed and bandaged, and the weapon with
+  which the wound was inflicted was carefully anointed with the
+  unguent. Empirics, ignorant barbers, and men of that sort are said
+  to have especially employed it. _Still there was not wanting some
+  among the more respectable members of the medical profession who
+  supported its claims_. [Italics ours.] The composition of this
+  ointment was complicated, in the different formulas given by
+  different authorities; but some substances addressed to the
+  imagination, rather than the wound or weapon, entered into all. Such
+  were portions of mummy, of human blood and of moss from the skull of
+  a thief hung in chains.
+
+  Hildanus was a wise and learned man, one of the best surgeons of his
+  time. He was fully aware that a part of the real secret of the
+  Unguentum Armarium consisted in the washing and bandaging the wound
+  and then letting it alone. But he could not resist the solemn
+  assertions respecting its efficacy; he gave way before the outcry of
+  facts (!), and therefore, instead of denying all their pretensions,
+  he admitted and tried to account for them upon supernatural grounds.
+
+Holmes says further:
+
+  Lord Bacon speaks of the weapon ointment, in his Natural History, as
+  having in its favor the testimony of men of credit, though, in his
+  own language, he himself "as yet is not fully inclined to believe
+  it." His remarks upon the asserted facts respecting it show a
+  mixture of wise suspicion and partial belief. He does not like the
+  precise directions given as to the circumstances under which the
+  animals from which some of the materials were obtained were to be
+  killed, for he thought it looked like a provision for an excuse in
+  case of failure, by laying the fault to the omission of some of
+  these circumstances. But he likes well that "they do not observe the
+  confecting of the Ointment under any certain constellation; which
+  is commonly the excuse of magical medicines, when they fail, that
+  they {55} were not made under a fit figure of heaven." It was
+  pretended that if the offending weapon should not he had, it would
+  serve the purpose to anoint a wooden one made like it. "This," says
+  Lord Bacon, "I should doubt to be a device to keep this strange form
+  of cure in request and use, because many times you cannot come by
+  the weapon itself." And in closing his remarks on the statements of
+  the advocates of the ointment, he says, "Lastly, it will cure a
+  beast as well as a man, which I like best of all the rest, because
+  it subjecteth the matter to an easy trial." It is worth remembering
+  that more than 200 years ago, when an absurd and fantastic remedy
+  was asserted to possess wonderful power, and when sensible persons
+  ascribe its pretended influence to imagination, it was boldly
+  answered that the cure took place when the wounded party did not
+  know of the application made to the weapon, and even when the brute
+  animal was the subject of the experiment, and that this assertion,
+  lie as we all know it was, came in such a shape as to shake the
+  incredulity of the keenest thinker of his time.
+
+It is interesting to follow up some of the controversies among
+scientific men with regard to the weapon ointment, for they serve to
+show how the remedy came to maintain its prominence for so long.
+Podmore, in his "Mesmerism and Christian Science" (London, 1909),
+tells the story of the controversy between Goclenius, a professor of
+medicine at the University of Marburg, who published as the Inaugural
+Thesis for his professorship, a treatise on the "Weapon Salve," and
+Father Roberti, a Jesuit scientist and philosopher, whose final
+treatise in the controversy was entitled after the lengthy fashion of
+titles in that day, "Goclenius Corrected Out of His Own Mouth; or, The
+Downfall of the Magnetic Cure and the Weapon Salve." The decision of
+the controversy was eventually referred to the great physician of the
+time. Van Helmont, who decided that both disputants were partly wrong,
+the Jesuit erring most, but that above all Goclenius should
+distinguish between the cases when the weapon had blood on it and when
+it had not. When there is blood on the weapon, he held, then the salve
+is always effective; when there is not, then much stronger remedies
+were required. In both cases, of course, the salve or ointment was
+applied to the weapon.
+
+In the midst of this discussion of the points at issue, it is
+interesting to note Van Helmont's opinion with regard to many curious
+things used in medicine at that time. He insists that Goclenius makes
+a mistake in attributing therapeutic power alone to the moss taken
+from the skull of a condemned criminal who had been hung in chains.
+This material, under the name of _usnea_, was apparently quite popular
+in prescriptions for various chronic ills, and especially those that
+we now recognize as prolonged neurotic affections. Van Helmont
+emphasizes the fact that the experience of all physicians shows that
+material taken from the heads of condemned criminals executed in other
+ways, as, for instance, those broken on the wheel, may be just as
+effective. Van Helmont conceived of the magnetic and sympathetic
+feeling as a natural process. All the force of the stars might be
+concentrated in objects that had been beneath their beams for a long
+time, and this might be communicated in some wonderful way to patients
+so as to supply defects of vitality. Such defects of vitality Van
+Helmont's prescriptions actually were compensating, but the source was
+in the patients themselves--that reservoir of surplus energy which
+remains unused unless some strong suggestion brings it out.
+
+
+Sympathetic Powder.--After the weapon ointment, the best known of the
+nostrums of older times is probably Sir Kenelm Digby's famous
+Sympathetic {56} Powder, which Dr. Holmes talks of as even better
+known than its great therapeutic predecessor. This, too, was a
+wonderworker. Unlike the Unguentum Armarium, however, its composition
+was simple. It was nothing else than copper sulphate which had been
+allowed to deliquesce to a white powder. This powder would cure any
+injury as infallibly as the weapon ointment. It, too, was not applied
+to the wound, but to the _bloodstained_ garments (Van Helmont's
+distinctions between the bloody and the bright weapon should be
+recalled) of the wounded person. The patient did not need to be
+present at the time the application was made. He might be far away and
+yet its efficacy was, according to many very intelligent and highly
+educated persons, quite assured.
+
+For the sympathetic powder we have one of the stories of far-fetched
+discovery that have since become so familiar. A missionary, traveling
+in the East, was said to have brought the recipe to Europe about the
+middle of the seventeenth century. The Grand Duke of Tuscany, in whose
+dominions the missionary took up his residence, heard of the cures
+performed by him and tried by offers of money and favor to obtain the
+missionary's secret, but without success. Sir Kenelm Digby, however,
+who was traveling in Italy, happened by good fortune to do a favor for
+the missionary, and put him under such deep obligations that he felt
+the only way he could properly repay his benefactor was to confide to
+him the composition of this wonderful remedy. Sir Kenelm Digby was at
+this time one of the best known of English scholars. After having
+reached distinction in the English navy, he had devoted himself to
+literature, to philosophy, and to politics. He had devoted much time
+to the old books of alchemy. Therefore, the offer of this precious
+piece of information especially appealed to him. On his return to
+England he proceeded to use it for the benefit of his friends, and it
+created a sensation. The French dictionary of the Medical Sciences
+tells the story of the application of the powder for the first time in
+England and of the subsequent use of it, especially on the nobility of
+England:
+
+  An opportunity soon presented itself to try the powers of the famous
+  powder. A certain Mr. Howell, having been wounded in endeavoring to
+  part two of his friends who were fighting a duel, submitted himself
+  to a trial of the sympathetic powder. Four days after he received
+  his wounds, Sir Kenelm dipped one of Mr. Howell's garters in a
+  solution of the powder, and immediately, it is said, the wounds,
+  which were very painful, grew easy, although the patient, who was
+  conversing in a corner of the chamber, had not the least idea of
+  what was doing with his garter. He then returned home leaving his
+  garter in the hands of Sir Kenelm, who had hung it up to dry, when
+  Mr. Howell sent his servant in a great hurry to tell him that his
+  wounds were paining him horribly; the garter was therefore replaced
+  in the solution of the Powder, and the patient got well after five
+  or six days of its continued immersion.
+
+  King James I, his son, afterwards Charles I, the Duke of Buckingham,
+  then Prime Minister, and all the principal personages of the time
+  were cognizant of this fact; and James himself, being curious to
+  know the secret of this remedy, asked it of Sir Kenelm, who revealed
+  it to him, and his majesty had the opportunity of making several
+  trials of its efficacy, _which all succeeded in a surprising manner_.
+
+
+Tar Water and Therapeutic Faith.--One further story of an old nostrum
+deserves to be told because of the distinction of its chief promoter,
+who did not, however, as do most of the nostrum promoters, make a
+fortune by it. {57} This is the incident of Bishop Berkeley and his
+tar water. Berkeley was one of the leaders of thought of the
+eighteenth century. At one time he came to America with the idea of
+enlightening the ignorance of the colonists and of founding a school
+of philosophy. Besides being one of the most learned men of his time,
+he was one of the best. He was known for his gentleness, his
+unselfishness, and his lack of pretension. Yet all of these virtues
+were unable to save him from falling a victim to a medical delusion.
+One of his essays is on the value of tar water in medicine, and is
+entitled "Siris, a Chain of Philosophical Reflections and Inquiries
+Concerning the Virtues of Tar Water," etc.
+
+Tar water was prepared by stirring a gallon of water with a quart of
+tar, letting it stand for several days, and then pouring off the clear
+water. It, in fact, retained scarcely more of the tar than the odor.
+According to the great philosopher, this not only cured, but prevented
+diseases. The list is, indeed, so long that it is hard to understand
+how the claims for it could have received any credence. They did,
+however, and Berkeley himself, and many of his friends, were cured of
+many and various ills, and were protected from many more by its
+frequent use. The odor was the factor that proved of suggestive value
+and set free the springs of vital energy.
+
+
+Sarsaparilla.--It might be thought that such deception of self and
+others as has been illustrated in the weapon salve and sympathetic
+powder would be impossible in our enlightened day. Anyone who thinks
+so forgets certain incidents of recent times. The story of
+sarsaparilla is a striking illustration. Few drugs have been more
+popular in the last half century, and it is even yet popularly
+supposed to be a wonderful tonic, a cure for many diseases. During the
+first half of the nineteenth century, when the humoral theory of the
+causation of diseases was generally accepted, certain German
+physicians thought they observed that a decoction of sarsaparilla was
+a sovereign remedy for various ailments having their origin in the
+blood. The blood was at that time supposed to become impure for many
+reasons, and the possibility of neutralizing such impurity by medical
+measures was seriously attempted. As Virchow used to insist, the
+humoral pathology still holds its ground in popular estimation, and so
+blood purifiers are favorite remedies, and will doubtless continue to
+be for at least another generation, until cellular pathology secures a
+hold on the popular mind.
+
+Sarsaparilla came in, then, as a great blood purifier, and was used
+for ten years by many of the physicians of the world, confident that
+they were obtaining excellent results from its use. After a time,
+however, further study of the drug showed that it was inert. Gradually
+the employment of sarsaparilla as a remedial agent ceased, though it
+continued to be used as an elegant vehicle in the prescription of
+nauseating remedies.
+
+Only after it had been thus abandoned by the regular profession, was
+it taken up extensively by others who advertised its virtues widely
+and secured a great clientele for it. Probably more money has been
+spent on sarsaparilla during the last fifty years than on any other
+single drug. Many millions were every year appropriated by rival
+concerns to advertise its virtues. It has been possible at any time
+during the last half century to secure any number of people who were
+willing and ready to declare--and most of them convinced of the truth
+of what they said--that various preparations of {58} sarsaparilla had
+cured them of long-standing ills, and that they considered it a
+life-saving remedy.
+
+The efficient ingredient in the sarsaparilla, so far as any of its
+various preparations have seemed to do good, has not been anything
+that was in the bottle, but the printer's ink that was absorbed from
+the outside of it. People were persuaded that they would get better,
+and, as far as most of them were concerned, this was of itself quite
+sufficient to turn the scale in favor of improvement that led to the
+obliteration of symptoms. So long as these symptoms were a source of
+worry and trouble to them, they continued to be quite incurable. Just
+as soon as the inhibition of nervous energy, due to worry and
+over-attention to their sensations, stopped, then the natural force of
+the body was sufficient to remove the sources of complaint.
+
+
+Psychology, Old and New, of Remedies.--Men have always known how to
+take advantage of the possibility of influencing patients' minds by
+wondrous claims for remedies. Anyone is sadly deceived who thinks that
+it is only in recent times that men have learned to make their
+advertisements of nostrums suggestive by the promises made or that we
+have developed the psychology of advertising to such a degree as to
+appeal to the ailing more forcibly and surely than was done in the
+past. Here is the announcement that went with a remedy in old Irish
+medicine more than 1,000 years ago. It was, according to its inventor,
+"a preservative from death, a restorative for the want of sinews
+(strength), for the tongue-tied, a cure for swelling in the head, and
+of wounds from iron and of burning by fire, and of the bite of the
+hound; it preventeth the lassitude of old age, cures the decline, the
+rupture of the blood vessels, takes away the virulence of the
+festering sore, the fever of the blood, the poignancy of grief--he to
+whom it shall be applied shall be made whole." The announcement ended
+up with the panegyric "extolled be the elixir of life bequeathed by
+Diancecht to his people; by which everything to which it is applied is
+made whole." When it is noted that, besides death and loss of muscle
+power and aphasia and wounds and burns and bites, it also cures old
+age and consumption (for that is what is meant by decline) and
+hemorrhages, and probably aneurysms, and fevers and also grief, there
+are not many modern panaceas that exceed it in power.
+
+Always, as in this Irish announcement of the olden time, the climax of
+the advertisement is a note of exultant praise for the inventor who
+has brought such a magnificent blessing to mankind. The ways of the
+nostrum vender are ever the same.
+
+
+Roman Nostrums.--How old are all these methods, and how little human
+nature has changed through all the centuries! The patent medicine men
+of Rome in the early Christian eras made use of just the same methods
+that are employed to-day. Friedländer, in his "Roman Life and Manners
+Under the Early Roman Empire," tells the story well. Many remedies
+were known by special arbitrary names, instead of descriptive names
+recalling the ingredients. Sometimes they were named after famous
+physicians who had used them, or were said to have done so; again, the
+preparations were named after persons of distinction who actually, or
+supposedly, were cured thereby, much as, in our own day, cigars are
+named after poets, statesmen and pugilists. The titles of some of
+these preparations, for instance, were "Ointment for Gout, Made for
+Patroculus, Imperial Freedman--Safe Cure"; "Ointment for {59} Aburnius
+Valens" (probably the famous jurist) called the "Expensive Ointment";
+"Eye Salve with Which Florus Cured Antonia, the Wife of Drusus (the
+Emperor's son) After the Other Doctors had Nearly Blinded Her." Many
+of these remedies were labeled "instantaneous," "safe," "sure cure,"
+"Harmless remedy," and the like. Frequently euphonious names,
+sometimes from the Greek, were chosen: Ambrosia, Anicetum, Nectarium,
+for the promoters evidently knew the satisfying effect, on both
+patient and physician, of a mystifying foreign name.
+
+
+_Proprietary Remedies_.--A corresponding abuse very like that of our
+own time was with reference to proprietary medicines. Physicians,
+instead of compounding their own, accepted those made by others with
+the exaggerated claims for them, used them on patients, transferring
+their own confidence in them to the patients, thus producing cures
+which, after a time, proved to be due entirely to the influence on the
+patient's mind. Pliny, the elder, complains that physicians of his
+time (the first century after Christ) often bought their remedies so
+as to avoid the trouble of preparation. He evidently refers to
+compounds supposed to be curative for various affections; for
+Friedländer says that "often the physicians did not know the exact
+ingredients of the compounds that they used and should they desire to
+make up written prescriptions, would be cheated by the salesmen." Both
+Galen and Pliny complain that physicians used ready-made medicines,
+instead of original prescriptions carefully prepared by or under the
+supervision of the physicians themselves. It is evident that the
+proprietary remedy had come into existence thus early, and that
+various drug manufacturers made specialties which physicians,
+following the line of least resistance, found it easy to prescribe,
+though men like Pliny and Galen realized that this was an abdication
+of one of the most important functions of their profession, which was
+bound to work harm in the end both to themselves and to their
+patients.
+
+How curious it is to find exactly the same state of affairs recurring
+in our time, with absolutely similar results. Simple remedies that are
+well known combinations of ordinary drugs receive high-sounding names,
+usually derivatives from the Greek or the like, and are claimed to
+work just as many wonders as the old-fashioned nostrums. Even
+imitations of the old-fashioned poultices, when thus exploited, give a
+new lease of life to the exploded idea of the drawing-out power of
+external applications.
+
+
+Common Ailments and Nostrums.--Certain ailments are particularly the
+subject of exploitation by the manufacturers of remedies. Rheumatism
+is one of these, neuralgia is another, catarrh is a third, and
+headache a fourth. Then there are various forms of indigestion and all
+the pains and aches associated with it. All of these ailments are
+rather vague and are in some cases at least, due to the insistent
+dwelling of the patient's mind on some symptom of very little
+significance. Others are real pains and aches, relieved by some simple
+anodyne drugs, doubly efficient when taken with the suggestion that
+they represent a wonderful discovery, which came only after long years
+of study and investigation, and are said to represent a new departure
+in medicine. Another favorite field for the nostrum vender is the
+series of pains and aches associated with the menstrual condition.
+Many of these nostrums are used by hundreds of thousands, and yet an
+analysis shows that probably the only active substance in them is the
+alcohol in which certain of the drug {60} principles are dissolved.
+This makes the patient feel better by the exaltation that comes from
+the dose of alcohol and the rest is merely suggestion, though there is
+no doubt that symptoms which have failed to be cured by physicians are
+sometimes relieved by these remedies. It is a cure by faith, not by
+medicine.
+
+
+Cured Cases as Evidence.--As all of the nostrums, and indeed all the
+therapeutic movements supposedly medical or physical or religious,
+secure their vogue on the strength of reported cures, this would seem
+to be the best possible evidence for the efficacy of a remedy. But
+unless the cases supposed to be cured are critically examined and
+analyzed, and above all, followed for some time afterwards, such
+evidence is open to all sorts of errors. Is it any wonder, then, that
+the physician, familiar with the history of medicine in this regard,
+asks for the careful study and analysis of these cases. We know that
+it was on the strength of cures effected by it, that the weapon
+ointment became possible throughout Europe. We know that portions of
+the body of executed criminals and the touch of the hanged cured as
+many cases as, let us say, osteopathy or Eddyism. The sympathetic
+powder and its advocates appealed to the many cures that followed its
+use. Every other nostrum from the beginning of time has made this same
+appeal.
+
+
+
+CHAPTER VIII
+
+AMULETS, TALISMANS, CHARMS
+
+Amulets, talismans, charms--these words are commonly used with
+something of the same significance, and for our purpose all three may
+be treated in common.
+
+
+Prophylactic Objects.--From the earliest ages men have worn amulets,
+that is, objects often resembling jewelry, though sometimes the
+remains of animals or even of men, [Footnote 10] with the idea that
+they would ward off illness, or cure it when present. Rings of many
+sorts, brooches, various objects suspended around the neck, ear-rings,
+head-bands, belts for the waist, and rings for the wrists and the
+ankles, ornamented bracelets and anklets, have at all times had a
+medicinal power attached to them in some minds. Earrings are still
+worn by many with the idea that they are helpful in affections of the
+eyes. I have known children's ears to be pierced and earrings inserted
+because the little ones were suffering from headache. Precious stones
+were supposed to have this power when worn. The amethyst protected its
+wearer from drunkenness; the bloodstone cured anemia; while the opal
+was supposed to portend evil. Occasionally such gems were ground up
+and used as internal or external remedies, because of the power
+supposed to be attached to them. Their influence upon the mind, at
+least, can be readily understood. The earliest prescription we have in
+America is at the Metropolitan Museum, New York, among the curiosities
+from Egypt (about 1500 B.C.). It calls for the use of ground up
+precious stones in fumigations, probably for an hysterical person.
+
+  [Footnote 10: A king of Italy of the later nineteenth century used
+  to send the parings of his toe-nails to friends to be worn in rings
+  for luck and protection against disease.]
+
+The precious metals were used also as powerful cures. Chaucer says,
+"for {61} gold in physick is a cordial." Some think that our own use
+of chloride of gold a few years ago for many chronic ills had little
+more reason than the preciousness of gold impressing itself on
+patients. Inscriptions were made on the metals, and these were
+supposed to add to their healing or preservative quality. Famous among
+these was the abracadabra. It had to be written in a particular
+triangular form, and was then very powerful. Here the amulet invades
+the sphere of the charm. Prayers were written on parchment, or on
+paper, or on papyrus, in the old time in Egypt, Babylon and Assyria,
+and when worn about the body were supposed to do great good. It is
+surprising to us now how many physicians and scientists placed
+confidence in these things because they thought that they had seen
+good results. Alexander of Tralles recommends a number of them. Robert
+Boyle, the father of chemistry, says that he was cured of a severe
+ague, that the doctors could not benefit, by the application of an
+amulet to his wrists. Burton, in the "Anatomy of Melancholy," has a
+series of references that show how much he, himself, and the educated
+men of his time, believed in the power of amulets to help in illnesses
+and Boyle, particularly, has a number of references to precious stones
+and their curative virtue.
+
+
+Rings in Therapy.--Under Faith Cures I mention the cramp rings blest
+by the Queen of England and effective against abdominal pains. Other
+kinds of therapeutic rings were used rather commonly. All through the
+Middle Ages iron rings were worn, which were good for colic and
+biliousness and also for rheumatic pains. There are literally
+thousands of such rings worn now, here in the United States, and by
+quite intelligent people. Personally, I know of more than a dozen
+cases where they have been worn for years. The wearers faithfully take
+them off each day, rub off the rust which collects on the inside, call
+their own and others' attention to the fact that all this material has
+been drawn out of the body through the supposed electrical power of
+the ring, and then they replace them. Here is pseudo science obtruding
+itself. Usually these rings are of polished steel and look a little
+like silver. They may, however, be obtained in gold plate, and then
+are supposed to be quite as efficacious. The iron or steel rings cost
+two dollars each; gold-plated rings cost five to ten dollars,
+according to the ability of the patient to pay, for metallotherapy has
+as one of its effects the lessening of congestion of the purse. Those
+who wear them would not part with them, because they feel the benefits
+derived. These rings are supposed to be particularly good for vague,
+painful conditions in the joints, especially the so-called rheumatic
+pains.
+
+In old times these rings were sometimes engraved with a legend that
+was itself a strong suggestive element. The rings of the Middle Ages
+that were supposed to be a cure for biliousness were engraved with a
+command to the bile to go and take possession of a bird. Occasionally
+rings were supposed to be valuable because of their origin. Epileptic
+fits, for instance, were rendered much less frequent and less severe
+if a ring made of money that had been given in the church were worn.
+The condition was that the sufferer should stand at the church door
+asking a penny from every unmarried man who passed in or out. After
+sufficient alms had been thus collected the money was exchanged for
+silver money that had been contributed to the church, and from this
+the ring was made. It was to have a cross and sometimes a verselet
+from Scripture, or an exorcism, or a prayer, engraved on it. It is
+{62} easy to understand that all of this represents strong suggestive
+influence and that the standing at the church door begging alms might
+well represent an enforced prolonged opportunity to get rest and air,
+for many unmarried men do not go to church, and so there were also
+physical factors at work in the cure noted.
+
+
+Precious Stones as Preservatives.--Pettigrew, in his "Superstitions
+Connected with Medicine and Surgery," mentions a number of the
+precious stones and their power to heal. Garnet hung about the neck
+relieves sorrow and refreshes the heart; chrysolite is the wisdom
+stone, the enemy of folly; heliotrope staunches blood and acts as an
+antidote; sapphire is good for ague and gout, and also gives its
+wearer courage; it also stops bleeding at the nose and was an
+antidote; the topaz was good for lunatics; the carnelian cured bloody
+fluxes and also fluxes of anger and passion. Jasper, hematite and
+similar stones had certain general powers of doing good. The Bezoar
+stone had a great reputation against melancholy; the smaragdum was
+infallible against epilepsy; the onyx was good for sleep; the sardonyx
+prevented bad dreams. The most wonderful stone, however, was the
+agate; taken in liquid it was good for any disease. It made the skin
+healthy. It preserved against snakebite, and against all poisons, and
+it prevented the devil from injuring one who wore it or drank it, and
+also preserved him from being struck by lightning. Considering how
+common agates were and how readily they could be obtained, it is
+rather surprising that we should have so many stories of illness and
+deaths by lightning and from poison and from venomous serpents in the
+old days when its curative value was rated so high.
+
+
+Amulets.--The coin given by the kings of England when they healed the
+scrofulus or epileptic came to be, in one sense, an amulet. The sight
+and the touch of this acted as an ever recurrent suggestion tending to
+make these patients better, and undoubtedly the coin was of great
+service by its renewal of the mental influence of the touch of the
+king. There are traditions, also, that these coins healed others who
+touched them, and sometimes for generations they were kept in families
+as representing a fountain of healing and of preservation of health.
+Any object that thus became invested with reverence produced healing
+effects. Virchow, in the introduction to Schliemann's "Troas," tells
+of going to a long distance for water, during the time when he was
+present at the excavations, in order to be sure that the water would
+be absolutely pure. The natives had heard that he was a great
+physician from the West. They concluded that the reason why he went to
+this particular distant spring for water, in spite of the trouble
+involved, was that it must have some wonderful healing virtues.
+Accordingly a tradition of healing grew up around it, and people came
+from long distances, drank from it and were cured.
+
+There are still people who carry horse chestnuts for rheumatism, and
+occasionally a farmer carries a potato for the same purpose. The
+feeling is, if they do no good, at least they can do no harm.
+Doubtless in the Middle Ages the same feeling prevailed as to other
+favorite objects. At present, among the better informed classes,
+various pendants supposed to have some connection with electricity are
+popular. I have seen a medal made of alternate discs of copper and
+zinc, and confidently believed to be strongly electrical, worn even by
+an otherwise sensible merchant in a country town. Electric belts still
+are {63} extremely common--and expensive. Supposed electric insoles,
+one made of copper, the other of zinc, are sold in great numbers and
+at good prices, though, quite needless to say, they are absolutely
+inert electrically. Various electric contrivances, small batteries,
+and the like, really are of the nature of amulets. People have a faith
+in them that is not justified by anything in science, but that faith
+helps them in their ills. Most of the supposed medicinal plasters are
+in the same class. As a rule, sufficient curative material cannot be
+incorporated in a plaster to be of any service, and most of them,
+though widely advertised, are scarcely more than rubber adhesive
+plaster. They do good partly by their mechanical effect, because they
+actually support muscles, but mainly because of faith in their
+efficacy. Whenever a particular discomfort occurs the feeling that a
+plaster is covering the spot gives the patient assurance that he or
+she must soon be better. In all of these effects there is no
+manifestation of any physical or marvelous supernormal power, but
+simply and solely of the influence of the mind on the body.
+
+
+
+CHAPTER IX
+
+DETERRENT THERAPEUTICS
+
+In the history of therapy a peculiar phase was the use of all sorts of
+materials, intensely repugnant to human nature and deterrent to all
+the finer feelings, but which, nevertheless, proved curative of many
+ills. We know now that there was absolutely nothing remedial in these
+substances or methods of treatment, but only the effect produced upon
+the patient's mind. If the patient makes sufficient effort to overcome
+the intense repugnance, that enables him to release hitherto latent
+vital energies, or to correct hampering inhibitions which have
+prevented curative reactions. The more the patient had to conquer
+himself, or herself, the more surely did the remedy produce a good
+effect. It was effective, however, not only among the poor and the
+uneducated, but often also among the better informed, provided the
+patients became persuaded of its efficiency. Persuasion in these
+matters is usually best secured by the reports of cured cases. It is
+easy to obtain "cures" from almost anything. They are set up as
+confident proofs of the remedial virtue of methods of treatment. They
+have been, in the history of medicine, more often the indexes of
+action upon mind than upon body. Real remedies help patients to get
+better. Supposed remedies, that afterwards prove quite inert, _cure_.
+
+
+Portions of Corpses.--One of the ingredients of the famous Unguentum
+Armarium (see chapter on Nostrums) was, as has been said, moss scraped
+from the skull of a man who had been hanged. It was declared to be
+particularly efficacious against so-called dead members, such as the
+blanched fingers of Raynaud's disease, or the hysterical palsies, and
+other functional paralytic conditions of the limbs. The real
+therapeutic factor was not the gruesome material itself, but the
+potent suggestions awakened by it. It is probable that the quacks and
+witch doctors who gave out the formula of their remedies as containing
+such material often did not take the trouble to collect them, and that
+their salves and ointments were really quite inoffensive preparations.
+
+{64}
+
+Touch of the Hanged.--Some of the traditions which gather round the
+effect of contact with the body of a hanged person are curiously
+interesting from the standpoint of psychotherapy. This form of
+execution seems to have had a much more potent influence in producing
+therapeutic elements in the bodies of the victims than any other. We
+do not hear much of the touch of a beheaded person's body nor of any
+place in medicine for portions of the victims of execution by
+shooting, though Van Helmont claims curative properties for these in
+lesser degree. All sorts of ailments were, however, supposed to be
+cured by the touch of a hanged person. Thomas Hardy in his "Wessex
+Tales" tells of a young woman in his time suffering from a paralyzed
+arm, apparently a form of paralysis due to a functional nervous
+condition, who was recommended by an old "conjure" doctor to touch her
+bared arm, as soon after the execution as possible, to the purple mark
+of the rope around the neck of a man who had been hanged. The doctor
+assured her this was the only means by which she could be cured. We
+would not be surprised to hear of her cure under such circumstances.
+
+Hardy has carefully collected his material regarding the traditions of
+the southern part of England, and he makes the hangman say, when the
+woman applies to him for permission to touch the body of the victim,
+that such a request had not been made for some years, but that there
+used to be many applicants when he was a younger man. He adds,
+moreover, that it was the custom to apply to the governor of the
+prison and that usually this application was made by the physician of
+the patient who accompanied him or her on the visit to the corpse.
+There is no doubt that physicians did, in many cases, have recourse to
+such methods, and that the reasons for their belief in the efficacy of
+the touch of the dead was that they had seen the cure in this way of
+many puzzling diseased conditions, which their skill in wortcraft and
+herbal medicines had not enabled them to relieve. The touch of the
+corpse was supposed to bring about a "turning of the blood," and this
+produced the good effects. Occasionally the patients fainted from
+terror, yet afterwards were found to be able to use limbs that had
+been quite beyond their control before. The story is typical of what
+happened in country districts all over Europe for centuries.
+
+
+Mummies.--How little distant we are from the use of such material for
+therapeutic purposes will be appreciated from the fact that mummy was
+used in medicine down nearly to the end of the eighteenth century. The
+first edition of the "Encyclopedia Brittanica" (1768) said:
+
+  We have two different substances preserved for medicinal use under
+  the name of mummy, though both in some degree of the same origin.
+  The one is the dried and preserved flesh of human bodies, embalmed
+  with myrrh and spices; the other is the liquor running from such
+  mummies, when newly prepared, or when affected by great heat or
+  damps. The latter is sometimes in a liquid, sometimes of a solid
+  form, as it is preserved in vials well stopped, or suffered to dry
+  and harden in the air. The first kind of mummy is brought to us in
+  large pieces, of a lax and friable texture, light and spongy, of a
+  blackish brown color, and often damp and clammy on the surface: it
+  is of a strong but disagreeable smell. The second kind of mummy, in
+  its liquid state, is a thick, opaque, and viscous fluid, of a
+  blackish color, but not disagreeable smell. In its indurated state,
+  it is a dry solid substance, of a fine shining black color, and
+  close texture, easily broken, and of a good smell; very inflammable,
+  and yielding a scent of myrrh and aromatic ingredients while
+  burning. This, if we cannot be content without medicines from our own
+  bodies, ought
+{65}
+  to be the mummy used in the shops; but it is very scarce and dear;
+  while the other is so cheap, that it will always be most in use.
+
+  All these kinds of mummy are brought from Egypt. But we are not to
+  imagine, that anybody breaks up the real Egyptian mummies, to sell
+  them in pieces to the druggists, as they may make a much better
+  market of them in Europe whole, when they can contrive to get them.
+  What our druggists are supplied with, is the flesh of executed
+  criminals, or of any other bodies the Jews can get, who fill them
+  with the common bitumen so plentiful in that part of the world; and
+  adding a little aloes, and two or three other cheap ingredients,
+  send them to be baked in an oven, till the juices are exhaled, and
+  the embalming matter has penetrated so thoroughly that the flesh
+  will keep and bear transportation into Europe. Mummy has been
+  esteemed resolvent and balsamic: but whatever virtues have been
+  attributed to it, seem to be such as depend more upon the
+  ingredients used in preparing the flesh, than in the flesh itself;
+  and it would surely be better to give those ingredients without so
+  shocking an addition.
+
+
+Serpents in Therapeutics.--Snakes and portions of snakes have been
+prominent features of deterrent therapeutics at all times. Headaches
+were cured by wrapping a dead snake around the head, or by the touch
+of a snake's skin, and sore throat by wearing a snake's skin around
+the throat at night. This seems one degree better than the custom,
+still common, of wrapping the stocking, that has been worn during the
+day, around the neck. In the chapter on Graves Disease, the use of the
+touch of a snake, or of a snake's skin worn around the neck, is
+mentioned. Girdles made of snake's skin or snakes themselves, were
+supposed to be good for colic and for various internal troubles, and
+were sometimes, among barbarous peoples, a sovereign remedy for the
+ills of pregnancy and assured the woman a safe delivery and an easy
+labor. Undoubtedly they lessened dreads by suggestion and the effort
+necessary to overcome repugnance. Some of the symptoms of the
+menopause have been cured in the same way. Rattlesnake oil has had a
+special reputation among mountainous people, where the snakes
+abounded, for the pains and aches of the old, and the vague joint
+discomfort, sometimes spoken of as rheumatic, but really due to
+various individual conditions. It is probable that in most cases the
+oil thus employed was not extracted from the rattlesnake, but was some
+ordinary oil palmed off under that name, and having its special
+effectiveness because of the thought associated with it.
+
+Various portions of serpents are still in use, sometimes in the hands
+of physicians, though usually in popular medicine. I knew a physician
+in a small inland city who had a great local reputation for curing
+external eye troubles, and who owed not a little of it to the fact
+that the people in his neighborhood thought that he used rattlesnake
+oil as one of the ingredients for his strongest prescriptions. He was
+supposed to be able to dissolve even cataract by his remedies, and
+there is no doubt that in many cases of chronic indolent ulcer of the
+eye he was able to bring about a cure sooner, and have it last longer,
+than those of the regular profession who had not the advantage of this
+popular faith. He was careful to buy rattlesnakes from certain of the
+mountain people, who killed and brought them to him and who advertised
+the fact that they had such commissions from him. The stories were
+made all the more interesting by the fact that the doctor would not
+purchase dead rattlesnakes. They must be brought to him alive, since
+the therapeutic virtues can only be extracted immediately after death.
+A mountaineer with a couple of live rattlesnakes with him is always an
+interesting object and a fine {66} advertisement. One would like to
+know what the doctor did with the snakes--that is, how he disposed of
+them without suspicion. Homeopathic physicians still have
+lachesis-viper venom in their pharmacopeia. Their remedies, however,
+if they really follow the dilution principle of their founder, can
+have an effect only on the mind, so that the use of lachesis is not
+surprising.
+
+
+Repugnant Remedial Measures.--Quite in keeping with the use of
+deterrent remedies of various kinds are the recommendations to do
+certain things that involve great self-control, and the overcoming of
+repugnance, or fright, or the like. A favorite mode of preparing
+remedies in the Middle Ages was to gather the particular herbs for the
+prescription in a graveyard in the dark of the moon. The patient
+himself was supposed to gather them and to be alone when doing so, if
+they were to be effective. How much occupation of mind and diversion
+of thought would be afforded for timid people by the effort to
+overcome themselves to this extent! The occupation of mind alone and
+the concentration of thought necessary for the ordeal would be quite
+sufficient to divert many people from the centralization of attention
+on themselves, which is responsible for so many of their symptoms, or
+for that exaggeration of symptoms that aggravates the ailment.
+
+
+_Ordures as Remedies_.--Among all primitive peoples we have the story
+of the use, as remedies, of ordures of various kinds, of repugnant
+portions of animals, of ground insects, of animal excrement and urine,
+and even of human excretions, of the blood of serpents, or eels, or
+carrion feeding birds, and the like. Ground lice and insects of
+various kinds are very common as prescriptions in the history of
+primitive medicine. They turn up here and there through the Middle
+Ages, and they are said to be still used in China. The more one knows
+about side-tracks in medicine, the more does one find of far-fetched
+repugnant materials vaunted as wonderful cures. Some of the substances
+employed are so disgusting that one does not care to mention, much
+less discuss, them. I have had a man tell me that, in a severe
+epidemic of diphtheria, he saved his children's lives when they were
+attacked by the disease, and the children of others were dying all
+around him, by blowing the dried excrement of dog down their throats.
+
+There are certain popular medical practices that are related to these
+old traditions of deterrent therapeutics. In many manufacturing
+establishments, in spite of progress with regard to sepsis and
+antisepsis and the diffusion of information as to first aid to the
+injured, it is still the custom to put spittle on wounds. I am sure
+that every doctor has seen quids of tobacco used in this way. Even
+native-born Americans, who are not illiterate, are sometimes found
+using some deterrent material. I have known such a man use his own
+urine as an eye-wash for sore eyes, and the use of children's urine
+for such purposes is much commoner than might be thought. After all,
+it is only a generation since physicians used to taste urine in order
+to determine whether it contained sugar or not, and I have seen a
+country doctor even take between his finger and his thumb a little of
+the excrement of a child and apply his tongue to it, pretending of
+course that he obtained very valuable information this way.
+
+
+_Excretions and Secretions_.--All the human excretions have formed the
+basis of vaunted remedies. Tears, on the principle that like cures
+like, were used for melancholia; nasal secretion to lessen respiratory
+difficulty through {67} the nose; sputum for various mouth affections,
+but also as an application to external abrasions, and to the eyes, the
+ears, and the like. Undoubtedly patients were helped by many of these,
+not because of any physical effect, but because they felt easier as a
+consequence of the satisfaction of having something done for them, and
+the consequent freedom from solicitude which allowed nature to produce
+her curative reaction without interference. The greater the effort he
+has to make, apparently the more efficiently does he control this
+disturbing state of mind. This is the secret of many cures now as well
+as in the olden time.
+
+Whatever good effect is produced in such cases comes, of course, from
+the persuasion that these substances will do good, and there must be a
+strong suggestion to that effect before the repugnance can be
+overcome. While we are prone to think the older peoples who used such
+materials commonly are to be condemned for ignorance and superstition,
+it is well to recall that human nature has not changed, and is still
+ready to be influenced in the same way. Brown Sequard's extract of
+testicular substance came in this category. We had a wave of
+organotherapy a few years ago, and we know now that whatever benefits
+patients derived from taking heart substance for heart troubles, and
+brain substance for brain troubles, and kidney for renal diseases, was
+entirely due to mental influence. The cannibal who eats the heart of
+his enemy, thinking that the vigor and courage of the other will pass
+into him, undoubtedly has for a time a power of accomplishment greater
+than before. Nothing acts so powerfully as suggestion of this kind to
+give renewed vigor and to enable us to tap sources of energy that we
+were not aware of in ourselves, and that enable us to accomplish what
+before seemed quite impossible, and even to bring about curative
+reactions.
+
+
+Diseases Benefited.--Observe the classes of disease that were
+particularly relieved by deterrent therapeutics. Headache was one of
+these. All sorts of things were cures for headaches--the touch of the
+hangman's rope, or of an executed criminal, or some herb gathered in
+the graveyard in the dark of the moon, or pills made of the excrement
+of various animals. The forms of headache thus relieved would be those
+in which over-attention to self, rather than real headache, produced
+queer feelings in the head, though concentration of attention might
+exaggerate this into an ache. Foot troubles were cured by deterrent
+therapeutics. To wear the shoes of a dead person, especially of a
+murderer who had been hanged, would cure them. Colic was cured by
+pills of excrementitious materials, and by all sorts of other
+deterrent remedies. For instance, one well-known remedy was to wash
+the feet and drink the wash-water. The wash-water of little babies was
+a favorite remedy for the vague abdominal pains of old maids, and for
+the symptoms due to the menopause.
+
+
+Deterrent Pain.--A striking illustration of a strong mental influence
+helping out a slight amount of therapeutic efficiency is found in the
+use of the actual cautery for medical affections. At a number of times
+in history most of the chronic pains and aches, the arthritises, the
+so-called gouty tendencies when localized, the rheumatic affections
+and especially the chronic rheumatisms, have been treated by means of
+the cautery. All of the neuralgias, many of the neuroses, all of the
+neuritises and a certain number of so-called palsies and paralyses,
+were treated successfully by this means. It is a very suggestive
+remedy producing a deep impression that now relief must be in sight.
+It {68} became popular over and over again, though after a time it
+always lost its influence, and ceased to have the beneficial effects
+that it had at the beginning of its reintroduction.
+
+During the second half of the eighteenth and the beginning of the
+nineteenth century the cautery became very popular. It was applied
+particularly in the form of the moxa. A cylinder of cotton was
+employed for this purpose, being set on fire and allowed to burn on
+the skin of the patient, producing a deep wound. The mental effect of
+this can be readily understood. Baron Larrey, one of the most eminent
+surgeons of the time, thought the moxa one of the best aids that he
+had in the treatment of many affections where the knife was not
+indicated. There were large groups of diseases in which it was almost
+a specific. Larrey employed it in affections of vision, of smell, of
+taste, of hearing and of speech. In many paralytic affections of the
+muscular system, in all chronic affections of the head, among which he
+enumerates non-traumatic affections, hydrocephalus, chronic headaches
+and many other affections supposed to be seated in the cranium. In
+asthma he was particularly successful with the moxa. Old catarrhal
+affections yielded to it. Consumption was frequently benefited by it.
+Most of the chronic affections of the uterus were benefited, as were
+also similar affections of the stomach. He considered that the moxa
+must be admitted, without contradiction, to be the remedy _par
+excellence_ against rachitis. In Pott's disease, which he called
+dorsal consumption, it worked wonders. In sacrocoxalgia, in
+cocygodynia and femero-coxalgia he had excellent results with the
+moxa.
+
+A glance at this list shows exactly the class of cases in which
+suggestion has always played a large role, and for which there has
+been, at various times, a series of specific remedies, medicinal,
+manipulative and surgical. Others extended the value of the moxa
+beyond these affections. Ponto found it valuable in gout, and in the
+various chronic affections which are sometimes grouped under the name
+chronic rheumatism. He insisted that the moxa could be placed on
+almost any part of the body, though the contra indications he suggests
+show how far the men of his time went with its use. Only these
+portions named might not have a moxa applied to them. It must not be
+used on the skull, on the eyelids, on the ears, on the mamme, on the
+larynx and on the genitals, though it might be applied to the perineum
+or the perineal body.
+
+
+Deterrent Taste and Smell.--The disturbing effects produced by other
+senses besides those of sight have been used in the same way for the
+production of definite therapeutic suggestive effects. A number of the
+ill-tasting, almost nauseating drugs of the olden time prove to have
+very little real therapeutic efficiency in the light of modern
+clinical careful observation. This is particularly true of the herbs
+and simples. Many a disgusting preparation apparently owed all of its'
+good effects on the patient to the effort that was required to swallow
+it, producing such a favorable influence upon the mind, by
+_contrecoup_ as it were, that the patient got better. A little girl
+said that cough medicines were nasty things they gave you in order to
+keep you from catching cold again. The sense of smell has been used in
+the same way. Valerian is probably an efficient drug in certain
+respects, but undoubtedly its efficiency is materially increased by
+its intensely repulsive odor. For many of the psycho-neuroses and
+neurotic conditions generally the ammonium valerianate is likely to be
+much more efficient than the strychnin valerianate, though probably
+the {69} latter should be considered as more physically efficacious in
+its tonic properties. Asafetida, musk and some preparations of the
+genital organs of animals that used to be in the pharmacopeia, owed
+most, if not all, of their power, whatever it was, to the mental
+effect of their odor and the feeling of deterrence that had to be
+overcome before they were taken.
+
+There is a precious therapeutic secret in this use of deterrent,
+repugnant, frightful materials which patients use to advantage under
+certain circumstances. It illustrates the influence of the mind over
+the body, and emphasizes the fact that such influence can be exerted
+in the full only when a deep impression is produced upon the patient.
+Whether this can be imitated without deceit, and without the use of
+undignified methods, must depend on the physician himself and his
+personality. There can be no doubt that there is a wonderful power
+here to be employed. It must be the physician's business to find out
+in each individual case, according to his own personal equation, just
+how he may be able to use at least some of it. It is well worth
+studying and striving for, because nothing is more potent for
+psychoneurotic conditions, and for neuroses on the borderland of the
+physical, than which no ailments are more obstinate to treatment.
+
+
+
+CHAPTER X
+
+INFLUENCE OF THE PERSONALITY IN THERAPEUTICS
+
+Though it has seldom been fully realized and has probably never been
+appreciated as in our time, one of the most important factors in
+therapeutics, in every period of the history of medicine, has been the
+personal influence of the physician. Therapeutic fashions have come
+and gone, new drugs have been introduced, have had their day and then
+been relegated to the limbo of worn-out ideas. At all times, however,
+physicians have succeeded in doing good, or at least using, with
+apparent success, the therapeutic means of their own time, however
+crude and inadequate these afterwards proved to be. They have
+succeeded in shortening the progress of disease as well as increasing
+the patient's resistive vitality and thus enabled him not infrequently
+to survive where otherwise a fatal termination might have occurred.
+All unsuspected during most of the time, it was the personal influence
+of the physician that counted for most in all of the historical
+vicissitudes of therapeusis. It mattered not that the means he
+employed might seem absurd to the second succeeding generation, as was
+so often, indeed almost invariably, the case, his personal influence
+has at all times overshadowed his available therapeutic auxiliaries.
+In spite of all our advance in scientific medicine, to a considerable
+degree this remains true even at the present time, and to fail
+properly to use this important auxiliary is to cripple medical
+practice.
+
+
+Place of Personal Influence.--When the antitoxins and directly
+curative serums seemed about to make for themselves a place in
+therapeusis, it looked for a time as though this personal element
+might be entirely superseded. It seemed that all other therapeutic
+factors must give way to definitely accurate doses of antitoxic
+principles, directly opposed to the toxins of disease and {70} capable
+of conquering it. With the success of diphtheria serum, the prospects
+for scientific therapeutics from the biological standpoint became very
+promising. Unfortunately, our further experience with antitoxins and
+therapeutic sera of various kinds has not been satisfactory, and now
+the medical world is looking elsewhere for progress in therapeutics.
+
+This throws us back once more on the old-time therapeutics, and we
+have to learn to use all their elements. One of the most important of
+these, if not, as we have suggested, absolutely the most important,
+the one that in all the many variations of therapeusis has maintained
+itself, is the personal influence of the physician by which he is able
+to soothe the patient's fears, allay his anxieties, make him face the
+situation calmly so that he may not use up any of his vital force in
+useless worry, but on the contrary employ all his available psychic
+energy in helping nature to overcome whatever disturbance there is
+within the organism. This personal influence was for several centuries
+spoken of as personal magnetism, not merely in the figurative sense in
+which we now employ that term, but in a literal sense. The implication
+was that some men possessed within themselves a reservoir of
+superfluous energy, vital in character, but thought to be related to
+the force exhibited by the magnet, when it attracted bodies to itself,
+and made metals for a time magnetic like itself, and which actually
+passed over from the physician to his patient. We have gotten away
+from the idea of any physical force flowing from physician to patient,
+but we know very well that certain physicians are much more capable
+than others of arousing the vital energies of the patient, sometimes
+to the extent of making him feel, after treatment, that he has more
+force than before. The patient feels that something must have been
+added to his natural powers, though he has only been brought into a
+state of mind where he can better use his own powers.
+
+It is the men whose presence created this impression in patients, an
+impression that is justified by the fact that somehow he enabled them
+to vitalize themselves better than before, who have been most
+successful in the treatment of patients. In all ages the men of
+reputation for healing have had this. A careful study of their lives
+shows that this counted for more in many of the experiences of their
+healing than the drugs and remedies which they employed. The men who
+have been the most sought by patients have not as a rule left us great
+therapeutic secrets; on the contrary, they have only employed the
+conventional remedies of their times with reasonable common-sense and
+have added to them their own personal influences. On the other hand,
+the men who have made discoveries in therapeutics, and in medicine,
+have not always been popular as physicians. They have known too much
+of their own lack of knowledge to be quite confident in their use of
+remedies, and this has hurt something of their personal influence over
+patients.
+
+
+
+IMPRESSIVE PERSONALITY
+
+As a matter of fact, it is easy to comprehend, even from the
+comparatively scanty details that we have of habits and methods of the
+great physicians, that their effect upon their patients was always
+largely a matter of impressive personality. Any one who, from a
+pharmaceutical standpoint, knows how {71} inefficient were many of the
+remedies that great physicians depended on, yet how effective they
+seemed to be to their patients, and even to themselves, will
+appreciate the factor of personal magnetism that entered into their
+employment. It is not alone in the olden time that great physicians
+have been almost worshiped. For their patients they have at all times
+been men of exalted knowledge, masters of secrets and comforters of
+the afflicted, just as was the first great physician of whom we have
+any account, I-em-Hetep, in Egypt nearly six thousand years ago. Such
+men as Hippocrates, as Galen, as Sydenham and Boerhaave, and Van
+Swieten, accomplished curative results far beyond the therapeutics of
+their time. The loving admiration of patients and of their disciples
+shows how strong were their personalities and gives us, almost better
+than the writings they have left to us, the secret of their successes
+as practitioners of medicine.
+
+A Great Modern Physician's Influence.--It is interesting to study in
+the lives of great physicians the details which illustrate their
+personal influence, their consciousness of it and how deliberately
+they used it. A typical example very close to us, whose reputation was
+still fresh while I was at the University of Paris, was Professor
+Charcot. He had made great discoveries in nervous pathology. To a
+great extent he had revolutionized our knowledge of nervous diseases
+and added many new chapters to this rather obscure department of
+medicine. Far from making the treatment of nervous diseases easier
+than before, or giving more assurance to the physician who dealt with
+them, his discoveries, however, had just the opposite effect. His work
+emphasized that practically all of the so-called nervous diseases were
+due to degenerations in the central nervous system, which no medicine
+could be expected to relieve in any way, and which nothing short of
+the impossible re-creation of damaged parts could ever cure. His
+studies included organic degenerations of other organs, and in his
+treatise on "Diseases of the Old" it is made clear that many of the
+symptoms of old age are due to organic lesions for which no cure can
+ever be expected. This would seem to discourage treatment, yet somehow
+Charcot became a great practicing physician as well as a medical
+scientist and pathologist.
+
+His success was due to his personal influence over his patients. In
+spite of the unfavorable prognosis that he had to give in so many
+cases, he was able by suggestion to help many patients with regard to
+their course of life, and to reassure them, so that many adventitious
+neurotic symptoms not due to their underlying nervous disease, but to
+their solicitude about themselves, disappeared. Very few people who
+came to him went away without feeling that his advice had been very
+valuable to them and without experiencing, as a rule, after they had
+followed his advice, that they were much better than they had been
+before. It was for the neurotic conditions associated with nervous
+affections that Charcot's personal influence over patients was of the
+greatest therapeutic significance.
+
+He himself recognized this and did not hesitate to use it to its
+fullest extent. Towards the end of his life, the method by which his
+patients were presented to him was calculated to make their relation
+to him, above all, a very personal one, and to give his influence the
+fullest weight. Nervous patients who came to see him, were each in his
+turn invited from the general waiting-room into a small ante-room just
+outside of Charcot's office and {72} there, in silence and dim light,
+asked to await the summons of the physician himself. When the time
+came for him to call them in, the folding doors between the rooms
+opened and he stood in a blaze of light inviting them to enter. Many a
+neurotic patient despairing of relief for symptoms that had lasted
+long in spite of the treatment of many other physicians, felt at once
+that here, in this kindly, gentle-voiced man standing so prominently
+in the light, was surely the long looked-for physician who would heal
+whatever ills there were. They came fully impressed with his power to
+heal, and all the valuable influence of auto-suggestion was enlisted
+on the side of their physician.
+
+What is true in the regular practice of medicine can be seen much more
+clearly in the history of those who were not physicians, but who,
+nevertheless, by personal magnetism, succeeded in curing various ills,
+or at least in lifting up patients so that they used their own natural
+powers of recovery to much better advantage than would have been
+possible if left unaided.
+
+Every successful healer has had this same personal influence, personal
+magnetism, call it what we will, which his patients have thought
+helpful to them through some direct communication, but which he
+himself, if he seriously studied it, and which every other thorough
+student of the question must realize, was due only to his power to
+call out the latent vitality of his patients. The mystery is not one
+of teledynamics, a transfer of energy from the operator, but one of
+awakening dormant faculties in the subject. Just why they should be
+dormant, since the patient so much wants to use them if he only could,
+is hard to understand. They do, however, lie dormant until the call of
+another strong personality wakens them to activity. Many people are so
+constituted that they cannot do effective work except under the
+direction of others. They lack initiative, though they may fill
+secondary places very well, indeed, much better often than the man of
+initiative who so frequently lacks capacity for details. In the same
+way many people are not able to bring out to the full all their own
+energies, even for their own bodily needs, unless under the guidance
+and influence of others; hence the stories of the healers that we have
+all down the centuries, and who have a definite place in the history
+of humanity and of medicine.
+
+
+A Modern Healer.--A typical instance of the really marvelous power of
+mental influence over the minds of sufferers from many kinds of ills,
+is found in the career of the well-known Father Kneipp. For more than
+twenty-five years he had attracted the attention of Europe, and had
+made the little town of Woerishofen well known all over the world
+because of the cures effected there by him. The exactly proper phrase
+is effected _by him_ because it is clear to anyone who has studied the
+therapeutic methods he employed, that it was not these, or at least
+not these alone, that enabled him to cure so many ailments which had
+resisted the efforts of some of the best physicians in Europe. It was
+his magnetic personality which won patients to the persuasion that
+they must get better because he said so, and then to the following out
+of certain very simple natural rules of life, and certain quite as
+simple remedial measures, which acted as alteratives and enabled
+patients to tap reservoirs of vitality, of which they themselves were
+unconscious, but which, supplying energies to overcome tendencies to
+various symptomatic conditions, brought about cures.
+
+{73}
+
+Pfarrer Kneipp had himself suffered from consumption, had been
+practically given up and then, as is the case of many another, had
+taken himself in hand, had secured much more outdoor air than before,
+and more abundant nutrition, until gradually his ailment was overcome.
+It is true that he used various hydrotherapeutic measures, some of
+them, as he confessed afterwards, to an excess, both as regards the
+temperature of water and the length of the application of it, that
+might have seriously hurt him if he had been less robust, but it was
+not so much his hydrotherapy as his own determination to get better
+and to live a little closer to nature that led to his cure. Then he
+became the apostle of cold water and of many natural remedial
+measures, and as a consequence, healer of all forms of ills in the
+many thousands who flocked to consult him in the little South German
+town. He made his patients get up early in the morning, get out in the
+air shortly after rising, the excuse, or, as he declared it, the
+reason being that they were to walk with bare feet in the dewy grass.
+After this he had them eat heartily of simple food, of such variety
+and in such quantity as relieved them of constipation, made them use
+water, internally and externally, in abundance, and after a time, sent
+most of them on their way rejoicing that they had been cured from
+chronic ills.
+
+Some of the highest in Europe came to him; the Empress of Austria was
+his patient, and he was asked to prescribe for the Pope; reigning
+princes and all the lesser order of the nobility were included among
+his patients. Several of the Rothschild family went to him and where
+they went, of course, others flocked. Very few failed to be benefited.
+People less educated, and less rich in the world's goods than these,
+came also, and went away relieved. After a time Kneipp societies were
+founded all over Europe and even spread through America. These
+consisted of organizations of men and women who encouraged each other
+to keep up the Kneipp practices. With his death there has come a
+decline in interest in Kneipp methods. He, himself, was sure that his
+remedies and recommendations were the important curative factors. Now
+it has become clear that it was mainly his forceful personality, his
+power to lift patients above their ills, and enable them to use mental
+resources or vital forces that they could not use until encouraged by
+him with the thought that they would surely get better. In the
+atmosphere he thus created, they seemed to borrow something of his
+overmastering personality. It can not be too often repeated that this
+is the secret of the success of the great world healers. They do not
+transfer force to others, but they enable others to use their _own_
+forces more successfully.
+
+
+An Ancient Healer.--Let us compare some of the details of the career
+of Father Kneipp with the story we have of one Aristides, who, as the
+result of dreams that came to him while practicing the cult of
+AEsculapius and the injunctions contained in these dreams, was cured
+of many ills, and afterward delivered a series of sacred orations.
+Aristides is one of the first of the large group of literary men, much
+interested in their own health and their own ills, whose writings have
+been preserved for us. He was intensely proud of the number and
+variety of his ills, and he was perhaps conceited about the curious
+ways in which some of them had been cured. Traveling in the winter
+time he caught a chill; then he suffered from earache and in the midst
+of a storm developed fever, asthma and toothache. Arrived in Rome, he
+had severe internal sufferings, shivering fits and want of breath.
+Treatment by the Roman {74} doctor only aggravated his sufferings. A
+stormy voyage home made him worse. When, at last, he arrived in
+Smyrna, the doctors gathered round him, and were astonished at the
+manifold nature of the disease. They could do nothing for him.
+
+Suffering from all these ills (which remind one of a modern literary
+man who has got his mind on his stomach and his body on his mind),
+Aristides went to a number of the old temple hospitals and received
+suggestions in sleep from AEsculapius. These he has described in what
+are called his sacred orations. In them we have every phase of modern
+therapy that has the strong element of suggestion in it. Like Pfarrer
+Kneipp, he tried very cold baths and was benefited by them. Walking in
+the dewy grass in his bare feet was another recommendation that had
+come to him in a dream. Occasionally he would run rapidly for a
+considerable distance, and then when heated plunge into a cold bath.
+We have many complaints of his fever and stomach troubles. Mud-baths
+were also recommended to him and, of course, tried with benefit for a
+time. Sand baths later proved to be beneficial. For rheumatism a cold
+bath, after running almost naked in the cold north wind, proved
+successful when other remedies failed. Aristides wrote out his
+experiences, and his writings had great influence over generations of
+patients and maintained the influence of the old Greek temples as cure
+houses long after the general acceptance of Christianity. As the
+result of his writings, no matter how bizarre a dream might be, some
+interpretation of a therapeutic nature was found from it.
+
+
+Constancy of the Law of Personal Influence.--Indeed, there has
+apparently never been a time when some strong character, full of
+religious enthusiasm and of high purpose, strong in the confidence of
+men, has not succeeded in accomplishing wonderful curative results by
+the reassurance that comes from a renewal of faith in the goodness of
+Providence. There are, for instance, a number of stories which show
+John Wesley's power to help men to tap the reservoir of surplus energy
+that all of us have within us, but that somehow we do not succeed in
+making use of, unless some strong mental influence is brought to bear
+on us. Practically every religious man who has had the love and the
+veneration and the respect of those around him has succeeded in
+accomplishing the cures that many people in recent years have been
+prone to regard as rather novel phenomena in the history of
+psychology. Men like St. Philip Neri, St. Francis Xavier, and St.
+Francis of Assisi, and St. Bernard, have many stories told of them
+which show how much they were able to help fellow mortals by enabling
+them to make use, even in a physical way, of their own highest and
+best powers. Their lives show how much more they did.
+
+Nor is this power confined to men. In nearly every century we have the
+story, also, of wonderfully strong women, leaders of their time, who
+inspired the profound confidence and veneration of those around them,
+and who were enabled, by their own strength of character, to help
+people physically as well as morally. The Life of St. Catherine of
+Siena is full of such instances. She spent her life mainly in caring
+for the sick and the distressed at the hospital in Siena, and the
+beautiful hospital there was completed largely as a monument to her.
+During her lifetime marvelous cures occurred that in many cases were
+evidently due to her power over the minds of people. The {75} life of
+St. Teresa has a number of similar examples, and Joan of Arc, in her
+lifetime, lifted many a dispirited man into vigorous strength because
+of her own abounding personality and the physical reaction which
+contact with her enthusiasm brought.
+
+
+Modern Examples.--Nor did such occurrences come only in older and less
+sophisticated centuries than ours. John Wesley is close enough to our
+time to negative any such impression, but there are many other
+examples. There is Pastor Gassner, whose cures remind Prof.
+Münsterberg of the Emanuel movement at the present time, but there are
+also a number of strong, religious characters whose influence was
+exercised in the alleviation of physical ills during the nineteenth
+century. The name of Father Matthew, the Irish "Apostle of
+Temperance," as he was called, is mainly connected with wonderful
+cures of the worst forms of alcoholic addiction. Physicians know how
+difficult such cases are to cure, yet there are many thousands of what
+were apparently hopeless cases to Father Matthew's credit. It may be
+remarked that this is one of the ills that modern mental treatment
+claims most success with. Besides these morbid habits there are,
+however, other cases, told in detail, in which Father Matthew's
+influence enabled people to shake off headaches, to get rid of
+illusions, to overcome hysteria, and even to relieve other and much
+more physical affections. Animal magnetism was the subject of much
+thought in his lifetime (nineteenth century), so that it is not
+surprising that Mr. John Francis McGuire, a member of the English
+Parliament, who wrote Father Matthew's life in 1864, declared that
+"Father Matthew possessed in a large degree the power of animal
+magnetism, and great relief was afforded by him to people suffering
+from various affections; and in some cases I was satisfied that
+permanent good was effected by his administrations."
+
+Another strong man of this same kind was Prince Alexander of
+Hohenlohe. Though a prince he had become a clergyman and spent his
+life in the service of the poor. Shortly after he became a priest he
+went through a great epidemic, fearlessly caring for his poor people,
+and as a consequence inspired them with so much confidence that ever
+after they came to him with all their ills. He was able to help, not
+only the poor, but also many of the nobility. Some of the things
+reported as accomplished through his influence show extraordinary
+power. His usual method was to endeavor to inspire in the people who
+came to him a faith in their cure, and then after a time the cure was
+actually accomplished.
+
+During the recent troubles in Russia, attention was called to the fact
+that the famous Father John of Cronstadt, the hero of Bloody Sunday,
+was looked up to with so much respect and veneration that many people
+found themselves helped physically by contact with him. There are a
+number of interesting stories of cures of ills of various kinds, some
+of them exclusively mental, but many of them fundamentally physical,
+which took place as a consequence of the new spirit of hope infused
+into people because of their confidence in Father John. His subsequent
+history seems to indicate that this was evidently due to the forceful
+personality of the man rather than to any special religious influence.
+His influence was not limited to the ignorant masses in Russia, for
+some of the cures reported occurred in families of the better class,
+thoroughly capable of judging the character of the man apart from his
+religion.
+
+{76}
+
+
+SUCCESS IN HEALING
+
+We have any number of examples, then, of this power of the healer in
+history. Over and over again we find that it was the personality of
+the man and the suggestive value of the means that he employed that
+enabled patients to cure themselves, that is, to use all the vital
+force which they had for curative purposes. This force had hitherto
+been inhibited by their own doubts of themselves and their doubts of
+the value of all ordinary means of cure which had been previously
+employed in their cases. This is the secret of the success of the
+healer, and this secret is much more valuable for therapeusis than any
+remedy which has come down to us from the olden time. It has,
+unfortunately, been neglected, and thus an important benefit to
+humanity has been lost. Now that we are able to review frankly and
+deliberately the conditions that obtained in the past, it is time to
+set about making use of this oldest secret in medicine, now no longer
+a secret, as a strong factor in the treatment not of disease but of
+patients.
+
+Healers are at all times strong characters who are helpful to others
+because of their own superabundant strength. The world is made up of
+two classes of people, lifters and leaners, and the leaners constitute
+by far the larger class. Most men and women are the subjects of doubts
+and dreads and difficulties with regard to their health, and the more
+time they have for introspection, the more are they likely to suffer.
+Unable to overcome them by themselves, they need the help of others.
+What they need, above all, is the reassurance that a trained strong
+mind can give them. The exercise of this mental influence over them,
+is only what corresponds to leadership in all the affairs of life.
+Most people need to be led and to be guided. The place of the
+physician is that of guide and director. The family physician of the
+olden time had a precious amount of influence that accrued to him from
+his character, and it was used to magnificent purpose. Most of his
+drug treatment would be looked upon as quite absurd at the present
+time, yet he did a great good work by lifting people up to their own
+highest possibilities of resistive vitality. That means more for the
+conquest of disease, even now, in most cases, than any remedies we
+possess.
+
+Often men do not realize how much their personal influence counts for.
+They think it is their method of treatment, or some new discovery in
+drugs or remedial measures, or some new phase of psychology they have
+hit upon, that is producing results. This makes it difficult to
+determine, in given cases, just what are the actual influences at
+work. Many men supposing themselves to be discoverers of some novel
+force, are merely exploiting that old-time influence of one mind over
+another that can be observed all down the centuries.
+
+It is interesting to study the careers of men who thought they were
+employing on their patients some new psychological method, when all
+they were exploiting was the old-fashioned influence of suggestion
+from a stronger personality to a weaker. A dozen times in history
+hypnotism has been announced as a wonderful curative agent. At present
+no one thinks it so, but, on the contrary, if used frequently, we
+think that it is much more likely to do harm than good. We went
+through a phase of interest in hypnotism a quarter of {77} a century
+ago and there are now signs of the possibility of its return in
+another form. In recent years we have heard much of psycho-analysis,
+of dominant ideas, of the auto-suggestion that comes from this, and
+how much benefit can be conferred on the patient by removing such
+ideas or revealing their unfavorable influence and so neutralizing
+them.
+
+The patients that come for treatment and to whom psychotherapy is of
+special benefit, are not, as a rule, those suffering from acute
+diseases or injuries, though even in these cases the attitude of mind
+is always an important therapeutic factor. The patients are mainly
+those suffering from chronic ailments, and from minor affections
+which, while they do not confine them to bed, often prove the source
+of such serious disturbance as makes them very miserable. The
+suffering in the world is out of all proportion to the actual disease.
+Many people who have little disease suffer a great deal, partly from
+over-sensitiveness, partly from concentration of mind on their
+ailments, and partly from such ignorance of whatever pathological
+condition is present that they grow discouraged and morbid over it.
+The rôle of psychotherapy is particularly to help patients of this
+kind. This does not mean that its main purpose is to treat imaginary
+disease, or disease which exists only in the mind of patients, for in
+nearly all of these cases there is a definite physical element in the
+affection. Even where the disease is quite imaginary, though that term
+has been so sadly abused that it is perhaps better to speak of
+affections as purely mental in origin, psychotherapy is important. As
+has been well said, a patient not having something physical the matter
+who thinks that there is something the matter, is in a worse state
+than one who really has something the matter. There are a great many
+such cases. If the principles of psychotherapy can relieve them and
+cure many of them, then it has a large place in human life.
+
+In order that the individual patient may be benefited, a thorough
+understanding must be established between physician and patient. This
+must take on the character of a personal relationship. The patient
+must feel that the physician has a personal interest in him--that
+there are certain individual features in his ailment which make his
+case mean something much more than ordinary to his physician. Some
+physicians have the power to make their patients feel this personal
+relationship to a marked degree. They are the eminently successful
+practitioners of medicine. Their patients sound their praises, and
+even though they may not be distinguished scientists, they acquire a
+large practice. Some of them are thoroughly scientific men. All of us
+know them and, while we may not be able to understand just how it is
+done, we recognize their power.
+
+
+
+CHAPTER XI
+
+FAITH CURES
+
+The series of phenomena that may be grouped under the term "faith
+cures" represent the oldest, the most frequent, universal, and
+constantly recurring examples of the influence of the mind over the
+body for the healing of ills. Whenever men have believed deeply and
+with conviction that some other being {78} was able to help them, many
+of their ills, or at least the conditions from which they suffered
+severely, have dropped from them and their complaints, real or
+imaginary have disappeared. This was true whether it was the touch of
+another human being supposed to have some wonderful power that was the
+agent, or some persuasion of the interference of the supernatural that
+appealed to them. Religions of all kinds have always had their cures,
+and one of the main reasons why men have accepted the various
+religions has nearly always been because of the weight of these
+healing phenomena. Apparently it does not matter how debased the form
+of religion may be, whether it is exercised by the medicine man of a
+savage tribe with methods that appeal only to barbarous instincts, or
+by a highly cultured priest of a form of religion appealing to the
+loftiest feeling and the profoundest intellectuality, cures take place
+whenever devotees have complete and absolute faith in the possibility
+of divine or supernatural interference in their behalf. The very
+earliest history that we have tells us of such cures, and the daily
+papers bring us reports of them from all quarters among the high and
+the low, the educated and the uneducated.
+
+The phenomenon is universal and we come logically to the belief that
+the Supreme Being intended that confidence in Him, and above all
+recognition of the fact that somehow the world with all its ills has a
+meaning for good, should be rewarded. The argument that religion is a
+natural revelation should then apparently be extended to include also
+the thought of a healing power in connection with it. Many of the
+founders of religions that have meant much for uplift to mankind, have
+made healing a principal portion of their message to man--the proof of
+their missions. Indeed, there actually seems to be an extension of
+power, above what is natural, to those who in profound confidence in
+Divinity, turn to this source of strength for relief from the ills
+that flesh is heir to. In any of these cases, definite inquiry as to
+the significance of the particular incident is needed, and not any
+general principle of either acceptance or rejection. Faith healing is
+a fact, its meaning is of the greatest importance for psychotherapy
+and its phenomena deserve that specific study which alone can give any
+certainty in the matter.
+
+
+Accessories of Faith Cures.--From the earliest dawn of history we have
+definite records of faith cures. It is true that they were usually
+associated with certain physical factors besides the mere act of the
+mind. In ancient Egypt the physicians were also priests, and while
+they administered various remedies, these had the added advantage of
+being supposed to be the result of divine inspiration, or suggestion,
+or to be in some way connected with religion. Among these men there
+were many strong personalities, contact with whom brought healing.
+Dreams and premonitions and hallucinations all had a definite place in
+their therapeutics because of their supposed connection with religion,
+or at least with the beings of another world. Spiritualism, itself a
+form of religion, is very old, and communications from spirits, real
+or supposed, were easily thought to have therapeutic significance.
+
+
+Miracles.--In most cases of faith healing, faith acts through the
+definite conviction that there is to be a direct interference with the
+ordinary course of nature in the patient's behalf. Some of the
+evidence for such direct interference on the part of Providence is so
+strong as to carry conviction even to serious and judicious and
+judicial minds. When the circumstances are such {79} that an exception
+to the laws of nature would not involve an absurdity, there is no good
+reason why its occurrence should be absolutely put out of the
+question. It may well be urged that we know so little about the laws
+of nature that we cannot determine absolutely what are and what are
+not exceptions to those laws. There is in itself, however, no
+absurdity in what is called a miracle, and unless one is ready to
+reject Christianity entirely, or to declare it absolutely impossible
+that the God who made the universe should have any personal care for
+it, or above all any interest in particular individuals in it, their
+possibility must be admitted. The attitude of utter negation and
+incredulity often assumed at the present day is only a reflection of a
+certain ignorance of philosophy, and too great dependence on a
+superficial knowledge of physical science, so characteristic of
+narrowly trained minds. After a visit to Lourdes and careful study of
+_"La clinique de Lourdes,"_ I am convinced that miracles happen there.
+There is more than natural power manifest.
+
+In a great many cases it is easy to see that the agents involved in
+the faith cures, and the circumstances surrounding them, are quite
+unworthy of any supposition that the Deity should have interfered.
+Where there is anything irrational, or sordid, or eminently selfish
+about the faith-healing, then any appeal to a supposed interference
+from on high is absurd. Horace said in another matter, but it will
+bear application here: "Nec deus intersit nisi dignus vindice nodus."
+Do not let a god intervene unless there is a set of circumstances
+worthy of him. In many of the faith-healing phenomena claimed to be
+connected with religion there are a number of absurdities. It may be
+suggested that any one person must not set himself up as the judge of
+such absurdity. When it is evident, however, that the ailing are being
+exploited for the benefit of one or of a few persons, or when there
+are certain manifestly irrational conditions in the circumstances of
+healing, then it is fair to conclude that what we have to do with are
+only examples of healing by means of strong mental influence. But it
+would be quite wrong on account of these abuses to dismiss the whole
+subject of miracle healing as all imposture or merely mental
+influence.
+
+
+The Royal Touch.--Probably the most interesting chapter in the history
+of faith cures is that of the touch of the King of England for
+scrofula, or, as it was known, the King's Evil. His touch was also
+supposed to be efficacious in epilepsy. English historians usually
+trace the origin of the custom to Edward the Confessor. Aubrey remarks
+that "the curing of the King's Evil by the touch of the King does much
+puzzle our philosophers, for whether our Kings were of the house of
+York or Lancaster, it did the cure for the most part."
+
+Even the change of religion in the time of Henry VIII and Elizabeth
+made no difference. Some people who hesitated about submitting to
+Elizabeth as queen lost their hesitancy when they heard that the
+queen's touch was successful in curing. James I wanted to drop it, but
+was warned not to, as it was a prerogative of the crown with which he
+had no right to interfere. Charles I was particularly successful.
+Charles II, whose licentious life apparently would quite unfit him for
+the exercise of any such power, was perhaps the English king who
+devoted most time to healing. While he was in exile in the
+Netherlands, many people crossed over to the Low Countries in order to
+be touched by him, and they returned cured of many different diseases.
+{80} This effectively prepared the minds of many for his return. Under
+scrofula were included most of the wasting diseases, and under
+epilepsy many neurotic conditions as well as many organic
+disturbances. It is easy to understand how great was the room for the
+successful employment here of mental influence.
+
+Queen Anne continued the practice, and many cures were reported in her
+time as late as the eighteenth century. William of Orange, when he
+ascended the throne with Mary, refused to believe that there was any
+special power for good in his touch. On one occasion he touched a
+person who came to him, saying as he did so: "God give you better
+health and more sense." In spite of this skeptical attitude his touch
+is said to have healed that particular person. In the next reign,
+however. Queen Anne resumed the practice, and Dr. Samuel Johnson, as a
+boy of five, was touched by her with some hundreds of others in 1712.
+No cure was effected in his case, but as the gruff old doctor lived to
+a round age in rather sturdy health, doubtless some would raise the
+question as to whether, if he had early scrofula, it was not greatly
+modified for the better.
+
+The circumstances connected with the royal touch were all calculated
+to be curative of the affections for which this practice had a
+therapeutic reputation. There were certain times in the year,
+particularly in the spring after Easter, when the king touched people
+for their ills. Ordinarily preparations would be made for some time
+before, and the patients would have all the benefit of expectancy.
+Then there came the journey to London to the king's presence, and as
+it was usually known that these ailing folks were on their way to the
+king, they received particular care from the people of the towns
+through which they passed. Then came the day of the touch itself, and
+the presentation of a coin, the so-called coin of the king's touch,
+which the patient was supposed to preserve. On the way home they were
+once more subjects of solicitude, and they had the royal coin to
+assure them every now and then that they had been touched by the
+king's hand, and that they ought to get well--for had not many others
+been thus cured? All this favorable suggestion, with the outing and
+the better food, was eminently calculated to cure the so-called
+scrofular conditions, under which term was grouped many vague forms of
+malnutrition and the milder epilepsies and pseudo epilepsies, for the
+cure of which the touch was famous.
+
+
+Cramp Rings.--Scarcely less famous than the king's touch for
+nutritional and neurotic conditions were the "cramp rings," which were
+blessed by the Queens of England and were supposed to cure all sorts
+of cramps. The power attached to them for this form of ailment was
+similar to that which the king's touch had for scrofula or the king's
+evil. Cramps seemed to be the "queen's evil." Whenever a queen died
+there was a great demand for these rings, because no more could be
+obtained until a new queen was crowned. The efficiency of these and
+the cures which they performed can be readily understood. Many of the
+hysterical conditions within the abdomen are cramplike in character.
+Hysteria will imitate nearly every form of cramp, including even those
+due to gallstone and kidney calculus. Any strong mental influence will
+do more for hysterical pain than our strongest medicines. On the other
+hand, many of the cramplike conditions within the abdomen may be
+relieved by concentration of mind on some distracting thought, and
+feelings of discomfort in the intestines may thus be relieved.
+
+{81}
+
+Mental Healers.--When the king was absent from England during
+Cromwell's time, the touching for the king's evil was sadly missed. If
+Cromwell himself had announced that he would touch for the diseases
+that used to come to the king, a number of cures would undoubtedly
+have been reported. As it was, Greatrakes, the Irish soldier
+adventurer, dreamt that he was commissioned from on high to touch for
+the same diseases as formerly had gone to the king, and, having begun
+it, cures followed until probably many more came to him every year
+than usually went to the sovereign in the olden times. He worked at
+least as great a proportion of cures. Greatrakes had many imitators,
+some of them doubtless quite sincere, but they were people of more or
+less deranged intellect, the kind who easily get the idea that they
+are commissioned for some purpose that sets them above the common
+people. Indeed, the story of the mental healers is probably, more than
+anything else, a chapter in the history of insanity, and the power of
+those with delusions to lead others to share their delusions. This is
+not a slur upon human nature, and especially upon some of the
+inspirations and aspirations that lift it up to do great things, but a
+literal statement of the view of these phenomena that seems forced
+upon us by modern advances in the knowledge of the psychology of
+mental influence and of psychic contagion.
+
+Most of the influence that was acquired by men who in the course of
+history claimed to have a heavenly mission has been due, as with
+healers heretofore referred to, to reputed cures made by them. Trace
+the story of this among the Eastern nations in the old time. The
+pseudo-Messiahs of the Jews always advanced as one evidence their
+healing power, but so did the founders of religions among all the
+other nations of antiquity. It must be borne in mind, however, that
+many of the queer religions of after times were founded by men who
+claimed to have a Messiahship, and put forth, as the evidence of a
+divine commission, their power to cure the afflicted. Sometimes the
+men who made these claims were good men. In many cases they were
+apparently self-deceived. Very often, however, they had no claim to
+goodness in the commonly accepted meaning of that term, for they
+counseled the violation of moral precepts, made exceptions, for their
+own benefit, to general laws, and exploited their followers for
+selfish reasons. Provided their followers had confidence in them,
+however, they continued to work cures, so that even reasonable people
+were likely to be led to the thought that there must be something
+supernatural about their activities. In every century there have been
+two or three men who have thus secured a following, and apparently
+healed many diseases.
+
+The phenomena of faith-healing as the result of belief in the heavenly
+mission of special men, are as common now as at any time. Dr. Cutten
+in his "Three Thousand Years of Mental Healing" (_Scribners_, 1911)
+has a chapter on "Healers of the Nineteenth Century," which shows how
+many phenomena of faith-healing can be studied in recent generations.
+Some of the men and the women who are mentioned secured wide
+reputations throughout our own country.
+
+These faith-healing movements have particularly affected the New
+England portion of our population, and many of our most prominent
+healers have been born in the New England States. Wherever the new
+cults flourished, it is usually found that some of the most prominent
+members are descendants of {82} the old New Englanders. It has been
+suggested that this is due to the gradual loss of belief in great
+religious truths by New Englanders, and a definite tendency toward
+reaction against this loss of the religious sense, which, as is usual
+with reactions, easily becomes exaggerated. From lack of belief they
+jump to excess of belief. Men without trust in Providence find the
+trials of life hard to bear, and they dread the development of
+physical ill so much that they exaggerate their feelings, or even
+create symptoms. Men are happier with the feeling that the
+supernatural powers surrounding them are interested in them directly
+and personally, and that somehow things, even in an incomprehensible
+world, are arranged, if not for the best, at least for such good as
+makes ills stepping-stones to new benefits. Whenever they are led far
+away from that thought, there is likely to be an exaggerated reaction
+back to it. The stronger minded apparently can get on without
+religion, but to the great mass of men a strong religious sense is
+needed to enable them to overcome the lack of self-confidence that is
+the root of dreads, doubts, difficulties of many kinds, and which is
+also the source of many symptoms as well as the cause of the
+exaggeration of many ailments.
+
+As a rule, modern healers have been founders of new religions, or at
+least they have broken away from old-established sects, and have
+formed congregations for themselves. They have sprung up in every part
+of the country. East, North, South, West, and among all the differing
+nationalities of our population. We cannot console ourselves with the
+idea that they affect especially the foreigners, for the native-born
+people have proved to be quite as susceptible to them. These healers
+have, as a rule, abused the medical profession and the use of drugs,
+and have taught that disease, if it really existed at all, was from
+the devil: that what one needed, in order to secure relief from pains
+and ills, was faith in God--but always through _them_. Many of these
+men and women have probably been serious and earnest and have deceived
+themselves first. Most of them have undoubtedly been more or less
+disequilibrated, though they have practically all exhibited the power
+to accumulate large amounts of money from their followers. The people
+who have gone to them have not been the ignorant among our population,
+but particularly those who read the newspapers, and who look upon
+themselves as well informed. The intelligence of the disciples of
+these healers, as we ordinarily estimate intelligence, has been a
+little above the average, rather than below it.
+
+
+_Schlatter and Dowie._--Probably the most disillusioning phenomena
+with regard to the complacent idea that the diffusion of information
+prevents manifestations of superstition are stories of the healers
+Schlatter and Dowie. At the end of the nineteenth century both of them
+attracted widespread attention. Schlatter was probably not quite sane.
+He wandered through the deserted portions of the Southwest, hatless,
+unkempt, with clothing torn and without shoes. In July, 1895, he first
+attracted attention as a public healer in New Mexico. After a reputed
+forty-day fast he went to Denver, where people flocked from all parts
+of the country to him. Files of people formed--sometimes five or six
+thousand--to be touched, and healed, by him. His reputation was due to
+the cures that were reported. Dowie was another of these healers. Just
+at the beginning of the twentieth century he organized a great new
+church of his own, and announced himself as Elijah, the prophet,
+returned to life. {83} Nearly 20,000 persons are claimed to have been
+healed during the first ten years of his healing career. Toward the
+end of his life he declared that he treated, and cured, over 50,000 a
+year. An abundance of crutches, canes and every form of surgical
+appliance for the ailing hung on the walls of his church at Zion City,
+Chicago, left by people who, having been healed, had no further use
+for them.
+
+
+{84}
+
+GENERAL PSYCHOTHERAPEUTICS
+
+
+SECTION II
+
+
+_GENERAL CONSIDERATIONS_
+
+
+CHAPTER I
+
+
+INFLUENCE OF MIND ON BODY
+
+
+The power of mind over body for the relief of symptoms has been
+recognized, not only by physicians, but by the generality of men at
+all times. Every one has had experiences of aches, or actual pains, or
+discomfort quite annoying while one is alone, but that disappear while
+in pleasant company or occupied in some absorbing occupation. Many a
+headache that was painful enough to disturb us seriously while we
+tried to apply ourselves to something of little interest, and became
+almost unbearable if we tried to do something disagreeable, and
+actually intolerable if the occupation of the moment was a drudgery,
+disappeared, at least for the time, when we turned to a pleasant game
+of cards or indulged in some other favorite pastime. Our relief was
+not, however, from an imaginary ill, for the symptoms usually
+reasserted themselves when we got through with the pleasant
+occupation, showing that they have been there all the time and that we
+have only turned our mind away from them, and hence have ceased to
+feel them. This is so familiar it seems almost too commonplace to
+repeat, yet it constitutes the special phenomenon that lies at the
+base of psychotherapeutics, or the mental healing of physical ills.
+
+It is not alone the slighter, more or less negligible aches or pains,
+nor the vague discomforts that thus disappear when our attention is
+occupied, but even quite severe and otherwise unbearable pain may be
+modified to a great extent. A toothache that is bearable, though it
+nags at us constantly and never lets us forget its presence while we
+are occupied with many other things during the evening, may become a
+positive torture when we get to bed. This is not only because of
+physical conditions modifying the pain, for there seems no doubt that
+the warmth induced by the preliminaries for sleep and the bed-covering
+have a tendency to increase congestion, but it is mainly because as we
+doze off we are able, less and less, to inhibit our attention, or
+divert it from the pain that is present, and so this is emphasized
+until we have to do something for it or lose hours of sleep. This lack
+of inhibition, which characterizes the dozing hours, represents the
+state of mind in which people are who have no interest in their
+occupations, and who have ceased to find recreation in the ordinary
+pleasures of life, when pain of any kind comes to them.
+
+Cabanis, at the beginning of the nineteenth century, under the title
+of {85} "The Influence of the Moral on the Physical," discusses what
+we would now call mental influence on the body. He says:
+
+  The great influence of what one may call the moral or mental on what
+  may be called the physical is an incontestible fact. Examples
+  without end confirm it every day. Every man capable of making
+  observations finds proofs of it thousands of times in himself. Many
+  physiologists and psychologists as well as moralists, have collected
+  the evidence that brings out clearly this power of the intellectual
+  operations and emotions on the different organs and the diverse
+  functions of the living body. All of us could add new illustrations
+  to these collections. Men who are rude and credulous talk of the
+  effect of the imagination, and if they are not themselves its
+  playthings and its victims, at least they know how to observe its
+  effects In others.
+
+  As a matter of fact, the action of our organs can be in turn
+  excited, suspended, or totally inhibited, according to the state of
+  mind, the change of ideas, the affections and the emotions.
+
+  A vigorous, healthy man has just made a good meal. In the midst of
+  the feeling of satisfaction which diffuses itself over all his body,
+  his food is digested with energy and without any bother. The
+  digestive juices perform their work steadily and without causing any
+  annoyance. But let such a man receive some bad news; let some sudden
+  emotion come to excite him, and especially to shock him into
+  profound sadness, and at once his stomach and intestines cease to
+  act upon the food which they inclose, or they at best perform their
+  functions badly. The digestive juices, by which the food materials
+  were gradually being dissolved, are suddenly stricken with
+  inactivity. What might seem to be a stupor comes over the digestive
+  tract, and while the nervous influence which determines digestion
+  ceases entirely, that which tends to bring about the expulsion of
+  material from the digestive tract may become more active and all the
+  material contained in the digestive viscera may, in a short time, be
+  expelled.
+
+
+Relief in Severe Injuries.--Even extremely severe injuries, which
+inflict serious organic lesions that ordinarily would produce shock
+and collapse, quite apart from the pain induced, may at moments of
+excitement pass unnoticed. A soldier often does not know that he is
+wounded until the flow of blood calls his attention to it, or perhaps
+a friend points it out to him, or loss of blood causes him to faint.
+The prostrating effects of even fatal wounds may thus be overcome for
+a considerable time in the excitement of battle, or because of a
+supreme occupation by a surpassing sense of duty. There is the
+well-known story of the young corporal detailed to make a report to
+Napoleon at a very important crisis of one of his great battles, who
+made the report with such minute accuracy that it called forth a
+compliment from Bonaparte, for it involved a very special exercise of
+memory for details, yet who was actually on the verge of death when he
+delivered the message. As his duty was accomplished the Emperor,
+noticing his extreme pallor, said: "But you are wounded, my lad." The
+young soldier replied, as if, now that duty was done, the
+consciousness of his wound had just come to him, "No, Sire, I am
+killed," dropping dead at the Emperor's feet as he uttered the words.
+
+In all of the great theater fires examples of this kind are recorded.
+A woman who barely escaped with her life from a theater fire some
+years ago had an ear torn off, very probably by some one grasping it
+in the crowd. She knew nothing of this until it was called to her
+attention after she got out of the theater, and then she promptly
+fainted from the pain and shock. Under such circumstances men walk
+with broken legs or limp even with dislocations, utterly unconscious
+that anything serious has happened to them. Men have been known to be
+unaware of a broken bone or even more serious conditions, {86}
+ordinarily quite painful and disabling, while laboring to help others
+in an accident.
+
+
+Suppression of Reaction.--This side of the influence of the mind on
+the body is so interesting that its effects have often been noted and
+studied. While we do not quite understand the mechanism by which it
+accomplishes its marvels of anesthesia and even of motility under
+apparently impossible conditions, there is no doubt that severe pain
+may utterly fail to reach the consciousness, though the nervous system
+is uninterruptedly carrying the messages just as it did before. The
+lack of attention suppresses the ordinary effect upon the personality.
+Evidently the messages originate and are carried to the nerve centers,
+but find no attention available for them, and so pass unnoticed. The
+study of phases of this phenomenon of suppression of reaction forms a
+good basis for the use of mental influence, and shows its marvelous
+power to overcome disturbing physical factors.
+
+
+Amputation Stump Aches.--An interesting example of the influence of
+mind over body, when circumstances favor its exercise or emphasize it,
+and at the same time a striking illustration of the potency of
+suggestion in the cure of discomfort, is found in the stories that are
+so common of cases of pains in amputation stumps. Any number of weird
+tales are told of men who complain of feeling cramps in the toes of an
+amputated limb after this portion of their body had been buried. The
+discomfort is common enough. In the special stories, however, the
+limbs have been dug up, the toes straightened out--according to the
+story, they were always found cramped in some way--and then the
+patient is at once restored to ease. In the good old times they
+probably believed in some direct connection between the straightening
+out of the toes of the amputated member and subsequent relief of pain.
+For us it is but an example of the power of suggestion. It is not the
+sort of suggestion that one likes to think of employing, though it has
+a certain dramatic quality which adds efficiency to suggestion.
+
+
+The Mind and Motility.--We have spoken thus far almost exclusively of
+painful conditions as relieved by suggestion or mental influence, but
+disturbance of motor function may also be favorably affected. There
+are any number of cases on record in which patients who had been
+utterly unable to walk were restored to motility by a shock. Many such
+patients have, in the midst of the excitement of a fire, or the scare
+caused by the presence of a burglar, got up and walked quite as well
+as ever, though sometimes they have been for years previously confined
+to bed. The San Francisco earthquake is said to have exerted such an
+effect on a number of patients, and, while such unusual disturbances
+cannot often be provided for the cure of these ailments, there can be
+no doubt at all of the power of a shock to the mind to overcome
+functional incapacity that has resisted every possible form of
+treatment.
+
+Ailments of this kind, which involve inability of the will to control,
+or rather to initiate, movements of the body, receive their best
+explanation on the neuron or neuroglia theory. (See the chapter on the
+Mechanism of Suggestion.) The central neurons become either quite
+separated from certain of the peripheral neurons, or at least the
+connections are not made with that nice adjustment necessary for the
+proper passage of nerve impulses. The shock communicated to the
+nervous system by fright is sufficient, however, to restore these
+connections, and consequently to enable the patient once more to
+exercise motor functions that have been in abeyance for some time.
+
+{87}
+
+_Astasia-abasia._--Any one who has had to deal with the cases for
+which the French have invented the rather impressive Greek name of
+astasia-abasia--how much better it would be to call the condition
+simply what we know it to be, nervous inability to stand or
+walk!--appreciates how almost a miracle is needed to improve them. The
+incapacity for station or movement to which the disease owes its name
+is so complete in many cases, and the patients' lack of confidence in
+self so absolute, that no ordinary remedial measure is capable of
+doing any good. These cases are usually a severe trial to the
+patients' friends. Indeed, the patients themselves maintain their
+nutrition so well and, as a rule, enjoy such good health, or, as has
+been said, enjoy their bad health so well, that it is for their
+attendants the physician feels most commiseration. Yet generally he is
+quite unable to do anything. It is certain, however, that with care
+and authoritative suggestion there would not need to be an earthquake,
+or a fire, or even a burglary, as a therapeutic measure in these
+cases. As a matter of fact, their cure when it occurs is always
+brought about by some strong mental influence.
+
+
+Mental Influence on Organs.--_The Heart_.--The influence of mind can
+be noted on practically every organ of the body in a concrete way. It
+might be thought that the heart, the first living thing in the animal
+being, the pulsations of which begin before there is any sign of the
+nervous system, might be free from this influence. On the contrary,
+the heart is so readily affected by mental states that, taking effect
+for cause, the old popular, and even scientific idea with regard to
+it, was that it was the organ of the emotions. The heart is stimulated
+more by favoring circumstances, and suffers more from depression, than
+almost any other organ. In the melancholic states it usually beats
+less frequently and is sluggish. When individuals are tired out and
+the heart has become weakened in its action, new courage will first be
+noted as having its effect upon the heart action. As the whole
+muscular system is much influenced by the mental state and, as the
+control of the arterial system depends on the muscles in the arteries,
+it is easy to understand how much the general bodily condition may by
+mental influence be modified for good and ill.
+
+
+_Digestive Tract_.--The stomach and intestines, though their functions
+might be presumed to be dependent entirely on physical conditions, are
+almost completely under the control of the mental state. At moments of
+depression, just after bad news has been received, the appetite is
+absent, or is very slight and digestion itself proceeds slowly and
+unsatisfactorily. On the other hand, when there is mental good feeling
+appetite is vigorous and digestion is usually quite capable of
+disposing of all that is eaten. If after a period of rejoicing in the
+midst of which food is taken abundantly bad news is brought, the
+mental influence on digestion can be seen very well. It is not alone
+that depression interferes with digestive processes, but apparently
+some favorable factors for digestion consequent upon the previous
+state of mind are withdrawn, and now what would have been a proper
+amount of food proves to be an excess and the digestive organs find it
+difficult to deal with it..
+
+
+Nervous Inhibition.--The mind can actually inhibit certain of the
+involuntary processes of the body by thinking about them, and, above
+all, by dwelling on the thought that they are going wrong. This
+becomes easier to understand when we recall how, in the same way, we
+may disturb many habitual and more or less unconscious actions that we
+have grown accustomed to. There {88} are any number of actions
+requiring careful attention to details which become so habitual that
+we do not have to think of them at all. Not infrequently it happens
+when we try to explain to others how we do them, we disturb the
+facility of performance and have to repeat the acts several times
+before we succeed in performing successfully what a moment before we
+did without any thought. The story of the centipede who was asked how
+he walked with all his hundred legs, and who tried to describe how
+easy it was and got so mixed up that he was unable to move at all, is
+a whimsical symbol of conscious attention disturbing actions which go
+on quite well of themselves if only we do not allow ourselves to think
+consciously of each and every phase of them.
+
+How much the mind may influence the body under certain conditions when
+trance-like states either assert themselves or are brought on, has
+often been noted. Lombroso in his book "After Death What?" [Footnote
+11] says of Eusapia Paladino the "medium," that "when she is about to
+enter the trance state the frequency of the respiratory movements is
+lessened just as is the case with the Indian fakirs. Before the trance
+she will have been breathing eighteen to twenty times a minute; as the
+trance begins the number of respirations is gradually reduced to
+fifteen; when the trance is fully developed she breathes twelve times
+a minute or less. On the other hand, at the same time the heart beats
+increase. Normally her pulse is about seventy, but during the early
+trance stage it rises to ninety, while during the course of a deep
+trance, it may go as high even as one hundred and twenty. The passing
+from a more or less rigid state to that of active somnambulism is
+marked by yawns and sobs and spontaneous perspiration on the
+forehead." The observation of these phenomena is, of course, entirely
+apart from any theory one may hold with regard to mediumistic
+manifestations, and it provides evidence of mental influence that is
+very striking.
+
+  [Footnote 11: Small, Maynard & Co.. Boston, 1909.]
+
+Imaginary Drug Effects.--Drug effects may be produced through the
+imagination. Physicians know that when patients are persuaded that
+certain effects are to be expected from a particular medicine, the
+effects may follow all the same in sensitive, imaginative people, if
+that medicine is replaced by some inert compound. Many a physician who
+has used bread pills or other placebos to replace a drug that he did
+not want the patient to acquire a habit for, has thus been able to
+allow good effects to go on without interruption, where the stoppage
+of medicine had previously interfered with the continuance of the good
+habit that had been formed. Very few physicians have not seen the
+effect of a hypodermic of pure water when a hypodermic of morphine is
+demanded, and when the patient would not sleep without having the
+hypodermic injection. Sleeping powders of various kinds can sometimes
+with distinct advantage be replaced by inert materials, because the
+patient's mind is fixed upon the idea of sleep coming after a certain
+time and they, in consequence, compose themselves to rest.
+
+
+The Nerves and Tissues.--Cases occur where disturbances of vitality
+are noted as a consequence of nervous affections, though no gross
+lesion of the nervous system is demonstrated. Certain nervous people
+suffer from ulcerative conditions of their hands, and it is evident
+that in some the nervous impulses {89} that would ordinarily keep the
+skin surface in good, healthy condition are insufficient. Some people
+who use a typewriter have no difficulty at all with the ends of their
+fingers, while others are subject even to loss of skin or ulcerative
+conditions that make it almost impossible for them to go on with their
+work. In some this is true in the winter, in others in the summer.
+There are a number of skin conditions which are due to nervous factors
+and these evidently point to the influence of the central nervous
+system in keeping the forces of our body in such health, and resistive
+vitality, as will enable us to carry on whatever work we may wish to.
+This is, of course, a very individual matter. Some people chap very
+easily, some suffer from chilblains, or are frost-bitten even on
+slight exposure, and these peculiarities are evidently dependent on
+the intensity of the nervous impulses as well as the tone of the
+circulation, which itself depends on the nerves to a great extent.
+
+It is evident that some of these disturbances are not enduring, but
+are only temporary and therefore are due to functional disturbances of
+the nervous system. Physicians often see hysterical patients suffering
+from intense pain that requires an injection of morphine, yet after a
+series of such incidents, the physician is able to give an injection
+of plain water and produce just as good an anodyne effect. In these
+cases some influence of the will is enough to correct the painful
+disturbances. Occasionally a single member loses sensation, or motion,
+or both, yet the fact that its nutrition does not suffer shows that
+there is only disturbance in the motor connections between it and the
+central nervous system and not in the sensory nor trophic tracts, and
+that this functional defect may be restored by some favorable
+influence.
+
+
+_Nerve Supply and Health_.--We know now that when a part of the body
+is cut off from its connections with the central nervous system, it
+begins at once to be lowered in vitality and gradually tends to
+dissolution. This will be true in spite of the fact that the
+circulation continues as actively as before. It is not necessary,
+indeed, that the nerve trunk to a part should be cut, if it is
+sufficiently compressed its function is stopped and various
+disturbances begin to appear in the vitality of the part which it
+supplies. A typical example is to be seen in certain fractures of the
+clavicle, where a fragment presses on one of the nerves leading to the
+arm. After a time pains develop in the arm, a burning feeling is
+noticed in the skin, which becomes shiny and cold and of distinctly
+lowered vitality. Even a slight injury to the arm will now produce a
+serious ulcerative condition. There are evidently important influences
+for life that flow down through the nerves from the central nervous
+system, quite as important in their way as the nutritional elements
+which flow through the blood.
+
+How these influences of the mind on the body are accomplished is a
+portion of that larger mystery of the influence of mind, or soul, or
+principle of life, on the material elements of which our body is
+composed. Why a man receives a shock of lightning or a charge of
+electricity at high voltage, and without a mark on his body or a
+change in any cell that we can make out, be dead, though he was living
+an instant before, is another of these mysteries too familiar for
+discussion. There is no change in the weight of the body, nothing
+physical has happened, but what was living matter with the power to
+accomplish the functions of living things is now simply dead material,
+unable to resist the invasion of saprophytic micro-organisms which
+will at once, {90} unhampered, proceed to tear it down, though the
+preceding moment resistive vitality was completely victorious. The
+mystery remains, but the mechanism of the influence can now at least
+be studied with much more satisfaction than was the case a few years
+ago.
+
+
+Death and the Mind.--The extent to which the mind can be made to
+influence the body is apparently without limit. While the doctor is
+frequently disturbed by the fact that death occurs when there is no
+adequate physical reason for it, just because the patient has looked
+forward to it with complete preoccupation of mind, there is no doubt
+that occasionally death may be put off in the same way. We talk about
+people living on their wills. This is a literal expression of what
+actually occurs in certain cases. On the other hand, without the will
+to live, it is sometimes extremely difficult to keep alive patients
+who are in a run down condition. If one of an old married couple dies
+when the other is ill, we conceal the sad news very carefully from the
+survivor. This is done not alone to put off the shock and sorrow for a
+time, but because often, under such circumstances, there will be no
+will to live.
+
+When the vital forces have run down to such a degree that it seems
+impossible, so far as ordinary medical reason goes, to look for
+anything but dissolution, patients still cling to life if there is
+some reason why they want to live until a definite time. It does not
+happen so much with the acute diseases but is quite common in chronic
+cases. Patients will live on expectant of seeing a friend who is known
+to be hurrying to them, or for some other purpose on which they very
+strongly set their minds. In the life of Professor William Stokes, the
+Irish physician, to whom we owe the introduction of the stethoscope to
+the English medical world, and many other important contributions to
+medicine, there is a striking story that illustrates this power of the
+will to maintain life until a definite moment.
+
+  An old pensioner, a patient of Stokes' in the Meath Hospital whose
+  life was despaired of, and whose death was hourly expected, was one
+  morning distressed and disappointed at observing that Stokes, who
+  believing that the man was unconscious at the time, and that it was
+  useless to attempt anything further as his condition was hopeless,
+  was passing by his bed. The patient cried out: "Don't pass me by,
+  your honor, you must keep me alive for four days." "We will keep you
+  as long as we can, my poor fellow," answered Stokes; "but why for
+  four days particularly?" "Because," said the other, "my pension will
+  be due then, and I want the money for my wife and children; don't
+  give me anything to sleep for if I sleep I'll die." On the third day
+  after this, to the amazement of Stokes and all the class, the
+  patient was still breathing. On the morning of the fourth day he was
+  found still breathing and quite conscious, and on Stokes' coming
+  into the ward, he saw the patient holding the certificate which
+  required the physician's signature in his hand. On Stokes
+  approaching him, the dying man gasped out. "Sign, sign!" This was
+  done, the man sank back exhausted, and in a few minutes after
+  crossed both hands over his breast and said, "The Lord have mercy on
+  my soul," and then passed quietly away.
+
+
+_Dread and Death_.--Dr. Laurent in his little book, "La Médecine des
+Âmes," [Footnote 12] has a story of similar kind but from a very
+different motive:
+
+    [Footnote 12: Paris, Maloine, 1804.]
+
+  They brought to the prison infirmary one day an old burglar, an
+  incorrigible offender, who was undergoing a long sentence. He was
+  suffering from cancer of the stomach, and was already in a very
+  advanced stage of the affection. The poor devil seemed to realize
+  his condition very well, and felt that it was only a question of a
+  short time until he should die. He had made up his mind to that with
+  the {91} resignation which so often characterizes people of this
+  kind. Only one thing put him out very much, and that was the fear of
+  dying in prison.
+
+  "I know well that I have to pass in my checks," he said over and
+  over again; "but I do not want to die here. I do not want to be cut
+  up after I am dead."
+
+  He still had two months of his sentence to undergo. Every day the
+  disease made notable progress. His cachexia became more profound.
+  Life was passing from him drop by drop. At the end of five weeks he
+  was scarcely more than a living skeleton. Every morning we expected
+  to find him dead, or at least in his last agony. Nevertheless, every
+  morning, by an effort, he was able to recognize me and a little life
+  shone out of his sharp, small eyes that seemed like those of a bird
+  of prey.
+
+  One morning he said to me: "Oh! you need not watch me. You shall not
+  have my carcass. I do not want to die in prison. I shall not die
+  here." He lived on till the end of his sentence. The morning of his
+  freedom he said to me, "I told you that I did not want to die here,
+  and that I would not die here."
+
+  By an effort of his will he aroused himself enough so that his
+  friends were able to take him out of the prison. It was the last bit
+  of energy he had, however. His will power was at an end. A few hours
+  after his arrival in the house of his son he went off into a
+  profound depression, and would not talk even to his own. Then his
+  death agony came on, and he died that same evening. The strange and
+  surprising struggle of this man against death, the marvelous force
+  of physiological resistance which the fear of autopsy, if he died,
+  gave him, struck me vividly at the time. What intimate and
+  mysterious bond connects mind and matter that the one is able to
+  react in so much energy upon the other. How wonderful to think that
+  the fear, lest his abandoned body should be cut up, should actually
+  keep body and mind together until after the danger of that dreaded
+  event was passed.
+
+
+_Suggestion and Death._--On the other hand, there are many stories
+that show us how the giving up of hope of life seems to even hasten
+death. We have many stories of the death on the same day of husband
+and wife, or of brothers and sisters who thought very much of each
+other. Some of these are mere coincidences, but there are too many to
+be all explained on the score of coincidence. It seems clear that the
+living one, on hearing of the death of the other, feels that now there
+is nothing more to live for, and gives up the struggle. Hence the
+important rule in medical practice that a seriously ill patient should
+not be told of an accident, and, above all, of the death of a near
+relative.
+
+On the other hand, strong expectation of death at a definite time,
+especially if accompanied by suggestions with some physical signs, may
+bring about actual dissolution. We have a number of well authenticated
+stories to illustrate this.
+
+
+_Renewal of Hope._--How much energy even the slightest hope may
+furnish, when apparently all power of effort is exhausted, is well
+illustrated by what happens to men who are lost at sea or in a desert.
+After the lapse of a certain length of time human nature seems utterly
+incapable of further effort and they sink down exhausted. The
+appearance of a light at a distance, a hail, any communication that
+gives them even the slightest hope will renew their energy and enable
+them to draw on unsuspected stores of vitality after the end seemed
+inevitable. It may be said that the exhaustion in these cases is more
+apparent than real, that discouragement prevents the release of even
+the energy that is present, and might be used under more favorable
+circumstances, but that is exactly the argument which favors the
+deliberate employment of psychotherapeutic motives to enable patients
+to use the energies which they possess. In the midst of disease, or
+the struggle for life, when vitality is {92} being sapped, hope is
+lost or obscured, just as it is when a man is alone in the desert or
+struggling far from help on the ocean. If we can prevent this
+discouragement from sapping his powers there will always be a
+prolongation of life, and often this will be sufficient to enable
+vital resistance to overcome exhausting disease.
+
+
+Law of Reserve Energy.--Prof. William James [Footnote 13] called
+particular attention to the law of reserve energy which recent studies
+in psychology have emphasized. This law of reserve energy is a
+conclusion from certain facts which are very familiar to men and have
+been observed as long as the memory of man runs, yet the full
+significance of which has never been read quite aright. Applied to a
+very limited range of actions, it has been applied only half-heartedly
+in ordinary life, and to its full extent only under the pressure of
+absolute necessity. This law holds out the best promise to
+psychotherapy. It shows that there are reservoirs of surplus energy in
+man which, if they can be successfully tapped, present possibilities
+of resistance to fatigue--and fatigue in many more ways than we used
+to think resembles disease. Besides, this law represents a very
+wonderful capacity for withstanding pains and aches and conquering
+disinclination that would otherwise seem impossible. If it can be made
+to apply to ordinary life as well as it does to extraordinary events,
+then the conscious deliberate use of psychotherapy or mental
+suggestion should prove to have wonderful remedial power. Prof. James
+said:
+
+    [Footnote 13: _American Magazine_, Sept., 1908.]
+
+  Everyone knows what it is to start a piece of work, either
+  intellectual or muscular, feeling stale--or "cold," as an Adirondack
+  guide once put it to me. And everybody knows what it is to warm up
+  to his job. The process of warming up gets particularly striking in
+  the phenomena known as second wind. On usual occasions we make a
+  practice of stopping an occupation as soon as we meet the first
+  effective layer (so to call it) of fatigue. We have then walked,
+  played, or worked enough, so we desist. That amount of fatigue is an
+  efficacious obstruction on this side of which our usual life is
+  cast.
+
+  But if an unusual necessity forces us to press onward, a surprising
+  thing occurs. The fatigue gets worse up to a certain critical point,
+  when gradually it passes away, and we are fresher than before. We
+  have evidently tapped a level of new energy, masked until then by
+  the fatigue obstacle usually obeyed. There may be layer after layer
+  of this experience. A third and fourth wind may supervene. Mental
+  activity shows the phenomenon as well as physical, and in
+  exceptional cases we may find, beyond the very extremity of fatigue
+  distress, amounts of ease and power that we never dreamed ourselves
+  to own--sources of strength habitually not taxed at all, because
+  habitually we never push through the obstruction, never pass those
+  early critical points.
+
+He then states what has come to be called the law of reserve energy.
+
+  _It is evident that our organism has stored up reserves of energy
+  that are ordinarily not called upon, but that may be called upon;
+  deeper and deeper strata of combustion or explosible material,
+  discontinuously arranged, but ready for use for any one who probes
+  so deep, and repairing themselves by rest as well as do the
+  superficial strata_.
+
+There is, then, a marvelous reserve power in men and women which can
+be used in emergencies and in times of severe strain, to enable men
+and women to accomplish what looks impossible and which has often
+contradicted the prognosis of the physician. History is full of
+applications of this law which, however, does not come into action,
+unless especially called. Men and women {93} may die simply because
+they give up the struggle. Men and women who _will not give up_ seem
+able to overcome severe illness that would take away ordinary people.
+It has often been said that tuberculosis takes only the quitters and
+that men of character constitute the typically favorable patients for
+tuberculosis sanatoria. Psychology is now getting at the explanation
+of many events that were formerly quite inexplicable. The science has
+come to recognize the reservoir of reserve energy in human nature
+which may be tapped under special favoring circumstances. The
+physicians of the past have often succeeded in tapping it deliberately
+as well as unconsciously. There is large room, however, for the
+further development of medicine along this line, to the great
+advantage of therapeutics and probably the most promising field at the
+present time in view in therapy lies in this direction. Hence the
+necessity for more deliberate conscious use of it in every possible
+suitable form.
+
+
+
+CHAPTER II
+
+UNFAVORABLE MENTAL INFLUENCE
+
+Much as may be accomplished by psychotherapeutics through favorable
+mental influence--the modifying of the mental attitude towards
+disease, diversions of mind from aches and pains, concentration of
+attention on subjects apart from ailments--much more may be done by
+removing any unfavorable mental influence. This of itself produces
+symptoms either by interfering with normal processes through
+surveillance of them, or by so exaggerating, through attention to
+them, slight symptoms that may be present that patients are made quite
+miserable, though there is no adequate physical cause for their
+condition. Perhaps the most striking example that we have of
+unfavorable mental influence as productive of the persuasion that
+disease is present, is familiar to every physician who is close to
+medical students when they are first introduced to the symptoms of
+disease. It is almost a rule that certain members of the class
+immediately conclude that they are suffering from one or more of the
+symptoms which they are studying, and that, therefore, they must have
+the diseases with which the symptoms are associated. If at this time
+they walk on the shady side of a street on an autumn day and have a
+little shivery feeling, or when they get into the sun they feel a
+glow, these two very normal feelings are exaggerated into chilliness
+and fever, and the student has to go to his professor to have his
+mental malaria or typhoid treated. To the student, his symptoms are
+for the moment very real, and unless someone in whom he has confidence
+reassures him, his discomfort will probably continue for some time.
+
+
+Pathological Suggestion.--In a word, suggestions of disease are much
+easier to take than is usually imagined, and if people read or hear
+much about diseases they are likely to jump to the conclusion that
+they are sufferers. Under present conditions there are many more such
+sinister suggestions put before people than used to be the case. The
+newspapers are constantly reporting curious cases and rare diseases,
+and usually those of absolutely unfavorable prognosis and inevitably
+fatal termination are particularly dilated on. Pathology has become a
+source of many sensations, until the community {94} generally has come
+to eke out the thrills of the day's news by reading about fatal
+diseases and fatal injuries, whenever murder and suicide sensations
+fail. As a consequence, many become persuaded that they are suffering
+from forms of disease of which they have not a symptom, and, not
+infrequently, the wonderful cures that are reported in the newspapers
+consist of nothing more than recoveries from these imaginary ills into
+which people have suggested themselves as the result of reading about
+morbid states.
+
+A typical illustration of the power of the mind to influence the body
+unfavorably is recognized in many of the comic stories that have had a
+vogue in recent years. Their underlying thought is that if a man is
+only told often enough, and by a number of different people, that he
+does not look well, or if he is even asked a little solicitously as to
+whether he feels well or not, he will almost invariably begin to
+persuade himself that there must be something the matter with him.
+After a time, under the influence of this unfavorable suggestion, he
+begins to feel tired and is likely to think that he cannot go on with
+his work. When meal time comes his appetite fails him. A victim has
+been even known to go home and send for the doctor, persuaded that
+there is something the matter, simply because a series of friends, for
+a joke, or sometimes through a mistake, have insisted on asking him
+questions that called attention to his state of health. Few men are
+strong enough to stand the influence of unfavorable suggestion of this
+kind, if it is frequently repeated. More direct forms of suggestion of
+disease have, of course, even greater effects. Many a man goes to a
+quack only feeling a little out of sorts and wanting to reassure
+himself, but easily becomes persuaded that there is something serious
+the matter with him.
+
+
+Unfavorable Suggestion in Ancient Times.--This unfavorable influence
+of the mind on the body, even to the extent of the production of
+disease by means of suggestion, was recognized by the ancients. They
+knew and wrote of hypochondriasis and, indeed, they invented the term.
+In many of these cases the seat of auto-suggestion is supposed to be
+the digestive organs and the localization of the discomfort is in the
+hypochondria, that is, in the upper abdominal region. The Grecian
+writers seemed to recognize clearly that the symptoms were the result
+of thinking over much about self and concentration of attention upon
+unfavorable suggestions.
+
+Plato, in the "Republic," says:
+
+  In former days the guild of Asclepius did not practice our present
+  system of medicine, which may be said, he declares, to educate
+  diseases. He cites the example of Herodicus who, "being a trainer
+  (of gymnasts) and himself of a sickly constitution, by a happy
+  combination of training and doctoring, came to the invention of
+  lingering death; for he had a mortal disease, which he perpetually
+  tended, and, as recovery was out of question, he passed his entire
+  life as a valetudinarian." Plato, finishing the description, makes
+  us recognize the hypochondriac when he says: "He could do nothing
+  but attend upon himself, and he was in constant torment whenever he
+  departed in anything from his usual regimen, and so dying hard, by
+  the help of science he struggled on to old age."
+
+The picture of the neurasthenic, or hypochondriac, who has educated
+himself, as Plato says, into disease, is an interesting parallel to
+modern conditions in this matter.
+
+Nowhere more than in this matter of knowledge of disease, can weight
+{95} be attached to Pope's dictum that a little knowledge is a
+dangerous thing, and that one must drink deep or touch not the Pierian
+Spring of medical information. The teaching of pathology under the
+guise of physiology, now so common in our schools, is likely to do
+more harm than good. Various pathological conditions, such as those
+produced by alcohol and tobacco, have been emphasized to such an
+extent as to produce unfavorable suggestions in the pupils' minds with
+regard to the untoward events that may happen in their insides, and
+the serious lasting pathological changes that may occur, though all
+unconsciously, to the sufferer as the result of indiscretions. The
+study of the morbid changes produced in the mucous membranes of the
+digestive tract by the use of stimulants, impresses ideas on the mind
+that are readily transferred to other abuses in eating or drinking.
+The rather vivid pictures and descriptions of the pathological
+conditions that may develop, become a portion of the acquired
+consciousness as to internal conditions, and this consciousness acts
+as an unfavorable suggestive factor whenever there are any digestive
+symptoms.
+
+
+Bacteriphobia.--The development of bacteriology has had a similar
+effect, especially because periodicals and newspapers like to take up
+only the sensational side of biological discoveries. Most physicians
+who have had anything to do with nervous diseases have seen cases of
+misophobia, the fear of dirt, which in our day has taken on the
+special character of fear of microbes. Those who are sensitive to the
+possibility of contamination learn of the almost sacrificial
+precautions that surgeons take to avoid wound infection, and conclude
+that practically everything they handle must fairly reek with
+microbes. They hesitate about touching the door knob or latch, and
+invent all sorts of excuses to wait for a moment outside the door in
+order to have someone else open it. Especially are they timorous about
+touching the door knobs of a physician's residence, or the chairs in
+his waiting room, or even to shake hands with him. Hospital walls and
+doors become an abomination to them. These cases emphasize how much of
+unfavorable suggestion there has been in the present spread of popular
+knowledge with regard to microbes.
+
+A writer on popular science once said that every time we spread a
+piece of bread of the size of the hand with butter, we scatter over
+its surface as many microbes as there are inhabitants in the United
+States. The expression has gone the rounds, producing its effect on
+sensitive people, occasionally causing even a disgust for so important
+an article of diet as butter, more often giving rise to an extreme
+sensitiveness with regard to any special savor that butter may have,
+and it may have many according to the prevailing food of the cow.
+There has been much emphasis laid on the potentialities for harm of
+the microbes, and very little on the important part which they play in
+the production of many forms of food materials. Most people know and
+dread the fact that microbes produce disease. Very few seem to realize
+that while we know many thousands of different kinds of microbes,
+scarcely more than a score of them are known to be seriously
+pathogenic, while all the others are either indifferent or, as we know
+of very many, are actually benefactors of mankind.
+
+People have heard much of the flora of the digestive tract, until they
+have come to think with anxiety of the almost infinite number and
+multitudinous variety of the minute plant life that finds a habitat in
+the human intestine. Most people think that all of these are, in
+tendency at least, {96} harmful, and are only kept from being
+positively dangerous by the overwhelming vital activity of the mucous
+membrane and the secretions which keep them from exerting their malign
+activity. Very few appreciate the fact that the intestinal flora, far
+from being a disturbing factor, are often an aid to digestion, and
+that the equilibrium established among them favors many biological and
+chemical processes which help in the preparation of food and in the
+breaking up of waste products that might be dangerous if reabsorbed
+during their stay in the intestinal tract. Microbes we have always
+with us and always will have, and men have lived to round old age, not
+only in spite of them, but very probably partially because of them.
+They are part of that beneficent mystery of nature of which as yet, in
+spite of scientific progress, we know comparatively little.
+
+
+_Opposing Favorable Suggestion_,--A recent striking change of
+sentiment with regard to one form of food material furnishes a good
+example of how little we know about the real effect of bacterial life
+within the digestive tract. There was a time, not so long since, when
+sour milk was supposed to be especially harmful, or at least only
+likely to do good to those of particularly strong digestive vitality.
+Metchnikoff's work on the influence of sour milk on the digestive
+tract, however, has brought a complete reversal of opinion in this
+matter. Now most physicians are convinced that the bacillus of sour
+milk, acts in the intestinal tract to inhibit the reproduction and
+growth of other, and possibly more disturbing, bacterial agents. Sour
+milk is looked upon as one of the things that, by neutralizing certain
+unfortunate bacterial processes in the digestive tract, lead to
+longevity. There seems no doubt at all, that those who consume a great
+deal of it, live longer lives than the average, and many old men have
+taken to its use with a consequent amelioration of digestive
+annoyances.
+
+The popularization of bacteriology, then, has been one of those
+moments of unfavorable suggestion that have affected a large number of
+people. Such influences do not mean much for people of phlegmatic
+temperament. For others, however, they have a weighty significance and
+make every symptom, or more properly every sensation, that is at all
+unusual in the digestive tract, seem of ominous import. Certain
+sensations inevitably accompany digestion. The peristaltic movements
+are usually said to be unfelt, but even a slight exaggeration brings
+them into the sphere of sensation. Where attention is given to the
+abdominal region and its contents, feelings that ordinarily are not
+noticed at all come to be perceived. With the unfavorable suggestion
+derived from the unfortunate diffusion of a superficial knowledge of
+pathology and of bacteriology instead of hygiene and the science of
+beneficent microbiology, these feelings produce a bad effect upon the
+individual.
+
+
+Familiar Examples of Unfavorable Suggestion.--There are many familiar
+examples of the discomfort that may be produced by the mental
+persuasion that something will disagree with us, or that certain
+feelings have a significance quite beyond that which ought to be
+attributed to them. Everyone knows how qualmy may be the feeling
+produced by being told that something eaten with a relish contained
+some unusual material, or was cooked under unclean conditions. Food
+that agrees quite well with people, so long as they do not know too
+much about it, often fails to be beneficial after they see how it has
+been prepared. It is often said that people would not relish the food
+{97} placed before them if they were aware how lacking in cleanliness
+was the place of its preparation, and how negligent those who had
+charge of it. Occasionally a peep at the kitchen of a boarding house
+effectually takes away appetite, or disturbs the equanimity with which
+food must be taken, if there is to be that undisturbed digestion which
+makes for healthy nutrition.
+
+It is, indeed, with regard to digestion that the influence of the mind
+on the body, favorable as well as unfavorable is, perhaps, most
+effectively exercised. Unfortunately the unfavorable influence is even
+more pronounced than its opposite. Some people are much more sensitive
+than others in this respect, and even the thought of certain defects
+in the preparation of their food seriously disturbs them. Everyone has
+had the experience of seeing sensitive persons leave the table because
+some one insisted on telling a nauseating tale. Anyone who has seen
+the effect of talking of blood sausage or fried brains with black
+butter sauce at a table on shipboard, when some practical joker was
+exercising his supposed wit, knows how much the imagination can
+disturb, not only appetite but digestion. The attitude of mind means
+much, and especially are such unfavorable suggestions likely to
+produce serious effects in inhibiting digestion.
+
+
+_Suggestion and Seasickness_.--Seasickness illustrates the place of
+unfavorable suggestion in digestion. The nausea, consequent upon the
+movement of a vessel at sea, is due to a disturbance of the
+circulation within the skull, and particularly of the circulation in
+the semi-circular canals. The organ of direction of the body is
+disturbed by the over-function demanded of it, consequent upon the
+continuous movement of the vessel. This is, however, only a
+predisposing element. A strong additional factor is the firm
+persuasion many people have that they will suffer from nausea and
+seasickness, and the unfavorable expectancy thus aroused. Most people
+have to give their dole to Neptune. Those who for weeks before have
+been expecting and dreading it usually pay a heavy tribute. Probably
+the best remedy for seasickness is the suggestion that there is no
+necessity for losing more than a meal or two, if even that much,
+provided there is simplicity of diet and proper predisposition of body
+by gentle opening of the bowels, and lack of the over-feeding that
+sometimes comes from dinners given before departure. I have known many
+people who, after suffering severely not in one but in many voyages,
+have, by means as simple as this, been saved from days of seasickness
+even in rough weather.
+
+Most of the cures for seasickness that have been suggested have
+depended principally on the suggestive element. For instance, there is
+no doubt that many people are relieved by wearing dark glasses, and
+this remedy does good for train sickness and other afflictions of a
+similar kind. There is, however, no good physical reason why wearing
+dark glasses should help except through their constant physical
+suggestion. A simple remedy that has helped many through seasickness
+is the wearing of a sheet of glazed paper, usually some heavy
+writing-paper, immediately over the skin of the abdominal region. This
+of itself has no physical effect, but the sensation of its presence
+constantly obtrudes itself, and by making people feel that they must
+be better because a great many other people have declared that they
+were bettered by this remedy, they actually suffer less from nausea
+and vomiting. Many of the internal remedies employed for seasickness
+are directed to the stomach and intestines. {98} As the seat of the
+difficulty is not here but within the skull, the reputation which
+these remedies have acquired has been due largely to the suggestive
+effect of taking them rather than to any physical qualities they
+possessed, though of course they have served to set at rest stomachs
+disturbed by unfavorable expectancy.
+
+
+Disease Groups and Suggestion.--Labeling groups of ailments with a
+single term gives rise to many unfortunate conclusions and dreads with
+regard to what a particular condition really is. The word
+"indigestion" is commonly used for any stomach discomfort or
+disturbance, especially that occurring after eating, from the slight
+distress because too much has been eaten, or the uncomfortable feeling
+of fullness because too much liquid has been taken, or the discomfort
+due to an unsuitable mixture of food materials, to such serious
+conditions as develop when there is motor insufficiency of the
+stomach, followed by dilatation, with delay of the food for long
+periods and with consequent fermentation, distress and bad breath.
+Whenever the word "indigestion" is mentioned, the patient may think of
+the worst cases that he has seen or heard of with this label, and
+concludes that while his ailment may not be very serious just now, it
+is only a question of time until it becomes so, and that unless he can
+get rid of his uncomfortable feeling he is destined to have one of the
+forms of "indigestion" that are productive of such serious discomfort,
+with probably ever increasing torment, until some fatal complication
+develops. The initial symptoms of gastric ulcer and cancer have been
+labeled indigestion, and people, often recalling the serious
+consequences that followed in such cases, fear for themselves.
+
+
+_Fearing the Worst_.--This looseness of terms is noted with regard to
+many other forms of disease. Rheumatism calls up the picture of
+advanced arthritis deformans, with the awful deformed joints and
+bed-riddenness, which should not bear the term rheumatism at all, but
+which the patient has heard called so. Catarrh is the simplest of
+inflammatory processes, meaning merely an increase of secretion,
+functional in character and without any serious disturbance of an
+organic character beneath it, but many people have heard the
+foul-smelling ozena called catarrh, at least popularly, and so the
+mental picture of such a repulsive progressive process as beginning in
+them is suggested. It is important, therefore, when using words that
+have such wide connotation as these, to explain exactly what is meant,
+and perhaps, better still, not to use the words, but to employ some
+more specific term that does not carry a cloud of dreads with it.
+Indigestion can be a very simple passing set of symptoms, but once
+certain people get the notion that they are troubled with indigestion,
+their minds dwell on it to such an extent that they are likely to
+limit their eating more than they should, and to disturb digestive
+processes by thinking about them and using up in worry nervous energy
+that should be allowed to flow down to actuate digestion.
+
+
+So-called Incurability.--Patients are likely to hear entirely too much
+of the incurability of disease. To the doctor and patient this word,
+incurability, often has an entirely different meaning. The doctor
+means only that the diseased tissues cannot be restored to their
+previous condition by any of our known remedies, and that the effects
+of the deterioration are likely to be felt to some degree for the rest
+of the patient's life. To the patient it means, as a rule, not only
+that the doctor can do nothing for him, which is usually {99} quite
+untrue, for much can be done for his symptoms even though the
+underlying disease may be intractable, but also that the symptoms are
+to grow constantly worse. This is often quite without foundation, for
+nature's compensatory powers are very wonderful and seldom fail to
+afford relief. In a great many cases fatal termination comes, not from
+the original affection, but through intercurrent disease. Above all,
+incurable means to many patients that finally the victim is to become
+more and more subject to the pains and ills of his "incurable" ailment
+until he becomes perhaps a pitiable object. Incurability, when we
+recall that patients are so likely to mistranslate this term in the
+way indicated, must be a word little used. Etymologically it is never
+true, for _cura_ means care, and we can always care for and relieve
+the patient. In every chronic case there is room for hope of much
+relief through accustomedness, various remedies, nature's compensatory
+methods, and, above all, the modification of the state of mind.
+
+There is probably no incurable disease that is ever quite as serious
+as it is pictured by its victim when he first hears this word
+pronounced. When we recall the chances of life, and that in any given
+case, almost as a rule, the patient will live to hear of the deaths of
+men and women who were in perfect good health when his ailment was
+pronounced incurable, there is much of consolation to be derived from
+conditions as they are. It seldom happens that a physician sees a
+sufferer from tuberculosis, whose affection is running a somewhat
+chronic course, without being able to find out that since the first
+symptoms of the disease manifested itself, one or more of the
+patient's near relatives have died because of exposure incident to
+their abounding health. Pneumonia, appendicitis, typhoid fever,
+accidents of various kinds, take off the healthy relatives, while the
+tuberculous patient, constantly obliged to care for his health, lives
+on, and often is able to accomplish a good deal of work. It is
+important to impress facts of this kind upon these "incurable" cases,
+for they represent the light in the desert, or the shout, or the
+whistle at sea, that give renewed energy when nature seems about to
+give up the struggle.
+
+
+Thinking Health.--Hudson in "The Law of Mental Medicine" [Footnote 14]
+suggests that we should think health and talk health on all suitable
+occasions, remembering that under the law of suggestion health, as
+well as disease, may be made contagious. This expression probably
+represents an important element for the prophylaxis of disease under
+all conditions. Under present conditions people talk entirely too much
+about disease and have too many suggestions of pathological
+possibilities constantly thrown around them by our newspapers, our
+magazines and by popular lecturers as well as by our free public
+libraries. People have learned to think and talk disease rather than
+health. This predisposes them to exaggerate the significance of their
+feelings, if it does not actually, on occasion, lower their resistive
+vitality because of solicitude. The medical student torments himself
+with the thought that he is suffering from the diseases that he
+studies, and we cannot expect that the general public will be even as
+sensible as he is in this matter. On the contrary, people generally
+are much more liable to exaggerate the significance of their feelings,
+hence the necessity for healthy suggestions rather than innuendoes of
+disease.
+
+  [Footnote 14: McClurg, Chicago, 1903.]
+
+In recent years, to paraphrase Plato's expression, people are much
+more {100} inclined to educate themselves in disease than in health.
+The result has been a storehouse of unfavorable suggestion, from which
+ideas are constantly being taken to make whatever symptoms that may be
+present seem unduly important. Consequently people look for the worst,
+and suggest themselves into conditions where not only are they
+exaggerating their symptoms, but they are absolutely preventing the
+flowing down of such nervous impulses as will enable them to overcome
+affections that are present. Whenever anything turns up that lessens
+their tendency to unfavorable auto-suggestion, their health improves.
+Hence the taking, with confidence, of any quack medicine, no matter
+what its constituents, cures them; hence the success of the numerous
+and very varied forms of mental treatment. New Thought, Eddyism,
+osteopathy, and the like, attain most of their successes because of
+the removal of unfavorable suggestions, and the setting up in their
+stead of favorable suggestion. In psychotherapy the first duty of the
+physician is to undo all the unfavorable suggestion at work, and, if
+successful in that, great therapeutic triumphs are possible.
+
+
+
+CHAPTER III
+
+THE INFLUENCE OF BODY ON MIND
+
+While trying to take advantage of the influence of the mind on the
+body for therapeutics, it is important to remember that the body has a
+great influence on the mind. There are many states of mind that are
+dependent on states of body, and that can be modified only by first
+modifying the body. Body changes can at least greatly help. In order
+to use the mind in the therapeutics of conditions in which it would
+help in the awakening of such vitality as is necessary for the cure,
+particularly of many of the chronic affections, it is necessary first
+to dispose the body so that it will not constantly be adding to, or at
+least emphasizing, an unfavorable state of mind. For this purpose it
+is important to study definitely and practically the influence that
+various attitudes, expressions and external manifestations may have in
+changing the internal feelings. This factor seems trivial when viewed
+from the standpoint of health, but it is one of the trifles that are
+very helpful in the predisposition of the patient to get better.
+Alteratives in medicine, while we have not been able to say just what
+their effect was, have done much for us, and the influence of body on
+mind is just such an alterative.
+
+Even those who have insisted most strenuously on the independence of
+mind from body have always recognized not only the influence of the
+mind on the body, but also of the body on the mind. Perhaps the most
+familiar example of this is the well-known liability to dream after
+eating things that disturb digestion and seem to interfere, probably
+by congestive tendencies, with the circulation of the brain during
+sleep. It has always been recognized that mental operations are
+sluggish for some time after eating, and that a period of depression
+is likely to follow any excess. The Romans feared the consequences of
+indigestion so much that, occasionally after they had surfeited
+themselves with rich food, they took such direct mechanical means as a
+feather or a finger in the throat to relieve their overloaded stomach,
+in order that they {101} might not suffer the after consequences, but
+especially the depression and irritability of mind.
+
+
+Disposition and Digestion.--The relation of the body to the mind in
+many other besides the purely animal digestive functions has always
+been realized. It has always been felt that the disposition of an
+individual depended to a great extent on his nutrition. Men were not
+usually approached for favors before their meals, and especially after
+a long fast, but, as far as possible, requests were made shortly after
+meals. It has always been recognized that the best time for men to get
+together in council is, at least so far as amiability goes, shortly
+after meals. Tiredness was also felt to be an important element in
+affecting the mind. The tired man, even though he may be hungry, can
+only eat a hearty meal at the risk of serious disturbance of
+digestion, for, as a consequence of the fatigue of the body being
+communicated to the mind, the mental influence which predisposes to
+good digestion is lacking, and it is easy for serious digestive
+disturbances to be set up. In a word, body and mind are inextricably
+involved in all that concerns not only health but good feeling, and
+these two terms are practically convertible.
+
+
+Feeling and Expression.--In nothing is the influence of the body on
+the mind more clear than in the influence of expression upon the
+disposition. Actors know that if they want to well express a certain
+feeling, they must arouse that feeling deeply, and the easiest, surest
+and most direct method of doing so is to fix the features in the
+expressions that would ordinarily indicate the presence within of
+these feelings. If we insist on putting our features into the shape
+which ordinarily expresses sadness, that will be reflected internally,
+and we shall become as sad as our expression. On the other hand, if
+the features are drawn, even by force of will, into the state that
+ordinarily expresses joy or lightness of heart, we shall be tempted
+more and more to feel that way, until at last even internal melancholy
+may be dissipated. In the oldest book in the world, "The Instruction
+of Ptah Hotep," written about 3,000 years before Christ, the old
+father giving advice to his sons says: "Let thy face be bright what
+time thou livest," and the literature of every time since then
+emphasizes the same idea.
+
+This influence of the expression on the mind is an extremely important
+element in psychotherapy. Men and women must be taught to shake off
+inner sadness, and over-occupation of mind, by training their facial
+muscles of expression as far as possible to occupy positions
+expressive of good feeling, but above all not to let them be fixed in
+positions indicative of ill feeling. It makes a great difference for
+the mental state whether a man has the corners of his mouth drawn down
+or up, or whether they are pulled straight across the face to give the
+severe, austere expression that some people seem to cultivate. If the
+corners of the mouth are allowed to droop the glumness and depression
+is likely to grow deeper. If the lips are curled upward and smile,
+even though it may be a forced smile, the inner feeling will soon
+yield to it. Actors are able to counterfeit the reality, but much more
+than this, as we have said, they realize that, by imitating the
+externals of the feeling, they awaken the feeling itself within them.
+This is true for anger and loathing, and for many of the more serious
+dispositions as well as for those that might be thought more
+superficial, and hence more controlled by the external muscles.
+
+{102}
+
+_The Mouth_.--It is interesting to realize how different are the
+expressions of the face as a consequence merely of control of the
+sphincter of the mouth and its associated muscles. Physiological
+psychologists have often called attention to the fact that only a few
+lines are necessary to picture the characteristic human expressions of
+sadness, joy and severity. If a little droop is given to the line that
+represents the lips, melancholy is at once expressed, while the upward
+curve expresses joy, and the straight line severity. These types of
+human expression are easy to control, and the internal effect of each
+is soon felt where there is deliberate, or indeliberate, perseverance
+in its maintenance.
+
+
+  [Illustration: Fig. 1.  Three abstract faces.]
+
+
+_The Eyes_.--A typical example of the influence of the mind on the
+body is to be found in the use of the eye muscles, especially the
+oblique muscles. Of definite and important use for many purposes, they
+are especially employed to attract attention by means of the eyes.
+Coquetry has used them to express various phases of sex attraction. We
+all know the picture of the young woman who "makes eyes." It is
+interesting, however, to set solemn people imitating these exercises
+of the oblique eye muscles. For most people it is practically
+impossible to use these muscles without a corresponding quasi-demure
+setting of the features, commonly associated with those who use them
+most. There is even likely to be a certain attitude of mind aroused
+corresponding to the setting of the features in a particular way.
+While this is true for almost any other expressive state of the
+countenance, it is not so easy to demonstrate as is this.
+
+The use of the superior recti muscles has also a definite effect upon
+the disposition. One of the pleasures of walking in a well-kept forest
+where the trees meet high overhead, is that the eyes are inevitably
+attracted upward to range among them, and there is a corresponding
+elevation of feeling. Bernard Shaw once said that it was impossible to
+enter a Gothic church without an elevation of the spirit, because the
+eyes were surely attracted upward by the height of the nave, and a
+corresponding uplift of feeling ensued. During a period of glumness it
+is apparently impossible to keep the eyes raised. People who are
+depressed and "cast down," as the expression is, invariably keep their
+eyes downward, and just as soon as a man "looks up and not down" there
+is a lifting of the depression. Even such apparently trivial muscular
+actions as this may influence the mind, and thus react upon the
+physical system generally.
+
+
+_Wrinkles_.--Many influences of the body on the mind group themselves
+in the muscles of expression around the eyes. Wrinkles, for instance,
+are originally a habit of mind, and then the emphasis of this, in the
+muscles of the face, is reflected back to deepen still further the
+dejection or nervous unrest that originally causes them. It is
+surprising to see what an influence it has on patients who go round
+much with wrinkled foreheads, to have them give over the practice and
+discipline themselves to appear with uncorrugated superciliary
+muscles. St. Ignatius Loyola, the founder of the Jesuits, and one of
+{103} the wisest managers of men that ever lived, has emphasized in
+one of his rules that "wrinkles on the forehead and still more on the
+nose" are a sign of interior disquiet and must not be seen. He
+realized that the interior feelings could be influenced by suggestion
+at least, by having those who indulged in wrinkles keep their
+foreheads and noses smooth. Most of the expression of the face is
+concerned with the eyebrows and neighboring regions, and people should
+occasionally be asked to look at themselves in the glass, so as to rid
+themselves of habits of expression indicative of a disturbed mind, for
+this will do much to help to relieve the mental disturbance.
+
+
+Attitudes and the Mind.--With regard to the influence of the body on
+the mind, and the stimulating mental reaction that follows even a pose
+of well-being and good feeling, perhaps nothing affords more striking
+evidence than the effect of assuming the expressions and attitudes
+usually associated with various states of mind and then noting the
+results. If a man throws his shoulders back, and takes in long breaths
+of air, expanding his chest and stimulating his circulation, his whole
+body as well as his mind feels the effect. A slow walk with bowed
+shoulders and head, while one moodily turns over all the possibilities
+for ill in the life around, does very little good, while a brisk walk
+with head thrown back, shoulders erect, brings a man home with mind
+and body both ready to throw off temporary obstacles of all kinds, and
+in addition to the fact that the mental depression has disappeared, to
+some extent at least, all the physical functions will be accomplished
+better than before.
+
+
+Tears and Feeling.--Some of the usual translations of the meaning of
+external expressions are not justified by what we know of their actual
+purpose and effects. For instance, tears are supposed to be a sign of
+deep grief. Except in the very young they are not, as a rule, to be
+thus understood. As we grow older they are much more frequently a sign
+of deep feeling that is usually quite pleasurable. It is almost
+impossible for a human being to be touched deeply without a glistening
+of the eyes that readily runs over into tears. A mother who is proud
+of something that her children have done is quite sure to have tears
+in her eyes. If she is present at a successful musical or dramatic
+performance given by a son or a daughter, especially where there is
+something of a triumph for them, she is sure to have tears in her
+eyes. There are few mothers who fail to be moved in this way when
+their children take prizes, or when some one writes to tell them how
+well their children are doing. Tears, indeed, far from being a sign of
+sadness, usually in adults indicate profound joy.
+
+Tears, then, instead of being discouraged, should rather be
+encouraged, unless when indulged in to excess. We realize how trying
+to health and strength is the stony grief that does not melt into
+tears. The mother who faints over the sudden death of her child, and
+who wakes to silent consciousness, is in a dangerous condition until
+the solace of tears comes to her. Until there are tears, we fear for
+the effect upon her mind of the grief. The sufferer from melancholia
+is sad, but a good outburst of tears will, indeed, often mean the end
+of a prolonged period of melancholia. In the trials of life tears are
+a consolation rather than an addition to sorrow. In the olden times
+men wept as well as women, and Homer's heroes thought it not at all
+beneath their dignity to be seen in tears. Over and over again, the
+physician learns that while people have been going to "shows" that
+were supposed to make them {104} laugh and so divert their minds, the
+best possible effect is derived not from trivial laughter, but from a
+serious play that touches the heart deeply and makes all who go to it
+melt a little. Many nervous patients never feel better than after they
+have had a good quiet cry.
+
+The influence of the serious things of life in producing favorable
+states of mind is not sufficiently appreciated, or at least has come
+to be neglected in our day. There is a seeking far and wide for
+pleasure and diversion that should be obtained near home, through the
+simple joys of domestic life or intimate contact with others who need
+us in some way. As has been well said, it is not far-fetched pleasure,
+but simple joys that are more needed in our time. Nothing so enables
+the patient to get his, and above all her, mind off self as care for
+others. This must be expressed, however, in external acts accomplished
+by ourselves for others to have any deep effect. Doing things for
+other people deepens the feeling of sympathy, and so makes the mind
+much more ready to respond to increase of these feelings so profoundly
+as to displace selfish considerations. Exercise is valuable, but
+exercise undertaken for a worthy motive, constantly before the mind
+during the time it is taken, means ever so much more in awakening all
+the sources of energy that there are in men and women to make life
+worth living for themselves and others.
+
+
+Application of Principles.--The best possible source of relief from
+that combination of mental despondency, and the lack of bodily
+vitality which so often accompanies it, and which, if not interrupted,
+may lead to a serious breakdown of mental health, is the discipline of
+work; above all, work for the benefit, of others, to which one forces
+one's self gradually but persistently, not with, long intervals, but
+day after day. The discipline of the asylum and the sanatorium is
+probably the most efficient curative agent when these cases are at
+their worst. When the symptoms are beginning, a discipline of a milder
+character, yet resembling that of the institution, but appealing to
+higher motives and leading to frequently repeated actions for the
+benefit of others, will undoubtedly do much to prevent worse
+developments or make the future condition of the patient less serious
+than it would otherwise be. Undoubtedly some of the old monastic
+regulations were efficient in preventing the more serious developments
+of despondency when the danger to himself and others of the
+melancholic was not so well recognized as at present.
+
+
+_Laughing Cures_.--Every now and then the newspapers announce that
+some physician has invented a laughing cure, or a smiling cure, or
+something of the kind. Sometimes these reports are founded on actual
+occurrences; oftener, perhaps, they are the invention of a reporter
+suffering from a dearth of news. There is, however, no doubt that a
+smiling cure will do much to make people, even those who have serious
+reasons to be depressed, feel better. Every physician knows that if
+melancholic patients of the milder type can be amused quietly, their
+depression is modified for the better. Accordingly, we advise them to
+see farces or lively comedy, and we try to pick out cheerful nurses
+for them. The depression consequent upon some serious illness can be
+better relieved in this way than by any tonics or stimulants. For the
+depression, for instance, that so often follows a stroke of apoplexy,
+the employment of a nurse with a good human sense of humor and a large
+sympathy with the humorous side of things in life will do more to
+arouse a man from the lethargy into which he settles than almost
+anything else.
+
+{105}
+
+With regard to laughing, there is, of course, another element that
+must be remembered. A hearty laugh moves the diaphragm up and down
+vigorously, empties and ventilates the lungs, stimulates the heart
+mechanically by its action upon the intra-thoracic viscera, and is one
+of the best tonics that we have for the circulation in the abdominal
+cavity, and probably also for the important nervous mechanisms
+centered there. Its action upon the lungs is readily recognized. Its
+influence upon the heart is usually not so much thought of, but
+deserves even a more prominent place. It is now well known that when
+patients have gone into coma or the apneic condition that sometimes
+follows shock, or the administration of an anesthetic, when the heart
+ceases to beat, the only effectual means of resuscitation is by
+directly irritating the organ. It has been suggested that if the
+abdominal cavity is open the surgeon's hands should be passed up and
+should squeeze the heart through the diaphragm. It has even been
+proclaimed that tapping on the chest vigorously over the precordium
+may arouse a heart that has for the moment stopped beating. It is easy
+to understand, then, that a hearty laugh, by stirring up all the
+intra-thoracic viscera, stimulates the heart mechanically and sets it
+beating more vigorously than before. This is one of the reasons why
+people feel so well after a hearty laugh.
+
+Even slight swallows of water act as a distinct heart stimulant. When
+people have fainted, a succession of swallows of water, each of them
+acting as a heart tonic, is one of the best methods that we have of
+stimulating the heart's action. It is usually said that this action is
+a consequence of the reflex from the terminal filaments of the vagus
+nerve running back and reflected down again to the heart. To me it has
+always seemed that the swallowing action had a direct mechanical
+effect upon the heart, because the esophagus passes so close to it in
+the thoracic cavity.
+
+Man is the only animal that laughs, and, as the old philosophers point
+out, he might very well be defined as _animal risibile_ with just as
+much truth as by the words _animal rationale_. It requires reason in
+order to have a sense of humor. The higher the reason, the more the
+humor. Peasants and the uneducated have, as a rule, a very undeveloped
+sense of humor. It is the highly educated man of deep intellectual
+powers who catches all the humor of a situation, and, though his
+expression of it may not be loud, it is deep and helpful at moments of
+depression. Humor is, of course, very different from wit, which is
+biting and which seems almost to be shared by the animals, if we can
+judge from the fact that they appear, occasionally, to play practical
+jokes upon one another.
+
+It seems almost absurd that a physician should tell patients that it
+will do them good to practice smiling, to take every possible
+opportunity to laugh, and even to take frequent glances into a looking
+glass, to see that they are not pulling long faces. The difference
+between a feeling of melancholy and one of gladness consists mainly in
+the position of the outer angles of the mouth. The putting into
+practice of the maxim, not to let the sad lines dominate the
+countenance, but to insist on keeping the others there as far as
+possible, means much for the correction of internal feelings of
+depression and discouragement that may be badly interfering with the
+flow of nerve impulses from the brain to the body.
+
+
+Mouth Breathing.--Since Meyer's discovery of the overgrowth of the
+{106} lymphoid tissue in the pharynx, we have learned to appreciate
+how important is mouth breathing, even for the intellectual life. We
+all knew before, and indeed from time immemorial it was well
+understood, that, as a rule, people who went around with their mouths
+open were of low grade intelligence. All sorts of methods were used to
+teach these young people to keep their mouths shut. They were reminded
+of it at home, they were told about it at school, and, if they
+married, their wives tried to keep them from this apparent
+manifestation of lack of intelligence. Of course, they were not, as a
+rule, able to carry out the well-meant intentions of their friends and
+advisors. The mouths were kept open because they could not breathe
+normally through their noses, and so respiration had to be
+accomplished by the only other available avenue. As a consequence of
+the open mouth, the lips were inclined to roll out somewhat, and
+certain indications of the human physiognomy were supposed to be
+associated with these thick lips.
+
+Now we know the real meaning of the condition. Mouth breathing is
+possible, but it is inadequate. Insufficient respiration leads to
+insufficient oxidation of tissues, and to lowered vitality in all
+structures, and this is particularly notable in the brain, as well as
+in certain other higher structures. It is not because the individuals
+are lacking in intelligence that their mouths are open, but because
+the same reason that compels the open mouth also affects their
+intellectual activity. The blocking of nasal respiration lowers vital
+activity of all kinds. Hence the lowered intellectual vitality. The
+thick lips, which are supposed to be characteristic of a certain
+passionateness of nature, and which usually are associated with a lack
+of thorough control over animal inclinations, probably owe their
+significance to the fact that this special peculiarity of feature
+usually accompanies mouth breathing, and that the individual who
+labors under this deficient respiration, is likely to lack control to
+at least some degree. There is even a question whether the deficient
+oxidation is not likely to be much more notable in its effect upon the
+higher faculties than on the lower, and as a consequence the latter
+develop somewhat to the detriment of the former.
+
+These studies in physiognomy may, indeed, be correlated in many ways
+with distinct physical conditions instead of as formerly with the
+general constitution of the individual. For instance, large protruding
+eyes used to be said to be characteristic of nervous, timid, sensitive
+individuals, easily scared, and not well able to take up the harder
+parts of the battle of life. Now we know that this feature is usually
+associated with an excess of secretion of the thyroid gland, and that
+the nervousness is not a matter of character so much as it is due to
+the disturbance of internal metabolism consequent upon this
+interference with the proper function of an important organ. It might
+well be called a slight thyroid intoxication. In large amounts it
+produces all the symptoms of Graves' disease.
+
+
+Bodily Conditions and Stupidity.--We have many illustrations of the
+influence of the body on the mind, when purely physical causes work
+rather serious results on disposition and character and energy. A
+typical example was the so-called tropical anemia which existed in
+Porto Rico when the Americans took possession of the island. There
+were so many cases of it that out of about 25,000 deaths reported in
+1903, nearly 6,000 were from so-called anemia. Investigation of the
+conditions soon revealed the real cause. It had been {107} thought to
+be due to a combination of the climate, malaria and the lack of
+nutrition on the part of the country people. The people were
+absolutely without ambition, they had no energy, they seemed scarcely
+able to keep body and soul together, and they cared for nothing except
+to get just enough to supply them with a meager sustenance. Of
+incentive to lift themselves up, there was none. This was largely
+attributed by the first Americans who went to the island to the
+conditions which had existed under Spanish rule, as the Spaniards had
+not encouraged manufactures or industries in the island, and had left
+the people without any incentives to the awakening of enterprise or
+initiative.
+
+
+_Hook-Worm Disease_.--Before long it was found that the real reason
+for the anemia of the Porto Ricans was the presence in their
+intestines in large numbers of the so-called hook-worm. These worms
+exhausted the vitality of the sufferers and left them without surplus
+energy and, indeed, with scarcely enough life to care whether or not
+life itself continued. It was not a moral condition, but a very
+definite physical cause that was at work. Shortly afterwards it was
+found that the same disease existed in our Southern states among the
+so-called "poor whites." Before this, these people had been supposed
+to be a characterless, unambitious, lazy people, who cared not to get
+on, who had sunk to about the lowest depths possible for civilized
+people, and who were quite satisfied to remain there. The discovery of
+hook-worm disease among them, however, soon made it clear that their
+laziness was the result of the drain upon their systems due to the
+presence of thousands of hook-worms. When these were removed, if
+nature was not already exhausted, the "poor whites" became normal
+human beings once more with ambition and initiative.
+
+This story of pathology influencing racial qualities is not new in the
+history of the world. It is not improbable that even certain periods
+of decadence in Egyptian history which have ordinarily been attributed
+to the so-called running out of particular ruling races or families,
+or to the degeneration of the people consequent upon luxury, were
+really the result of the spread of the hook-worm disease through
+certain portions of Egypt. Dr. Sandwith, who has studied the disease
+very carefully in Egypt, is sure that it has existed there for at
+least four thousand years, and that the descriptions of certain
+affections which occurred in Egypt in historic times were really due
+to the same cause as now is known to produce the so-called Egyptian
+chlorosis, the name that was used for hook-worm disease in Egypt.
+Workers in soil, and in mines and in tunnels, are especially likely to
+be affected by it, and whenever it is neglected it spreads rather
+widely, as is seen in the mines of Germany and Hungary at the present
+time. As the cause was unrecognized in the olden time, it is possible
+that periods of supposed lassitude among the people were really due to
+infection by this parasite.
+
+
+_Malaria and Degeneration_.--In recent years it has come to be
+generally recognized that the decadence of Greece, for instance, was
+not due to moral causes so much, perhaps, as to physical reasons.
+During the classic periods in Greece there are no traces of malaria.
+After the invasion of Sicily, the expedition against Syracuse and
+other attempts on the part of the cities of Greece to spread their
+dominion, malaria seems to have been introduced among her people, and
+as the _anopheles_ mosquito was already there, the malaria spread
+widely, and in the course of a century affected so many of the people
+that their energy and ambition and initiative were to a great extent
+destroyed. {108} It is well known that these effects often occur as a
+consequence of malaria, and as generation after generation is affected
+by the disease, are emphasized more and more. The relaxing effect of
+tropical climates, of which we have heard so much, and which is
+supposed after a time to bring about the inevitable production of a
+race eminently lazy and careless of the future, is probably much more
+due to certain affections, such as malaria and those consequent upon
+animal parasites, than to any constitutional change that has taken
+place in the body, or any profound corresponding change in the mind.
+It is a case of the body influencing the mind and producing an
+apparently different race from that which existed before, though all
+this may be changed for the better by some even slight amelioration of
+bodily conditions.
+
+In any attempt, then, to influence the human mind in order to use its
+power and its reserve energy for therapeutic purposes, the place of
+the body and its influence upon the mind must always be remembered. It
+is quite impossible to lift people up to enable them to use their
+mental reserve force if they are living in discouraging physical
+conditions, which use up so much of energy as to make it impossible to
+have any to spare. Many of the phases of mental discouragement and
+lack of initiative which are reflected in what we call lowered
+resistive vitality and lack of immunity to infection, are really
+consequent upon physical states representing a drain upon the system
+that can be removed, or at least greatly improved, if they are
+discovered and properly treated. Victims of chronic malaria and of
+hook-worm disease cannot be lifted up by psychotherapy. Neither can
+sufferers from other forms of chronic physical debility. After the
+removal of the debilitating cause, however, mental influence may be
+brought to bear to encourage them to rise to their opportunities, to
+literally take on new life, and gradually accumulate reserve energy
+that will enable them to accomplish, not only the average work of
+mankind, but even better, in the reaction that comes with the new
+feeling of physical energy. And what is thus true in these extreme
+cases is even more true of minor ailments and conditions.
+
+
+
+CHAPTER IV
+
+THE MECHANISM OF THE INFLUENCE OF MIND ON BODY
+
+The question as to how mind influences body, and body mind, has always
+proved a riddle to all but those with a special theory in the matter.
+The facts of the mutual influence of mind on body are so obtruded on
+observation that they could never be missed, but it is quite another
+thing to reach a satisfactory explanation of them. How the will
+initiates motion continues in spite of all our advance in psychology,
+to be as much a mystery as ever. Just how sensation is transformed
+into ideas is a parallel mystery. Since the mind is able to influence
+motion, it is not surprising that it should be capable of modifying
+secretion or inhibiting other kinds of functions. Any of these various
+activities is scarcely more mysterious than the other. Since the
+transformation of sensation into thought takes place, it is
+comparatively easy to conclude that the mental processes are able to
+exclude, or to some extent inhibit, sensation. All these activities
+have actually been observed. How does this mutual influence of mind on
+body take place? What principles underlie it?
+
+{109}
+
+At present, it would be futile to hope to outline the absolute
+principles on which the mechanism of mental influence or suggestion
+depends, but we can discuss recent explanations that have been
+offered, and this will help us to understand, not the mystery itself,
+but just where the mystery lies and what the physical mechanism
+connected with it is.
+
+
+  [Illustration: Fig. 2.--CORTEX OF HUMAN BRAIN ILLUSTRATING
+  COMPLEXITY OF THE SYSTEMS AND PLEXUSES OF NERVE FIBERS (Combination
+  of the methods of Weigert and Golgi--after Andriezen). _c, z.,_
+  clear zone free from nerve fibers; _M.P.,_ Exner's plexus in the
+  molecular layer; _A. str.,_ ambiguous cell stratum; _Subm, P.,_
+  sub-molecular plexus; _Gt. P. P.,_ great pyramidal plexus; _Pol.
+  P.,_ polymorphic plexus; _W.,_ white matter. (Barker.) ]
+
+
+{110}
+
+These explanations are as yet only theoretic, but theories have often
+helped students in science to make their thoughts more concrete and
+their investigations more practical. It would be a mistake to conclude
+that because some of the theories advanced are very plausible, we
+have, therefore, reached definite truth with regard to the mechanics
+of the brain that underlie suggestion and mental influence.
+
+
+Brain Complexity.--The most interesting feature of the discoveries in
+brain anatomy during the past generation, has been that the central
+nervous system is of even greater complexity than had been thought.
+Because of this, these new discoveries, instead of solving the
+biological mystery they subtend, or even helping very much to solve
+it, have made it still harder to understand just how we succeed in
+controlling and directing this immensely complex machine, of whose
+details we are utterly unconscious, yet which we learn to use with
+such discriminating nicety of adjustment and accomplishment. The
+discoveries of Golgi and of Ramon y Cajal show us that the brain
+consists of nerve cells with a number of ramifying fibers connecting
+each cell and each group of cells with other simple and compound
+elements of the brain, and sending down connecting fibers to every
+organ and every part of the body. Dr. Ford Robertson calculates that
+in an average human brain there are at least three billions of cells.
+Without knowing anything of their existence, much less anything of the
+infinite detail of their structure and mode of operation, we have
+learned to use these for many purposes.
+
+
+  [Illustration: FIG. 3.--SMALL AND MEDIUM-SIZED PYRAMIDAL CELLS OF
+  THE VISUAL CORTEX OF A CHILD TWENTY DAYS OLD. Section taken from the
+  neighborhood of the calcarine fissure. A. plexiform layer; B, layer
+  of the little pyramid; C, layer of the medium-sized pyramid; a,
+  descending axis cylinders; b, ascending or centripetal collaterals;
+  c, stems of the giant pyramidal cells. (Ramon y Cajal.)
+
+  (This and the next three illustrations illustrate the complexity of
+  the central nervous system as observed in the very young child where
+  the development does not as yet obscure the interesting details of
+  dentritic branching. They serve to emphasize the much more
+  pronounced condition which develops in the adult.)]
+
+
+Nerve Impulses.--We do not know even how nerve impulses travel.
+Probably they do so by a mode of vibration, just as heat and light and
+electricity are transmitted as modes of motion. The similarity that
+used to be thought to exist between the transmission of nerve impulses
+and of electrical energy is now known definitely to be only an
+analogy, and not to represent anything closer. Waves of nervous energy
+travel at a different rate of speed from electrical waves, and there
+are other notable differences. Such phases as molecular action, or
+motion, or vibration are only cloaks for our ignorance, A generation
+ago Huxley declared that "the forces exerted by living matter are
+either identical with those existing in the inorganic world or are
+convertible into them." He instanced nervous energy as the most
+recondite of all, and {111} yet as being in some way or other
+associated with the electrical processes of living beings. As Prof,
+Forel said in his "Hygiene of the Nerves," "the neurokym cannot be a
+simple physical wave, such as electricity, light or sound; if it were
+its exceedingly fine weak waves would soon exhaust themselves without
+causing the tremendous discharges which they actually call forth in
+the brain."
+
+
+Law of Avalanche.--How great is the power of the nervous system or the
+energy of it that may be set loose by some very simple reflex, as
+suggested by Forel, is illustrated by what Ramon y Cajal calls the Law
+of Avalanche. A single peripheral nerve ending is represented in many
+different portions of the brain. An ocular nerve ending, for instance,
+probably has direct connection with four or more portions of each
+hemisphere. Each of these portions of the brain has association fibers
+connecting it with other parts and so the stirring of a single nerve
+ending may disturb many thousands, perhaps hundreds of thousands, of
+brain cells; at least it affects them in some way or other. The older
+psychologists used to insist on the similarity, or analogy, between
+the cosmos ol the universe and the microcosmos that man is. The
+English poet of the nineteenth century told us that there is no
+moving of a flower without the stirring of a star, so intimately
+connected by the laws of gravitation is the universe. In the microcosm
+something of this same thing is true and a titillation of even the
+most trivial nerve ending may produce, in Ramon y Cajal's phrase, "an
+avalanche" of cell disturbances in the central nervous system which
+may seriously disturb the whole system.
+
+What is thus true for the brain is true, also, for the cord, and the
+complexity of spinal cells needs to be seen to be properly realized.
+
+
+  [Illustration: Fig. 4.--SERIES OF SECTIONS SHOWING THE FINE NERVE
+  ENDINGS AND BRANCHINGS OF THE FIRST AND SECOND LAYER OF THE VISUAL
+  CORTEX OF A CHILD FIFTEEN DAYS OLD. A and B, very thick nerve plexus
+  of the layer in which the little pyramids are contained; C, a plexus
+  containing a series of branches that is less thick and intricate; D,
+  small cells whose ascending axis-cylinders have resolved themselves
+  into a set of similar branches; E, arachnoid star cells whose axis
+  cylinders produce a thick plexus in the first layer; F and G, small
+  cells with short axis cylinders that have very few branches. (Ramon
+  y Cajal.)]
+
+
+
+Psychic States.--There are a number of human states representing
+extremes of sensory and intellectual conditions in man, that have
+always attracted attention, and in recent years have been special
+objects of investigation by physiologists. Natural sleep is one of
+these; the unconsciousness of narcotism or anesthesia is another.
+Hypnotism is allied to both of these, and would seem to lie on a plane
+between them. Then there are various states of exaltation in which
+sensations fail to produce their usual effect. Those {112} escaping
+from a fire, or passing through a severe panic of any kind may sustain
+all manner of injuries without being aware of them. Martyrs, for all
+manner of causes, are able to withstand suffering with such
+equanimity, and sometimes even joy, that it is evident that they
+cannot feel, as would people under ordinary conditions, the pain that
+is being inflicted on them.
+
+
+  [Illustration: Fig. 5.--FIRST, SECOND AND THIRD LAYER OF THE
+  ANTERIOR CENTRAL CONVOLUTION (THAT IS, OF THE ASCENDING FRONTAL
+  CONVOLUTION) OF THE BRAIN OF A CHILD ONE MONTH OLD. A, B, and C,
+  little pyramids; D and E, medium-sized pyramids; F, cells with two
+  sets of tufts; their axis cylinders resolved into end tufts; G,
+  protoplasmic layer that comes from one of the large pyramids of the
+  fourth layer; H and I, fine dentrites of the cells of the sixth and
+  seventh layer; J, small cells with two end tufts; K, spindle cells
+  with long axis cylinder. (Raymon y Cajal.)]
+
+
+  [Illustration: FIG. 6.--LAYERS OF THE POSTERIOR CENTRAL OR ASCENDING
+  PARIETAL CONVOLUTION OF A NEWBORN CHILD. 1. plexiform layer; 2.
+  small pyramids; 3. medium-sized pyramids; 4. external large
+  pyramids; 5. small pyramids and star shaped cells; 6, deep layer of
+  large pyramids; 7, spindle and triangular shaped cells. (Raymon y
+  Cajal.)]
+
+
+In the midst of intense mental preoccupation one may hold so cramped a
+position as would be quite impossible for the same length of time with
+the faculties normally engaged. There are pathological conditions,
+like hysteria, in which the pain and fatigue sense may, for a time at
+least, be quite in abeyance.
+
+{113}
+
+  [Illustration: FIG. 7.--DIAGRAM OF CELLS OF CEREBRAL CORTEX (after
+  Starr, Strong and Leaming). I, superficial layer; a, fusiform; b,
+  triangular; c, polygonal cells of Ramon y Cajal; II, layer of small
+  pyramids; d, smallest; e, small; f, medium-sized pyramidal cells
+  with axones descending to the white matter and giving off
+  collaterals in their course; III, layer of large pyramidal cells; g,
+  largest (giant) pyramidal cells; k, large pyramidal cells with very
+  numerous dendrites; all pyramidal cells are seen to send long apical
+  dendrites up to I; m, Martinotti cell with descending dendrites and
+  ascending axone; n, polygonal cells; IV, deep layer; p, fusiform
+  cell; q, polygonal cell; V, the white matter containing the axones
+  from the pyramidal cells, d, e, f, g, and from a cell of the deep
+  layer q; r, neuroglia fibers. (Barker.)]
+
+{114}
+
+
+  [Illustration: Fig. 8.--SCHEME OF LOWER MOTOR NEURON. The motor-cell
+  body, with protoplasmic processes, axis cylinder, side fibrils or
+  collaterals, and end ramifications, represents parts of a neuron. a.
+  h., axon hillock devoid of Nissl bodies, showing fibrillation; ax.,
+  axon. This process near the cell body becomes surrounded by myelin,
+  m., and a cellular sheath, the neurilemma (not an integral part of
+  the neuron); c, cytoplasm showing Nissl bodies and lighter ground
+  substance; d, protoplasmic processes (dendrites) containing Nissl
+  bodies; n., nucleus; n., nucleolus: n. r., node of Ranvier; s. f.,
+  side fibril; n. of n., nucleus of neurilemma; tel., motor end plate
+  or telodendrion; m., striped muscle fiber; s. l., segmentation of
+  Lautermann. (Barker.)]
+
+
+Neurons.--With the advance in our knowledge of brain anatomy, various
+explanations for these curious conditions have been suggested. The
+discovery that the central nervous system is composed of a large
+number of separate units, and not of a feltwork of continuous fibers
+with cells here and there, revolutionized all previous attempts at
+explanation of these conditions. We know now that it is not fibers but
+cells that are the most important components of the brain and
+spinal-cord substance, and that, indeed, the fibers are only
+prolongations of cells. The central nervous system is made up of nerve
+cells with various appendages, and each one of these cells and its
+appendages is called a neuron. These appendages are of two kinds, one
+the axon, the long conducting fiber which transmits the nerve force of
+the cell, the other the dendrons or connecting elements by which the
+cell is linked with the axon of another cell. The contact of the axon
+of one neuron with the dendrons of another is called a synapse. Each
+neuron does not extend to and from the brain and the periphery, but
+series of neurons connect the surface of the body with the brain.
+There is usually a group of neurons in the path from the surface to
+the brain cortex. The peripheral neuron for sensation runs from the
+surface of the body to the spinal cord, while for motion it runs in
+the opposite direction. There is a secondary neuron in each chain that
+runs up or down the spinal cord to and from the base of the brain. A
+third--sometimes, perhaps, a fourth--neuron connects in the two
+directions, afferent and efferent, the cortex and the base of the
+brain.
+
+
+_Neuronic Movement_.--Duval, the French anatomist and histologist,
+suggested the possibility of voluntary and involuntary movement in the
+neurons or nerve cells themselves, thus making and breaking
+connections.
+
+
+{115}
+
+  [Illustration: FIG. 9.--SCHEME OF THE VISUAL CONDUCTION PATHS (after
+  C. von Monakow). a, rods and cones; b, rods; c, nuclei of rods; d,
+  bipolar cells for the cones; e, bipolar cells for the rods; f, large
+  multipolar ganglion cells giving rise to the axons of the N.
+  opticus; g, centrifugal axon of a neuron, the cell body of which is
+  situated in the collieulus superior, its telodendron being situated
+  in the retina; h, Golgi cell of Type II, or dendraxon in the corpus
+  geniculatum laterale; i, neuron connecting the corpus geniculatum
+  laterale with the lobus occipitalis, its axon running in the radiato
+  occipito-thalamica (Gratioleti). The visual impulses are indicated
+  by the arrow. (Barker)]
+
+
+{116}
+
+
+  [Illustration: FIG. 10.--SCHEMATIC FRONTAL SECTION THROUGH THE
+  OCCIPITAL LOBE ILLUSTRATING MANIFOLD CONNECTIONS IN A SINGLE LOBE
+  (after H. Sachs), v, cornu posterius ventriculi lateralis; f. c,
+  fissura calcarina; b, upper division: i, lower division; coll,
+  sulcus collateralis; s. o. I, sulcus occipitalis superior (fissura
+  interparietalis); s. o. II, sulcus occipitalis medius; s. o. III,
+  sulcus occipitalis inferior; c. a., calcar avis; g. l., gyrus
+  lingualis; g. f., gyrus fusiformis; g. o. s., gyrus occipitalis
+  superior; g. o. m., gyrus occipitalis medius; g. o. i.. gyrus
+  occipitalis inferior; c, cuneus; 1-10, forceps; 11-14, stratum
+  sagittale internum: 15, stratum sagittale externum; 16, stratum
+  calcarinum; 17, stratum cunei transversum; 18, stratum proprium
+  cunei; 19, stratum proprium s. o. I; 20, stratum proprium s. o. II;
+  21, stratum proprium. s. o. III; 22, stratum proprium, s. coll.; 23,
+  stratum profundum convexitatis. (Barker.)]
+
+
+According to his suggestion, sleep would be due to a separation of the
+neurons that run from the surface of the body to the brain cortex,
+because the various neurons had become too tired for further function.
+As a consequence of fatigue, their terminal filaments would fall away
+from one another, external sensations would no longer be communicated
+to the brain, because the peripheral neuron was not connected with the
+next in the chain. As a further result, the brain, undisturbed by
+sensations, would be left at rest so far as the body was concerned.
+Within the brain certain connections through which flow thoughts that
+would keep us awake, are also supposed on this theory to be broken,
+and consequently all the nerve cells have a chance to rest, except, of
+course, those concerned with such very vital functions as heart
+movement, respiration and peristalsis.
+
+{117}
+
+
+  [Illustration: FIG. 11.--ISOLATED CELL FROM HUMAN SPINAL CORD
+  (Obersteiner).]
+
+
+Somehow, these vital neurons obtain their rest in the intervals
+between the impulses which they send down, just as cardiac cells do
+between heart beats.
+
+
+_Neurons in Psychic States_.--This same explanation would serve for
+narcosis, that is, for anesthesia, due to chloroform or ether, or any
+other drug. As a consequence of the effect of the narcotic upon the
+central neuron, they are brought into a condition resembling fatigue,
+at least to the extent of breaking their connections with other
+neurons so long as they are under the influence of the drug. While
+sensory nerves at the periphery, then, are being stimulated by the
+cutting of tissues to which they are attached, the message from them
+does not reach the brain because of a disturbance of the connections
+in the chain of neurons. Drunkenness illustrates the same phenomenon
+in a less degree. The effect of the intoxicant upon the central
+neurons disturbs sensation because it makes the connection much less
+complete than before, and so it is easy to understand the familiar
+occurrence of even severe injuries to drunken men without their being
+aware of them, or at least without their suffering nearly so much as
+would be the case if they were not intoxicated.
+
+
+_Hypnotism_.--The same theory would also hold for the phenomena
+observed in hypnotism. After all, the best explanation of hypnotism
+that we have is that there is a turning inward of the patient's
+attention, so that only those sensations are allowed to reach the
+brain to which mental attention has already been called by suggestion.
+Hypnotism usually begins with a certain fatigue of peripheral neurons
+until these do not act normally, and then the cerebral neurons become,
+as it were, short-circuited on themselves with a consequent internal
+concentration of attention. The anesthesia so often noted in hypnotic
+or hysterical states is explained by the same theory. For the time
+being, at least, the connection between the peripheral neurons and the
+central neurons is broken or but imperfectly made, and conduction does
+not take place, or is hampered. There may be loss of motion as well as
+of sensation, or of motion without sensation. In all these cases, the
+discontinuity of the nervous system enables us to understand more
+readily the mechanism by which these curious phenomena occur.
+Exaltation or intense interest or profound preoccupation may so
+concentrate nervous energy within the nerve centers themselves as to
+inhibit the flow of sensory impulses from without and thus enable
+{118} people to stand pain and fatigue that would otherwise seem quite
+unbearable.
+
+
+_Unconsciousness_.--The unconsciousness due to apoplexy, or to a blow
+on the head, would be comparatively easy of explanation on the same
+theory. The hemorrhage would actually push certain neurons apart
+within the skull, or the intracranial pressure produced by it would
+keep them from making proper connections. A blow on the head may
+readily be supposed to jar neuronic terminal filaments so severely
+that it would be some time before connections could be made, and the
+injury might be serious enough to prevent certain cells from ever
+again coming in contact in such a way as to allow the passage of nerve
+impulses from one to the other. Concussion of the brain would, on this
+theory, mean that neurons were so shaken apart as to produce some
+confusion in their terminal filaments and consequent serious
+disturbances of consciousness, if not its complete loss, and
+corresponding disturbance of the power to move. In a word, this theory
+would seem to afford a reasonably satisfactory explanation for most of
+the extraordinary phenomena of mental life and, therefore, might also
+be expected to be applicable to the ordinary phenomena, though these
+are so elusive that it is difficult to satisfactorily apply theories
+to them.
+
+  [Illustration: FIG. 12.--NEURON FROM THE OPTIC LOBE OF THE EMBRYO
+  CHICK (after Kölliker). The axon n runs toward the center, giving
+  off in its course several collaterals. One of these, c, is much
+  branched. (Barker.) ]
+
+_Tired States_.--When fatigued, it becomes extremely difficult for us
+to follow a train of thought, especially if it is somewhat intricate.
+It becomes easy to forget things, even such as under ordinary
+circumstances would be readily remembered. Names are much more likely
+to be forgotten. Facts and, above all, dates, refuse to come as they
+do under normal conditions. Efforts in the direction of recalling
+details are eminently unsatisfactory. The command goes forth, but
+there is {119} evidently hesitation about obedience. Other thoughts
+intrude themselves. Ideas come unbidden. The connection of thought is
+readily broken, and is hard to get at again. There may have been very
+little mental work, but somehow the fatigue of the general physical
+system is reflected through our central nervous system on the mind as
+well as the body. The early morning hours are the best for mental
+work, not, it seems, because the mind is fresher after its rest, but
+rather because the physical factors that are important for mental
+action are in good condition. Later they become disturbed by the
+fatigues of the day. The delicate cells of the brain become fatigued
+by sympathy with the somatic cells and it is harder to secure those
+nervous connections necessary for thought.
+
+
+  [Illustration: FIG. 13.--DEEP LAYER OF GIANT PYRAMIDAL CELLS OF THE
+  POSTERIOR CENTRAL OR ASCENDING PARIETAL, CONVOLUTION OF A CHILD
+  THIRTY DAYS OLD. a, axis-cylinder; c, collateral branch; d, long
+  basilar dendrites; e, end tuft. (Ramon y Cajal.)]
+
+
+ [Illustration: FIG. 14--PYRAMIDAL CELL OF CEREBRAL
+ CORTEX OF MOUSE (after Ramon y Cajal).]
+
+
+_Voluntary Neuron Motion_.--This theory of Duval's supposes that to
+some extent the neurons or nerve cells are possessed of voluntary
+movement. At least during certain states of the mind, they are moved
+and seem to have an inherent, if not quite voluntary, power {120} of
+motion. There are many objections urged against the theory because of
+this neuronic motion. It has been said that the movement of neurons
+has been observed in certain of the _Medusae_. The observation has
+been doubted and it lacks confirmation. In higher animals, of course,
+the observation is impossible because an investigation of the nervous
+system for this purpose would necessarily bring about the death of the
+animal and the cessation of spontaneous mobility. Whether it occurs or
+not, therefore, is a theoretic problem. So many objections tell
+against Duval's theory that it is now only discussed because of its
+subjective value.
+
+
+Neuroglia Theory.--Ramon y Cajal elaborated a second theory of
+explanation for the mechanism of the nervous system that has seemed to
+many authorities in brain physiology much more satisfactory than
+Duval's theory of the actual motion of the neurons themselves. The
+Spanish nervous histologist had made a special study of the neuroglia
+or connective tissue cells in the central nervous system. These are
+very small in size but very numerous. Ramon y Cajal suggested that it
+was because the terminal filaments of these neuroglia cells inserted
+themselves between the neuronic filaments, thus insulating one from
+another, somewhat as if an insulating plug were inserted between two
+portions of an electric circuit, that the interruption of nervous
+currents took place. This explanation is free from many of the
+objections urged against Duval's theory.
+
+The small size of the neuroglia cells makes it easy to understand how
+movement may take place in them sufficient to bring about separation
+of neurons. It would not be surprising if they should be more or less
+actively contractile. Whenever they contract, neuronic filaments which
+they have been holding apart, come together so as to permit the
+passage of nervous impulses, if any are flowing at the time. When the
+neuroglia cells become fatigued or seriously disturbed, they refuse
+any longer to obey the will in any way, or at least gradually get
+beyond control, and in their relaxation becoming prolonged, push
+neurons apart. When a man is very tired it gradually becomes
+impossible for him to keep awake. This is partly because poisons,
+produced in the course of fatigue, exhaust the vitality of the
+neuroglia cells and also of the neurons, so that less energy is
+required to push these latter apart.
+
+It is easy to understand that the neuroglia cells might well become
+affected by the various narcotics and intoxicants in such a way as to
+produce the phenomena of anesthesia and drunkenness. The rapid
+recovery from anesthetics seems to indicate that it is not neurons, or
+essential nerve cells, that are so deeply affected, but some
+extraneous, and less important, mechanism within the brain. The
+neuroglia theory explains this very well and does away with the
+difficulty. Certain curious phenomena of hysteria are easily explained
+on this theory. When there is anesthesia in a member because of
+hysteria, this anesthesia does not follow the distribution of certain
+nerves, but is limited by a line in the shape of a cuff drawn round
+the limb. This indicates that the trouble is not peripheral but
+central, and that owing to psychic disturbance, all the neurons that
+receive sensory impulses from a particular portion of the body are so
+affected by a psychic condition that they are no longer capable of
+receiving impulses from the periphery. The neuroglia cells in a
+particular area have passed from the control of the will and, relaxing
+themselves, have {121} inserted their processes between the terminal
+filaments of neurons, thus preventing conduction.
+
+
+  [Illustration: FIG. 15.--NEUROGLIA CELLS OR THE FASCIA DENTATA; IN
+  THE NEW-BORN RABBIT (method of Golgi). A, molecular layer; B,
+  granular layer; C, layer of polymorphis cells; D. horn of ammon; a.
+  neuroglia cell furnished with a descending appendage; b, another
+  neuroglia cell; piroform; c. a cell more deeply situated; d, spider
+  cell; e, fusiform neuroglia cell. (Ramon y Cajal.)]
+
+
+_Varieties of Neuroglia_.--The connective tissue cells are of many
+kinds, each probably exercising a special function. Ramon y Cajal has
+described and pictured a special kind of neuroglia cells for the gray
+and another for the white matter. In his description of these cells he
+has pointed out many interesting diversities of form, and probably
+also of function. He has also described particularly a special form of
+neuroglia cells which lie close to the blood vessels. These he calls
+perivascular cells, and they seem to have an important function in
+regulating the amount of blood that goes to a particular part of the
+brain. He has written so clearly and yet so concisely with regard to
+these that it seems better to cite his own words:   [Footnote 15]
+
+    [Footnote 15: This article is a translation made by the author shortly
+    after a visit to Ramon y Cajal in Madrid, in 1900. See _International
+    Clinics_, Phila., Vol. II Series Eleventh.]
+
+  Under the term neuroglia are included at least three kinds of
+  cells,--those of the white brain substance, those of the gray
+  substance, and the perivascular cells, which have been described by
+  Golgi. The neuroglia cells of the white brain material are easily
+  recognizable, being large and with rather prominent, smooth, and
+  sharply outlined processes. As my brother seems to have shown, their
+  object appears to be to furnish an insulating, or, at least, a badly
+  conducting, substance to serve as an interrupter of nerve-currents.
+  They certainly do not represent interstices of true nerve substance
+  through which lymphatic fluid can conveniently find its way.
+
+  The neuroglia cells of the gray matter present a very special and
+  highly characteristic appearance. They are of manifold form,--at
+  times star-shaped, at times {122} like a comet drawn out in length.
+  These are the tall cells of von Retzius. They have very numerous
+  prolongations, with a large number of short branched collaterals
+  which give the whole cell the appearance of having feathers
+  projecting from its periphery. These cells have been observed in two
+  different conditions. One is that of relaxation, and the picture is
+  that given above. The other is that of contraction, during which the
+  cell body has more protoplasm in it, and the processes become
+  shorter and thicker, and some of the secondary branches disappear
+  entirely. These cells resemble, in certain ways at least, the
+  pigment cells which occur in the skin of some animals. By means of
+  their contractility, these pigment cells can stretch out their
+  processes while in a state of contraction. It must be remembered
+  that this form of neuroglia cells is most abundantly present in
+  those parts of the brain in which it might be expected that a number
+  of nerve currents would frequently come together. They occur, for
+  example, with special frequency in the molecular layer of the
+  cerebral cortex, where the bundle of pyramidal fibers, with their
+  immense number of terminal nerve-endings, come in contact with one
+  another.
+
+
+    [Illustration: FIG. 16.--NEUROGLIA CELL FROM THE SUBCORTICAL LAYER
+    OF THE CEREBRUM FROM WHICH TWO PROCESSES GO TO A BLOOD VESSEL
+    (Obersteiner).]
+
+
+
+    [Illustration: FIG. 17.--NEUROGLIA CELLS FROM THE SPINAL CORD.
+    Longitudinal section (Obersteiner). ]
+
+
+  The third form of neuroglia cells consists of those known as the
+  perivascular cells. They are found only in the neighborhood of the
+  capillaries of the gray matter and they send one or more firm
+  prolongations to the outer surface of the endothelium of the blood
+  vessels.
+
+  These processes are inserted in the walls of the blood vessels.
+  Every capillary has thousands of these little pseudopod
+  prolongations, and from the vessel the cell reaches out in a number
+  of directions. The object of these cells undoubtedly is by
+  contraction of the prolongations to bring about local dilatation of
+  the blood vessels. This dilatation of the blood vessels causes
+  greater or less intensity of the psychical processes in certain
+  parts of the brain, because of the greater or less congestion of the
+  circulation in a part which it produces.
+
+  With the exception of these last cells the object of the neuroglia
+  cells is to insulate nerve fibrils and cells from one another. When
+  the cells are relaxed, the passage of a nerve current is either
+  entirely prevented or rendered much less easy than before. It is in
+  this way that the true nature of intellectual rest is explained.
+  Sleep--not only natural sleep, but also artificial narcosis, such as
+  is produced by narcotics, hypnotics or hypnotization--is evidently
+  the result of the same conditions.
+
+  During the state of contraction the pseudopod of the neuroglia cells
+  are drawn in; that is to say, the protoplasm of the cells absorbs
+  the processes, and so the true nerve cells and nerve fibrils which
+  were separated from each other by the interposition of neuroglia
+  come into contact. By this mechanism the brain passes from the
+  condition of rest into one of activity. These neuroglia contractions
+  may, particularly in certain parts of the brain, occur
+  automatically. Often, however, they are produced by the action of
+  the will, which, in this manner is able to influence {123} the
+  definite groups of neuroglia cells. As the result of this influence
+  of the will the association of intellectual operations can be guided
+  in various directions. The unusual course that the association of
+  ideas sometimes takes, the flow of words and of thoughts at certain
+  moments, the passing difficulty of speech, the recurrence of
+  tormenting thoughts, the disappearance of expressions or ideas from
+  the memory, even the increase of mental activity and of every kind
+  of motor reaction as well as many other phenomena of intellection,
+  can be satisfactorily explained on this hypothesis. It is only
+  necessary to suppose that in certain parts of the brain the
+  neuroglia cells are at rest, while at other parts they are in a
+  condition of active contraction.
+
+  To put it all in a few words, the neuroglia cells of the gray
+  substance of the brain represent an insulating and switching
+  apparatus for nerve currents. They are an insulation apparatus when
+  in a state of contraction, a switching and insulating apparatus when
+  in a state of rest. It is to be remarked, then, that according to
+  this theory the contraction of brain cells does not take place, as
+  in Duval's theory, during intellectual rest, but, on the contrary,
+  during the state of activity of the cerebral cortex. It is much more
+  probable that the action of cells coincides with the active stage of
+  intellection than that brain cellular activity--that is,
+  contraction--should correspond with psychic rest.
+
+The application of some of these theories enables us to understand
+just how short-circuiting may come about, how many of the curious
+phenomena of memory happen, and what are the effects, as well as the
+causes, of attention and distraction of attention and of diversion of
+mind. It is particularly the latter portion of Ramon y Cajal's theory,
+with regard to attention and the more or less voluntary though
+unconscious and usually indeliberate control of blood supply to
+various portions of the brain, that is of special interest. If the
+neuroglia cells, whose end plates are attached to blood-vessel walls,
+become over-contracted or lose their power of relaxation or of
+contraction, many of the curious phenomena of over-tiredness in
+neurotic conditions, and the lack of the power of concentration, and
+sufficient attention to things, can be readily understood. In a word,
+the theory enables us to translate many expressions that are vague and
+indefinite, from terms of mind into terms of the physical basis of
+mind--the anatomy and physiology of the brain.
+
+While I have dwelt on Ramon y Cajal's theory, because for years it has
+been familiar, of course I must reëcho his own warning that it is,
+after all, only a theory. It presupposes an active interposition of
+the glia cells between the axon of one neuron and the dendrons of
+another. This cannot be demonstrated. A third theory of mental
+operations, then, has been suggested, and the English school, so ably
+led by Sherrington ("Integrative Action of the Nervous System,"
+London, 1903) and McDougal ("Synapse Theory of Fatigue," _Brain_,
+1910) has deservedly attracted wide attention. They contend that all
+the phenomena can be more simply explained without postulating the
+movement required for the Duval Theory or the glial activity of Ramon
+y Cajal's hypothesis. They consider that each nerve cell has, as it
+were, a certain potential energy which it sends forth in nerve
+impulses. These are transferred from neuron to neuron through the
+synapse. If what we might call, to borrow a figure from electricity,
+the voltage of the cell impulse be sufficient to overcome the
+resistance at the synapse, the impulse passes from neuron to neuron.
+In fatigue the potential energy of the cell is gradually dissipated.
+The impulses become feebler till they cease to pass. This occurs in
+the state we usually experience as tiredness and in analogous states
+such as sleep, unconsciousness, narcosis and the like. Obviously this
+{124} theory can be elaborated and applied parallel with the neuroglia
+theory except that here we are substituting synapse resistance for the
+hypothetical, undemonstrated action of the glial cells. But, as the
+latter seems a simpler process upon which to explain the various
+phenomena, especially to those not familiar with very recent
+developments in nervous histology and studies in nervous mechanism,
+and as it merely involves a question of the nature of the resistance
+and not of its site, I have used it for explanatory purposes without
+advocating either theory in the present state of our knowledge.
+
+
+
+CHAPTER V
+
+BRAIN CELLS AND MENTAL OPERATIONS
+
+
+While the theories of neuronic action we have discussed do not
+represent absolute knowledge, they are at least suggestive and helpful
+in psychotherapy. Whenever there are disturbances of mental
+operations, patients are likely to become very solicitous, lest these
+represent organic and incurable changes. The application of Ramon y
+Cajal's neuroglia theory serves to bring out the fact that most of
+them can be very well explained as merely functional, due to passing
+disturbances of activity, and not necessarily to tissue changes. When
+patients become possessed of the fear that certain nervous symptoms
+portend definite injuries to the nervous system, this unfavorable
+suggestion keeps them from using, to its proper and full extent for
+repair and convalescence, the nervous energy which they possess. This
+disturbing influence can be counteracted by a straightforward
+exposition of Ramon y Cajal's or the newer English theory of brain
+mechanism.
+
+Patients become very much disturbed if they observe a failure of
+certain faculties in themselves, and are prone to think that such a
+failure means serious exhaustion or enduring change. The power of
+attention is one of the faculties often disturbed in neurotic cases
+and causes patients needless solicitude. Disturbances of memory are
+the next most alarming elements in these cases. There are then many
+forms of mental distraction, absorption and preoccupation that
+sometimes frighten neurotic individuals who have become solicitous
+about themselves. Though only passing incidents, due to overattention
+to themselves and their ills, real or fancied, and the consequent lack
+of concentration of mind on a particular subject, the patients fear
+serious deterioration of their mental condition, or at least of mental
+control. The neuroglia theory of mental action throws a light on all
+these phases of mentality that serves to lessen the solicitude of
+patients and enable them to understand that, in spite of their fears,
+there is nothing but functional disturbance. The condition can be
+readily explained and it admits of complete restoration to health.
+
+
+ATTENTION
+
+Even more important, perhaps, than any other of the functions
+attributed to the neuroglia cells, is the rôle they may play in
+enabling the individual to concentrate attention on a particular
+subject, or at least to use a particular {125} portion of his brain,
+by bringing about a more active circulation in that portion than in
+any other, Ramon y Cajal attributes this power to the perivascular
+neuroglia cells. Every capillary in the brain has thousands of these
+little pseudopod prolongations. When the cells in a particular region
+contract, the blood vessels of the part are pulled wide open and a
+larger supply of blood flows more freely, stimulating the nerve cells
+by which it passes and supplying them with nutrition for the
+expenditure of energy that they may have to make. This is the physical
+process that underlies attention. When too much, that is, too
+long-continued attention is paid to any subject, without diversion of
+mind, the capillaries may easily acquire the habit of being open, and
+cells the custom of contraction, so that relaxation does not readily
+take place. Something of this kind is the most important element in
+the etiology of many functional nervous disorders.
+
+
+  [Illustration: FIG. 18.--AN ARTERY FROM THE CEREBRAL CORTEX.--One
+  can see numerous fine fibers passing over to the brain substance
+  (Obersteiner).]
+
+
+Ease and Pleasure in Mental Operations.--On the other hand this same
+set of ideas explains many things otherwise difficult of
+understanding. For instance, we all know that habit enables us to
+apply ourselves to a particular subject with ever growing ease. What
+was extremely difficult for us at the beginning, may after a time
+become comparatively easy, and later even positively pleasant. Study,
+that is application of mind, is, at the beginning, for most people,
+not agreeable. If persisted in, it almost inevitably becomes a
+pleasure. Hard exercise of any kind is, at the beginning, sure to
+require great energy of purpose, and requires some subsidiary motive
+of approbation or reward to make us persist in it. But what was a
+distinct labor at the beginning becomes pleasant after a while. This
+may be applied to the neuroglia cells apparently as well as to the
+muscle fibers. On this theory, the reason for the gradual acquirement
+of an intense pleasure in the intellectual life becomes easy to
+understand.
+
+
+Dangers of Over-attention.--The danger of concentration of mind on
+one's self, quite as much as on any other subject, becomes clearer
+when this theory is accepted as explaining the physical basis of the
+mental operations involved in attention. If people allow thoughts of
+themselves and of their physical processes constantly to occupy their
+minds, gradually that portion of the brain ruling over these becomes
+over-fatigued and fails to respond to the calls for relaxation.
+Insomnia may develop readily as a consequence of continued solicitude
+and prove to be, as the worst forms of insomnia so often are, quite
+unamenable to direct drug treatment, because, even during the enforced
+sleep that comes from drugs, dreams with regard to self and the
+supposed ills may still occupy the overworked portion of the brain.
+Nervous people are, most occupied with those parts of the brain which
+have something to do with the omission and transmission of trophic
+influence to particular parts of the body. As a consequence of the
+persistent hyperemia, too many trophic impulses are sent down. These
+cause an exaggeration of physiological function, in the stomach, the
+heart, or some other important organ. Hence these organs may become
+oversensitive.
+
+For all these reasons, this theory of attention, of the great Spanish
+{126} investigator, deserves to be well known by those who hope to
+treat neurotic affections, especially functional diseases of the
+brain, and therefore I prefer once more to give it in his own words.
+[Footnote 16]
+
+    [Footnote 16: _International Clinics_, Vol II, Series 11.]
+
+  Ramon y Cajal's Theory of Attention.--Under usual conditions, the
+  motor apparatus of the gray matter suffices for the explanation or
+  the varied course of association of ideas and of the reaction
+  produced by voluntary motion. But as soon as attention is
+  concentrated upon an idea, or a small number of associated ideas,
+  there enters into the problem, besides the active retraction of the
+  neuroglia of the corresponding part of the brain, a new factor--the
+  active congestion of the capillaries of the over-excited region. As
+  a consequence of this, the energy of emotion reaches a maximum. The
+  heat and metabolism of the hyperemic parts is increased, which, of
+  course, makes these parts capable of more work.
+
+  [Illustration: FIG. 19.--NEUROGLIA CELLS OF THE SUPERFICIAL LAYERS
+  OF THE BRAIN FROM AN INFANT AGED TWO MONTHS (method of Golgi). A, B,
+  C, D, neuroglia cells of the plexiform layer; E, F, G, H, K, R,
+  neuroglia cells of the second and third layers; I, J, neuroglia
+  cells with vascular pedicles; V, blood-vessel. (Ramon j Cajal.)]
+
+
+This congestion of various parts of the brain has been experimentally
+observed {127} by a number of physiologists. It can be best explained
+by considering that the will has an influence upon the nerves which
+produce a dilatation of the blood-vessels in different parts of the
+cerebral cortex. The process of attention, however, by which
+intellectual activity is concentrated upon a limited number of ideas,
+seems to be but very little under the control of the sympathetic nerve
+endings.
+
+As a matter of fact, the capillaries of the brain are wanting in
+nerves and smooth muscle fibers. Hence they are not under the control
+of the sympathetic system. Only the relatively large arteries of the
+pia mater, which possesses a tunica muscularis are under a certain
+limited control of the sympathetic, which is able to produce in them
+an incomplete and not very well limited congestion. One of the
+difficulties of the problem of the activity of the sympathetic is best
+realized when we recall that vasomotor activity is usually
+involuntary. The process of attention, however, is entirely conscious
+and voluntary.
+
+In the hypothesis that we have given, most of the difficulties
+disappear. Under the influence of the will, the pseudopod branches of
+the neuroglia cells, which end in the walls of the capillaries,
+contract. As the result of this, the bloodvessels, all of which are
+surrounded by lymph spaces, dilate, and this dilatation may proceed to
+such an extent that the vessels occupy the whole of the lymph spaces.
+Thus we can easily understand how the very limited congestions which
+are necessary for the concentration of thought upon a single idea may
+be brought about.
+
+The perivascular lymph spaces which exist in the brain seem to be for
+the purpose of making these limited hyperemias easier. At the same
+time they serve a very useful purpose in preventing pressure or
+concussion, such as might be caused upon the neighboring nerve cells
+by too great dilatation of the blood vessels of a part.
+
+It is needless to add that we do not consider the hypothesis that we
+have advanced to be absolutely without objection. On the contrary we
+believe that, owing to the difficulty of the problem and our, as yet,
+extremely slight knowledge of the anatomy and physiology of the nerve
+protoplasm, any theory as to the special mechanism of psychic
+processes is sure to be faulty. Rational hypotheses, however, which
+are supported by well-known facts, are not only justified, but are
+often fruitful of suggestive ideas. A scientific hypothesis often
+gives a new direction, suggests an untried method of observation, or
+hints at new ways of experiment, and, though it may not lead directly
+to truth, always brings us closer to methods of investigation and of
+criticism that are invaluable. Even though our further investigations
+should not confirm our hypothesis, the result will not be less
+positive. Negative conclusions lessen the number of possible
+hypotheses and therefore diminish the possibility of error in future
+investigations.
+
+
+MEMORY
+
+It is evident that some of the physical mechanisms that are employed
+for the lower grade mental processes at least can be explained on the
+neuroglia theory. Memory we share to a great extent with the animals,
+and for this the physical processes can be rather interestingly
+studied. We have all had the experience of being unable to recall a
+word when we wanted it. Commonly the word is a proper name with which
+there are not many direct connecting ideas, so that, somehow, we seem
+unable to trace the word to its depository in the brain. Occasionally
+we are sure that we know the first letter of the word. Sometimes we
+are able to name this letter, and, if we do so, the rest of the word
+will usually turn up a moment later. At times, however, the word fails
+to come and we grope for it. Then if we stop deliberately seeking it,
+the word will often after a longer or shorter time, come up
+spontaneously.
+
+This experience is familiar to everyone. It is especially frequent
+with public speakers. Certain words have a habit of slipping away just
+when we {128} want them. At times by beginning a sentence confidently,
+even though there is a feeling that there is a missing word ahead, the
+word will turn up in time. Often it will not, and then a weak
+circumlocution must be indulged in. If it is a proper name, a
+description may have to be substituted, sometimes a confession may
+have to be made that the name will not come and the audience, unless
+it is very young, will sympathize with the speaker.
+
+If we accept the idea that the memory has a definite location in the
+brain, the process is easily understood. Just how we cannot say, but
+somehow brain cells serve as the media by which our memory processes
+revert to knowledge that has been previously stored up. If now we
+assume that the repetition of things known is accomplished by bringing
+brain cells into connection with one another, and with the organs of
+speech, it is easy to understand that somehow the connection with a
+particular cell or set of cells cannot be secured at a given moment.
+This delay prevents us from being able to repeat things that we know,
+and know that we know, though we cannot somehow get at them. The will
+fails to reach the proper insulating plug of a neuroglia cell, which,
+if acted upon, would put a cell or group of cells in communication
+with others. As a result the message from it cannot flow down. We feel
+that we have it on the tip of our tongue, as we say, that a little
+effort may bring it to us and sometimes that effort succeeds. If there
+is any disturbance of consciousness by secondary motives, however, as
+by the excitement of public speaking or the flustering that comes to
+some people when they try to introduce even old-time friends and
+forget their names, then we cannot control the brain processes and
+memory fails. We do not for a moment think of attributing this failure
+of memory to the faculty of memory itself. We have the feeling that
+there is some mechanical obstacle. Ramon y Cajal's theory enables us
+to understand this obstacle better, perhaps, than any other.
+
+An interesting phase of this lapse in memory helping us to a
+revelation of something of the physical process which underlies the
+faculty, is the fact that it implies a very intricate machine.
+Recalling has become such an obvious incident that we do not think of
+the complexity of action involved. Many things are brought together,
+and relations of all kinds serve to recall various facts and names and
+dates. Some of these relations are most bizarre. Particular names
+recall a definite series of facts. A color will bring up a scene or
+the memory of an individual. An odor will recall scenes long since
+apparently forgotten and will set trains of thought at work that are
+quite unexpected. Sometimes we wake in the morning with a name or a
+fact on our lips that we have been looking for for several days.
+
+
+
+UNCONSCIOUS CEREBRATION
+
+Some people actually learn to depend on unconscious cerebration. A
+man, for instance, who has to make an address on a particular subject
+or to write an article, will record that fact on a tablet and after
+gathering a few basic thoughts in connection with the subject
+proposed, will put it aside for the time being. He is confident that
+various illustrations and thoughts in connection with the subject will
+occur to him at intervals during the next few days, and that he will
+thus without direct labor accumulate an amount of {129} material for
+use. In the early morning hours he may find that thoughts on it come
+to him unbidden. Sometimes he will find these thoughts precious germs,
+that will develop during the course of the following days, and will be
+of great help to him. If he is worried and preoccupied with other
+things very much, this may not happen, but under ordinary
+circumstances he can continue routine occupations which demand
+practically all of his time, yet continue to develop the subject
+selected for his paper or address. The more he has occupied his mind
+with the subject at the beginning, the more will this unconscious
+cerebration continue.
+
+
+ABSTRACTION OF MIND
+
+Features of the mechanism of mental operations are brought out in
+certain phenomena of abstraction of mind, which show how the attention
+can be so short-circuited that sensations from the periphery utterly
+fail to penetrate to the consciousness. Most men have had the
+experience of taking out their watches, looking at them, and then
+putting them back. Presently somebody asks what time it is. Unable to
+recollect what it was that they saw, they have to look again. There is
+no doubt that they meant to observe the time.
+
+The same thing is true for practically all the senses. A pickpocket
+takes advantage of our being occupied with many other feelings in the
+midst of the jostling in a crowd on a car, or before a show window, or
+he has a confederate add to the sensations already streaming up to us,
+calling attention particularly to the other side of the body, and then
+inserts his hand into our pocket and extracts what he finds. Sometimes
+we have a faint memory of something having happened to that pocket,
+but our attention was occupied elsewhere.
+
+In hearing we have the same experience. When thoroughly occupied with
+a book, a person may talk to us or ask us a question and we have no
+idea of what was said, sometimes utterly failing to hear the voice;
+sometimes we hear the sound of the voice, but do not comprehend the
+meaning of the words.
+
+When we are unprepared for a question we nearly always have to have it
+repeated to us. Sitting in a railroad train, if the person behind us,
+whom we did not expect to talk to us, asks a question, it is very
+probable that on the first asking we shall not notice it at all,
+considering that it is addressed to someone else. On its repetition,
+it may appeal to us as addressed to ourselves, but even then we
+readily lose its significance because our attention has not been
+called to the wording of it soon enough to enable us to comprehend it
+thoroughly. These experiences, so familiar that we have probably all
+had them at some time or other, indicate how universal is the power of
+the mind to concentrate itself upon itself to the extent of neglecting
+sensations from the outer world, even though they may pass the
+periphery of the organism and manifestly affect the first neuron of
+the chain that leads up to our brain and consequently to
+consciousness. They do not reach the center with sufficient intensity
+to be understood, and a conscious act of attention must be made before
+we comprehend their meaning.
+
+{130}
+
+
+PREOCCUPATION OF MIND
+
+This is true, not only for ordinary sensations, but even for such as
+would ordinarily be presumed to be so insistent in their call that
+they could not be neglected. The concentration of mind necessary for
+this is not common to all mankind; it is possessed only by a few
+individuals whose intellect represents the larger portion of their
+personality. Certain of the great investigating scientific geniuses
+have had the faculty of so concentrating their attention upon the
+questions with which their intellects were engaged, that even the call
+of appetite did not make itself felt. Newton was one of these. Over
+and over again, he was known to neglect to take his meals, even though
+they were brought to him, and, occasionally, he would entirely forget
+whether he had taken a meal or not. But Newton is not an extreme
+exception. Most of the great mathematicians have had experiences of
+this kind and, indeed, mathematics seems to be that special branch of
+intellectual work which most readily brings about a preoccupation of
+mind sufficient to completely shut out the outer world for the time
+being. Archimedes, the great ancient mathematician, lost his life
+because of preoccupation with mathematical problems that kept him from
+telling the Roman soldiers, who had strict orders to spare him, who he
+was.
+
+Complete absorption of mind to the exclusion of all external
+sensations is not, however, confined to the mathematicians. Mommsen,
+the historian, was famous for his fits of mental abstraction. Once he
+patted a school-boy on the head and asked whose boy he was, to be told
+rather startlingly, "Yours." Lombroso, the criminal psychologist, was
+subject to abstraction in almost as great a degree. Men have become so
+preoccupied in study as not to appreciate the significance of
+warnings, indicating that a serious accident was about to happen, such
+as a fire or the fall of some object that they should have avoided, or
+some other danger to themselves. The tendency to such abstraction is
+responsible for many accidents on busy city streets. When so
+preoccupied, painters walk off scaffolds, and such preoccupation of
+mind is extremely dangerous, not only for the man himself, but for
+those who are working with him.
+
+Everyone knows that a slight headache frequently disappears in
+pleasant company. There is sometimes the suspicion, though it is quite
+unjustified, that because a person has a headache which can be cured
+by engaging in a favorite occupation, the headache is more imaginary
+than real. The common experience with toothache shows the falsity of
+this opinion. There is no imagination in regard to toothache, yet it,
+too, except in very severe cases, will be so modified as to be quite
+negligible if the victim has some mental occupation that is very
+absorbing. Pains of other kinds that are just as real, may be modified
+in the same way. I have known a boy to suffer enough from the presence
+of an unsuspected kidney stone to give up play and come into the
+house, yet he could be made entirely to forget his discomfort by a
+game of checkers. On account of the ease with which the pain was thus
+dispelled, the suspicion was harbored that his ache was more imaginary
+than real. The ache continued and at the end of about a year there was
+an acute exacerbation which justified an operation, and the stone was
+removed.
+
+In all these instances there is evidently a question of the unmaking,
+or at {131} least imperfect making, of connections between the
+peripheral and central neurons, because of the existence of
+connections between different portions of the brain itself which take
+up the attention. This attention to mental things may become
+exaggerated, and must be guarded against, but it represents a valuable
+psychotherapeutic remedy. Whenever the peripheral connections are
+unmade, external sensation is unfelt. Even though the peripheral
+neuron may be suffering to some extent, this is true. It is this law
+of attention that must be taken advantage of for psychotherapeutics.
+People who are liable to be too much concerned with their sensations,
+must be taught to occupy themselves with interests that will absorb
+the attention. Central neurons can, except under very serious
+circumstances, be made to connect with one another so intimately as to
+bring about the neglect of many bothersome external sensations.
+
+
+  [Illustration: FIG. 20.--COMPLEXITY OF CELL OF THE CENTRAL NERVOUS
+  SYSTEM. A Golgi cell after Andriezen. (Barker.)]
+
+
+On the other hand, when the connections with the periphery are well
+made, external sensations flow in on us to the exclusion of thought
+and then even simple sensations may be exaggerated so as to become
+painful. Anything that attracts our attention so much that we cannot
+think quietly about it, is likely to be a disturbance rather than a
+pleasure. Music is distinctly pleasant, yet very loud music becomes
+painful. The reason is that the peripheral neuron is so much disturbed
+that these excessive vibrations are communicated to other neurons
+connected with it and they are unable to occupy themselves with
+anything except this over-strenuous sensation. A very bright light has
+something of the same effect, and the same thing is true for all the
+other senses. A pleasant odor, if over strong, becomes disgusting. A
+very sweet taste is cloying. This over excitation of neurons may come
+from without, or may come from within. If the central neuron is so
+much occupied with itself, and the sensation that is flowing into it,
+that it is prevented from making such connections as would communicate
+and distribute the sensations properly, then the sensory phenomenon
+becomes painful, though it may not be exaggerated in the peripheral
+neuron.
+
+
+VITAL ENERGY BEHIND BRAIN CELLS
+
+In all of these phenomena there is something more than brain cells at
+work. Brain cells are guided, co-ordinated, controlled, and even
+overseen, in their labors. The same conclusion becomes inevitable with
+regard to the action of the cells of the body generally. A generation
+or two ago it was the custom to attempt to explain all the processes
+in the body by chemical and physical principles. Respiration, for
+instance, and absorption of gases into the blood in the lungs and the
+expiration of gases that have been generated within the body during
+vital processes, were supposed to be entirely explicable on the
+principle of the diffusion of gases. The absorption of various
+substances into the body proper from the intestinal tract, and the
+excretion {132} of various substances from within the body into the
+excretory organs, as well as the process of secretion, were supposed
+to be nothing more than varying phenomena of osmosis and exosmosis.
+There has since been a general recognition of the fact that these
+principles do not explain many of the incidents within the body in its
+relations to its surroundings, and that vital processes are something
+much more than merely manifestations of physics and chemistry.
+
+The lungs are not mere laboratories in which refinements
+of the laws of the diffusion of gases may be studied, for under
+varying pressures from without that would vitiate the ordinary
+laws of diffusion, inspiration and expiration continues. Fishes
+live at depths where the pressure is so great that expiration
+would seem to be impossible, yet they succeed in eliminating
+harmful gaseous material. Prof. Haldane of Cambridge has
+called attention to many of these processes. Animal stomachs
+are not test-tubes. Animal excretion, and above all, secretion,
+is carried on sometimes in accordance with but, almost more
+often, in defiance of chemical and physical principles. The
+individual, even in the lower animals, counts for much more
+than the chemical constituents of the tissues and the physical
+principles involved.
+
+Besides, all the parts of the organism are co-ordinated, and
+there are wonderful checks and counterchecks which show that
+animals are much more than colonies of cells fortuitously
+growing together and habituated to such common life by many
+generations of heredity and environment and training. In a
+word, the old vitalistic principle has become popular once
+more and even great physiologists have insisted that there is a
+principle of life which guides and controls and co-ordinates the
+different portions of the body. Especially does this seem to be
+true of the brain. We have here an intensely complex machine,
+composed literally of billions of parts which work together, and
+in doing so accomplish wonderful results. Of the existence of
+this machine, much more of the great intricacy of its parts
+and mechanism, we are quite unconscious. We learn to use it
+in very early years with an assurance and a perfection that is
+amazing, considering how complex it is. The less we think
+about it and its workings, the better does it work and the less
+disturbance of function is there in its accomplishment.
+
+
+  [Illustration: Fig. 21.--SECTION THROUGH THE CORTEX OF THE
+  GYRUS OCCIPITALIS SUPERIOR. (Hammarberg. Barker.)]
+
+
+If a vitalistic principle were needed to enable us to understand the
+workings of the ordinary body cells, how much more is it required for
+the workings of brain cells. There is something behind that guides and
+rules the brain, and through which it accomplishes its work. It is
+this that brings about an unconscious cerebration accomplishing
+intellectual results for us even when the brain machine itself is at
+rest as when asleep, or fails, for some reason, to be in readiness to
+take up the work that we demand of it. It is this vital principle that
+coordinates the movements of brain cells which represent {133} the
+physical processes underlying memory and the nervous elements of the
+sensitive and motor phenomena of the organism. Reflection on the
+physical mechanism underlying mental operations of various kinds,
+demands the vitalistic explanation much more than the physiological
+phenomena which have converted physiologists to the old way of
+thinking in our time. Our individuality is probably largely due to the
+physical basis of our mentality, but there is something more than that
+required for any theory of mental operations that would satisfy all
+the questions that come to us. There is, then, actual proof of the
+existence of a force that is part of us, that constitutes a bit of the
+essence of our personalities, yet is capable of accomplishing results
+that we cannot understand, and of managing a machine that transcends
+any physical powers that we can think of.
+
+
+  [Illustration: FIG. 22--MOTOR CELL OF VENTRAL HORN OF SPINAL CORD
+  FROM THE HUMAN FETUS, THIRTY CENTIMETERS LONG (method of Golgi;
+  after von Lenhossek. Barker.)]
+
+
+This vital force behind the nervous system contains stores of energy
+that can be called on for therapeutic purposes. It is the directing,
+co-ordinating and energizing force which controls the central nervous
+system, and enables it to accomplish its purposes. It is the
+disappearance of this force at death which leaves the body without
+vital activity, though no physical difference between the dead and the
+living body can be demonstrated. Changes in the body _follow_ death;
+they are not simultaneous. This vital force supplies the energy that
+we call the will, and underlies the process called "living on the
+will" which so often serves to maintain existence when there is every
+reason to think that a fatal termination is due. The amount of energy
+thus available is limited, {134} but is much more powerful than has
+been thought. It is of the greatest possible service in preserving
+health and eliminating disease. Its existence, demonstrated by the
+complex nervous system which we employ with such confidence, though we
+know nothing of it, furnishes the best possible basis for confident
+attempts at rousing the patient to use the vital energy he possesses
+for the strengthening of weakness, the correction of deficiency and
+the control of evil tendencies.
+
+
+
+CHAPTER VI
+
+UNCONSCIOUS CEREBRATION
+
+Many of the exhausting neurotic and psycho-neurotic affections so
+common in recent years are largely due to the failure of patients to
+secure such mental relaxation as will permit complete repair of
+nervous waste. We are proud of being a generation of specialists. Some
+men never get completely away from the set of thoughts with which they
+are occupied in their particular specialty. Waking or sleeping these
+thoughts are with them. It is almost impossible, then, for cells of
+the central nervous system to secure such rest as they need. Cells
+must be put at absolute rest so that nutritional processes may go on
+entirely undisturbed, and every portion of the cell be renewed in
+vigor. Re-creation, in its original meaning, is exactly what must be
+provided for nerve cells.
+
+The trouble is not alone that men occupy a very narrow set of brain
+cells with their special interest, and make all their energy pass
+through that set, but among men who are lacking in a certain
+insulation in the nervous system, this particular set of cells
+continues to be active, even at times when they think they are resting
+or diverting themselves. Unconscious cerebration (the occupation of
+the mind with subjects when we are not deliberately giving our
+attention to them) is a common phenomenon in human psychology. With
+the rise of extreme specialization, it has become even more dangerous
+than before. In the past unconscious cerebration might mean any
+occupation, with any one of a number of interests. At the present it
+is likely to mean concentration of thought on a particular subject
+with which the brain is prone to be occupied more than is good for it,
+even during the hours of ordinary labor. It seems worth while to
+discuss at some length, then, the subject of unconscious cerebration,
+because it constitutes the pathological physiology of many nervous
+states that we see in modern life.
+
+
+Frequency of Unconscious Cerebration.--The mind, having been set to
+work over a given thought, continues at it sub-consciously, even while
+apparently completely occupied with something else. Most people who
+devote themselves to the intellectual life have experienced phenomena
+more striking and going much farther in unconscious cerebration than
+this. Most writers have a common experience: if they arrange their
+thoughts on a given subject and then turn aside to something else,
+they find, when they go over the same subject next day, much more
+material than came the day before. The thoughts for an article will
+often gradually accumulate by unconscious cerebration after the
+process has been consciously started.
+
+{135}
+
+At intervals during the next few days succeeding the determination to
+write a certain article (at moments when no conscious thought is being
+given to it), ideas crop up that help to fill out the original scheme
+of thought, and if these are jotted down, a good deal of intellectual
+work is accomplished without the necessity for that labor over a desk
+that most of us scheme to avoid. The more familiar literary work
+becomes, the more frequent are these experiences, and one occasionally
+wakes up with a thought that opens up a new vista and adds valuable
+material to what has already been accumulated. If the subject is a
+large one, as for a book, then most writers will probably confess that
+some of their best thoughts have come in this "hit and miss" fashion
+rather than at the times when they were seriously applying themselves
+to elaborating their theme.
+
+
+Inspiration.--Some of the great literary writers have felt that their
+brain work was so independent of themselves that the word inspiration
+properly suited what they were accomplishing. Thackeray destroyed
+sheet after sheet of manuscript, utterly dissatisfied with it until,
+as the result of keeping at it, inspiration would come. Then he would
+be able to fill up rapidly many pages with work so finished that it
+needed little correction or polish. George Eliot, at times, became so
+absorbed in her writing that it almost appeared to her that some other
+personality than her own was wielding the pen. Her imaginary
+characters became real to her, and it was while under the stimulus of
+this impression of living in an imaginative world with them that she
+succeeded in accomplishing her best work. Many other authors were, of
+course, very different. Some of them ridiculed the idea of waiting for
+inspiration. Most of them, however, found it difficult to begin their
+task at certain times, yet if they forced themselves to it, and once
+got their minds going, the line of thought ran on easily and, at the
+close of the task, they looked back with pleasure and wonder that they
+were able to accomplish so much.
+
+
+_Illustrations_.--This is true not only of literary work, whose main
+purpose is the arrangement of details of information of various kinds
+with personal opinions concerning it, but also of original thought of
+any kind. Many stories of poets are told illustrating this. They
+wander round with pencils and jot down thoughts that come here and
+there at what are called moments of inspiration. The poets dream over
+their subjects, catch fleeting thoughts that, vague at first, sing
+themselves into musical expression. Music seems to be on the same
+plane with poetry, for there is the well-known story of the
+distinguished German musician who, walking with his wife in the park,
+found himself without paper at the moment when he had an inspiration.
+He used his own cuffs to write upon, and then finally impressed those
+of his wife into the service of carrying home the precious musical
+motifs that he was afraid might not come again if he allowed the
+favorable moment to pass without recording them.
+
+There are stories of Tennyson finding some of his most perfect lines
+in the fields, after hours of seclusion and effort in his study had
+failed to round them out to his satisfaction, or dreaming them into
+shape, or waking to find one ready made to be written down. The
+letters of Wordsworth tell how often such incidents happened in his
+life.
+
+{136}
+
+
+SLEEP COMMUNICATIONS
+
+Any one who has been thinking much for several days about a problem is
+likely to wake up with the thought that he has dreamed a solution of
+it, though unfortunately the solution has not remained in his memory.
+It seems as if a communication has been made to him during sleep. I
+have discussed dream life with many men engaged in serious work, and
+practically all of them confess to such experiences. Preoccupation of
+mind with a subject during the waking hours leads to at least some
+occupation of mind with the same subject during sleep. This
+unconscious occupation must often require rather strenuous attention,
+exhausting nutrition, using up nerve force and hampering the rest that
+is so important for tired human nature. [Footnote 17]
+
+  [Footnote 17: A number of poetic products of dreams are in our
+  literature, some of them interesting for more than their curious
+  origin. Dr. S. Weir Mitchell, in his latest volume of poems, "The
+  Comfort of the Hills," made an interesting contribution to the
+  psychology of dreams by publishing two poems which were composed by
+  him while asleep. The little poem, "Which?" has all the curious
+  alliterativeness and frequent rhyme that is so likely to be noted in
+  expressions that come during sleep, or just as we awake. The other
+  is more like a somnambulistic effort. What we might suggest here is
+  that the habit of poetizing during sleep would surely be dangerous
+  to any one less eminently sane than their author. We give them as
+  curious examples that will interest patients who complain that their
+  dreams are too vivid.
+
+      APRIL FIRST
+
+    Come, let us be the willing fools
+      Of April's earliest day.
+    And dream we own all pleasant things
+      The years have reft away.
+
+    'Tis but to take the poet's wand,
+      A touch or here or there,
+    And I have lost that ancient stoop,
+      And you are young and fair.
+
+    Ah, no! The years that gave and took
+      Have left with you and me
+    The wisdom of the widening stream;
+      Trust we the larger sea.
+
+    WHICH?
+
+    Birth-day or Earth-day,
+    Which the true mirth-day?
+    Earth-day or birth-day,
+    Which the well-worth day?
+
+  For further details on this subject, see the chapter on Dreams.]
+
+
+Art in Dreams.--Many a painter testifies that as he slept interesting
+details have been added to his scheme for a picture. Mr. Huntington,
+who was for so long president of the National Academy, once told me
+that some of the arrangements of his famous picture, "Mercy's Dream"
+in the Corcoran Art Gallery at Washington, had come to him during
+sleep. Giovanni Dupré, the French sculptor, confessed that the ideas
+for his beautiful _pieta_ had practically all come to him in a dream.
+He had been thinking for a long time how he should arrange it, without
+allowing any of the ideas of sculptors whose treatment of the subject
+was well known to influence him too much, and had almost felt that it
+would be impossible to make anything individual. While deeply occupied
+with it one day he fell asleep, and when he awoke the whole scheme was
+clear.
+
+
+Mathematical Dreams.--Such phenomena of unconscious cerebration are
+not uncommon in the exact sciences. Some of the best examples of these
+{137} curious phenomena that we have are to be found in the history of
+them. We all know the stories of mathematicians who, occupied deeply
+with a problem which they have been unable to solve, have gone to bed
+still thinking about it, have slept deeply and, as they thought,
+dreamlessly, and yet they have waked in the morning to find by the
+bedside the problem all worked out in their own penciling--all
+accomplished during a somnambulistic state. Missing factors have been
+found in dreams; mistakes in the working out of problems have been
+clearly pointed out in dreams, so that, on awaking, the calculator
+could at once correct his calculations, and even serious errors have
+been thus corrected.
+
+
+Agassiz's Experience.--Some examples of these experiences in other
+sciences are striking. One that is likely to be impressive because it
+occurred in the experience of Professor Louis Agassiz, seems worth
+reporting.   [Footnote 18]
+
+  [Footnote 18: "Louis Agassiz, His Life and Correspondence,"
+  edited by Elizabeth Cary Agassiz, Houghton, Mifflin and Co., 1885.]
+
+  It is interesting both as psychological fact and as showing how,
+  sleeping and waking, his work was ever present with him. He had been
+  for two weeks striving to decipher the somewhat obscure impression
+  of a fossil fish on the stone slab in which it was preserved. Weary
+  and perplexed he put his work aside at last, and tried to dismiss it
+  from his mind. Shortly after, he waked one night persuaded that
+  while asleep he had seen his fish with all the missing features
+  perfectly restored. But when he tried to hold and make fast the
+  image it escaped him. Nevertheless he went early to the Jardin des
+  Plantes, thinking that on looking anew at the impression he should
+  see something that would put him on the track of his vision. In
+  vain--the blurred record was as blank as ever. The next night he saw
+  the fish again, but with no more satisfactory result. When he woke
+  it disappeared from his memory as before. Hoping that the same
+  experience might be repeated, on the third night he placed a pencil
+  and paper beside his bed before going to sleep. Accordingly toward
+  morning the fish reappeared in his dream, confusedly at first, but
+  at last with such distinctness that he had no longer any doubt as to
+  its zoological characters. Still half dreaming, in perfect darkness,
+  he traced these characters on the sheet of paper at the bedside. In
+  the morning he was surprised to see in his nocturnal sketch features
+  which he thought it impossible the fossil itself should reveal. He
+  hastened to the Jardin des Plantes, and, with his drawing as a
+  guide, succeeded in chiseling away the surface of the stone under
+  which the portions of the fish proved to be hidden. When wholly
+  exposed, it corresponded with his drawing, and his dream, and he
+  succeeded in classifying it with ease. He often spoke of this as a
+  good illustration of the well-known fact that when the body is at
+  rest the tired brain will do the work it refused before.
+
+
+Hilprecht's Sleep Vision.--Quite as surprising a dream was that of
+Prof. Hilprecht, of the University of Pennsylvania. He had been trying
+for some time to decipher certain characters on ancient cylinders from
+the Orient. In spite of much hard mental labor he had been utterly
+unable to reach definite conclusions. In the midst of work on the
+subject he dreamt one night that a priest of the olden time appeared
+to him and read off the inscription that he had in vain been trying to
+decipher. Immediately after waking he told his wife of his dream and
+wrote down the interpretation that had thus been given. It was quite
+different from anything that he himself had obtained any hint of in
+his previous studies. When he got back to the inscription he found
+that this interpretation would satisfy the conditions better than any
+other, and there seemed no doubt that it represented the missing
+solution.
+
+{138}
+
+Somnambulism.--These curiously vivid dreams are occasionally
+associated with somnambulistic phenomena. Sometimes very definite
+purposes, requiring careful adaptation of means to ends, are
+accomplished in the somnambulistic state, and yet the actions are
+completely forgotten. I have recently been consulted about a case in
+which a young woman, on a visit to a family, had been shown some
+pretty though not expensive jewels. Evidently the guest envied their
+possession, for she got up during sleep and took the jewels and hid
+them. There seems no reason to doubt her statement that she remembered
+nothing at all about the incident. The taking was not attributed to
+her. There had been previous experiences of the same kind with things
+belonging to this young woman's sister. Somnambulism represents a
+degree of unconscious cerebration that may have serious results.
+Combinations of intellectual work with somnambulism are not
+infrequent, though many of the stories that are told are exaggerated.
+Some of them are authenticated. Ribot has a typical example of
+intellectual accomplishment, in a somnambulistic condition, that shows
+how far this may go:
+
+  A clear case of somnambulism was that of a clergyman, whom his wife
+  saw rise from bed in his sleep, go to a writing table, and write
+  rapidly for some minutes. This done he returned to bed, and slept on
+  until morning. On awaking, he told her that in a dream he had worked
+  out an argument for a sermon, of which he now retained no
+  recollection whatever. She led him to the writing table, and showed
+  him the written sheet upon which he found his argument worked out in
+  the most satisfactory manner.
+
+
+PATHOLOGICAL SIGNIFICANCE
+
+Unconscious cerebration is not, then, a trivial matter, and not an
+unusual experience. It probably occurs in every individual to a much
+greater extent than he thinks, unless he is engaged in analyzing his
+mental processes and their ways rather carefully. This constitutes one
+of the dangers of the intellectual life, which must also be guarded
+against in business life or in any absorbing occupation. When the mind
+has become intensely occupied with a subject, it is not easy to
+relinquish it. Even when we turn to something else, mental activity in
+the old groove continues to some extent, and so will prevent the rest
+that is necessary for the repair of tissue. Under these conditions the
+_re-creation_ that is so important does not take place quite as well
+as it should, and even sleep does not relieve us from the burden of
+mental work. Mental exhaustion will result as a consequence of
+constant occupation, and so mental relaxation must be secured.
+Deliberate means and methods must be employed in order that we may not
+deceive ourselves into thinking we are securing mental recreation,
+though all the time certain exhausting mental processes continue to be
+active.
+
+
+Dual Mental Occupation.--Many are inclined to think that reading,
+especially the reading of newspapers and magazines, which has become
+so popular in our time, furnishes an occupation of mind that enables
+one, for a time at least, to get away from cares and worries. This is
+probably true when the news is of special interest, or there is some
+form of excitement, or at the beginning of such reading before one
+grows accustomed to the usual {139} formula of the magazine stories;
+but as years go on and cares increase, such reading does not afford an
+occupation of mind that enables one to throw them off. It helps to
+pass the time, but the cares and worries keep insistently presenting
+themselves, and the effort to inhibit them, and at the same time pay
+some attention to what we are reading, makes a double task. Such
+reading, then, far from being restful, rather adds to the burden of
+care and to the labor of the mind, for besides the conscious
+cerebration, there is the undercurrent of subconscious cerebration
+disturbing the rest of cells that should be free from labor. The
+constant renewal of effort to keep one train of thought from
+interfering with another is itself a waste of nervous energy. This
+whole matter of reading is coming to occupy a new place in the minds
+of educators, especially of those who are trying to realize the
+scientific significance of various phases of education. In his address
+as the President of the British Association for the Advancement of
+Science, at the Winnipeg meeting in 1909, Prof. J. J. Thompson, the
+British physicist, sums up the value of reading as an intellectual
+exercise in a way that would not be gratifying to those who, in recent
+years, have apparently accepted the doctrine that in much reading
+there is much information and, therefore, much education. He says:
+
+  It is possible to read books to pass examinations without the higher
+  qualities of the mind being called into play. Indeed, I doubt if
+  there is any process in which the mind is more quiescent than in
+  reading without interest. I might appeal to the widespread habit of
+  reading in bed as a prevention of insomnia as a proof of this.
+
+
+Social Duties.--So-called social duties are, in this respect, very
+like reading. When we meet new people who are interesting, we get
+diversion of mind in their company. When the people with whom we are,
+however, already familiar, and perhaps most of them a little tiresome,
+then what is presumed to be a social diversion becomes merely a bore,
+all the problems of the day obtrude themselves, of real rest there is
+none, and re-creation can scarcely be possible. Nearly the same thing
+is true of the present-day theater, after we have become used to its
+offerings. A serious play, well constructed and with life's problems
+touched deeply, may grip us and take us out of ourselves, constituting
+a complete and magnificent diversion. For a limited number of people
+music accomplishes this purpose. Unfortunately, the number is very
+limited, and for those for whom music is the greatest diversion, it
+sometimes constitutes in itself a poignant source of mental
+exhaustion. Music may be a very trying thing, especially for women,
+and for those who have souls extremely sensitive to its manifold
+effects.
+
+Upon these considerations, the importance of unconscious cerebration
+is brought home to the physician. It is impossible for a great many
+people to keep their minds inactive, and this is particularly true of
+two classes of people: those who have superabundant mental energy and
+those who lack self-control. To both of these classes of men and
+women, the physician must point out the dangers of unconscious
+cerebration--the occupation of mind with some subject, even at times
+while they imagine they are occupied with something else, or even
+during sleep. Such continuous occupation with a single subject is
+dangerous. Physicians must emphasize that many supposed {140} mental
+occupations are really so superficial that they allow other more
+exhausting processes to continue below them in the sphere of
+consciousness. As a consequence, the mind, instead of being relaxed,
+is really more tense than before, because occupied with two sets of
+thoughts. Very often it would be better for such people to continue
+with the more serious problem until its solution came, or until they
+realized that they must divert themselves.
+
+
+MENTAL RELAXATION
+
+What is important for mental relaxation, apparently, is not that a man
+shall try to set his mind at absolute rest, for that seems to be
+impossible, if a man really has a mind; nor that he shall occupy it
+with trivial things (because his interest will not be caught by them
+and will revert to the last serious thing that he was doing), but that
+he shall have an outlet for mental activity in entirely another
+direction from that to which he usually devotes himself. In other
+words, it is important that a man shall have a hobby, and that he
+shall ride that hobby whenever his ordinary business, whatever that
+may be, will permit him, and the more interesting the hobby, the
+better.
+
+
+REMEDIAL MEASURES
+
+The most important general remedy for over-prolonged mental occupation
+with a single subject, is some outdoor sport or form of exercise that
+requires all the attention. Horseback exercise is particularly
+valuable; boating, especially where the man has charge of the boat
+himself and where he has to have his wits about him, and the various
+sports. It is particularly important that men should not be alone
+during the taking of their exercise and diversion of mind. Above all,
+human interests take a man outside of himself and keep him from
+disturbing his mental equipoise by too much devotion to a single
+subject.
+
+
+
+CHAPTER VII
+
+DISTANT MENTAL INFLUENCE
+
+There is a very general impression that it is possible, at least under
+certain circumstances, for one human mind to influence another at a
+distance without any of the ordinary known means of communication.
+Many people have had the experience of thinking about a friend whom
+they have not seen for a long while, and shortly after meeting him.
+Sometimes it is found that the friend was making up his mind to bring
+about the meeting just about the time that the thought of him came.
+Many have had the experience of writing a letter and having it cross
+in the mails with another from their correspondent, evidently written
+within a few hours, though there had perhaps been no communication for
+weeks or months before. There are people who insist that they can, by
+concentrating the mind and fixing their eyes on the head of a {141}
+person some distance in front of them in a theater, or a railway car,
+cause the person to turn around. There are others who say that by
+thinking strongly of some person in a distant part of a large room,
+that person can be made to think of them. In general, there are many
+persons who are quite sure that there is evidence enough to indicate
+the possibility of distant mental influence, or, as it has come to be
+called learnedly, telepathy.
+
+Telepathy, from the two Greek words, _tele_, at a distance, and
+_pathos_, feeling, has been much discussed in recent years. Many
+people who use the word glibly are inclined to think they know much
+about it. A long word, however, is not an explanation, and, just here,
+George Eliot's expression "we map out our ignorance in long Greek
+names" is worth recalling. There are a number of phenomena that seem
+to require some such theory as that of telepathy, but the phenomena
+are still under discussion and their significance is by no means
+clear. As we understand it, telepathy may mean either thought
+transference or mind reading, that is, either the active process by
+which we communicate our thought to someone at a distance, or the
+passive process by which we receive communications from others. These
+thoughts include the idea of mental influence at a distance; that is,
+we can by willing influence the wills, or at least the motives to
+action, of people at a distance and they may, in turn, influence ours.
+The further thought has come, that since the mind largely influences
+the body in matters of health, so mental influence from a distance by
+affecting mind, may either improve or injure health.
+
+Some sensitive people are disturbed by the thought that they may be
+influenced from a distance by others, or at least that suggestions
+that come to them, may be due to telepathic influence. Investigation
+would probably show that there are at least as many persons disturbed
+by real or supposed telepathic influences as there are of those who
+have hallucinations. Sometimes it is said that such persons are not
+quite sane, but the more experience a physician has with them, the
+more he dismisses the thought of insanity and proceeds to use contrary
+suggestion and frank discussion, in order to counteract the mental
+influences. Insane persons think they are being influenced from a
+distance just as they hear voices and see visions, but such
+hallucinations may occur to the sane, as apparent telepathic
+experiences may also.
+
+
+Witchcraft.--It used to be a common belief that people could be
+influenced, even at a distance, by the mere evil wishes or intentions
+of others. After all, the old beliefs in witchcraft that were so
+common in Europe and in America until well into the eighteenth century
+represent the conviction of mankind that at least certain people
+might, from a distance, seriously influence them for evil. Always the
+fear of malign influence was uppermost in people's minds and literally
+hundreds of thousands of witches were prosecuted, and many thousands
+of them put to death, because of this belief in the possibility of
+their working evil to others at a distance, merely by willing it.
+Occasionally some such material auxiliary to malign purpose as an
+image in wax of the one to whom the evil was to be done was used. Into
+this the ill wisher stuck pins according to the part that he or she
+would want to be affected in the enemy, but as a rule the will, and
+nothing more, was used.
+
+
+Absent Treatment.--In our own time a system of healing, that has
+attracted many followers, has taken up the idea of beneficent mental
+influence at a distance. "Absent treatment" has now become a familiar
+expression. {142} That those who believe in such favorable influence
+at a distance should also believe in unfavorable influence seems
+inevitable. As a matter of fact, we know that the founder of this
+special sect always insisted on the power for evil over herself and
+her followers of those who want to exert the injurious influence of
+animal magnetism--malicious animal magnetism as it is called. A very
+definite attempt was made to bring a case of this kind before the
+courts, the subject matter of which exactly resembled some of the old
+witchcraft trials in New England! And in spite of the insistence and
+emphatic assertion that no such thing is intended, from the principles
+that are accepted the necessary logical conclusion is a return to the
+belief in witchcraft.
+
+
+Malignant Magnetism.--As a number of persons are likely to fear such
+evil influence of others upon them, the question of the possibility of
+it must come up for discussion in order that its status may be clear
+in the physician's mind, for by just as much as he can make certain to
+the patient that modern psychology refuses to accept distant
+influence, will he be able to reassure his patient. Of course, the
+patients who come with such complaints have usually some element of
+mental trouble. The alienist sees any number of people who are sure
+that enemies at a distance are working spells upon them, some by
+electrical, some by magnetic means, and some by telepathic absent
+treatment, or absent ill-wishing. Such notions are the delusions of
+the disequilibrated and these persons often cannot be reasoned with.
+Yet very often a distinct delusion may be reasoned out of even a
+subrational person, if it is taken seriously, and some striking
+expression of its irrationality and of its total disagreement with
+scientific views can be shown to the patient.
+
+
+Action Without a Medium.--The medieval scholastic philosophers quoted
+as an absolutely accepted principle the Latin axiom, _"actio in
+distans repugnat."_ Literally translated this means action at a
+distance is repugnant to reason. Expressed less technically, the
+principle declares that any action of one body on another, where there
+is no medium connecting them, no link that in some way places them in
+contact with one another, is absurd. The expression _in distans_ means
+that the two bodies are separated from one another and stand in two
+places having no connection of any kind. This principle would
+ordinarily seem to preclude the possibility of one person acting on
+another, unless there is some mode of communication.
+
+
+Crookes' Theory.--Sir William Crookes, at a meeting of the British
+Association for the Advancement of Science about ten years ago, in
+discussing telepathy, directed attention to the fact that there exists
+by scientific hypothesis, generally accepted, a definite medium of
+communication by which minds at a distance might influence one
+another. The medium is the ether which, according to physical
+theories, besides carrying light, also carries heat and electrical
+waves, and in recent years is recognized as transmitting the impulses
+of wireless telegraphy. It is possible that when the cells of certain
+human minds are stimulated to a particular phase of vibration, they
+may, even at long distances, affect the cells of other individuals
+that resemble them, or are attuned to them, that is, have the same
+moment of vibration. This is the principle which underlies wireless
+telegraphy. Whether the vibrations of living nerve cells can be made
+thus to radiate out over the ether and arouse in any way other cells,
+especially to the extent of communicating ideas, is a matter still
+open for investigation. The possibility of this occurring {143} cannot
+be denied. We are, however, still in the presence of a condition and
+not a theory. The question is whether minds are thus influenced at a
+distance--whether we have data enough to establish the occurrence of
+telepathy or mental communications of any kind at a distance.
+
+
+No Practical Thought Transfer.--At the beginning, it is of the
+greatest importance to recall that, while many people think there must
+be something in telepathy and presume that the investigations of
+recent years have shown not only the possibility of the communication
+of ideas from mind to mind and of the mental influence of one person
+over another, even at long distances, but also its actual occurrence,
+yet all our ordinary life is founded on the absolute negation of any
+such phenomenon. For instance, our courts of law are conducted in
+direct contradiction of the possibility of anything like telepathy.
+Juries are summoned of twelve good men and true who, as far as
+possible, know nothing about the prisoner and as little as may be
+about the case. They are supposed to get all their information in the
+court room. We do not believe that any of them by any wonderful
+process might be able to know what was going on in the prisoner's mind
+in spite of his plea. Nor do we think for a moment that they can know
+what is going on, apart from what he communicates in evidence, in the
+mind of any witness. Neither is there the slightest presumption that
+the judge or any of our lawyers can know anything about what is in the
+minds of any of the persons present, except as they reveal it by
+outward signs.
+
+A lawyer who could employ telepathy with success would be simply
+invaluable. Before a month had passed, he would have all the business
+of the criminal courts in his hands.
+
+
+Mental Retention.--In answer to this it may be said that these
+represent conditions in which determined effort is made to keep all
+possible information that may be in the minds of all concerned from
+passing to others. Everyone concedes the power of such absolute self
+retention of our thoughts, when we deliberately wish to keep them from
+being known to others. When people wish to communicate their thoughts
+to others, then it may be different. In that case the sending and
+receiving minds are both active and the conditions for interaction, if
+it were at all possible, would be favorable. Just this condition
+obtains in the court room every day. An innocent prisoner wants with
+all his heart and soul to communicate the idea of his innocence to the
+judge and jury. Of course, he does not succeed by telepathic means in
+transferring to them any inkling of the truth. On the contrary, his
+very nervousness and anxiety to set himself right before them will
+sometimes actually cause prejudice.
+
+The rule that has thus been exemplified in our courts of law holds for
+all business transactions. The ordinary customs of business presume
+that the buyer does not know what the seller paid for the particular
+article that is being exchanged, and it is on the strength of this
+that profit becomes possible. A few telepathic merchants or customers
+would work serious havoc in business life.
+
+What thus holds for important affairs in life is just as strikingly
+exemplified in the trivial round of social existence and in our
+intercourse with friends. Suppose one woman knew what another woman
+thought of her!
+
+That charming, old-fashioned institution "courting" would go entirely
+by {144} the board, if there were any such thing as real telepathy. In
+general, social life in all its features would become very, very
+different to what it is.
+
+
+How Much Slight External Expression Conveys.--Mrs. Coventry Patmore,
+the English poet's wife, once told a little story of some people who
+lived in a distant island where the inhabitants possessed tails. These
+tails were, as they are on the animals, organs of expression, but of
+involuntary and quite unconscious expression. It was utterly
+impossible for the people there to say nice things to one another when
+they had quite other things in mind, because if they did not like the
+person their tails hung down behind; if they did like them they wagged
+rather vigorously, no matter what their owner might be saying. This
+simple revelation of feelings, so much less than even the slightest
+degree of telepathy would occasion, was quite enough to work a
+revolution in the social affairs of this romantic island. It made the
+people truthful and candid in their relations with one another.
+
+
+Negation of Telepathy.--There is, perhaps, some evidence of the
+occurring of telepathy in special cases, but all of our present-day
+life is organized on a firm basis of complete negation of the
+existence or occurrence of telepathy to even the slightest degree.
+Every-day experiences teach us that husbands and wives, even those who
+have the greatest love and confidence toward each other, do not really
+know their life partners, for it frequently happens that something
+turns up which reveals an unsuspected side of character even after
+many years of intimate union.
+
+We human beings are "infinitely repellent particles," to use the
+phrase, of Matthew Arnold. We never get close enough to one another to
+have a real glimpse into the depths of other minds. The information
+that is supposed to pass by telepathy from one person to another is so
+often just the kind that we would most sedulously conceal. There is
+extreme unlikelihood then that any such passage of information takes
+place. The cases cited, as proof of this transference of thought, are
+much more likely to be coincidences than any evidence of true
+telepathy.
+
+
+Supposed Examples of Telepathy.--In the first place, though there are
+opportunities for the exhibition of the phenomena of telepathy every
+day and every hour of existence, the cases in which it is supposed to
+occur are extremely rare and are distant from one another, both in
+time and place. Even the people who claim to have had the phenomena of
+telepathy happen to them once or twice, do not pretend that it is at
+all a common occurrence with them, and as for the supposed exhibitions
+of telepathy upon the stage, these have been exposed over and over
+again as the simplest fakes.
+
+As to the cases of telepathy that have been reported, with careful
+collection of evidence, to the psychic research societies, and which
+are few in number, though some of them are very difficult to explain,
+there is no reason why they should not be striking coincidences rather
+than startling examples of telepathy. An example will illustrate what
+I mean:
+
+A few years ago what seemed to be a complete case of telepathy was
+reported in connection with a railroad accident. A Western man about
+to take an express train for the East was the object of a good deal of
+solicitude. There had previously been a series of accidents to this
+very fast train which he was to take. This fact had been discussed in
+the family, and did not tend to allay the fears of those who remained
+at home. During the night the {145} train actually left the track, and
+the car in which the subject of the story was asleep rolled down the
+bank.
+
+At the moment his train went down the bank the thought of his wife and
+daughter came very vividly to his mind. For a moment the awful
+position in which they would be placed if anything serious happened to
+him occupied his mind to the exclusion of all other thoughts. As soon
+as he could, he telegraphed home that he was unhurt, with the
+understanding that the telegram should not be delivered before the
+following morning.
+
+During the night mother and daughter sleeping in adjoining rooms were
+wakened at the same moment, and very seriously disturbed, by
+something, they knew not quite what. They rose at once to go to each
+other and met at the door. They felt vaguely that father was in some
+way connected with their awakening and disturbance of mind. After they
+received his telegram they were sure that what disturbed them during
+the night was the telepathic communication of father's danger. Each
+had, however, deliberately kept from speaking of her impression. When
+they found that he had passed through the danger unhurt, they were
+sure that it was a call from him that each had heard.
+
+This bears most of the ear-marks of a genuine case of telepathy. Here
+are minds whose cells by custom and inheritance are finely attuned to
+those of a distant mind that is suddenly very much disturbed. If the
+perturbations of that first mind were carried through the ether by a
+sort of wireless telegraphy, it would apparently not be very
+surprising. So carried, they woke the receptive cells of similar minds
+at a long distance, and mother and daughter felt the thrill at the
+same instant. Vague though it was, there was a telepathic message.
+
+But there were other passengers in this train who had near and dear
+relatives, yet none of them received communications. There have been
+literally hundreds of thousands of other accidents in the past fifty
+years of railroading in which passengers who have been put in very
+serious danger, have thought intensely of their loved ones, and yet,
+there has been at most only a dozen or so examples of vague telepathy
+of this class. Similar cases to this are extremely rare, though
+accidents in America are very frequent. At most, then, we are in the
+presence of a very exceptional case. Such cases would mean nothing as
+evidence for a scientific law, since they occur so rarely as to aptly
+exemplify the old adage that the exception proves the rule. The rule
+evidently is that there is no communication at a distance, hence the
+surprise when there seems to be some reason for thinking that a
+communication has actually taken place. Instead of proving that
+telepathy occurs, such cases make it clear, to the limit of
+demonstration, that telepathy does not occur unless some extremely
+special conditions intervene to make it possible.
+
+How much more easy it is to explain such a case on the score of
+coincidence! Of course, mother and daughter, with father absent, and
+absent in the midst of what they thought was danger, would go to bed
+anxiously thinking of him. They would sleep lightly because of the
+worry. Any slight unusual noise would wake them, and at once the
+thought of father and his danger would occur to them. If the noise was
+sudden, and not repeated, and therefore inexplicable to one awakened
+out of sleep, they would probably be so disturbed that it is easy to
+understand that they would arise at once and seek each other's
+company. Their meeting, therefore, in the doorway between their rooms
+would be readily explicable. Neither would say much {146} about the
+subject uppermost in her thoughts in order to shield the other. The
+telegram in the morning would throw a glow of retrospective light on
+the events and seem to give an entirely new significance to their
+thoughts. The whole affair, though only a coincidence, would seem to
+be a demonstration of telepathy.
+
+Even more marvelous instances of coincidence, in which there was no
+question of anything more than coincidence, have been related. The
+English Psychical Research Society reported the case of a young man
+sent to find some trace of his brother who had disappeared
+mysteriously from a steamer sailing from Plymouth to Lisbon. On board
+the steamer late at night he stood by the rail thinking of his lost
+brother and wondering what could possibly have become of him. Suddenly
+as he looked down into the ocean a body came bobbing up out of the
+waves almost directly under his gaze. He reported it to the officers
+of the vessel and it was grappled for and lifted aboard. It proved to
+be the body of his brother. Is this an example of telepathy, that is,
+of the mental influence of the perturbed spirit of the live brother
+upon the dead brother's body floating below the surface? No one would
+stretch supposed telepathy to that extent. The steamer disturbed the
+body which had been floating below the surface, as bodies do,
+gradually developing within themselves the gases of decomposition.
+After a time any slight disturbance, as, for instance, the booming of
+a cannon or the passage of even a small boat, will bring a body up. It
+so happened that the brother was on the spot, and actually thinking of
+the body, but that was the merest coincidence. There was no connection
+of cause and effect.
+
+Most of the cases of so-called telepathy can be explained in this way.
+As we have said, no source of error is so copious as that of
+concluding that because one thing happens after another therefore the
+second is caused by the first. People who are so inclined will still
+continue to accept such a notion of connection of cause and effect,
+however, and we shall have many cases of supposed telepathy exploited
+for us on no better grounds than this.
+
+
+Twins and Telepathy.--There is a definite popular impression that
+twins are gifted with the power of telepathic communication much more
+than others. Accepting Sir Wm. Crookes' theory, the possibility of
+mental reciprocal influence, even at a distance, is greater for them,
+since their brain cells must be considered as having corresponding
+moments of vibration. Twins of the same sex, especially those who
+resemble one another closely, are usually born from a single ovum. The
+intimate relations of two such beings to each other can be readily
+understood, so that we have many stories of mental communication at
+long distances and curious warnings, forebodings and communications of
+danger, and especially of sickness and death.
+
+Especially does one find stories of wraith-like appearances of one to
+the other of such persons at the moment of death. A series of these
+stories, apparently well authenticated, is published by the Psychic
+Research Society. There are also a number of tales, seemingly well
+attested, of cloud-like shapes of other persons at the moment of
+death. As a consequence, there has been developed an idea that there
+is some evidence of the distinct possibility of such appearances when
+the soul leaves the body. It, however, seems very doubtful whether
+these are anything more than a very striking coincidence. Twins are
+likely to be almost constantly in one another's minds, so there is
+abundant {147} room for coincidences. But any number of twins have
+died at a distance from each other without there being any such
+warning. Occasionally such startling appearances occur in connection
+with people who are so slightly related, or whose existence bears such
+slight importance to each other, that it is hard to understand why the
+appearance may have come. Whether they are anything more than the
+figment of an excited imagination remains to be seen, for, while we
+have a little positive evidence, this only emphasizes the possibility
+of coincidental day-dreaming in nervous persons.
+
+
+Negative Tests.--We hear much of the possibility of reading minds at a
+distance, or of getting definite information from sealed documents and
+the like, but it must not be forgotten that whenever definite
+conditions have been set down, so that all the actions of the supposed
+clairvoyant could be controlled, then telepathy has always failed to
+be manifested. Sir James Simpson, for instance, publicly offered to
+give a five-hundred-pound note, which he had placed in a safe deposit
+vault, to anyone who could read its number which he had carefully
+impressed on his own mind. Needless to say, no one got it. In the days
+when Bishop, the exhibiting mind reader, was creating such a furore in
+New York and London by supposedly reading people's minds, Labouchère,
+the editor of London _Truth_, offered a similar opportunity to Bishop,
+but advantage of it was not taken. Bishop's power was entirely due to
+muscle reading. People make involuntary movements of muscles that are
+very slight, but sufficient for a trained observer to notice,
+especially if his hand is on the individual experiencing the emotions,
+and the consequent muscle reflexes. [Footnote 19] About the middle of
+the last century, the French Academy made a labored investigation of
+telepathy and found that whatever there seemed to be in it, when
+control was not properly kept, it at once was demonstrated to be
+impossible when conditions were planned so as to prevent deception.
+
+  [Footnote 19: The story of Hans, the calculating horse, shows that
+  even animals usually thought rather dull-witted may catch muscle
+  movements so slight as to be scarcely visible to any but one looking
+  particularly for them.]
+
+If patients are worried over disturbing influences from others or the
+reading of their thoughts or telepathic suggestions, a calm review
+with them of the practical side of this subject, as we have come to
+know it in the modern time from actual investigation, will do more
+than anything else to relieve their apprehensions. Most of these
+patients are unfortunately insane, but the reasoning will help even
+some of these. There are some quite rational believers in such
+manifestations who will be greatly benefitted.
+
+
+
+CHAPTER VIII
+
+SECONDARY PERSONALITY
+
+So much attention has recently been directed to the subject of
+secondary personality by the startling phenomena described in numerous
+books and articles on the subject, that a certain class of "nervous"
+patients have permitted themselves to be influenced by the
+auto-suggestion, flattering the vanity, that they, too, have a
+secondary personality. They even do not hesitate to hint that this
+condition is responsible for many of the failures on {148} their part
+to do what they ought to do, or at least what they think they would
+like to do; but self-control and self-discipline require such constant
+attention and effort that they fail. Even when these patients have not
+quite reached the persuasion of a complete secondary personality, they
+at least think that the subconscious (or their subliminal self) plays
+a large role in their conduct. As a consequence, they assert, it is
+more or less beyond their power to control themselves, and their
+responsibility for certain acts is surely somewhat impaired. This is a
+rather satisfying doctrine for those who do not feel quite equal to
+the effort of conquering vicious or unfortunate tendencies. Those who
+like to have some excuse for self-indulgence take refuge in this
+supposedly scientific explanation to absolve them from blame, and from
+the necessity of self-control. The drug habitué, the inebriate, the
+victim of other habits, sometimes hug this flattering invention to
+their souls, especially when they are of the class who delight in the
+study of the abnormal. Reform becomes well-nigh impossible as long as
+such an auto-suggestion of inherent weakness and lack of will-power is
+at work.
+
+
+The Other Self.--From the beginning of written history, man has always
+been inclined to find some scapegoat for his failings. The story of
+Adam blaming the first fault on the woman and the woman blaming it on
+the serpent, is a lively symbol of what their descendants have been
+doing ever since. The less personal the blame is, the better, and the
+more it can be foisted over on some inevitable condition of human
+nature, the more generally satisfying it is. A secondary personality
+can scarcely resent being blamed for its acts by the primary
+personality to which it is attached, and so the field of
+auto-suggestion as to the blameless inevitability of certain acts is
+likely to widen if it is given a quasi-scientific basis. Long ago St.
+Paul spoke of the law in his members opposed to the higher authority,
+and declared that the things he would do he did not, while what he
+would not do he sometimes did. There is no doubt that there are two
+natures in the curious personality of man. Everyone at times has the
+uncanny feeling that there is something within almost apart from
+himself, leading him in ways that he does not quite understand.
+Usually the leading is away from what is considered best in us. But
+those who have dwelt much on the better side of man and have tried to
+climb above mere selfish aims, have realized that there is also a
+power within them leading to higher paths. Indeed, some of the
+greatest thoughts that men think, and the resolves that lift them up
+to heroic heights, are apparently so far beyond ordinary human powers,
+that the hero and the poet and even the more ordinary literary man, is
+quite ready to proclaim inspiration as the source of his best
+ideas--as if they were breathed into him from without and above.
+
+
+Personal Responsibility.--For ordinary normal individuals, this
+question of secondary personality has scant interest. Normal persons
+go about their work realizing that what they want to do, they may do,
+and what they do not want to do they can keep from doing, unless some
+contrary _physical_ force intervenes. There are many metaphysical
+arguments for free will, but none of them is so convincing as the
+observation that every sane man, with regard to his own actions, has
+the power to choose between two things that attract him. He may be
+much drawn to one thing, yet choose another. He may allow himself to
+be ruled by baser motives; he may sternly follow the {149} dictates of
+reason, or he may do neither and hold himself inactive. In any case,
+he realizes his power to choose. While this power may be impaired by
+many external conditions, his consciousness of its actuality makes him
+appreciate his responsibility. He realizes that punishment for wrong
+done is not only a part of the law, but it is also a proper
+vindication of that consciousness of free will which all men have, and
+which does not deceive them. The question has been obscured by much
+talk, but the reality is there, and the common-sense of mankind has
+proclaimed its truth. All our laws are founded on it. Without it
+punishment as meted out is an awful injustice and crime is a misnomer.
+
+
+Hysterical Phenomena.--Most of the cases of secondary personality that
+have been discussed at greatest length have been in persons who were
+as desirous of attracting attention, and as pleased over being the
+subject of special study as were the hysterical patients who used to
+delight in investigation two generations ago. That most of the
+phenomena of so-called dual personalities are mainly hysterical seems
+now to be clear. In a few cases, where the patient has found that the
+existence of a double personality was of special interest, a definite
+tendency to the formation of further personalities has been noted.
+Some triple personalities have been discussed and, in a few cases, a
+group of personalities, even up to five or more, began to assert
+themselves. This _reductio ad absurdum_, of the hypothesis of
+supernumerary personality has revealed the real hysteric character of
+the phenomena.
+
+The whole story of secondary personality in recent years vividly
+recalls commonplaces in the older medical literature that gathered
+around the study of hysteria, and that afford a striking confirmation
+of the conclusion as to the relation of the conditions ascribed to
+hysteria. Physicians of a generation or two ago who found their
+hysterical patients interesting, because of certain marvelous symptoms
+which they presented, were usually astonished to learn that their
+patients could, under suggestion, develop still further and more
+surprising symptoms. Each new visit, especially when other physicians
+were brought to see the patient, showed the existence of still further
+symptoms and revealed new depths of interesting disease. Indeed, the
+soil was found to be inexhaustible in its power to produce ever new
+and interesting crops of symptoms.
+
+When the real significance of hysteria as a mental condition in which
+patients devoted themselves to the task of furnishing new symptoms for
+the physician began to be realized, one of the most potent objections
+against this explanation was that it would have been impossible for
+the patients to have studied out their symptoms enough to furnish the
+new material for study which physicians found so interesting. The
+patients were supposed to be mentally incapable of fooling the
+physicians. When, however, a person devotes entire attention to the
+one subject of making phenomena in themselves appear interesting to
+others, some very startling results are usually produced.
+
+After having attracted the sensational attention so common with any
+novel observation and having been exaggerated out of all proportion to
+its due significance, the phenomenon is now settling down to its
+proper place--a rather obscure neurotic phenomenon of memory in
+hysteric individuals.
+
+
+_Other Neurotic Symptoms_.--Janet's studies at the Salpetriêre seem to
+show that the alterations of memory which bring about what we call
+{150} secondary personality (the forgetting of certain phases of
+existence and the maintenance for a time of a small portion of
+consciousness and memory quite apart from the rest) correspond with
+alterations in the physical basis of memory, that is, in the
+circulation to certain portions of the brain, and probably also in the
+modes of association of brain cells. They occur, particularly, in
+connection with certain phenomena of hystero-epilepsy so-called, or
+with the deeper forms of epilepsy in which there are various
+paresthesias, hyperesthesias and anesthesias as a consequence of a
+disturbance of the circulation in the central nervous system; and
+probably also of the connections made by neurons and the movements of
+neuroglia cells in making and breaking these connections. These
+alterations of memory are represented physically by such cases as
+those in which patients so lose their consciousness of sensation that
+they are unable to tell even where their feet are. As they themselves
+say, "they have lost their legs." In these cases, patients are often
+very deaf or have a limited auditory power, and their fields of vision
+are extremely narrowed. In most of these cases, recovery of the
+original personality takes place after hypnosis. This probably
+represents a relaxation of that short-circuiting, within the nervous
+system, which brought about the curious phenomenon studied as
+secondary personality.
+
+
+Dual Dispositions.--The studies of secondary personality that we have
+had seem to show us persons under the influence of some strong
+suggestion, in what is practically a hypnotic condition. There are
+many similarities between the actions and the mentality of hypnotics
+and of those in secondary-personality conditions. The individuals are,
+for the moment, unable to recall what happened in other states. They
+may be very different in disposition, gentle and tractable in one
+state, but morose and difficult to get along with in another. Such
+differences are, however, only exaggerations of the variations of
+normal personality. There are times when, under the stress of
+circumstances, even the mildest of men and women become querulous and
+difficult. It is often noted that people are much more gentle and
+careful in their relations with some people than with others. Men who
+are known in their business relations to be quiet, easy to get along
+with, are at times bears in their homes. This is a matter of the
+exercise of inhibition for certain mental qualities, and this
+inhibition is neglected for some places and persons. An American
+humorist said not long since that a young girl passing a weekend at
+the house of a friend, should remember that she is expected to be
+unselfish, thoughtful for others, and ready to help her hostess to
+make it pleasant for others, so that the party may be successful. He
+adds that, of course, as soon as she returns home she should be
+perfectly natural again.
+
+At least in a limited sense, all of us have buried in us secondary
+personalities that are due to a lack of control of ourselves, or
+occasionally to a lack of such initiative as makes possible the best
+that is in us. The secondary personality of some people, that side of
+their characters that their friends see only rarely, is the best side
+of them. Many people, under the demand of some great purpose, rise up
+to be really heroic in quality, yet in the commonplace relations of
+life they are quite ordinary. The secondary personality in either of
+these cases is not something abnormal. It is due to a tapping of
+deeper levels in personality than most people realize that they
+possess. When taken in connection with hypnotism and the power of
+suggestion over {151} susceptible individuals, these adumbrations of
+the deeper problem of secondary personality as the psychologists have
+discussed it, furnish the best data for its fuller explanation.
+Excuses for actions founded on secondary personality must either rest
+ultimately on insanity, or else on that lack of inhibition which
+constitutes the source of so many of our actions that we regret.
+
+People who are susceptible to hypnotism may remember absolutely
+nothing of what occurs to them in the hypnotic condition, though they
+will recall it without any difficulty if during hypnosis it is
+suggested to them that they should remember it. This represents the
+most prominent feature of secondary personality; the individuals who
+are affected by it do not recall in one state of personality what
+happens to them in the other. In the two states they are very
+different in character. These differences have been much emphasized
+with regard to a few cases that are especially abnormal and have not
+attracted much attention in cases where the differences are slight.
+Indeed, in a number of the cases where secondary personality asserted
+itself, the differences in the character of the individual in the two
+states were practically nil. The only difference was a lapse of memory
+for certain important events. Considerations such as these help in the
+understanding and psychotherapy of what are sometimes puzzling cases
+of apparent dualism of disposition.
+
+What we have to do with here are the suggestions of secondary
+personality which neurotic patients have been inclined to make to
+themselves as a consequence of the interest in the subject in recent
+years. The investigations of Head and of Gordon Holmes have
+undoubtedly shown, however, that there are true pathological
+conditions associated with certain definite and very marked
+manifestations of dualism of disposition consequent upon lesions in
+the optic thalamus. These cases so far as can be judged at the present
+time, at least, are quite rare and at most would account for duality
+and not for the plurality of personality that has come to be discussed
+by certain enthusiastic neurologists in recent years. The magnificent
+work done on this shows how much may yet be accomplished in the
+elucidation of nervous diseases by faithful study and investigation of
+selected cases.
+
+
+
+CHAPTER IX
+
+HYPNOTISM
+
+Hypnotism is popularly supposed to be a mysterious psychological
+process by which susceptible subjects are brought under the influence
+of a person possessing some marvelous power over others' minds and
+wills. According to this supposition, during the periods in which the
+subjects are under this influence, they either have some new source of
+energy transferred to them from the operator's strong personality, or
+else they share to some extent in the will power possessed by him. In
+the midst of the sub-consciousness which characterizes the hypnotic
+condition, then, they are in some way endowed with new strength, which
+enables them to overcome obstacles to physical or mental health, some
+of which seemed at least quite insurmountable under their normal
+condition.
+
+{152}
+
+As a matter of fact, hypnotism is much simpler than this, consisting
+merely of a state of mental absorption in which all distracting
+thoughts are for the moment warded off, and only such thoughts as are
+suggested by the hypnotist reach the consciousness of the patient. The
+essence of hypnotism is the concentration of mind on one idea or only
+a few ideas dictated by the hypnotist. This mental concentration
+produces the effect of greater strength, whether apparent or real, to
+carry out the purposes connected with those thoughts. It is usually
+considered that hypnotism involves sleep, and in some cases it does.
+This is often undesirable. True, therapeutic hypnosis leaves at least
+certain senses of the subject open to perceive such things as are
+presented by the hypnotist's suggestion though these senses may be,
+and usually are, quite closed to all other perceptions. In a great
+many cases, though there is a real hypnotic condition, a state
+resembling true sleep does not occur. There is only a more or less
+complete concentration of attention on the suggestions of the
+operator, and a complete cessation of all spontaneous thought, or of
+all suggestions that might come in ordinary ways from the subject's
+own senses.
+
+
+Effects of Hypnotism.--Most people have a very erroneous notion with
+regard to the effects of hypnotism. Some expect that the hypnotic
+sleep will work miracles. Nothing is more common in the experience of
+one who is known to employ hypnotism, even occasionally, than to have
+a patient who is addicted to some habit, alcoholic, drug, or sexual,
+ask, "Do you hypnotize?" If an affirmative answer is given, the
+patient proceeds to say that he has heard that one can be hypnotized,
+and then all the tendency to fall back into the old habit is
+immediately lost, and he has no further bother from it. This supposed
+miraculous effect of hypnotism in supplanting the necessity for using
+the human will has been cultivated very sedulously in the public mind
+by quacks and charlatans of various kinds and even exploiters of
+hypnotism who belong to the medical profession. But there is nothing
+in it. Hypnotism will not change character unless it be for the worse,
+since the habit of it sometimes leads to dependence on suggestion
+rather than spontaneous motives. Hypnotism cannot be substituted for
+weakness of will. The suggestions given in the hypnotic state are
+practically no stronger than those given in the waking state, if the
+patient would only equally concentrate his mind to receive them, and
+would be as ready in response. It is the readiness of response which
+comes in cumulative fashion, in the midst of the utter abstraction
+from other thoughts, that characterizes the hypnotic condition.
+
+This is, of course, quite a different valuation of hypnotism from the
+very strong expressions, with regard to the power of hypnotists to
+influence the human will, which have at various times been made. These
+exaggerated claims have been no stronger than those often made for
+remedies of various kinds that have been long since discredited. I
+have heard a serious though young professor of psychology declare that
+he was not sure whether he was justified in using all the power that
+he possessed by hypnotism to influence men's wills to keep them from
+indulging in liquor to excess, because after all men had a right to
+their free will, even in a matter of this kind, and it would be wrong
+to take it away from them. He added very philosophically that no human
+being had the right to play the role of Providence in directing
+others' actions even for good, unless they themselves were perfectly
+satisfied. {153} If there was any such force in hypnotism as is thus
+suggested, the reformation of the world, or still more its
+deformation, at the hands of some of the strong-minded practicers of
+hypnotism, would be a comparatively easy process. As a matter of fact,
+however, the hypnotizer has, except as regards abnormally suggestible
+people, only as much influence over the person hypnotized as the
+subject permits, and the subject retains all his personality as an
+individual with all his weaknesses. After he has been helped away from
+his weaknesses by hypnotism, he is just as likely as ever to yield to
+them again, unless, during the interval of conquest, he has succeeded
+in bracing up his will to resist them.
+
+
+FORMER METHODS OF HYPNOTIZATION
+
+All the methods of hypnotizing, then, are directed to securing this
+state of concentration of the patient's mind. The hypnotic state is
+brought about in different ways by different operators, and even the
+same operator must employ quite different methods to secure hypnotic
+influence over different subjects. In the old times, mysterious passes
+and strokings and rubbings of various kinds, and instruments that
+flashed light, or that made special sounds, were employed. Among the
+pioneers, each worker invented methods of his own. A review of these
+will bring out the fact that none of them represents essentials, and
+that they are only auxiliaries to secure concentration of the
+patient's mind.
+
+The methods of hypnotism practiced by those most noted in the history
+of the art were very different from one another, but not more
+different than are the methods in vogue to-day among individual
+hypnotizers. Indeed, the practices of the past have come down as a
+heritage to our own time. Stroking and touching, of which we have
+hints in the oldest times in Egypt and Babylonia and Greece, have
+always been prominent features. Valentine Greatrakes dreamt that he
+heard a voice in his dream telling him that his right hand should be
+dead and that stroking it with his left should cause it to recover its
+power once more. After this had happened three times in succession he
+began to apply this method to the ills of others. Greatrakes seems
+really to have come in to replace the touching by the king for the
+King's Evil at a time when there was no king in England, Pastor
+Gassner, the next worker who attracted attention by hypnotic
+procedures, used words of command after attracting the profound
+attention of his patients. Father Hell employed the touch of magnets.
+Mesmer used music to predispose the mind, but had many of the methods
+of modern hypnotists.
+
+
+Mesmer.--While Mesmer undoubtedly attracted attention to certain
+phases of hypnotism that were to prove valuable, he was by no means
+the first to do so, and what he did had such a tincture of
+charlatanism it is no wonder that he was discredited. There was a
+little truth, but there was a deal of mere pretense in his work. While
+he undoubtedly obtained results, he did so mainly because of certain
+mentally impressive methods that he employed in connection with
+whatever of hypnotism he used. Binet and Feré, who have given us some
+details of his work, describe his methods in such a way as to make it
+clear that they smacked largely of quackery:
+
+{154}
+
+  Mesmer, wearing a coat of lilac silk, walked up and down amid his
+  agitated throng, accompanied by Dezlon and his associates, whom he
+  chose for their youth and comeliness. Mesmer carried a long iron
+  wand with which he touched the bodies of the patients and especially
+  the diseased parts. Often laying aside the wand, he magnetized the
+  patients with his eyes, fixing his gaze on theirs, or applying his
+  hand to the hypochondriac region and to the abdomen. This
+  application was often applied for hours, and at other times the
+  master made use of passes. He began by placing himself "en rapport"
+  with his subject. Seated opposite to him, foot against foot, knee
+  against knee, Mesmer laid his fingers upon the hypochondriac region
+  and moved them to and fro, lightly touching the ribs. Magnetism,
+  with strong electric currents, was substituted for these
+  manipulations when more energetic results were to be produced. The
+  master, raising his fingers in a pyramidal form, passed his hands
+  all over the patient's body, beginning with the head, and going
+  downward over the shoulders to the feet. He then returned to the
+  head, both back and front, then the belly and the back, and renewed
+  the process again and again until the magnetized person was
+  saturated with the healing fluid and transported with pain or
+  pleasure, both sensations being equally salutary. Young women were
+  so much gratified by the crisis that they wished to be thrown into
+  it anew. They followed Mesmer through the halls and confessed that
+  it was impossible not to be warmly attached to the person of the
+  magnetizer.
+
+
+De Puysegur and His Successors.--De Puysegur has some definite
+instructions for hypnotizers, whom he called magnetizers. It is
+instructive even now to read these, for they emphasize the most
+important element in all hypnotism, the confidence of the operator in
+his own power, for this, communicated to the subject, produces the
+beneficial results:
+
+  You are to consider yourself as a magnet; your arms, and
+  particularly your hands, being its poles; and when you touch a
+  patient by laying one of your hands on his back, and the other in
+  direct opposition upon his stomach, you are to imagine that the
+  magnetic fluid has a tendency to circulate from one hand to the
+  other through the body of the patient. You may vary this position by
+  placing one hand on the head and the other on the stomach, still
+  with the same intention, the same desire of doing good. The
+  circulation from one hand to the other will continue, the head and
+  stomach being the parts of the body where the greatest number of
+  nerves converge; these are, therefore, the two centres to which your
+  action ought to be mostly directed. Friction is quite unnecessary;
+  it is sufficient to touch with great attention.
+
+Some of these methods continued to be employed by the successors of
+Mesmer and De Puysegur, the sense of touch being the principal
+adjuvant, though Mesmer employed also the sense of hearing. Braid
+seems to have been the first to realize that the sense of sight could
+be used effectively, or perhaps that the tiring of the muscle sense
+might well serve as a point for the concentration of attention. He
+used the flash of a light from some bright object or tired the eye
+muscles by having the patient look upward at some object brought near
+so as to require convergence of vision. His methods were imitated by
+most of the hypnotizers of the nineteenth century. Liebault and
+Bernheim, at Nancy, employed them regularly, and they were used in the
+investigations at the Salpêtrière. It was found, however, that after a
+patient had been once hypnotized, all that was needed was a word of
+command or a definite suggestion, and the hypnotic state recurred.
+Further experience showed also that the original hypnotic phenomena
+might, in most cases, be secured very simply by word-suggestion to the
+patient, though some individuals required persistent efforts in the
+application of several methods {155} to secure the concentration of
+mind on a single idea or set of ideas that is the essence of
+hypnotism.
+
+By most serious hypnotists, especially those who use hypnotism for
+therapeutic purposes, all the rubbings and manipulations are now
+either completely eliminated, or are used only under special
+circumstances. The important element of the operator's influence
+consists in obtaining the complete confidence of the subject in the
+operator's power to control his intelligence for the time being;
+getting the subject to resign himself completely, with absolute
+assurance that his trust will be for his good, and can by no means
+result in harm. Without this attitude of mind on the part of the
+subject, anything like real hypnotism is impossible. Even with this,
+only a slight degree of the hypnotic condition may be secured in
+certain people, but the majority have a distinct susceptibility to it.
+
+
+PRESENT DAY METHODS OF HYPNOTIZATION
+
+Though various methods of producing the hypnotic sleep are in use, the
+rule is now that, in the course of a hypnotizer's experience, less and
+less external auxiliaries of any kind are needed, and more and more
+dependence is placed on the bringing about of mental _rapport_ between
+the active and passive agencies in hypnotism by persuasion and
+command. If the hypnotic sleep has once been obtained, usually all
+that is necessary is a few gentle words, and then the command to
+sleep. It is at the initial attempts to hypnotize a particular person
+somewhat refractory to the condition that auxiliaries are needed. In
+these cases it is often well to tire the eyes of the patient. This is
+done by directing them to the fingers of the operator held well above
+the patient's head. After a minute or two of effort the distinct
+fatigue which occurs may induce forgetfulness of everything else and
+cause absorption in the single idea of attending only to the
+hypnotizer's suggestions. This constitutes the beginning of hypnotism.
+Occasionally the flash of a bright object, or a revolving mirror, may
+be used, but these are only adjuncts and may be dispensed with
+entirely if the operator has the patience and the time to give to the
+subject.
+
+
+Accessories.--Some operators use a mirror on which a ray of light is
+cast for the purpose of concentrating the attention and bringing about
+tiredness of the eye muscles. In so far as it has a more universal
+application, sight is certainly the best sense to act upon. Other
+senses may be appealed to, as I suggest later. Instead of a mirror, a
+polished match-box or pencil-case may be used, but as a rule the less
+artificiality enters into it and the simpler the procedure, the
+better. One of the inconveniences of using the flash of a bright
+object is that occasionally patients who are very susceptible may,
+after they have had a number of hypnotic experiences, be thrown into a
+hypnotic condition by the flash of a light in the street, or by the
+reflection of light from a mirror in their own homes. These conditions
+of facile auto-hypnotism constitute one of the serious dangers of the
+practice on susceptible subjects. Whatever good may be accomplished by
+hypnotism will probably be reached during the first half dozen
+seances. To proceed with the treatment beyond this, if it is employed
+at regular and short intervals, is almost sure to result in harm
+rather than good.
+
+{156}
+
+Sensations.--Besides sight, sounds have sometimes been used for the
+purpose of inducing hypnotism. The ticks of a watch, for instance,
+placed at a little distance and listened to very intently, have been
+known to assist in securing the hypnotic state. Sometimes the sound of
+a gong, or an imitation of a cathedral chime, have been used in the
+same way. Soft music has also been used by operators with decided
+advantage. It is necessary that the sounds should be of a kind that do
+not disturb, but only attract attention to one sensation, and then, as
+concentration on this is secured, the hypnotic condition results.
+Practically any other sensation may be used in the same way. Touch is
+often employed. Mesmer stroked his patients gently, and others have
+used the same process with advantage. Some of the French workers in
+hypnotism have claimed that there were special portions of the body
+the stroking of which was likely to produce this favorable effect.
+They have called these regions zones hypnogenes--areas that give rise
+to hypnotic conditions. Strokings of the forehead, of the cheeks, of
+the hands, are favorite locations for these auxiliary touches. In
+this, as with regard to sound, the main thing is to concentrate
+attention on some one sensation without producing disturbing thoughts.
+
+
+Stroking.--Stroking seems to affect many people and to easily induce a
+sort of hypnoidal condition. It is done very naturally to a child when
+one wants to console or encourage or admonish slightly but kindly. In
+older people it is a familiar gesture among those who think much of
+one another, and represents a very natural tendency. Even in the midst
+of physical discomfort its effect is quite soothing, and it is evident
+that something resembling hypnotism is at work. Evidently, what really
+happens is a concentration of attention on the sensation thus
+produced, which concentration prevents distracting thoughts from
+making themselves felt and permits the words of the one who does the
+stroking to produce a deeper effect on the mind than would ordinarily
+be possible. This seems to be nature's method of making suggestion
+more effective. It has been adopted, quite spontaneously, by many of
+the pioneers in hypnotism as the result of their observations upon its
+efficacy. Lloyd Tuckey calls attention to an illustration of this
+practice, which makes clear its effectiveness and at the same time
+shows how naturally it suggests itself as a mode of using mental
+influence. He says:
+
+  Among the medical men who have come to watch some of my cases was a
+  gentleman who seemed much struck at seeing the method I adopted with
+  a rather refractory subject. I held his hand and stroked his
+  forehead while at the same time suggesting the symptoms of sleep.
+  The gentleman told me afterward the reason why he was so interested.
+  It appears that he had a few months previously been in attendance on
+  a very severe and protracted case of delirium tremens. The patient
+  could get no sleep, and the doctor was afraid of death from
+  exhaustion. On the third evening he resolved to make a strong effort
+  to produce sleep, and, if necessary, to sit up all night with the
+  patient. He told the man that he would not leave him until he slept,
+  and sitting down by the bedside, he took his hand in one of his own,
+  and with the other gently stroked the forehead. At the same time he
+  talked quietly and reassuringly to him. In less than half an hour he
+  was rewarded by seeing the restlessness entirely cease and the man
+  drop off into a quiet sleep. That sleep, the doctor told me, lasted
+  fourteen hours, and the patient awoke out of it weak, but cured.
+  Manipulation about the head has in many persons a most soporific
+  effect, and several persons have told me that they always become
+  drowsy under their barber's hands.
+
+{157}
+
+Drugs.--A number of drugs and related substances have been used as
+aids to hypnosis, but in nearly all of these cases it is doubtful
+whether it is true hypnotism that results and whether the suggestions
+in these states have much therapeutic value. One of the drugs most
+frequently administered by hypnotists is _cannabis indica_, which has
+long been used in the East for a similar purpose. After this,
+chloroform is most popular. Schrenck-Notzing even ventured to employ
+alcohol as an aid in hypnosis, and claims that he has succeeded at
+times in making intoxication pass into the true hypnotic condition.
+Bernheim and many others of the French school have used chloral and
+morphine. These substances are, however, liable to great abuse.
+Whenever they have to be employed it means that the patient is but
+little susceptible to hypnotic influence. These aids are employed only
+because hypnotists do not want to confess that a very considerable
+portion of humanity is not directly susceptible to the hypnotic
+influence.
+
+Serious harm may be done by the employment of these drugs. A
+physician, who hoped that he would be able to overcome a drug
+addiction that had been the bane of his existence for a long while,
+went to a well-known hypnotist physician with the idea that perhaps
+the miracle of hypnotism would be worked in his case. He was one of
+these flighty mortals whom it is extremely difficult to have fix their
+minds upon any one idea for a definite time. As it was impossible to
+bring him into anything like a hypnotic condition by ordinary means, a
+large dose of chloral was administered. He already had an idea that
+his heart had been affected by his previous drug-taking habit, but the
+chloral was administered to him before he realized what it was. When
+he came out of the sleep it induced, he was in an agony of solicitude
+and anxiety lest his heart should have been further hurt by the
+chloral. He went back for no more doses of that kind of hypnotism.
+
+The use of drugs seems to be a confession of failure to secure true
+hypnotism, so that it is doubtful whether their employment is
+justified. Suggestions received while in the more or less comatose
+state induced by drugs, instead of having a strengthening effect on
+the patient's will, rather tend to produce the idea of the
+impossibility of effectively using his own will, or even exercising
+his will when helped, as he supposes, by the will of the operator. The
+real value of hypnotism consists in the concentration of mind upon a
+particular idea without any distractions, which enables the subject to
+make firm resolutions and then to have his mind help his body as much
+as possible by directing his energy to the accomplishment of one end.
+When drugs are employed, they have a diffusive rather than a
+concentrating influence, so that the real purpose of hypnotism is
+entirely missed.
+
+
+
+PRACTICE OF HYPNOTISM
+
+In the ordinary practice of hypnotism now, the patient is placed
+sitting on a comfortable chair and the operator on one side facing
+prepares the mind of the subject by proper assurances. The patient
+must be brought into a thoroughly assured and comfortable state of
+mind and must be quite ready to submit to hypnotism. Then in most
+people, if the finger is held rather close to the patient and well
+above the line of sight, requiring special effort {158} on the part of
+the superior recti muscles as well as of the power of convergence, a
+tired feeling will come over the subject with a tendency of the lids
+to droop. When this happens the subject is asked to allow the lids to
+drop and to quietly concentrate the attention on the idea of sleep so
+as to permit the drowsy feeling gradually to increase. On a first
+seance this may take ten minutes, subsequently much less time will be
+needed, and, as a rule, in five minutes the subject is quite
+predisposed to sleep. In more difficult cases a much longer time may
+be needed, and repeated efforts may have to be made. Great patience is
+required. The operator soon learns to adjust himself to certain
+peculiarities of individuals in predisposing them to the hypnotic
+condition.
+
+
+Hypnotism Simple, Natural, Not Mysterious.--The most important thing
+to know about hypnotism is the fact that any one who wishes can
+hypnotize. There may be need for favoring circumstances, but there is
+no need for any special faculty in the operator. If he has confidence
+in himself so as to take up the question of hypnotizing seriously, if
+the subjects are reasonably susceptible and if they are persuaded that
+they may be hypnotized, or even if they are not, so long as they take
+the operator seriously a hypnotic state will result. Nothing is more
+surprising to the operator himself, the first time he succeeds, than
+his success. This at once gives him renewed confidence, and future
+hypnosis becomes a comparatively simple matter. To have this idea
+widely diffused would do much good, since it would at once strip the
+charlatans, who abuse hypnotism, of most of the mystery that surrounds
+them. The general diffusion of such knowledge would also do good in
+another way. It would expose the supposed wonderful power that some
+people are presumed to possess. Hypnotism works no wonders; it is a
+mere natural manifestation not unlike sleep, and probably not a whit
+more mysterious.
+
+
+Stages.--A number of divisions of the hypnotic state have been
+suggested, but probably the simple division into three stages is the
+best for ordinary teaching purposes, and helps to the understanding
+both of the conditions themselves and of many things that are written
+about hypnotism.
+
+The first stage consists of a subdued, dreamy condition, in which the
+patient is not asleep and yet not thoroughly awake to all that is
+going on around him. He has his mind so concentrated on certain
+thoughts that he is preoccupied, and suggestions are much more
+efficient than under ordinary circumstances. This is really only a
+state of intense attention to the suggestions that are being made,
+with the banishment of all distracting thoughts. It is rather
+difficult for any one to keep from being distracted, and whenever this
+is accomplished, the ideas that then enter the mind penetrate more
+deeply and, above all, seem to affect the will more forcibly than when
+they are merely superficially considered. This first stage of
+hypnotism would not be considered hypnotic by most people who
+associate the idea of sleep with hypnotism.
+
+In recent years it has been found that most of the good that is
+accomplished, especially for nervous people, by hypnotic suggestion,
+can be attained almost, if not quite as well, in this first stage, and
+without the hypnotic trance. The first stage is much less liable to
+the dangers of hypnotism in many ways, and it represents one of the
+most interesting phases of psychotherapy.
+
+{159}
+
+The second stage of hypnotism is the hypnotic sleep. The patient loses
+consciousness of his surroundings, though his senses are still open to
+suggestion from the operator. Practically all that happens in the room
+apart from what is brought to the subject through the operator's
+direction remains unnoticed. If the sleep is very deep, even the
+suggestions of the operator do not penetrate after a time, so it may
+be quite difficult to awaken the subject. It may be even some hours
+before the person hypnotized will come out of the lethargy which has
+been induced in these cases. Under these circumstances, this second
+stage partakes somewhat of the nature of the deeper trance condition
+that characterizes the third stage.
+
+The third stage of hypnotism consists of a profound trance-like
+condition in which there is catalepsy--that is, firm contracture of
+muscles all over the body--and as the extensors are stronger than the
+flexors, this contracture takes place in the extended position. The
+cataleptic condition is really a nervous spasmodic seizure rather than
+a true stage of hypnotism. It is probably always harmful for the
+patient to have it induced. Its occurrence as one manifestation of
+hysteria, apart from hypnotism, shows its real character. It is with
+this stage of hypnotism that professional hypnotists, who give
+exhibitions, make their demonstrations--that is, of course, when their
+demonstrations are really hypnotic and are not merely, as is often the
+case, performances by actors trained for the purpose. Catalepsy is
+entirely pathological; experiment with it then is eminently
+undesirable, and certainly should not be undertaken except under the
+most careful precautions and by a physician. One of its dangers was
+very clearly pointed out by the death of a young man, who in a
+cataleptic condition was subjected to certain strains upon his thorax
+which brought about the rupture of an aortic aneurism. Catalepsy never
+permits of suggestion in such a way as to be helpful to the patient.
+It always leads to further functional deterioration of the nervous
+system, and yet it has unfortunately come to mean for many people the
+most essential characteristic of hypnotism. Its production is supposed
+to represent the acme of skill in the hypnotist. Nothing could
+possibly be less true nor be more likely to do harm.
+
+
+Susceptibility.--As to the number of people who are susceptible to
+hypnotism, there are great differences of opinion. Liebault declared
+that practically every one is susceptible in the hands of a patient
+operator. In a carefully made series of cases his failures were less
+than three per cent. Van Rentergehem and Van Eeden, in a series of
+over 1,000 persons, failed only with fifty-eight, or little more than
+five per cent. Schrenk-Notzing's statistics, collected from many
+countries, seem to show that only about six per cent. were
+uninfluenced. Bernheim, at Nancy, was not nearly so successful as
+Liebault, his master, and his failures amounted to twenty-five per
+cent. at the beginning and at least twenty per cent. later. I remember
+that when I was at the Saltpêtrière fifteen years ago, they were
+inclined to discount the enthusiasm of the Nancy school with regard to
+the value and significance of hypnotism. They insisted that probably
+not more than one out of two of the persons presenting themselves at a
+nervous clinic could be hypnotized to the extent that is ordinarily
+associated with the word--could be brought beyond the drowsy stage.
+There are other workers in the subject who have insisted that not more
+than one out of three ordinary individuals can be so {160} deeply
+hypnotized as to exhibit the ordinary symptoms. These symptoms consist
+of complete neglect of surroundings and absolute absorption in the
+suggestions of the operator.
+
+Some people can be hypnotized to the extent of being thrown into sleep
+and yet walk and talk under the absolute control of the operator.
+These are so-called somnambules, the class of persons who are
+exhibited by professional hypnotizers who want to attract popular
+attention, and, indeed, the class usually exhibited by physicians
+before medical societies, and even by professors before their classes.
+This extreme susceptibility is, however, quite rare. Even the most
+ardent advocates of hypnotism and of the susceptibility of humanity to
+it do not claim that more than one in ten of average individuals can
+be influenced to this degree. There are milder degrees of hypnotism
+than this, until we reach a state in which all the patients feel is a
+certain dreamy sense of well-being and a heaviness of the eyes, with a
+readiness to respond to suggestions. Most people who think of the
+somnambulistic stage as representing hypnotism would not consider
+these latter to have been at all subjected to the hypnotic state.
+
+
+_Repeated Efforts_.--As to this question of susceptibility, much
+depends on how often the operator has tried to hypnotize the
+particular subject, for susceptibility develops with repeated trials,
+not only where there is a manifest impression at first, but also where
+there is not. It is not uncommon to find that a patient who cannot be
+brought at all under the influence of hypnotism in the first or second
+or third trial, will, at the fifth or sixth trial, yield to the
+suggestion to go into a hypnotic sleep. A dozen unsuccessful efforts
+may be followed by the development of a very satisfactory hypnosis.
+Those who have practiced hypnotism much tell of having tried a score
+or even two score of times before finally bringing on a hypnotic
+condition. Dr. J. Milne Bramwell, one of the English authorities on
+hypnotism, tells the story [Footnote 20] of having tried sixty or more
+times to hypnotize patients before finally succeeding. It is this
+persistence that enables successful hypnotic operators to accomplish
+results where less confident physicians fail. It is also the frequency
+of trial that makes all the difference in the statistics as to the
+susceptibility of patients to hypnotism in the hands of different
+individuals. There must be the confidence of the patient in the
+physician's power to hypnotize, but, above all, there must be the
+physician's own confidence in his power to bring on the hypnotic sleep
+so that he tries and tries again, even to seventy times.
+
+  [Footnote 20: "Hypnotism. Its History, Practice and Theory," by J. M.
+  Bramwell, 2nd edn. London, The De la More Press, 1906.]
+
+
+ANIMAL HYPNOTISM
+
+The hypnotization of animals shows that only a very low grade
+intelligence is needed for the production of this state. The famous
+experiment of Father Kircher with the hen, which any one may repeat at
+any time, is a good illustration. The fascination exerted upon birds
+by snakes is another familiar example. The bird is paralyzed with
+terror at the sight of the snake, and so cannot escape from its enemy,
+fairly glueing its eyes on the terrifying object, and thus loses power
+to control its wings. Stories of snake {161} fascination are usually
+told as if the eye of the snake attracted the bird, who thereupon
+proceeded to approach the snake. These are, however, doubtful stories.
+The paralysis of motion seems to be the main effect. The rabbit is
+affected in nearly the same way. There is a tremor of horror in
+anticipation, and then the animal stands perfectly quiet, though
+ordinarily he would be quite able to escape, while its enemy
+approaches. The underlying mechanism is evidently a concentration of
+attention, which completely precludes the possibility of the exertion
+of any spontaneous energy except that involved in the one act of
+watching the awful object.
+
+
+DANGERS OF HYPNOTISM
+
+There are many and various opinions of the dangers of hypnotism. Some
+of those who have given it a fair trial have insisted on its dangers.
+Some of those who have had very large experience have declared
+emphatically that there is no danger at all. Occasionally it has
+seemed that such a declaration must be considered as having been
+dictated by such intensity of interest as sometimes leads men to
+overlook the darker side of things with which they are much occupied.
+Certain moral aspects of hypnotism are at least dubious, and, it must
+be admitted, present opportunities for abuse. There are certain
+dangers connected with its effect upon nervous patients, and
+especially with its influence upon character, that have become more
+and more clear in recent years. Dr. John K. Mitchell, in his "Self
+Help for Nervous Women," a series of familiar talks on economy in
+nervous expenditure, [Footnote 21] has dwelt on certain of these
+dangers of hypnotism for nervous patients in a passage that deserves
+to be recalled. As a representative of a school of thought that is
+worthy of special regard from American physicians his expressions must
+carry weight:
+
+  [Footnote 21: Philadelphia, Lippincott, 1909.]
+
+  The greatest danger of all is the use of hypnotism in any form or
+  degree, a two-edged sword, capable indeed of usefulness, but more
+  capable of harm. After years of study, beginning with too easy an
+  approval of it, hypnotism, whether called by that name or by the
+  unsuitable one of suggestion, has been laid aside by the medical
+  profession as a means too dangerous for ordinary use, involving
+  great risk of deterioration of character in the subject if often
+  repeated, and putting a terribly tempting tool in the hands of the
+  user, fascinating in the ease with which it can produce superficial
+  and temporary good results and equally capable of being used for
+  harmful ones.
+
+  A susceptible person, once hypnotized, is more and more easily
+  thrown into the hypnotic state until even the slightest hint
+  suffices to bring about the condition. It is not necessary for the
+  hypnotization to go so far as deep sleep; this more advanced stage
+  is indeed seldom required, and to say that persons are not
+  hypnotized because they are not put into a sleep or a trance shows
+  ignorance of the subject.
+
+  I am not asserting that very slight degrees of the hypnotic
+  condition are as dangerous as the deeper, but I do say that all
+  degrees of it are dangerous to the integrity and healthy action of
+  the subject's nervous system. The danger of harm increases with
+  every repetition of the hypnotization.
+
+  In suggestible, that is, over-susceptible, individuals, who are
+  almost universally neurotic persons, to fix the eyes on a small
+  point, especially a bright one, sometimes even to fix the mind on
+  the one idea of going into the hypnotic state (mild or deep), is
+  enough without further intervention from any one to put them into
+  that state.
+
+
+{162}
+
+In an article on the "Danger and Uses of Hypnotism" Prof. Forel, of
+Zurich, twenty years ago, while frankly admitting that hypnotism is by
+no means a panacea for all nervous affections and unfortunate habits,
+found it to be an extremely valuable help in the treatment of many
+forms of functional nervous disease. He suggests that some of its many
+dangers are due to the fact that hypnotism is practiced by men who are
+too distrustful of it, and this distrust, unconsciously communicated
+to the patients, produces an unfortunate effect. On the other hand,
+fear and distrust on the part of the subjects seriously disturbs the
+process of hypnotization, interferes with its effect and sometimes
+leads to unfortunate results.
+
+In some cases it seems that the state of dependence on some one else,
+at least by suggestion, that had been created during the hypnotic
+experience, resulted in a diminution of will power and caused a less
+hopeful state on the patient's part than before. I found personally
+that suggestion in the waking state might in most cases be used quite
+as efficiently as hypnosis itself, and that when improvement came
+under these circumstances, the patient always felt more confidence in
+himself and less in the operator. Anything that restores
+self-confidence and gives patients the feeling that they can conquer
+inclinations, tendencies, even habits, if they only will, merely by
+firmly resolving to do so, is the best possible mental influence for
+them. The hypnotic relief is always easier, but nothing that is easy
+is likely to be of lasting value. The enduring effect of gradual cure
+by suggestion means much more than the hypnotic miracle that these
+patients are so prone to crave.
+
+At present there is a very general feeling among those who have had
+considerable experience with hypnotism, that in spite of the claims of
+certain votaries for it, there is no justification for its frequent or
+habitual use. It has a definite place in diagnosis, in certain
+difficult cases, and at the beginning of the treatment of certain
+forms of the psycho-neuroses. When repeated frequently it is not
+therapeutic, but is likely to produce serious results in a certain
+lack of self-control and tendencies to auto-hypnotization with
+deterioration of character. There is very seldom need of a repetition
+of deep hypnosis, and, as a rule, all the diagnostic benefit can be
+secured in one or two seances. Its continued use only illustrates the
+tendency noted at all times, in the history of medicine, for the
+unthinking or unprofessional to persist in the application of supposed
+remedial measures after they have been shown to be useless or even
+harmful. The subject well deserves further study, but investigations
+should be carefully made by men who realize the dangers, and who are
+not likely to be tempted to exploit patients and curious psychological
+phenomena for the sake of sensational reputation. The use of hypnotism
+for exhibition purposes, by men who are not physicians, is an unmixed
+evil, producing entirely wrong impressions on the public, and doing
+untold evil to the subjects employed.
+
+
+{163}
+
+SECTION III
+
+_THE INDIVIDUAL PATIENT_
+
+
+CHAPTER I
+
+PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT
+
+
+The most important element in Psychotherapy is the individual patient.
+Old Dr. Parry of Bath said a century ago, "It is much more important
+to know what sort of a patient has a disease, than what sort of a
+disease a patient has." Mental influence is not of the slightest avail
+against pneumonia or typhoid fever, nor constipation nor rheumatism as
+such; mental influence may be, and often is, of the greatest possible
+help to the patient suffering from any of these diseases.
+
+We recognize frankly now that for most diseases we can do nothing to
+counteract the disease directly or to cure it specifically. The idea
+of specifics in medicine has to a large extent disappeared. Two or
+three of them possibly we have, but even with regard to these, there
+are certain doubts as to the essential modes of their activity. We
+have learned, however, to help the patient to overcome disease. We
+know how to conserve his forces, to increase his vital reaction, to
+maintain his nutrition without disturbing his general condition, and
+to secure elimination in such a way as to prevent nature from being
+interfered with in her curative purposes. To this, psychotherapy would
+enable us to add such encouragement of the patient as would tap new
+sources of energy in him according to the law of reserve energy, and
+would prevent discouragement and the inhibition of favorable nerve
+impulses that so often follow. The outcome of any disease depends on
+two factors. One is the condition of the patient at the time the
+infection was acquired, the other is the virulence of the infection.
+We can do nothing to modify this latter element, once the disease
+manifests itself. We can, however, do much to enable the patient to
+throw off the disease and, above all, by securing a favorable attitude
+of mind, we can enable him to use his forces to the best advantage.
+
+Anyone who has noted the difference between the patient's state just
+before and just after his physician has called, though absolutely no
+physical remedy has been employed, is able to realize very well how
+much psychotherapy is able to accomplish. One who did not know, would
+be sure to assume that some potent remedy had been administered--and
+there has been. This potent remedy is psychotherapy. Whether the
+personal magnetism necessary to produce therapeutic effects of this
+kind can be learned or not depends on the individuality of the
+physician. Undoubtedly, however, everyone can add to whatever of
+personal influence he has by definitely recognizing its place, by
+{164} making every effort to employ it, and then by regular systematic
+effort in securing as much personal information as possible with
+regard to the patient. This personal relationship of physician and
+patient makes instruction easier and suggestion more effective.
+
+The securing of personal information is of the utmost importance in
+determining the affections that psychotherapy will relieve, because
+very often details of life and habits are discovered that can be so
+modified by instruction as to bring about a disappearance of
+unfavorable physical influences. It is indeed surprising to find how
+many unreasonable things people do from habit, from unfortunate
+persuasion, or from lack of knowledge. In many of the minor chronic
+ailments that are the source of so much mental discomfort to patients,
+the physician finds that a change in the patients' habits, not
+necessarily of marked degree, may make all the difference between
+cheerful health and rather despondent low-spirited feeling. Now that
+epidemic disease has become rarer, a physician's practice, especially
+among the better classes, is much more taken up with these minor
+ailments than with the typical classical diseases.
+
+The ordinary history of their ailments, as patients commonly present
+them, especially when there are neurotic elements, is likely to be
+meager in what is objective, but consists mostly of the subjective.
+Such patients have much to say of their sensations, their feelings,
+their dreads, their surmises, their conclusions as to their particular
+condition, and especially the hereditary elements in it, but
+comparatively little of the objective realities of their ills and of
+their environment. What the physician needs to know about them is
+their habits of life, their daily routine of existence, just as
+minutely as it is possible to obtain the information. There is just
+one way to get the latter details, and that is to inquire particularly
+with regard to actual happenings. In chronic conditions of many kinds,
+it is so helpful that it will always be worth the physician's while to
+get at these details, especially in supposedly puzzling cases for
+which various forms of treatment have been already tried.
+
+In spite of every precaution in this matter, the physician sometimes
+finds, after a series of consultations, that some point which when
+brought to light he considers to be of great importance, has been
+thought so trivial by the patient that it was never mentioned, in
+spite of the most careful questioning. In all medical practice the
+rule is that mistakes of diagnosis are much more due to neglect in
+eliciting necessary information than either to lack of expertness in
+diagnosis, or lack of knowledge of the significance of symptoms.
+
+In the affections that can be relieved by psychotherapeutics, the most
+important element for diagnosis, besides a minute knowledge of the
+patient's habits, is just as detailed information as possible with
+regard to his ways and modes of thought as to his ills. Practically
+every motive, as well as every action of the day, must be scrutinized,
+and often it will be found that little things mean much for the
+individual. "Trifles make perfection, but perfection is no trifle," as
+said by Michelangelo, might well be changed for the physician to,
+"Trifles make all the difference between health and discomfort, though
+health is no trifle."
+
+
+{165}
+
+CHAPTER II
+
+THE MORNING HOURS
+
+
+In getting the history of patients for diagnostic purposes the safest
+way is to begin with the getting up in the morning and then to follow
+out the various actions of the day. The hour and mode of rising should
+be inquired into. Practically all nervous people, and nearly all those
+beyond middle life, feel less fit in the morning hours than at any
+other time in the day. Apparently as a consequence of their will
+having been allowed to lose its hold during sleep, it does not secure
+thorough command over the organism for some time. Nervous people, as a
+rule, wake up with a tired feeling, a dread of the day, wondering
+whether life is worth living. They dread--for it is a real dread--to
+get up and tackle the daily round of life once more.
+
+If they have nothing very definite to do, then slight tired feelings
+or discomfort, even of very minor degree, may lead them to think that
+they cannot get up. Any yielding in this matter is almost sure to do
+harm. When there are no objective signs, that is, when there is no
+fever recognizable by the thermometer and there has been no diarrhea
+or any physical weakness, nervous patients should get up promptly at a
+particular hour every morning, because, as a rule, within a half hour
+after getting up they feel better, and by the time they are washed and
+have had their breakfast, life has grown not only quite possible but
+even plausible, and the day's work does not seem such a nightmare as
+it was at first. It is not advisable to tell people all this as soon
+as they confess their habit of dawdling in the morning, for they must
+be gradually brought to discipline themselves. The detail emphasizes
+the necessity of knowing how they get up as well as when.
+
+
+Mode of Awaking.--It is often valuable to know how patients awake.
+Sometimes it will be found that they are anxious and solicitous to be
+at work at a particular hour, or to catch a train at a particular
+time, and that as a consequence their sleep is disturbed in the early
+morning hours. At best it may be fitful and when they awake they fear
+to go to sleep again lest they oversleep. An alarm clock will
+sometimes remedy this state of affairs. Better still is an arrangement
+by which someone, who can be depended on, will wake them at a
+particular time. Occasionally patients cannot content themselves in
+spite of the assurance that they will be waked. They dread that the
+alarm clock may not go off, or that the awakener may make a mistake,
+and so they go to bed with a dominant idea, which is more or less
+constantly present in their mind during all their sleeping hours,
+disturbing sleep and preventing complete rest. It may be necessary to
+insist on a change of occupation for such persons, or a change of
+residence that will do away with the necessity for early rising. When
+this is done, many a neurotic condition that has before proved
+intractable will disappear.
+
+
+Amount of Sleep.--It is of cardinal importance to know how long
+patients sleep. In our large cities most people have too little sleep.
+A comparison of the hours when they get to bed with those when they
+get up will often show that at least three or four nights in the week
+some patients who are complaining of nervous symptoms, especially
+nervous indigestion, are {166} sleeping less than seven hours. There
+are but few men, and still fewer women, who will retain their health
+under such conditions. Some men have been able to do it, but they are
+comparatively rare. King Alfred's rule of dividing the day into three
+eight-hour periods--one for sleep, one for work, and the third for
+bodily necessities and recreation, still remains the best for human
+nature. Whenever people try to live the strenuous life and get along
+on less than eight hours of sleep, they are almost sure, sooner or
+later, to render themselves uncomfortable, to make themselves liable
+to all sorts of neurotic symptoms and, above all, to detract from
+their efficiency for whatever work they are engaged in. Whether they
+sleep or not, they should be in bed for nearly eight hours.
+
+
+Bathing.--_Morning Bath_.--In our larger cities at least, many of the
+inhabitants begin the day with a bath. In this matter one finds all
+sorts of harmful fads that need to be corrected. Many men take a cold
+bath, and unless they are particularly strong and vigorous, this is
+rather an exhausting experience for the beginning of the day, when the
+last nutrition the body absorbed is twelve hours before. On the other
+hand, large, athletic men who manufacture a great deal of heat, their
+muscles--the heat-making organs--being well developed, will be
+benefited by having a cold bath because of the abstraction of heat
+that it involves. It is not, however, infrequent to find that the man
+for whom it will be good is not taking it, while the thin, neurotic
+individual, already exhausting more of his vitality by worry and
+dieting and in various fads with regard to his health than is good for
+him, is regularly taking his cold plunge or douche. Unless especially
+asked about it, few men give particulars in this matter, yet they are
+extremely important.
+
+Women, on the other hand, are likely to take hot baths more frequently
+than is good for them. Especially when they have maids to assist in
+dressing and undressing, it is not unusual to find that women take
+two, and sometimes even three, hot baths in a day. They take them in
+the early morning when they first get up, and in the evening before
+dressing for dinner. I have known cases where some took a third hot
+bath before going to bed and sometimes even put in a fourth before
+luncheon in case they had had any exercise in the morning
+hours--tennis, or horseback riding, or the like--that made them
+perspire. These are details which the physician will learn only if he
+asks particularly about them. Until he has actually had the experience
+of finding that they play an important role in some ailment he is
+almost sure not to think of it. It is probable that even two hot baths
+a day are too many. I have known women to begin at once to get better
+of neurotic symptoms that before had proved quite intractable, when
+their hot baths were limited or when they were changed for a single
+warm bath with a cold rub after it in the morning, or sometimes just
+before dinner.
+
+Bathing is more liable to abuse than is usually thought to be
+possible. While the habits of modern life call for it often, and many
+people are quite sure that they would not be healthy without it, the
+people who live longest, and who have had the best health far beyond
+three score years and ten, have usually not been noted for bathing
+proclivities. The human body is composed of nearly seven-eighths
+water, and so our cells are constantly bathed in it, but the making of
+the whole organism a marine animal once more, as seems to be the
+definite tendency of some people, is not nearly so hygienic as {167}
+it is often thought to be. Enough bathing for thorough cleanliness,
+but not for luxury, must be the rule for people who have active work
+and want to retain their health.
+
+
+_Bathing Fads_.--While such mistakes are usually made only by the
+wealthy and leisure classes, the physician will sometimes be surprised
+to find that women who have no maids for personal service are
+indulging themselves in these over-frequent bathing practices. They
+have heard that it softens the skin and renews youth, or they have
+heard that the Japanese take hot baths and are revivified when they
+are very fatigued, and so they go to great lengths in bathing. Often
+this is the main reason for the relaxation of muscle tissue and the
+sense of prostration that has come over them. Neurotic people are
+constantly going to extremes. Even delicate women will sometimes be
+found to take very cold baths which are surely doing them harm. Over
+frequent washings of hands and face are sometimes responsible for skin
+lesions, especially if the soap used is one of the varieties so
+scented that the manufacturer is enabled to conceal the impurities in
+its ingredients. Some women easily run into what is really a
+misophobia, an exaggerated morbid fear of dirt, and need to be
+restrained from washing themselves over frequently. Many a chapped
+hand would be saved by avoiding unnecessary washings, and especially
+in warm water just before one goes out, for it leaves the skin without
+its proper oily protection.
+
+
+Clothing.--Then comes the question of clothing. It is curious how
+irrationally many people clothe themselves. People complain of cold
+hands and feet when they are wearing thin cotton undergarments, and
+who need only to have these changed for wool for their feelings to be
+at once improved. In the meantime they have been persuaded that they
+have a defective circulation. The usual excuse for not wearing wool is
+that it produces hyperemia of the skin with itchy discomfort, but
+this, as a rule, is only passing and is due to unaccustomedness. The
+coarser wools should not be worn by the sensitive. A thin cotton
+garment may, if absolutely necessary, be worn next the skin. There is
+too little variety in the underclothing that people wear. Some change
+from light to heavy weight and only that, but there should be a medium
+weight worn, and occasionally, when there is a spell of mild weather
+in the winter time, even during the season when heavy weight is
+usually worn, medium weight should be substituted for comfort's sake.
+
+It is even more common to find that neurotic individuals, who fear to
+catch cold, wear too much clothing, especially around the chest. Very
+often they alternate from this during the day to next to nothing in
+the evening, and by so doing subject themselves to special risks of
+internal congestions. When the skin is covered with too much clothing
+it loses the habit of reacting, and the warmth and the irritation of
+wool keep up an artificial hyperemia which gradually lowers the tone
+of the peripheral vessels. Many people wear "chest protectors," as is
+evident from the prominent display of these abominations in the
+drug-store windows. By leaving certain portions of the chest
+unprotected while other parts are kept over-warm, these add greatly to
+the risk of such disturbances of circulatory equilibrium as predispose
+to the infections grouped under the term "taking cold." It is not
+heavy clothing that keeps people warm so much as the layers of
+non-conducting air between the skin and the outer air. It is better,
+therefore, to wear three thin {168} garments than two heavy ones
+because of the additional layers of air that are thus confined. A
+paper vest, if one is driving in the wind, will probably protect
+better than the heaviest woolen garment worn. The wearing of chamois
+garments is not, as a rule, advisable because chamois does not permit
+free access of air and it hampers transpiration.
+
+
+Before Breakfast.--After dressing comes breakfast, with regard to
+which it may be advisable to ask many questions. It is well to begin
+with a query as to whether liquids are taken before breakfast. Many
+people have taken to the fad of drinking a large quantity of warm
+water, sometimes as much as a pint, before breakfast. Surely this
+never does any good and, in most cases, just as surely does harm.
+Plain water will not dissolve mucus that may have collected in the
+stomach, and warm water merely dilates that organ, relaxes its fibers,
+and renders the whole gastric digestive system atonic. If cold water
+can be borne, it will often be found that a glass of cold water the
+first thing in the morning stimulates peristalsis, and serves to
+lessen the necessity for laxatives. Many people complain that cold
+water is too much of a shock. Usually, if they are reminded that when
+we want to warm our hands we rub them vigorously with cold water and
+that the reaction after this gives a healthy glow, the effect of the
+supposed shock, which was merely an unfavorable suggestion, will
+disappear. Sometimes delicate people cannot drink cold water. If there
+is any reason to suspect an accumulation of mucus in the stomach, a
+small bouillon cup of _very hot water_, just as hot as it can be
+borne, in which a pinch of salt and a pinch of bi-carbonate of soda
+have been dissolved will prove an excellent aperitive for the day.
+This is physiological and appropriately chemical, as well as naturally
+stimulating. Mucus does not dissolve in ordinary water but dissolves
+readily in an alkaline salt solution, and this is just what is thus
+recommended. This drink is quite grateful to the palate. Indeed, it
+tastes very much like clear soup, and, if the eyes are closed, cannot,
+as a rule, be distinguished from some of the bouillon commonly served.
+I have known this cup of hot water to stimulate an appetite when drug
+tonics had failed.
+
+It is better to take the glass of cold water from fifteen to twenty
+minutes before the morning meal--say immediately on rising. If,
+instead, the small cup of hot water is chosen, it should come
+immediately before eating, and will usually prove an appetizer.
+
+
+Breakfast.--The exact details of the amount of breakfast taken and how
+it is eaten should be known. Nervous people eat little breakfast. When
+ordered to eat, they find it difficult at first, but the habit is
+easily formed, and then they want their breakfast like anyone else. It
+is surprising how often physicians will find that nervous persons, who
+are under weight, are not taking enough breakfast. They will
+ordinarily say that they are eating breakfast about as other people do
+and will, perhaps, mention eggs and rolls, but it will be found that
+their ordinary breakfast consists of a roll and piece of toast and
+coffee, and only occasionally do they have any of the other things
+mentioned.
+
+Breakfast is ordinarily the meal which those who work are likely to
+eat too hurriedly. Those who are neurotically inclined are especially
+victims of the habit. They lie abed until there is only a few minutes
+left to get the train so as to reach their place of occupation in
+time, and thus their breakfast is {169} skimped. Their oatmeal or
+other soft cereal is fairly shovelled in, coffee is gulped, toast is
+unchewed, the coffee softening it; if they have creamed potatoes they
+are swallowed in such large pieces that, as every physician knows, if
+for some reason they vomit they are surprised, beyond all measure, at
+the large portions they have been able to pass down into their
+stomachs. A breakfast thus eaten makes a bad beginning for a nervous
+man's day, and the more that is so eaten the worse for the victim.
+With a habit like this, it will be utterly impossible by means of
+drugs or directions as to diet to relieve the discomfort of neurotic
+indigestion, or to keep the patient from suffering that stomach
+discomfort so often complained of in the morning.
+
+
+Working Women.--Working women are even more prone than are men to take
+a hurried breakfast, and having, as a rule, less appetite than men,
+their meal is likely to be deficient. It is not unusual to find that a
+young woman who is under weight and who needs three meals a day, is
+taking so little for the first meal that even she hesitates to regard
+it as a meal. Very often her last previous meal has been taken before
+seven o'clock the night before, so that she goes out ill prepared for
+her day's work. Much more than men, women are annoyed in the morning
+by our transportation systems, and by worry as to whether they will
+get to the office on time. Suggestions as to the modification of this
+unfortunate routine, the taking of an earlier train, the using of a
+quiet local instead of a crowded express, a short walk at least before
+taking the train, will often help in producing a marked change in the
+general health.
+
+
+Home Keeping Women.--For those who really have homes, the morning
+duties are usually sufficient to rouse their activities and make them
+begin the day well. For those who live in apartment-hotels, however,
+and for those who have the luxury of many servants, the morning hours
+are often a serious problem. Madame does not get up, or if she does,
+it is only to lie around in dressing gown for most of the morning.
+Breakfast is easily neglected or may be eaten hurriedly because the
+head of the house is rushing to business. The lack of an incentive
+requiring them to rise, and get outside for a time every morning, is
+probably at the root of more feminine symptoms among leisure class
+patients than anything else. As we grow older all of us are likely to
+note the lowered physiological cycle of the morning hours, so that
+unless there is some sharp reason to compel action, we are rather
+prone to persuade ourselves that it is better to lie abed, or at least
+to loll around. This leads to a concentration of attention on self and
+on one's feelings that easily gives rise to neurotic conditions.
+
+
+Interest in life.--In my special clientéle I have often found that
+going to church in the early morning hours was an excellent remedy for
+many of these patients. It gives them a definite reason for rising
+promptly, the service provides motives to rouse them to activity, they
+are likely to think during it of how they shall make their life a
+little bit more livable for others as the result of their trying to be
+better, and so the apathy that is so fruitful of ill feeling is shaken
+off. This can only serve for those who have faith in the service. For
+others, the old-fashioned going out to market, or the making of
+appointments at morning hours that will tempt them to regular activity
+early in the day, is of special significance. It is always ominous for
+health when a woman can look forward to a whole long day without any
+particular duties {170} in it until the late afternoon or evening
+hours. This has become so frequently the case for the women of our
+large cities, particularly those who live in apartment hotels, it is
+no wonder that neuroses and psychoneuroses of various kinds have grown
+in frequency. The best prophylaxis for them is occupation of mind. The
+cure for them is the securing of many interests and such diversion of
+mind as will prevent concentration of attention on self.
+
+
+Mail Before Breakfast.--Many people receive their most important mail
+in the early morning, and personal mail, in cities especially, is
+likely to be placed beside the breakfast plate. Not infrequently,
+letters contain serious matters that are likely to disturb people, and
+occasionally even important business finds its way to the side of the
+plate at breakfast time. Authors often find their rejected manuscripts
+sent back in the morning's mail. Occasionally bad news of other kinds
+comes in this way, and, as a rule, it is the very worst time for its
+reception. The human system--it cannot be too often repeated--is at
+its lowest physiological term in the morning, the temperature is lower
+than during the rest of the day, all the nervous vitality is below the
+normal. Half an hour after breakfast the reception of bad news, or the
+coming of important matters requiring decision, would not make so much
+difference. Hence, the necessity for knowing whether the mail is
+ordinarily read in the early morning, in order to know something about
+people, and about the consumption and digestion of their breakfast.
+
+
+Company at Breakfast.--Pleasant company during meals is an important
+factor that makes for good digestion. At the other meals there is much
+more likelihood of having such pleasant company, while the morning
+meal is often a solitary, and quite as often as not, a rather glum
+quarter of an hour, preoccupied with the business cares of the day. As
+may be readily understood from our discussion of this problem of
+mental preoccupation during digestion, this may seriously hamper
+digestive processes. Often men take refuge in their paper. The
+thoughts aroused by reading the modern newspaper are not the
+pleasantest in the world and consist, very often, of the following out
+of details of hideous crimes and scandals. When, as is sometimes the
+case, these scandals concern relatives, friends or acquaintances in
+whom we are interested, and with regard to whom we feel poignantly
+because of the publicity involved, nearly the same effect is produced
+as when bad news is received in letters, or when business worries are
+thus brought to the breakfast table.
+
+The best conditions for the eating of breakfast are those in which it
+becomes like the other meals, a family matter. When father, mother and
+children eat their breakfast together, nearly always family interests
+and especially the enlivening effect of the joyousness with which
+children face a new day is the best possible tonic for a business man
+in whom a solitary breakfast starts a day of digestive disturbance.
+Sociability and sufficient time must be insisted on, whether at home
+or in a boarding house, at breakfast as well as the other meals, and
+it will often be surprising to find how much difference this makes
+both as regards the quantity eaten and the digestion of the food.
+
+
+Morbid Habits.--In matters of diet, it is important to ask for
+details, for it is surprising what unexpected things may be discovered
+after weeks of treatment. That was illustrated for me once by a case
+of persistent acne in a young girl, which all the ordinary remedies
+failed to cure. I felt sure that {171} I had given her such explicit
+directions with regard to diet that I knew exactly what she was taking
+and that nothing could be hoped for from any change. As a last resort,
+I asked once more with regard to all that she ate and only then
+discovered that before breakfast every day she ate a baked banana. It
+had been recommended to her by a friend as a sure cure for
+constipation, she had formed the habit of taking it as a medicine, and
+so had not spoken of it. Baked bananas agree with many people well,
+but just as soon as this was eliminated from her diet her acne began
+to improve and before long had disappeared almost entirely. The taking
+of large amounts of warm water, already spoken of, is another of these
+morbid habits. Then many people take a glass of salt water, or
+laxative water, and some have curious habits with regard to the eating
+to excess of salt on cereal or on fruit, or sometimes they eat too
+great a variety of fruit. All this should be known, but often will not
+be ascertained unless particularly inquired about.
+
+
+
+CHAPTER III
+
+THE DAY'S WORK
+
+Probably even more important than details with regard to the early
+hours of the day, is detailed information as to the day's work, the
+kind and character of the occupation and the length of time spent at
+it, the interruptions that may occur, the habits with regard to
+luncheon, and, above all, the state of mind in which the occupation is
+pursued. The physician will only learn these details when he sets
+before himself a definite schedule of what he wants to know, and then
+proceeds to secure information with regard to it. With this sufficient
+can be learned in a short time to ascertain the source of the
+affection or the symptoms complained of. In some cases it is, however,
+only when the whole day's occupation is reviewed that proper
+suggestions can be made.
+
+
+Getting to Work.--Many a man, especially if he has been accustomed to
+much exercise in younger years, craves muscular exercise, feels much
+better whenever he has the opportunity to take it, yet rides down to
+business every morning and back every evening. On his vacation in the
+summer time, he gets up early for the sake of a morning walk, but he
+scarcely has time to take his breakfast and ride to business at other
+times, though the main reason for his better feeling during his
+vacation is his exercise. There is usually the story of crowded cars
+in the busy hours, often with annoying thoughts pestering him that he
+may not be in time and with a constant call on nervous energy while he
+stands up in the train, jolted, pushed, crowded, or unable to read his
+paper with satisfaction, even if he has a seat. The discomfort
+experienced during a ride in crowded cars to business is about as bad
+a way to begin a day for a nervous person as could be imagined.
+
+As a rule, it will take more than half an hour to get to business in
+this way. If an extra twenty minutes were taken, it would be possible
+to walk the distance. On at least two out of every three days in the
+year this would give a magnificent opportunity for exercise of the
+best kind, for fresh air, {172} for diversion of mind, for the route
+could be frequently changed, and, during the spring and fall, if there
+are parks on the way, these would provide occasion for pleasant
+thoughts to replace the annoyances which too intimate contact with
+over-strenuous humanity in overcrowded cars is likely to occasion.
+
+This seems almost too trivial for a doctor to talk about, but it is on
+the care of trivialities that good health often depends. It is easy to
+assume that this amounts to little for health but tempt a dissatisfied
+patient, whose digestion and sleep are disturbed, to do it, especially
+in the spring and in the fall, and see what a difference it makes in
+all his physical functions. If he is not used to walking, he will have
+to begin by walking only a mile or two, but after a time he will do
+his four-mile walk in about an hour, with no waste of business time,
+and with a renewal of energy that will seem little short of marvelous.
+
+
+Details of the Day's Work.--If patients are to be benefited through
+mental influence it is extremely important that details as to
+occupation be completely secured. This must include, especially in
+cases where there are objective but obscure symptoms, minute
+information that may seem trivial, and yet which often proves to be of
+great importance. In recent years there has been profound study of the
+dangers of trades and occupations. Anyone who wants to treat nervous
+patients, must know much about these occupations, for otherwise
+symptoms may be ascribed to old infections, to obscure rheumatic
+conditions, to intestinal auto-intoxication, or to nervous weakness or
+exhaustion, when they are really the result of occupation-conditions.
+The various poisons must be carefully looked for, or affections will
+be wrongly treated. I have had a series of cases of lead poisoning
+[Footnote 22] under most unexpected conditions which have taught me
+much as to the possibilities of obscure plumbism. Lead poisoning from
+new lead pipes--with no one else in the household suffering from it,
+lead poisoning from frequent drinking of carbonated waters, the
+bottles of which had the old-fashioned lead stoppers, lead poisoning
+from the painting of a flat by a settlement worker who could not get a
+painter to do it, show how carefully such things must be looked for.
+
+  [Footnote 22: "Curiosities of Lead Poisoning,"
+  _International Clinics_, Eighth Series, Vol. II.]
+
+
+_Dust and Respiratory Affections_.--Mechanical conditions connected
+with trades are especially important. Workers in dusty trades are
+almost sure to suffer severely from bronchitis at times, and to have
+the affection oftener than others, to have it "hang on longer," as
+they say, and eventually to have tuberculosis develop. There are some
+of the polishing trades in the metal industries in which it is
+impossible to maintain the ordinary death benefit fund that workmen
+have in other trades, because the men die so frequently and at such an
+early age from consumption that the drain on the treasury makes it
+impossible to maintain the fund. Practically all of the dusty
+occupations have this same tendency. This is true often in occupations
+where dust is sometimes not supposed to be much of a factor. Railroad
+trainmen suffer more frequently from colds than do those in other
+trades because of the dust to which they are exposed, and a trainman
+with incipient consumption will be greatly benefited by getting out of
+the dust during the summer months. Sweepers in large buildings,
+janitors and janitresses have colds that are often untractable because
+of the dust in their occupations. It is to be hoped that {173} the new
+vacuum cleaning system now becoming so popular will obviate these
+dangers, though like all improvements, it will probably bring its own
+dangers with it.
+
+
+_Lack of Light_.--People who work at occupations that keep them from
+the light are likely to suffer from lung symptoms and to have quite
+intractable colds which will not clear up until they get more
+sunlight. Workers in theaters and like places who do their sweeping
+where sunlight does not penetrate, are in more danger than others from
+respiratory disease. Those who work in gloomy lower stories,
+especially in narrow but busy and dusty streets, suffer the same way.
+Attendants at moving picture shows who work much in the dark where the
+frequently changing crowd brings in dust which cannot be well removed,
+and in quarters where the sun does not penetrate, are almost sure to
+have persistent repeated respiratory troubles.
+
+
+_Habitual Movements_.--After the question of dust comes the mode of
+the occupation. Many occupations demand certain habitual and repeated
+movements. When people come complaining of pains in muscles in and
+around joints, or of achy conditions in the limbs, it is important to
+know every detail of their occupation movements, if the physician is
+to appreciate just what pathological causes are at work. It is not
+enough, for instance, to know that a man is a clerk, or a bookkeeper,
+but it should be asked whether he stands much at his occupation, or
+walks considerably, or whether he sits practically all the day. If he
+stands much, we can expect that he will have various painful
+conditions in his feet and legs, unless he takes care to change his
+position frequently, to wear the most comfortable shoes obtainable
+and, above all, to provide against any yielding of the arch of the
+foot. Often it will be found that people who complain of discomfort in
+the feet stand much on a cold, and sometimes damp and draughty floor,
+and this needs to be corrected or their symptoms, often carelessly
+called rheumatic, will not disappear. If he sits down always during
+his occupation, he will need exercise and air or he will suffer from
+many vague discomforts, over sensitiveness and irritability of nerves,
+as well as from physical conditions.
+
+Most patients prefer to think that they are suffering from some
+constitutional condition, rather than from a merely local
+manifestation due to their occupations. Those who have to stand much
+can often make such arrangements as will permit their sitting down
+from time to time. They may, if they are standing at a desk, have a
+high stool; they may during their hour of lunch sit down restfully, or
+even to recline for a time, so as to restore the circulation in the
+legs. For many people who suffer from the achy discomfort connected
+with varicose veins in the leg, a rest of half an hour in the middle
+of the day with the feet a little higher than the head, will do more
+than anything else to make them comfortable. This same thing is true
+for people with flat-foot, and there are many occupations with regard
+to which advice of this kind will be appreciated. The well known
+tendency of many men to sit with their feet higher than their head is
+not a mere caprice, but is due to the fact that this is an extremely
+restful posture and thoroughly hygienic for those who have been
+standing much.
+
+Unfortunately, it is not so easy to secure such relief for working
+women, but occasionally the advice to lie down during the middle of
+the day on the couches of the retiring rooms may be the best medical
+prescription that can {174} be given. This will carry young women over
+trying periods of the month when everything seems to be going wrong.
+In women particularly, if there are complaints of the pains in the
+lower limbs, footwear must be investigated. When the heels are too
+high those who have to stand much are thrown forward and there is a
+strain of the muscles of the thighs and on the muscles of the back.
+Many young women suffer from backache supposed to be due to internal
+conditions usually of gynecological character, when it is only due to
+high heels or a combination of high heels and constipation. On the
+other hand, heels that are too low are not comfortable and women's
+shoes, in spite of the outcry against them, have been better adapted
+than men's to prevent them from developing flat foot. Fewer women than
+men suffer from this affection. Shoes that are too loose are almost as
+bad, sometimes it would seem worse, than those that are too tight.
+
+
+_Habitual Motions and So-Called Rheumatism_.--The habitual movements
+of various trades are extremely important for the diagnosis of
+conditions that develop in the muscular system. Much of the so-called
+rheumatism of the working people is really due to the muscular
+over-activity demanded by their trades. This affects all kinds of
+working people. Men who have to work foot-lathes, or women who have to
+work sewing machines, or men or women who have to use their arms much
+in repeated vigorous movements, are likely to suffer from achy
+discomfort. The strong and healthy ones do not suffer, but the
+delicate do. The suffering is much more prevalent in rainy, damp
+weather; it is worse during the spring and fall than at other times.
+It is particularly noticeable whenever the patient is run down
+physically, is worrying about many things, or, above all, is getting
+insufficient nutrition. The discomfort is particularly likely to recur
+in those who do not know how to use their muscles properly, who are
+naturally awkward, and who perhaps have from nature an insufficient
+control over opposing and coödinating muscles, so that they do not
+accomplish movements quite as readily as would be the case if they
+were normal. The personal element enters largely into these
+affections. Many patients, however, can be trained to do their
+habitual movements under the best possible mechanical conditions,
+whereas very often they are found accomplishing them under the worst
+possible mechanical conditions.
+
+Men who have to do much writing may have to be taught the application
+of Gowers' rule, that the forearm should so move as a whole during
+writing that if a pen were fastened to the elbow it would execute
+exactly all the movements of a pen held in the hand. The writing must
+all be done from the shoulder. People who do typewriting may have to
+be instructed not to allow the machine to be too much above them, nor
+on the other hand, too much below them when they sit down. Young
+people particularly who, from long hours of practice on the piano,
+suffer from neurotic conditions, may have to be instructed to do this
+under good mechanical conditions.
+
+Men who do much filing of metal will often suffer from painful
+conditions in the arms. These will be much worse in case the filing is
+done at a table or workbench so high that pressure has to be brought
+to bear upon the file by the arms instead of through the weight of the
+body. This same thing is true for women who iron much. If the ironing
+board is so high that the additional pressure applied is made by the
+arms, then painful conditions will {175} almost inevitably develop if
+the work is long continued. These details are discussed in the
+chapters on joint and muscular affections.
+
+
+Night Work.--In a large city there are many workmen who are on night
+duty. They will be disturbed in many ways in health, unless they make
+special arrangements to live under conditions that enable them to have
+full eight hours of sleep every day and, above all, to have their
+meals regularly. When they come home in the morning they usually have
+a rather hearty meal. Most of them can sleep very well with this, but
+very few of them sleep the full eight hours, and all need this amount.
+Usually they have another full meal about five in the evening. Very
+often it will be found that the third meal of the day consists of a
+sandwich, with a glass of milk or a glass of beer, and some cake or
+some crackers and cheese, or the inevitable pie. Every workman should
+have three full meals, and a man who is suffering from almost any
+symptoms will be improved at once if the third good meal is insisted
+upon. At one time I had occasion to see a number of men whose work
+began not later than seven in the evening and did not finish until six
+or seven in the morning. They were sufferers from all sorts of
+complaints. Most of them were under weight. Not a few were
+constipated. Some were suffering from severe headaches that came
+rather frequently, and a few from a headache that was severe but came
+only every two or four weeks. These patients alternated night and day
+work, and it was the week after they had been on day work, and first
+went on to night work, that they suffered from headache.
+
+In every one of these cases instructions with regard to eating and
+sleeping proved to be the best remedy. Nearly all of them were not
+eating enough, and were skimping the third meal. Three of them were
+taking only between four and five hours of sleep. They stayed up after
+breakfast to read the paper, went to bed about nine and got up about
+two o'clock. Just as soon as two or three hours was added to their
+sleep, they began to feel better, and various symptoms, digestive,
+rheumatic and nervous, of which they complained, began to disappear.
+
+Nearly always night workers are more prone than the ordinary run of
+workmen to some indulgence in spirituous liquors. Cold and shivery on
+the way home from work in the early morning, they take a nip of
+whiskey to brace them up. Alcoholic cirrhosis of the liver is a little
+more common among sea captains, policemen, printers and night workmen
+on the railroads than among the average of the population. The reason
+for it seems to be that undilute whiskey is thrown into the
+circulation by being taken into the stomach at a time when that viscus
+is empty and all the cells are craving food and drink. It is carried
+directly to the liver, and there either produces or predisposes to the
+bad effects upon liver cells which we know as cirrhosis.
+
+It is usually useless to treat such men for the indigestion and other
+symptoms that are likely to develop as a consequence of their habits,
+without getting at their story completely. It is easy, as a rule, to
+relieve them of certain of their symptoms by ordinary drug
+therapeutics. Unless their habits are changed, this relief, however,
+is only temporary. It must not be forgotten that in recent years women
+have come to do a good deal of work at night that was not usual to
+them before. In the telephone service of certain cities, as cashiers
+in restaurants, as ticket sellers in various places of entertainment,
+{176} as office help at busy seasons of the year, women may be kept
+occupied either all night or at least until quite late. Not
+infrequently during times when rehearsals are on, chorus girls are
+kept until the wee small hours. They are particularly likely to suffer
+from such variations in normal habits, and no treatment is so
+effective with them as pointing out how they must live, if they want
+to preserve their appearance and continue in such exacting
+occupations. A healthy young woman can burn the candle of life at both
+ends with less protest from nature at the beginning than man, but she
+suffers more for it and the suffering begins sooner.
+
+
+Positions During Occupations.--The question of position during
+occupation, especially as regards its influence upon digestive
+processes, has always seemed to me much more important than most
+people think. Our idea of digestion has been so largely one of
+digestive secretions, to the neglect of the motor side of the gastric
+and intestinal functions, that we have missed some important points.
+If a person leans over a desk shortly after a meal, there is no doubt
+that the crowding of the abdominal viscera hinders peristalsis, at
+least to some degree, not of course in the robust and healthy, but in
+those who already have some irregularity or sluggishness in this
+region. The old high desks at which many clerks used to stand, at
+which even proprietors did not hesitate to take their position, had a
+reason in common sense that has been forgotten in the modern times,
+and the variation of position thus permitted seems to have been good
+for the workers.
+
+A good deal of comfort may be obtained by having a suitable desk and
+chair for business hours. Not infrequently it happens that a desk is
+too high for comfortable writing. Any discomfort that is continuous
+and makes itself felt intrusively during occupation with other things,
+will have an unfortunate effect. Such things seem trivial by contrast
+with serious disease and may seem safely negligible. Trivial they are,
+but little things count both in themselves and as to the attitude of
+mind which they occasion. It is the attitude of mind that we try to
+modify by psychotherapy, and even the removal of little sources of
+annoyance help a patient materially to get through life more happily
+and through work more efficiently and without any more discomfort than
+is absolutely unavoidable.
+
+
+_Positions After Meals_.--While we have talked thus of business
+people, what is said refers, also, to the positions assumed out of
+business hours, as, for instance, at home after dinner. A Morris chair
+that permits of a somewhat reclining position, or a rocking chair that
+temps one to sit back, pretty well distending the abdomen and giving
+all due play to the internal viscera, will be found not only much more
+comfortable than a straight-back chair which tempts a man to lean
+forward, but also there will be less interference with gastric
+motility, the most important digestive function of the stomach.
+Arm-chairs which really support the arms, and therefore tend to keep
+the shoulders up, have something of the same effect. We naturally
+assume these positions, though occasionally social usage forbids them.
+The tendency, for instance, for elbows to be put on the table,
+especially toward the end of a meal, represents a natural instinct to
+lift up the shoulders and keep the weight of the upper part of the
+trunk off the abdominal organs. Children's instincts often curiously
+guide their postures--as is illustrated by the story of the little boy
+who, when asked by his grandmother if he could manage {177} another
+tart, said that he thought he could if he stood up. (See chapter on
+Position.)
+
+
+Mental Conditions of Occupations.--While the details of manual
+occupations have to be learned with great care if we are to modify the
+conditions so as to prevent certain unfortunate effects, just as much
+care has to be exercised, with those not employed manually, in finding
+out details as to mental worries, and the various disturbances
+consequent upon business conditions. Many a man has not brain enough
+to run his business and his liver. This is the old English expression,
+and the liver, as the largest of the abdominal organs, is taken for
+the physical life generally. Many people have not vital energy enough
+to waste any of it on worries and then be able to complete their
+digestion and other physiological functions with success. The
+preceding mental condition is a predisposing cause of many a purely
+physical ailment. It used to be said that during a cabinet crisis in
+England, or rather just after it was over, attacks of gout were most
+frequent among prominent politicians. Mental influence usually kept
+the attacks off until the very end of the crisis. Merchants come down
+with pneumonia or digestive disturbances more frequently during
+periods of acute business depression. Physicians are attacked by
+pneumonia, or influenza in bad form, after they have been wearing
+themselves out in an epidemic and worrying about patients. Just after
+a mother has nursed a child through a severe ailment she herself is
+prone to suffer from some acute infection. Such common-place
+infections as boils, styes, abscesses and even the more serious
+osteomyelitis are likely to come at these times.
+
+It is important, then, to know as much as possible about a business
+man's affairs. Any one who has had a series of tuberculous patients
+(who were getting along quite well in spite of latent or even active
+lesions) disturbed by anxieties of one kind or another, knows how much
+worries may mean. Men will lose weight and appetite and weaken in
+their general condition as a consequence of some serious business
+incident, while all the time physical conditions are the same as they
+were when they were improving. And it must not be forgotten that even
+in those who do no physical labor, there may be physical conditions of
+their occupation that are important. Many a business man does his work
+cooped up in a small office, with insufficient ventilation, and
+sometimes, especially where his business is on the ground floor of a
+large building, with so little sunlight that his environment is quite
+unhygienic. The great air purifier is sunlight. Unless sunlight is
+admitted for hours every day to the rooms in which people live, the
+dust that is inevitably breathed will contain living germs, active and
+noxious, though had they been exposed to sunlight these germs would be
+harmless.
+
+Especially then for people with respiratory defects of any kind,
+whether these be tuberculous or of chronic bronchitic character, the
+conditions surrounding the occupation should be carefully inquired
+into. Once the family physician knew such things as a matter of
+course. Now he is likely to know very little. The lack of such
+information may not be important for the more serious conditions that
+he has to treat at patients' homes, but they usually mean much for the
+submorbid conditions, so to say, the discomforts and chronic
+conditions, which come for office treatment. They mean much for
+comfort in life, and for the conservation of health and strength. They
+{178} represent that newer medicine which people are asking of us now
+so much more than before, which shall keep them in good health and
+prevent them, as much as possible, from suffering even from minor
+ills.
+
+
+Business Habits.--The modern idea of having a flat-top business desk,
+instead of a roll-top desk, and having it thoroughly cleared off every
+evening, so that each day's work does not accumulate, is an important
+psychic factor in the strenuous life, which in recent years many
+corporations have been taking advantage of. It is well for those who
+are their own masters to realize the value of this principle. Nothing
+so disturbs the efficiency of work, nor adds so much to the incubus
+that work may become, as having a number of unfinished things which
+keep intruding themselves. It is not always possible to dispose of
+problems, but discipline is necessary to keep us from pushing business
+matters aside. Then they have to be done in a rush, very often at a
+moment when other things are also pressing. The result is poor work,
+but, above all, a waste of nerve force and energy that leads up to
+nervous symptoms and eventually nervous exhaustion. The orderly man,
+who has learned to settle things as they come up, or at definite
+times, can accomplish an immense amount of work. Some men are born
+orderly, but any one who wants to do much work must have order grafted
+on his makeup--a habit which can be made a second nature. It may seem
+that a physician is unwarranted in intruding on a man's business
+affairs thus to inquire about the ways he does things, but this is the
+difference between psychotherapy and the regulation of life as
+compared with cures by more material but less effective means.
+
+
+Personal Hygiene.--Expert Advice.--For many men who are much occupied
+with business, the best possible safeguard for health, as well as the
+best guarantee against nervous or physical breakdown, would be a
+detailed consultation once a year with a physician regarding their
+habits of life and their business in relation to their health, present
+and future. In recent years many a business firm has found it not only
+expedient but profitable to turn to an expert accountant or auditing
+company and ask advice with regard to the management of its business.
+It is often found that certain business customs are causing serious
+drains, and that there are newer ways of doing things that save time
+and money. Sometimes a reorganization of the accounting system, or of
+the method of dealing with credits and debits, or the receiving or
+shipping department, proves advantageous to the business. Sometimes it
+is found that the capital invested will not justify the extension of
+business that is proposed, and not infrequently it is shown that a
+proposed extension adds to business movement but does not add to
+profits. Sometimes there are departments that can be dropped to
+advantage, though they seem to be adding to both business and profit.
+
+All of this may well be transferred to the question of health in its
+relation to business. Not infrequently it is found that the capital of
+strength of the business man is not sufficient to justify the
+extension that he is planning or has already attempted. Sometimes
+suggestions can be made with regard to the mode of doing business, the
+hours employed and the hours of relaxation, that will make business
+less of a drain on the system. Occasionally arrangements for sleep and
+exercise, as well as for afternoons or special times of diversion, may
+save a man from that concentration of attention on one thing {179}
+which frequently leads to nervous breakdown. Not infrequently business
+men who are of neurotic habit have customs of doing business which add
+to their nervous irritability, and these might be modified so as to
+lessen the call on nervous energy. There is need that the physician be
+looked to as an expert in personal health and its relation to
+business, just as the expert accountant or auditing firm is looked to
+for advice with regard to business methods.
+
+
+
+CHAPTER IV
+
+THE MIDDLE OP THE DAY
+
+Information regarding the mid-day meal will be of value to the
+physician in many cases. In cities, luncheon, likely to be rather an
+apology for a meal, is taken rapidly, and immediately there is a
+return to work. As a medical student in Vienna, I was much interested
+in the mid-day meal of the bankers and merchants of the old Austrian
+capital. At that time--I hope they have not changed the good custom
+since--the banks closed at 12 o'clock and did not open again until 3
+o'clock. This gave time for taking the mid-day meal in comfort, and
+for a proper interval for digestion. In all the southern countries of
+Europe, for seven or eight months in the year at least, little is done
+during the two or three hours in the middle of the day. The people get
+up earlier and rest at mid-day as a break between the afternoon and
+morning. It is quite beyond expectation that anything like this will
+ever again be possible in the great commercial cities. The fact that
+this was the custom of our European forefathers, however, shows how
+business has obtruded itself on the habits that man would naturally
+form for himself. Business men hurry to luncheon, or if they take any
+time over it, it is because they have invited some one to lunch with
+them with whom they wish to talk over important matters. This means of
+saving time recalls the well-known expression of James Jeffrey Roche:
+"Time is money. Every second saved from your dinner now is a sequin in
+your doctor's pocket later on in life!"
+
+
+Hurried Lunch.--The seeds of our frequent American dyspepsia are sown
+partly at the hurried breakfast and then at the hurried mid-day lunch.
+When a physician finds this to be the case, then the patient's habits
+must be reformed. Otherwise there is little prospect of relief from
+neurotic digestive symptoms, or from those uncomfortable feelings so
+often supposed to refer to the heart, or other important organ, when
+digestion is interfered with. There should be pleasant company at
+luncheon if possible; it should be preceded by fifteen or twenty
+minutes in the open air, with, as far as possible, complete seclusion
+from business thoughts so as to allow the stomach to secure its share
+of blood, and it should be followed by at least half an hour of
+pleasant occupation that does not call for serious mental work. This
+may not be possible for every one, and many will complain that this is
+asking too much in our busy time. We physicians are not here to make
+the nice customs of medicine courtesy to great kings of finance or to
+the busy tyrants of the professions, but to tell them what we think
+should be {180} done in order that nature may not be abused. Men
+should be advised to take their luncheon in some building different
+from that in which their offices are located, or, if they eat in the
+same building, to go out on the street for a while before the meal. In
+the old days men used to call on one another in order to transact
+business, and these little trips were often made just before or after
+luncheons.
+
+Now the telephone and the messenger boy have done away with this, with
+a great saving of time, but with an increase of intensity of labor
+that makes for nervous exhaustion. Luncheon clubs are excellent things
+when men do not talk shop, but they have one fatal defect. Almost
+invariably they lack simplicity of menu, and, because of the variety
+supplied and the example of others, there is a tendency to eat to
+excess. A game of billiards after eating is often excellent, because,
+when standing, digestion is accomplished with more comfort than when
+seated. A walk after the lighter midday meal is a good thing, though
+the old saw said "after dinner sit a while," but that was in reference
+to the largest meal of the day, and may still hold good for the
+evening meal, which is likely to be the heaviest one.
+
+
+Women's Lunch.--Women are very likely to take their mid-day meal, when
+it is their luncheon, very irregularly. If they have to get it for
+themselves they are likely to be satisfied with almost anything. If
+they get it outside the house they are likely to take it rather late,
+so that if they have breakfast before eight o'clock, this putting off
+of the next meal causes some disturbance of the economy. When the
+stomach gets to be empty, either there is a tendency to swallow air,
+or there is a rumbling sense of fullness that disturbs the appetite,
+or the appetite itself is capricious, and a headache develops. How
+many headaches are due to missed meals it would be hard to say, but
+this is one of the most fruitful causes of the ordinary passing
+headache. Delicate women, and especially those who work, are likely
+not to eat enough luncheon. All the details with regard to this meal
+must be known or the physician will find it hard to get rid of many
+neurotic symptoms, particularly in working women. The same thing is
+true for the so-called society woman, since she is likely to have a
+late breakfast and then skip her mid-day meal. This is permissible if
+she is so stout as to be able to spare it, but it is all wrong if she
+is thin and needs every ounce of weight.
+
+
+Nature of the Noon Meal.--During the last two generations fashion,
+custom and the increasing demands of business have pushed the hour of
+taking the principal meal farther and farther away from mid-day. There
+are, however, cases in which it seems better that the principal meal
+should be taken in accordance with the old custom, about noon time.
+For tuberculous patients this is especially important. They often have
+fever in the afternoon that seriously disturbs appetite. They may eat
+with comfort and relish a couple of hours before the fever is due. For
+delicate persons, especially those who have not much appetite for
+breakfast and who can not be persuaded to eat a sufficient amount
+early in the morning, a hearty meal at noon is almost a necessity.
+They should be shown how low their nutrition is during working hours.
+Their principal meal of the day before was taken between six and seven
+o'clock. They have had a light breakfast, a meager lunch, and
+naturally have little reserve force during the afternoon hours. As a
+consequence they become overtired, this lessens the appetite, they do
+not eat properly, and, {181} above all, they do not digest as well as
+they would if their last good meal were not so far away. They are
+suffering from inanition, and, as is well known, starving people
+cannot be allowed to eat heartily, because their stomachs have not
+enough vitality to digest well.
+
+It is often difficult to change the hour of taking the principal meal,
+but in special cases this can be done with decided advantage. I have
+seen such a change make all the difference between slow recuperation
+from bad colds, and have seen it of the greatest possible importance
+in tuberculosis. The very changing of the hour will sometimes
+suggestively react to make the patient eat more heartily than usual,
+the day is broken up better, the reaction against the morning
+discouragement comes earlier, and the patient's general condition
+improves. Many people rest better at night if their principal meal is
+taken at the middle of the day.
+
+
+
+CHAPTER V
+
+THE LEISURE HOURS.
+
+Then comes the return from business. Here once more the ordinary
+method of getting on a crowded train, standing up to be pushed and
+jammed, to have all sorts of unpleasant things happen, to have the
+pessimism of one's nature stirred to its depths by the utter disregard
+for women, the heedless rush of men, the roughness of railroad
+employees, and the general lack of humanity that characterizes the
+evening rush from business in a large city, is eminently unsuitable as
+a preparation for dinner; while a calm walk of three to five miles is
+ideal. To walk home will probably take twenty minutes or half an hour
+longer, but not more than this--and it avoids the undesirable features
+of the usual method.
+
+
+Gymnastics.--Occasionally one finds that men rush through the last
+hour of business in order to spend an hour in a gymnasium. Often this
+is quite undesirable. Exercise within doors, taken in a routine manner
+and merely for the sake of exercise, with no diversion of mind, is
+eminently unsuitable for the busy man. What he needs is air much more
+than exercise. Walking out of doors is the very best thing for him. If
+he walks at a rapid pace, swinging his arms a little freely and
+carrying a cane in one hand and perhaps a book in the other, because
+this exercises his fingers and keeps him from having any unpleasant
+congestion of the hands when they hang down, then the exercise is
+almost ideal. Owing to the novelty of it, and the interest that a new
+occupation arouses, great benefit will at first be derived from the
+gymnasium. Very often, too, the cold plunge after the exercise does
+more good than the exercise itself. The plunge is real fun, especially
+when taken with many others, but the exercise itself is likely to
+degenerate into the sorriest kind of a task. If the man who walks home
+will take a bath before dinner, the temperature of the water being
+made suitable to him and the reaction that comes to his particular
+nature, there is no need of anything else, and there is nothing better
+that he could do. The walk must be varied. The course must not always
+be through the same streets. Occasionally it {182} should even lead
+one to see some monument or new building, or to go out of the way with
+a friend, so that variety is introduced.
+
+
+Work at Home.--There are men who in busy times take some of their work
+home with them. This is a mistake. And though it is the custom to tell
+the doctor that they cannot do otherwise, it is practically always a
+bit of self-deception. When the case is properly put before them, they
+realize, if they already have any neurotic symptoms, that to continue
+home work will be a serious risk. Most men who carry business home
+with them, easily get into the habit of pushing certain details away
+from them during the day with the idea that they will have more time
+for that in the evening. They do a certain amount of dawdling over
+their work. If they really resolved to finish work during business
+hours they could do it, and do it better than during the evening at
+home. Six hours of work is about all that a man ought to do with his
+intellect at high pressure. This should be pretty well divided into
+two periods of three hours each, with an interval of an hour to an
+hour and a half between. The nearer a man can come to this arrangement
+the better for him, and the better, also, for his affairs. If he has
+assumed obligations that require more of his time and attention than
+this, he is trying to do too much.
+
+
+After-Dinner Hours.--The evening hours and their proper occupation are
+important for the business man, or for anyone who is much occupied
+during the day. The temptation to let the work of the day run over
+into the evening must be overcome at all costs, or it will prove
+serious for the health of most men. It is important as far as possible
+to get something completely different for men to do at night. Many men
+settle down to the reading of a newspaper or of a magazine or novel.
+While this does very well under some circumstances, reading does not
+provide diversion whenever there is serious worry or solicitude over
+business matters. A man may think that he is occupying himself with
+the newspaper, but we all know very well that business cares intrude,
+that business troubles are often doubled by reading about others. The
+reading of novels does well for a while, but the serious-minded man
+tires of them and then, while they may occupy a couple of hours, they
+have exactly the same objection as the newspaper. A genuine diversion
+should give the physical basis of mind an opportunity literally to
+remake itself by storing up new energies.
+
+
+_Amusements_.--The fact of the matter is that a man must have, if
+possible, some other serious interest in life besides his business. He
+must have a hobby. We have discussed this in the chapter on Diversion
+of Mind and refer to it here only to indicate the importance of
+knowing something about a man's recreation as well as his work. It is
+not a casual occupation but a real interest that he should have. This
+need not necessarily be a useful employment and, indeed, it may be
+absolutely useless provided it is absorbing. Card playing is an
+excellent diversion for many people. When joined with gambling, new
+worries and feverish excitement usually make it harmful for neurotic
+persons. Chess is hard work, but of a different kind from that of the
+day and, therefore, often makes an excellent recreation. Any games are
+good. Bowling, for instance, is excellent, and billiards, if a man has
+an interest in it, is a fine sport for evening hours. It has the added
+advantage of physical exercise. A man does not sit down during
+billiards, crowding his {183} already well-distended abdominal
+viscera, but walks around and gives his viscera a better chance for
+their work and aids rather than retards peristalsis.
+
+
+_Encroachment on Sleep_.--There is just one defect about some of the
+more absorbing recreations--they keep a man up too late. Whenever a
+so-called recreation takes up such time that a man has less than eight
+full hours in bed, then a mistake, almost sure to be serious sooner or
+later, is being made. When the physician tries to limit a man's
+recreation by suggesting an earlier hour for retirement, he may be
+told that his patient must have some time for diversion and
+recreation. But the physician must insist that no form of recreation
+is as good as sleep, and any other form must be limited in order that
+sleep may be obtained. A man may easily regulate his affairs so that
+he shall have eight hours of sleep, and it is only negligence of such
+regulation that gives him the idea that recreation cannot be obtained
+except after eleven o'clock at night. Little suppers after the theater
+are often fine diversions, but whenever they interfere with sleep they
+must not be allowed except at long intervals. Other diversions that
+keep a man out of bed after midnight are sure not to do good in the
+long run, though an occasional lapse in this matter may prove a
+stimulant rather than a depressant. It is custom that must be
+regulated; an occasional variant from it is rather good than
+otherwise.
+
+
+Leisure of the Working Woman.--A woman's occupation, unlike a man's,
+holds out little future for her. Her occupation does not arouse her
+ambition. Daily work is a monotonous grind that must be endured for
+the sake of the wages that it brings. For a time this serves to occupy
+attention. After some years, when the prospects of matrimony grow
+less, and further advance is out of the question, women often need to
+have some special interest that will grip them. The working woman may
+then need to be tempted to some occupation of mind, especially with
+the companionship of others, that will give her renewed interests in
+life. Clubs, charities in which they are active, friends, serious
+intellectual interests, must all be appealed to, in different cases,
+in order to secure diversion. Women must have something to look
+forward to each week. They must know on Monday that before the
+following Sunday there is going to be a theater party, a lecture, a
+visit to friends, something to break the deadliness of weekly routine,
+which is anticipated with pleasure and then pleasantly remembered.
+This may seem to be only a slight matter, but it is of importance in
+many cases.
+
+
+Feminine Occupations.--The occupations of women who stay at home are
+even more important than those of women who go out to work. In our
+time the root of much nervousness, as it is called, neurotic symptoms
+of various kinds and of many symptoms apparently quite distant from
+real nervousness, is really a lack of occupation. Many women who live
+in apartment hotels have almost nothing with which to occupy their
+minds. They are not obliged to get up in the morning if they do not
+want to, or, at least, any excuse, however slight, serves to keep them
+in bed. Very often there are either no children or the mother has
+nothing to do with her children early in the morning. After the age of
+three, they go off to kindergarten; later on they go to school.
+Breakfast is sent up, there may be a nap of an hour or two after the
+meal, and often a magazine is glanced over lying in bed, and perhaps
+it will be twelve o'clock before madame gets up. Anyone in a position
+to do this, and who allows the habit to grow, is sure to be profoundly
+{184} miserable. Without any real occupation of mind, the mind
+occupies itself with the body and emphasizes every sensation, evokes
+new pains and aches, and the consequence is likely to be a highly
+neurotic state.
+
+Such women have nothing serious to think about in the afternoon. At
+best it is a luncheon engagement with a friend, or attendance at the
+matinee, or a lecture, or a meeting of a club. For a while, and for a
+certain few, these things are satisfying, but after they have been
+indulged in for a time, they pall so completely on most people as to
+leave them almost helplessly at the mercy of their feelings. These
+persons may have some favorite charities that occupy part of their
+time. They may have other interests, but most of these interests are
+quite amateurish. They create no obligations; they arouse no sense of
+duty; they are abandoned at a moment for anything else that turns up,
+and consequently they lack that absorbing power that a real interest
+gives. It is quite impossible that these people should be either happy
+or healthy. These ladies of leisure sometimes have fads for physical
+exercise that keep them from becoming absolutely sluggish, but except
+in a few cases, these fads pall after a time, and in a few years women
+of the leisure classes are generally without any interest that will
+save them from themselves. The root of many a case of nervousness that
+wanders from physician to physician and then from quack to quack, and
+from charlatan of one kind to charlatan of another kind, that takes up
+now this remedy and now that, and advertises each new method of
+healing--mental, hypnotic, mechanical--is due to nothing more serious
+than lack of proper occupation of mind.
+
+
+The Ambition to Have Nothing to Do.--It seems to be the ambition of
+everyone to reach a place in life so that he can give up work and do
+nothing. Men and women often envy those whose material situation is
+such that they are not compelled to work. It is from the leisure
+classes, however, that our neurotic invalids are mainly recruited. The
+symptoms these people give will sometimes make one wonder whether they
+may not be suffering from some serious ailment, but just as soon as
+the details of their daily occupation are gone into, the real cause
+for their complaints can be readily seen. Nothing will do them any
+lasting good until they get interested enough in life to be distracted
+from themselves. Such men and women are invalids by profession. They
+are profoundly to be pitied, for they are much more the victims of
+present-day social conditions than of any special fault of their own.
+They go from one health resort to another seeking relief and now and
+again finding it, not because of any special effect of the remedies
+that they take, but just in proportion to the amount of diversion and
+occupation of mind they are able to secure in their wanderings. After
+a time they relapse, then, the old cures having lost novelty, the
+physician who succeeds in occupying their minds does them good; his
+brother physician, who does not, fails; but anyone else, however
+absurd his quackery, who can in any way catch their attention, will
+benefit them at least for the time being.
+
+
+Business Anxieties.--The physician should know all that concerns such
+sources of excitement, worry and anxiety, as are suggested by the
+words speculation, investment, going on bonds and securities,
+especially when the person bonded gets into trouble. Fortunately most
+of these latter sources of worry have been eliminated by the bonding
+companies of recent years. Details {185} of this kind were given to
+the old family physician as a matter of course. With the going out of
+the family physician there has often been no one to replace him in
+hearing such stories, and it has been harder for some to bear the
+consequences in solitude. The very telling of many cares lessens the
+burden of them. The warnings of a medical friend may be more effective
+in keeping a man from serious loss than those of financial friends.
+Everyone realizes that the physician's advice is quite unselfish and
+that what he objects to, even more than the danger and loss of money,
+is worry and anxiety which may lead to loss of health.
+
+For ordinary therapeutic purposes, the physician may be content to
+know only the physical signs and symptoms of his patient's affection.
+For psychotherapeutics, he must, if he would be successful, know every
+possible source of worry and annoyance and, as nearly as may be
+ascertained, every slight phase of physical fatigue that may be a
+disturbing factor in his patient's life. It is surprising how many
+things the physician will find to correct when he carefully goes over
+all the actions of the day and ascertains all the possible sources of
+worry and anxiety his patient may have. It may happen that in many
+cases he will be unable immediately to remove these sources of worry.
+But there is relief in telling them, and then, even when they cannot
+be completely eradicated, they can often be modified. Every
+improvement of this kind, however slight, is a fountain of favorable
+suggestion which makes the patient look on the brighter side of life.
+From every amelioration, however trivial, there is a reaction on the
+feelings that gives more and more confidence.
+
+
+{186}
+
+SECTION IV
+
+_GENERAL PSYCHOTHERAPEUTICS_
+
+
+CHAPTER I
+
+GENERAL PRINCIPLES OF PSYCHOTHERAPY
+
+
+In formal, deliberate psychotherapeutics the first and most important
+principle is the treatment of the individual patient, and not of his
+disease. It is much more important to know the kind of an individual
+who has pneumonia, as a rule, than to be able to tell the amount of
+pulmonary involvement. If heart, kidneys or lungs are affected when
+the disease declares itself, the outlook is extremely unfavorable.
+Similar conditions are true of the patient's mind. If he is of the
+worrying kind, the outlook is serious. If, on the contrary, he faces
+it bravely, and without after-thought except that of responding to
+medical treatment, he will probably get well.
+
+Pneumonia is only one example of the part the individual plays in
+therapeutics. In the popular mind it is supposed that for each disease
+there is a definite remedy, and that when the physician gives that
+remedy the patient gets well. This idea of specific remedies has come
+to the people from the physician, but only the quack now pretends to
+cure disease, the physician helps the patient to overcome the
+affection from which he is suffering.
+
+
+No Incurable Patients.--There are many incurable diseases, but there
+are no patients to whom a doctor should say with truth, "I can do
+nothing for you." We may be unable to do anything for the underlying
+disease. That may be absolutely incurable. In spite of this, there are
+practically always symptoms for which the patient can be afforded so
+much relief that he feels better than before. This is the most
+important attitude of mind for the physician who would use
+psychotherapy. He can always do something. Prof. Richet said not long
+since, "Physicians can seldom cure, but they can nearly always relieve
+and they can always console," and it is the physician's duty to lift
+up and console the mind as well as to heal the body.
+
+
+Unfavorable Suggestions.--Patients often have many opinions and
+conclusions with regard to their ailments which are not confided to
+their medical attendants, and which constitute the basis of many
+annoying symptoms. They have mental convictions with regard to the
+incurableness of their ailments, the supposed progressive character of
+the disease, and the development of symptoms which will still further
+annoy them, that are often more serious and harder to bear than the
+symptoms from which they are actually suffering. Unless the physician
+has their complete confidence, these patients may suffer much in
+silence, though the revelation of their state of mind would {187}
+often be sufficient to afford a good measure of relief, and the
+correction of false notions would do nearly all the rest.
+Psychotherapy confers its benefits mainly by securing the most
+complete _rapport_ between the mind of patient and physician. Good
+advice is often more important than any medicine. The correction of
+wrong notions will do more to relieve the patient, and make whatever
+symptoms he has bearable, than most of the anodyne drugs. The
+stimulation of hope means more than almost anything else in arousing
+the latent forces of nature and predisposing to recovery. The removal
+of unfavorable suggestions is but little less efficient.
+
+
+_Study of the Individual_.--The great differences in the relations
+between physicians and their patients is well recognized. To some
+physicians a patient will present only conventional symptoms, while a
+follow practitioner will discover the elements of an interesting case.
+Above all, the painstaking physician, interested in psychology, will
+find mental and other personal manifestations in his patient that
+distinctly modify the course of the disease. We must know all that is
+possible about the patient's attitude of mind toward his malady, and
+all the ideas that he has acquired with regard to it, either from
+previous relations with physicians or from what he may have read or
+heard from others. The removal of many false notions that are thus
+working harm will reward the medical practitioner who gets at his
+patient's ideas. The old rule in therapeutics is _non nocere_--to be
+sure to do no harm. The special rule in psychotherapy is to be sure to
+remove all the ideas that are doing harm to the patient and making his
+symptoms mean more to him than they really signify.
+
+
+_Neutralizing Contrary Suggestion_.--In the application of
+psychotherapy, then, the first principle is the neutralization of
+unfavorable mental influence. In our day men have such a smattering of
+knowledge about disease, especially about the worst forms of it, that
+they are likely to be in a frame of mind with regard to many
+affections that is quite unfavorable. Many patients think disease and
+not health. Disease means discomfort, and consequent loss of vital
+energy and disturbance of the resistive vitality that would enable the
+patient to throw off the affection. Sometimes the physician does not
+realize what a large part unfavorable suggestions are playing in the
+affection. Sometimes patients conceal their state of mind lest the
+doctor should confirm their worst fears. The preliminary to all
+successful treatment is to remove unfavorable suggestion.
+
+
+Favorable Suggestion.--The next thing is to set certain favorable
+suggestions at work. It is possible always to do this. Even in certain
+of the acute diseases favorable suggestion has its place, and for all
+chronic cases this form of therapeutics is extremely important. The
+very presence of the physician, especially if he is thoroughly in
+control of himself, placid, imperturbed, evidently ready to use all
+his powers without any excitement, is of itself the strongest kind of
+favorable suggestion. From the very beginning of medical history the
+presence of the physician has in most cases meant even more than his
+medicines.
+
+Münsterberg, in his recent book on Psychotherapy, has emphasized this
+in a way that deserves to be recalled:
+
+  There is one more feature of general treatment which seems almost a
+  matter of course, and yet which is perhaps the most difficult to
+  apply because it cannot {188} simply be prescribed: the sympathy of
+  the psychotherapist. The feelings with which an operation is
+  performed or drugs given do not determine success, but when we build
+  up a mental life, the feelings are a decisive factor. To be sure, we
+  must not forget that we have to deal here with a causal and not with
+  a purposive point of view. Our sympathy is therefore not in question
+  in its moral value, but only as a cause of a desired effect. It is
+  therefore not really our sympathy which counts but the appearance of
+  sympathy, the impression which secures the belief of the patient
+  that sympathy for him exists. The physician who, although full of
+  real sympathy, does not understand how to express it and make it
+  felt will thus be less successful than his colleague who may at
+  heart remain entirely indifferent but has a skillful routine of
+  going through the symptoms of sympathy. The sympathetic vibration of
+  the voice and skillful words and suggestive movements may be all
+  that is needed, but without some power of awakening this feeling of
+  personal relation, almost of intimacy, the wisest psychotherapeutic
+  treatment may remain ineffective. That reaches its extreme in those
+  frequent cases in which social conditions have brought about an
+  emotional isolation of the patient and have filled him with an
+  instinctive longing to break his mental loneliness, or in the still
+  more frequent cases where the patient's psychical sufferings are
+  misunderstood or ridiculed as mere fancies, or misjudged as merely
+  imaginary evils. Again everything depends upon the experience and
+  tact of the physician. His sympathy may easily overdo the intention
+  and further reinforce the patient's feeling of misery, or make him
+  an hypochondriac. It ought to be sympathy with authority and
+  sympathy which always at the same time shows the way to discipline.
+  Under special conditions, it is even advisable to group patients
+  with similar diseases together, and to give them strength through
+  the natural mutual sympathy; yet this too can be in question only
+  where this community becomes a starting point for common action and
+  common effort, not for mere common depression. In this way a certain
+  psychical value may be acknowledged for the social classes of
+  tuberculosis as they have recently been instituted.
+
+
+Favorable Environment--After the removal of unfavorable suggestion and
+the implanting of favorable suggestion, the next point must be the
+persistent occupation of the patient's mind with thoughts favorable to
+his condition. A nurse who is inclined to be pessimistic must be taken
+out of the sick room, and there must be only cheerful faces and cheery
+people around him. Hence the modern trained nurse, and especially the
+picked nurse, who does not allow herself to be disturbed, who is not
+fussy, who is not forcibly cheerful but quietly placid and confident
+and cheery, means much for the patient's recovery. Relatives are
+almost sure to exert strong unfavorable suggestions, though time was
+when the devoted wife or mother might be depended upon to cover up all
+her personal feelings and give the best possible service for the
+mental uplift of the patient. When she can thus conceal her own
+solicitude, a near relative may be the best possible auxiliary in
+psychotherapeutics.
+
+
+Natural Relief.--The fourth step in the application of
+psychotherapeutics is that all the natural modes for the relief of
+symptoms, the making of patients comfortable in body as well as in
+mind, must be employed. In acute rheumatism, for instance, a number of
+small pillows must be at the disposition of the patient so that his
+limbs can be fixed in those positions in which there is the least
+discomfort. Every physician should frequently read Hilton's classical
+volume on "Rest and Pain" because of its unpretentious significance
+for psychotherapy, as well as its enduring value in the treatment of
+painful conditions. Just as soon as a patient finds that simple
+procedures relieve his pain and add to his comfort, his fear of the
+seriousness of his ailment is lessened, {189} and he begins to get
+bettor. Cold water in fevers, cold fresh air in pneumonia, all the
+natural modes of treating disease, thus become active factors in the
+application of psychotherapy. When fevers were treated by the
+administration of hot drinks the effect upon the patient's mind must
+have been quite serious. Freedom to use cold water, just as one wants
+it and whenever it is craved for, is of itself an excellent
+suggestion.
+
+
+Neuroses in Organic Disease.--Fifth, psychotherapy, by suggestion, may
+alleviate or even completely eradicate neurotic symptoms that develop
+in connection with organic diseases. Such neurotic symptoms may prove
+even more bothersome to the patient than the symptoms due to his
+underlying affection, and may, by interfering with nutrition, hamper
+recovery. The appetite of a patient who is worrying about a chronic
+disease will be disturbed, and, as a consequence of insufficient food,
+constipation and a whole train of attendant evils may ensue. Headache,
+sleeplessness, worry at slight irritation and exaggerated complaints
+from slight pain may all be due to this worry and not to the
+underlying disease. All these, the result of over-solicitude, are
+attributed by the patient to his chronic ailment. They can be relieved
+by simple measures after he is saved from his own worry. Until the
+patient is made to rouse himself and look hopefully at the situation,
+eating more, getting out more, and relaxing his mind from its constant
+attention to himself, he cannot get better.
+
+
+Application of Principles.--It should be pointed out to the patient
+that there is a constant tendency to exaggerate the significance of
+disease. This is true in acute as well as in chronic disease, but in
+acute diseases the necessity for removing unfavorable influences
+directly is not so urgent, since usually the presence of the
+physician, with his simple declaration of the meaning of symptoms, is
+sufficient to neutralize the effect of previous exaggerations.
+
+Secondly, the action of unfavorable suggestions due to imperfect
+knowledge (everything unknown is magnified, as Cicero said), or to
+previous medical opinions which the case does not justify, must be
+stopped. The natural dread which comes to all men in the presence of
+symptoms of disease must be as far as possible removed.
+
+Thirdly, the favorable elements in the case should be emphasized. This
+needs to be thoroughly done in order to secure the patient's
+co-operation, even though the serious possibilities of his ailment may
+be pointed out to his friends. These friends, however, must be persons
+who can be absolutely depended on not to reveal by word, or, what is
+much more important, by their looks or actions, the possible worse
+prognosis of the case.
+
+Unfortunately, people expect a doctor to tell them the worst, rather
+than the best. Many physicians seem to have formed the habit of
+representing the condition of patients as grave as possible, in order,
+apparently, that they may have more credit when the patient recovers.
+Not a little of the tendency of ills to hang on in neurotic persons is
+due to this habit. Over-cautiousness leads some physicians to reveal a
+case in its worst aspect, lest, by any chance, something unexpected
+should happen, and the friends of the patient might think that the
+physician was incompetent because he had not anticipated it. Some of
+the serious accidents of disease are quite beyond anticipation; but
+they occur only rarely. For the sake of safeguarding the possible
+reflection on the physician because of them, it is quite unjustifiable
+to make bad {190} prognosis habitually, for this acts deterrently on
+the vital resistance and delays recovery.
+
+
+_Symptoms of Organic Disease_.--It is usually considered that
+psychotherapy is beneficial only in nervous cases; yet we know that
+all sorts of affections with tissue changes in the skin, in the
+circulation, and very probably also in the internal organs, may be
+produced in hysterical affections--ailments dependent on loss of
+control over the vaso-motor nervous system. Just as ills can be
+produced, so they may also be cured. As a matter of fact, analysis of
+the statistics of disease cured by mental influence, shows that it has
+been more strikingly manifest in organic than in so-called nervous or
+functional diseases. Neurotic patients often make extremely unsuitable
+subjects for the exercise of mental influence, because their very
+nervousness is a manifestation of lack of power properly to control
+the mind. Cures by mental influence have oftenest been reported in
+non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence
+of the Mind on the Body" as long ago as 1884, it is in such cases as
+rheumatism, gout and dropsy that benefit was most frequently reported
+by mental means.
+
+Tuberculosis, certain digestive and intestinal ailments that evidently
+are associated with tissue changes, have in recent years come
+particularly into this category of ailments affected by psychotherapy.
+Dr. Hack Tuke's declaration, made nearly thirty years ago, seems
+conservative even at the present day: "The only inference which we are
+justified in drawing from the statistics of the affections cured by
+mental means is that the beneficial influence of psychotherapeutics is
+by no means confined to nervous disorders." Many physicians are likely
+to hold that when cures take place the so-called organic diseases were
+not actual, but were only _supposed_ to exist because of certain
+obscure symptoms that apparently could not otherwise be explained. But
+many of the cases have had external symptoms, striking and
+unmistakable. To assume that physicians of experience and authority
+were in error in diagnosing them is simply to beg the question. It is
+more probable that mental influence acted curatively even over tissue
+changes as it so often does, directly under our observation, in the
+production of such changes in the skin.
+
+
+_Tissue Changes From Nerves_.--Until one recalls how many physical
+changes may be brought about by mental influences or emotional
+disturbances, it is not always clear just how mental influence can
+affect disease favorably or unfavorably. Prof. Forel, of Zurich, in
+his "Hygiene der Nerven und des Geistes im Gesunden und Kranken
+Zusande," Zurich, 1905, English translation 1907, brings together into
+a single paragraph most of these physical and physiological influences
+of the mind upon the central nervous system:
+
+  Through the brain and spinal cord, thoughts can lead to a paralysing
+  or stimulation of the sympathetic ganglion nodes, and consequently
+  to blushing or blanching of certain peripheral parts. Through
+  disturbance of this mechanism, many nervous disorders arise, such as
+  chilblains, sweats, bleeding of the nose, chills and congestions,
+  various disturbances of the reproductive organs, and, if it lasts
+  long enough, nutritional disturbances in the part of the body
+  supplied by the blood vessels affected. In the same way there are
+  peripheral ganglionic mechanisms which superintend glandular
+  secretion, the action of the intestinal muscles, etc. These likewise
+  can be influenced through the brain by ideas and emotions. Thus we
+  can explain how constipation and a vast number of other disturbances
+  of digestion and of menstruation can be produced through the brain,
+  without having their cause in {191} the place in which they appear.
+  It is for the same reason that such disturbances can be cured by
+  hypnotic suggestion.
+
+_Health and the Central Nervous System_.--Nature has so constituted
+and ordered the human economy that its health depends to a great
+extent on conditions in the central nervous system. We discuss
+elsewhere the return of vitalism in physiology--that is, the
+reassertion of a principle of life behind the chemical and physical
+forces of the human organism regulating it, supplying energy,
+occasionally enabling it to transcend the ordinary laws of osmosis, or
+the diffusion of gases. The main seat of this principle of life is in
+the central nervous system and especially in the cerebral cortex. The
+importance of this portion of the human anatomy can scarcely be
+exaggerated. In his inaugural address to the Royal Medical Society,
+[Footnote 23] delivered at Edinburgh in 1896, Prof. T. S. Clouston,
+the distinguished English psychiatrist, has a passage on this subject
+that deserves to be recalled:
+
+    [Footnote 23: _British Medical Journal_, January 18, 1896.]
+
+  I would desire this evening to lay down and to enforce a principle
+  that is, I think, not sufficiently, and often not at all, considered
+  in practical medicine and surgery. It is founded on a physiological
+  basis, and it is of the highest practical importance. The principle
+  is that the brain cortex, and especially the mental cortex, has such
+  a position in the economy that it has to be reckoned with more or
+  less as a factor for good or evil in all diseases of every organ, in
+  all operations and in all injuries. Physiologically, the cortex is
+  the great regulator of all functions, the ever active controller of
+  every organ and the ultimate court of appeal in every organic
+  disturbance.
+
+
+_Psychotherapy in Its Relation to Patient and Physician_.--In spite of
+the present-day fad for psychotherapy, I have no illusions with regard
+to its popularity among patients, unless practiced with due regard to
+individuals and with proper tact. Psychotherapy has been most
+effective in the past when it was cloaked beneath the personality of
+the physician; when it was felt that there was in him a power to do
+good that must help the patient. This personal influence has to be
+maintained if the patient's mind is to be influenced favorably. Very
+few people are willing to think, and still less to welcome the
+thought, that they themselves are either bringing about a continuance
+of their symptoms or are hindering their own recovery. They are quick
+to conclude that this would be a confession that their ills are
+imaginary. "Imaginary" has no place in medicine. There are physical
+ills and mental ills. Mental ills are just as real as physical ills.
+There are no fancied ills. A person may be ailing because he persuades
+himself that he is ailing, but in that case his mind is so affecting
+his body that he is actually ailing physically, though the etiology of
+the trouble is mental.
+
+It is the duty of the physician to get at these mental causes of
+physical ills and remove them by persuasion, by reassurance, by
+changing the mental attitude, by making people understand just how
+mind influences body, but this must be done tactfully. From the
+beginning of time we have written our prescriptions in such a way that
+ninety-nine out of one hundred patients have not been able to
+understand them. It has often been said that we should change this
+method of prescription writing, and write directions for the
+compounding of our medicines in plain vernacular. Besides the many
+{192} scientific reasons against this, it is better for patients not
+to know exactly the details of their treatment. Physicians, because of
+their real or supposed knowledge, are usually the worst patients. If,
+when a physician is ill, a drug is administered in which he has lost
+confidence, he will really oppose its action by contrary suggestion,
+and perhaps neutralize it. Confidence added to the action of the drug
+itself, makes it much more potent and much more direct. Hence the
+suggestive value of a prescription the ingredients of which are
+unknown. Every physician knows of patients who have declared that a
+drug has been tried on them without avail, when it has only been used
+in such small quantities as to be quite nugatory in its effect. Such
+use was enough to prejudice them against it so that when given in
+physiological doses it failed to work properly.
+
+Opium given to a trusting patient, in gradually reduced doses until
+practically there is nothing but the flavor of the drug in the
+compound that he takes, will continue to have its effect. But to a
+patient prejudiced against the drug, even large doses of opium will
+prove unavailing, because the lack of confidence disturbs the mind,
+directs attention to whatever discomfort may be present, emphasizes
+the ill and prevents sleep by preoccupying the mind with the thought
+that neither the drug nor the dose can accomplish its purpose. In a
+word, medicine plus mental influence is extremely valuable. Medicine
+minus mental influence is valuable but sometimes ineffective.
+Medicine, with mental influence opposed to it, is often without effect
+because of the strong power the mind has over bodily functions.
+
+Most people would rather be cured by some supposedly wonderful
+discovery, which presumedly made it clear that they had been suffering
+from a severe and quite unusual ailment, than by ordinary simple
+methods. The recent growth of interest in psychotherapy and psychology
+has, however, somewhat prepared people to accept mental influence as
+an important factor in therapeutics. The direct and frank use of
+psychotherapy will be of benefit to these people. But in most cases
+mental influence will have to be exerted in such a way as to conceal
+from patients that it is their own energy we want to tap to help them
+cure themselves. This would be for them quite an unsatisfactory method
+of being cured. In practically all cases such a combination of methods
+is needed that the place of mental influence is not over-emphasized.
+As a rule, mental influence must not be used alone. Its place is that
+of an adjunct, a precious auxiliary, to other methods of treatment.
+
+Psychotherapy represents one of the important elements in
+therapeutics, and we must learn to use it in a way suitable to our
+patients. We have to learn to use our drugs in accordance with the
+nature and physical make-up of the patient. We have to find out by
+experience just how to use hydrotherapy for each individual. Varying
+currents of electricity and varying forms of electrical action are
+needed for different individuals. Just in the same way, our
+psychotherapy must be dosed out according to the special need of each
+individual, the form of the affection and the particular kind of mind
+that is to be dealt with. To learn the place of mental influence in
+healing, so that we shall not be attributing to other therapeutic
+factors what is really due to the mind, will be a great advance in
+therapeutics. This is the mistake that we have been making in the
+past.
+
+In brief, the applications of the general principles of psychotherapy
+{193} include all means, apart from the physical, of influencing
+patients. Drugs will always have a large place in rational therapy.
+Many physical remedial measures, hydrotherapy, electrotherapy,
+climatotherapy and others, must be important adjuncts. To these is now
+added psychotherapy. It has been used before, as have most of the
+other forms of therapy, but in our day we are trying to systematize
+therapeutic modes so as to secure the greatest possible information
+with regard to their exact application. This is what must be done with
+regard to psychotherapy also. Just now its importance is being
+exaggerated by ardent advocates. In every department of therapy this
+has always been done by enthusiasts. The business of the practicing
+physician must be to select what is best, and above all what is sure
+and harmless, from the many suggestions offered, so as to build up a
+practical body of applied truth.
+
+
+{194}
+
+SECTION V
+
+_ADJUVANTS AND DISTURBING FACTORS_
+
+
+CHAPTER I
+
+SUGGESTION
+
+Under the head of Adjuvants and Disturbing Factors in the psychic
+treatment of patients come the various phases of life which make for
+and against such a favorable state of mind as predisposes to the
+continuance of good health, minimizes inhibition, and adds to
+favorable suggestion. By modifying the modes of life, an ever renewed
+set of suggestions is initiated. By definite instruction and advice
+with regard to exercise, position, training, habit, pain, occupation
+of mind and diversion of mind, patients may be profoundly influenced,
+and gradually made to take on an entirely new attitude of mind towards
+themselves. These chapters, then, while apparently much more concerned
+with physiotherapy than psychotherapy, are really directions for the
+use of such physical methods as by frequent repetition make the most
+valuable suggestions. There is probably nothing more valuable in the
+ordinary application of psychotherapy than these various auxiliaries,
+with their power to remove disturbing factors, while, on the other
+hand, nothing aids more in bringing relief for many conditions than
+the removal of certain disturbing factors.
+
+There is now a general recognition of the fact that suggestion in the
+waking state can in most cases be as therapeutically efficient as
+hypnotism, and is probably even more enduring in its effects when
+successful, without the dangers and sequelae connected with hypnosis.
+_Every idea tends to act itself out_. When we crave something, when
+there are active ideas of desire, there usually are movements of our
+flexor muscles. These affect the hands especially. At moments of
+hatred, detestation or abhorrence our extensor muscles are affected,
+as if we would wave these things away from us. There may even be an
+involuntary turning of the trunk muscles, as if we would no longer
+face what is abhorrent, though the repulsive thing may be present only
+to the mind. It is not far-fetched to argue that, since the voluntary
+function of muscles is thus influenced, other functions are also
+touched by emotions, ideas, trains of thought, especially when the
+mind is much concentrated on them.
+
+Bishop, the so-called mind-reader, whose exhibitions attracted much
+attention in London and New York some years ago, confessed that his
+feats were accomplished mainly through muscle reading. He would permit
+a committee to select a book in a library in a certain house, and even
+a particular page of {195} that book, and then, blindfolded, sitting
+with the committee in a carriage with his hand on the forehead and the
+arm of one of the committee, he would direct just where the carriage
+should be driven and would, while always continuing his contact with
+the member of the committee, go to the particular house and room,
+select the special book, and eventually find the page. There was no
+opportunity for collusion in some of these feats. The most startling
+things were often accomplished by the system of forcing a choice which
+prestidigitateurs use in order to compel the taking of the particular
+card by suggestion (though all the time they seemed to be leaving
+absolute liberty of selection to the person), but there was much,
+besides this, required to accomplish what he did. He said that there
+were always involuntary muscle movements, little starts and tremors
+that guided him in his work. Other exhibitors have been able to use
+this to a considerable extent, though not with Bishop's success. That
+our thoughts can be read in our muscle system is interesting and
+valuable confirmation of the unconscious tendency of ideas to affect
+the body.
+
+When a single idea occupies the consciousness it will, some
+psychologists insist, necessarily act itself out unless some
+distracting thought prevents it. We know how difficult it is to stand
+at the edge of a height, say at the brink of a waterfall or on the
+cornice of a high building, or to look down a mine or elevator shaft,
+because the thought comes to us, how dreadful it would be to plunge
+over. As a consequence of this insistent idea taking possession of our
+consciousness, we have the sense of falling, we become tremulous and
+have to withdraw, or we would actually fall, or find in ourselves a
+tendency to throw ourselves over. There are persons who cannot even
+sit in the front row of a balcony because of the constant effort
+required to neutralize the suggestion that they may fall or throw
+themselves over its railing. Curious sensations become associated with
+this idea--a feeling of numbness and tingling in the back, sometimes a
+girdle feeling, sometimes a sense of suffocation. All of these are due
+to the concentration of attention on a single idea and its
+suggestions.
+
+Very few men, shaving themselves with an old-fashioned razor, have
+not, at moments of worry and nervousness, sometimes had the thought of
+how easy it would be to end existence by drawing the edge of the razor
+through the important structures in the neck. Some are so affected by
+this thought that they have to give up shaving themselves. It is a
+surprise usually to find how otherwise sensible, according to all our
+ordinary standards, are the individuals who confess to having had
+annoyance from such thoughts. This illustrates how strongly suggestive
+the concentration of attention may make an idea, and how much a single
+idea, when it alone occupies the center of consciousness, tends to
+work itself out in act, though there is no reason at all for willing
+in that direction. It is not improbable that in some inexplicable
+cases of suicide the tendency has actually worked itself out.
+
+The expression, "he is a man of one idea," enshrines in popular
+language the conclusion of psychologists that if a single idea is
+present in the mind it will surely work itself out. We all know how
+much men of one idea accomplish. All their powers, physical and
+mental, are brought to bear on its development. Obstacles that deter
+other men, conditions that prevent others from daring even to think of
+doing the thing, seem as nothing to the man {196} of one idea, and in
+spite of discouragement, and even apparent failure, he often succeeds,
+notwithstanding obstacles that seemed insurmountable. What is thus
+true in the practical world is paralleled, for both good and ill, in
+the microcosm of the human body. A man who has one idea to urge him on
+is capable of accomplishing things in spite of pains and aches and all
+sorts of disturbances of function. On the other hand, if the one idea
+is unfavorable, then, in spite of a heritage of good physical and
+mental powers, his efficiency is inhibited. If a man gets an idea that
+there is something the matter with any organ, and concentrates
+attention on it, he will surely disturb the function of that organ.
+Just the opposite, however, will happen in case, even with physical
+defect, he believes that there is nothing the matter, or only
+something that can be overcome. This is the power of faith as
+illustrated in the various forms of faith healing, from mental science
+to Eddyism and the rest.
+
+This is the power that the physician must learn to use. In _The
+Lancet_ for November, 1905, Dr. J. W. Springthorpe, writing on the
+"Position, Use and Abuse of Mental Therapeutics," said:
+
+  Few indeed are the medical practitioners who daily prescribe
+  suggestion as well as diet, hygiene and drugs. Yet the physician who
+  makes even a minimum effort in this direction often does more for
+  his patient than his more highly qualified confrère, who makes none.
+  To some, and they naturally the most successful, this endeavor comes
+  without conscious search, and improves with experience, but in some
+  measure it may be acquired by all and no one who has become familiar
+  with its powers will henceforward be content to remain without its
+  constant aid.
+
+This power is thoroughly exploited by the irregular practitioner, and
+the regular practitioner is bound in duty to learn to use it just as
+thoroughly.
+
+What is true for the lesser faculties is eminently true for our most
+important faculty, the intellect. We all know how intellectual
+training enables us to accomplish without difficulty what at first
+seemed almost impossible. Not only that, but we acquire the power to
+devote ourselves to a subject that was at first irksome, if not
+actually forbidding. There are educators who insist that this
+discipline of mind, by which the power to devote ourselves to what we
+do not care for is gained, is the principal fruit of genuine
+education. It has been lost, or at least impaired to a great degree,
+by educational experiments, especially those related to the elective
+system which pushed interest, instead of discipline, into the
+foreground of education. In the same way the power of self-control,
+and the faculty of self-denial, so precious to the human race, have
+been lessened by the methods of training which omitted the
+consideration of these and emphasized the idea of personal comfort.
+Much can be done to make the unpleasant things that are inevitable in
+life not only tolerable, but actually to give a satisfaction
+surpassing selfish pleasure. It is this discipline that is needed in
+psychotherapy at the present time and the physician must endeavor to
+encourage it by every means in his power.
+
+The one purpose of the use of suggestion in therapeutics, then, is to
+secure as far as possible concentration of mind on a single idea. This
+is what is done in hypnosis, but frequently in such a way as to leave
+the idea {197} to work out unfavorably associated suggestions. If
+there could, in the conscious state, be the same absolute
+concentration of mind on an idea, a great force for good, without
+accompaniment of ill, would be secured. Experience has shown that with
+patient effort and definite methods such concentration of attention on
+a single idea can be secured, at least to such an extent as to make it
+efficiently therapeutic.
+
+Ordinarily, suggestion accompanies the material remedies that the
+doctor prescribes. He must emphasize just when and how the medicine is
+to be taken, and it is well to emphasize the effects that are expected
+and just about how they will come. If he is prescribing a tonic, he
+does not merely say before meals. He specifies from ten to twenty
+minutes before meals, according as he wishes it taken, with a definite
+amount of water, stating that the taste of it will excite appetite and
+that only food in reasonably liberal quantities will satisfy the
+craving produced by it. If he is prescribing a laxative, he states
+just when it should be taken and when its effects may be expected. The
+arousing of expectancy does much to relax inhibition and to permit the
+flow of nervous impulses that may be helpful. If a sleeping potion is
+given, the patient is directed to compose himself for sleep
+immediately after it is taken, or to take it just a definite time
+before he gets into bed, and then to expect its action in the course
+of twenty minutes or a half hour, designating rather definitely just
+when it shall have its climax of effect. Two or three things done
+together, as, for instance, a gentle rubbing with cool water over the
+body to produce a glow, a warm foot-bath, and then a sleeping potion,
+will combine to produce a climax of physical and psychical effect.
+
+In many conditions that come for treatment to the modern physician,
+the physical remedies are much less important than the psychical. This
+is particularly true for the affections known as psychoneuroses, in
+which some slight nervous disturbance is exaggerated into an extremely
+painful condition or a disturbing paralytic state; in the so-called
+hysteria of the older times; in the drug habits; in the sex habits; in
+the over-eating and under-eating habits, and then with regard to
+dreads and other psychic disturbances connected with dreams,
+premonitions and the like. In all these cases it is important to
+secure concentration of the patient's mind on a neutralizing
+suggestion. This must be done deliberately and in such a way as to
+secure thorough concentration of attention. It is often a time-taking
+process, but nearly everything worth while requires time, and the
+results justify the expenditure. Methods mean much in the attainment
+of this. They must be impressive, the patient must be convinced of the
+power of the physician to help him, and he must have trust in the
+efficacy of the mode of treatment.
+
+The patient should be put into a comfortable position, preferably in a
+large, easy arm-chair, should be asked to compose himself in such a
+way as to bring about thorough relaxation of muscles, and then to give
+his whole attention to the subjects in hand. Occasionally the arms
+should be lifted and allowed to fall, to see whether relaxation is
+complete, and the knee jerks may be tested, to show the patient that
+he is not yet allowing himself fully to relax. There should be no
+lines in the face: the muscles around the mouth, and especially those
+in the forehead, should relax. It is surprising how {198} much can be
+done, sometimes by slight touches on the forehead, to secure this. The
+patient should then be made to feel that the tension in which he has
+been holding himself, and which makes it so difficult for him to
+relax, has really been consuming energy that he can use to overcome
+the tendencies to sensory or motor disturbance, or to supply the lack
+of will which makes him a victim of a drug or other habit, or takes
+away from him that mental control that would enable him to at once
+throw off dreads and doubts and questionings and bothersome
+premonitions which now, because of the short circuiting on himself
+through worry and nervousness, he cannot do.
+
+Two or three séances usually show a patient how much better control
+over himself even a short period of relaxation will give. He comes out
+of a ten-minute session of relaxation, during which he has been talked
+to quietly, soothingly, encouragingly, with a new sense of power.
+Often he feels that there will be no difficulty in overcoming his
+habit. This may pass, of course, but he has received a new idea of his
+own resources of energy and self-control.
+
+In most cases it is well, after securing relaxation, to ask the
+patient to close his eyes gently and to keep them closed till all his
+muscles are relaxed. Then suggestions may be made to him with regard
+to his power to control cravings, and to put away doubts and
+questionings, because, after all, as he sees them himself, they are
+quite irrational and entirely due to habitual tendencies that he has
+allowed to grow on him. A concentration of attention on the idea, not
+only of conquering but of being able to conquer, will be secured.
+Unless this complete attention can be had, suggestion in the waking
+state may not prove efficient. There are nervous, excitable people for
+whom, at the beginning, it will be quite impossible to secure such
+relaxation and peaceful quiet as will be helpful to them. For these a
+number of séances may be necessary, but on each occasion a little more
+of quieting influence is secured.
+
+In recent years, this quiet, peaceful condition, with eyes closed,
+thorough relaxation and absolute attention, has sometimes been spoken
+of as the hypnoidal state. If it be recalled that hypnos in Greek
+means sleep, and that this is a state resembling sleep with the
+restfulness that sleep gives, the term is valuable in its suggestions.
+If, however, the word is connected with hypnotism, then there may be
+an unfortunate connotation. This state is entirely free from the
+dangers of hypnotism, and instead of making a patient dependent on his
+physician, teaches him to depend on his own will. It is not a new
+invention as this term hypnoidal might seem to indicate, but is as old
+as our history at least.
+
+
+
+CHAPTER II
+
+EXERCISE
+
+In recent years a great change has come over the popular mind
+regarding exercise, especially in the open air. It is well to
+emphasize at the very beginning the subject of too much exercise,
+because there is no doubt in the minds of many who study the question,
+that many Americans, and indeed people of the northern nations
+generally, take a certain amount of voluntary {199} exercise that is
+not good for them, though they take it at the cost of considerable
+effort and sacrifice of time and are firmly persuaded that it is of
+great benefit.
+
+
+Sufficient Exercise.--There is a much larger number of persons who do
+not take sufficient exercise. The amount to be taken is eminently an
+individual matter. Neurotic patients exaggerate everything in either
+direction, so that perhaps the state of affairs that exists is not so
+surprising as it might otherwise seem. Instead of the uncertainty that
+prompts now to too much exercise, and again to too little, for
+health's sake there must, as far as possible, be a definite settlement
+of the needs.
+
+
+National Customs.--There is a curious difference in the attitude of
+mind of the various nations towards exercise. Most of the southern
+nations of Europe do not as a rule take any violent exercise. As is
+well known, however, they are not for this reason any less healthy
+than their northern contemporaries, though perhaps they are less
+strong and muscular. But muscularity and health are not convertible
+terms, though many people seem to think they are. An excess of any
+tissue is not good. Our economy should be taxed to maintain only what
+is useful to it. Nature evidently intended, in cold climates at least,
+that men should maintain a certain blanket of fat to help them retain
+their natural heat, but any excess of fat lessens their resistive
+vitality by lowering oxidation processes. Fat in cold climates can be
+used to advantage as a retainer of heat. In the warmer climate it
+would be a decided disadvantage. Muscular tissue is a manufacturer of
+heat and this is a decided advantage in the colder climates, but in
+the temperate zone, where the summers are very warm, muscle in
+over-abundance, unless its energy is consumed by actual physical
+exercise, may be quite as much of a burden as fat. Muscular people do
+not stand heat well. They demand exercise to keep muscle energy from
+being converted into heat, and they require frequent cold baths, and
+other forms of heat dissipation, in order to be reasonably
+comfortable.
+
+
+Exercise in Early Years.--The question of the amount of exercise that
+is to be taken must be decided at an early age for individuals. Most
+of the young people of the Celtic and Anglo-Saxon races are tempted by
+traditions and by social usage to develop considerable muscle during
+their growing years. In this respect, the difference between the
+German and the English schoolboy is very striking. The English
+schoolboy is likely to be as "hard as nails," as the expression is, as
+a consequence of violent exercise in his various sports, taken often
+to the uttermost limit of fatigue. The German schoolboy has his walk
+to and from school, and some other simple methodical exercises, with
+some mild amusements that make little demand on muscle, but of games
+in the open he has very few, and of the violent sports he has none at
+all. A comparison of the health of the two nations will not show that
+the English boy, who receives a public school and a university
+education, with all their temptations to exercise, enjoys any better
+health, and, above all, reaches an average longer life than the German
+youth, who has gone through a similar educational career in his own
+country, but without the athletic training that the English schoolboy
+has had.
+
+As a consequence of the absence of athletics and its diverting
+interest, the German is apt to have learned more than his English
+colleague, but a {200} comparison of mortality and morbidity tables
+would show that his resistive vitality, his power to overcome disease
+and recover from accident is not lower than that of his colleague from
+across the North Sea. The German is less strong muscularly, and in a
+contest of physical effort would as a rule come out second best, but
+then we have gotten beyond the period when it is important for a man
+to be able to defend himself by physical force, except in emergencies
+that may never come. Surely the English time and effort devoted to
+athletics is not justified by this.
+
+
+_Preparation for a Sedentary Life_.--Certainly if a young man is going
+to live a sedentary life in his after years, it does not seem
+advisable for him deliberately to devote much time to muscular
+exercise during his growing years. This only provides him with a set
+of muscles for which he has no use. Ordinarily it is assumed that
+muscles are organs for the single purpose of evolving energy. This is
+not true, since they are important organs for the disposition of
+certain food materials and for the manufacture of heat for the body.
+Nature in her economy probably never makes an organ for one function
+alone, but usually arranges so that each set of organs accomplishes
+two or three functions, thus saving space and utilizing nutrition to
+the full. The man with a well-developed muscular system, which he is
+not using, will have to feed it, and besides will have constantly to
+exert a controlling power over the heat that it manufactures whenever
+it is not dissipated by actual exercise. For these reasons he will be
+constantly nagged by it into taking more exercise than his occupation
+in life demands, and if he does not do this, his developed musculature
+is likely to deteriorate so as to be a serious impediment, or to
+degenerate by fatty metamorphosis into a lower order of tissue that is
+a clog and not a help to life.
+
+The Germans are more sensible. As students, they live quite sedentary
+lives, develop their muscles just enough to keep them in reasonably
+good health, and then, when it comes to living an indoor life, as will
+be almost inevitable in their chosen professions or occupations, they
+do not meet with the difficulties that confront the Anglo-Saxon with
+his burdensome, over-developed muscular system. German professors, as
+a class, do not find themselves under the necessity of taking
+systematic daily exercise. They are quite content and quite healthy
+with an hour or two of sitting in the open air, and a quiet walk from
+the home to the university or the school. With the ideas that some
+people have with regard to the value of exercise for health, it might
+be expected that the German professors would be less healthy than
+their Anglo-Saxon colleagues. This is notoriously untrue, for the
+Germans live longer lives on the average, and most of them accomplish
+much more, and above all are much more content in the accomplishment,
+than their physically strenuous Anglo-Saxon colleagues. They are not
+oppressed by the demands of a muscular system that insists on having
+its functions exercised, since it has been called into being in the
+formative period. These German professors live to a magnificent old
+age, requiring very little sleep and often doing a really enormous
+amount of work. The man with a developed muscular system generally
+requires prolonged sleep, particularly after exercise, but even
+without it very seldom is it possible for him to do with less than
+seven hours, while the Germans often are content and healthy with five
+hours, or less.
+
+{201}
+
+Our muscular system is our principal heat-making apparatus. It is easy
+to understand. If we have larger heat-making organs than are necessary
+for the maintenance of the temperature of the body, and if we have no
+mode of dissipating our heat by muscular energy, as through exercise,
+then there will be a constant tendency for our temperature to rise,
+which must be overcome, at considerable expense of energy, by the
+heat-regulating mechanism of the body. This heat-regulating mechanism
+is extremely delicate, yet does not seem to be easily disturbed. With
+the external temperature at 120° F. or--10°, human temperature is
+constant. With a heating apparatus entirely too large for its purpose,
+it is no wonder that irritability of the nervous system ensues because
+of the constant over-exercise of a function called for from it. It is
+this state of affairs which seems to me to account for the marked
+tendency to nervous unrest, and to the presence of many heart and
+digestive symptoms that often characterize athletes who develop a
+magnificent muscular system when they are young, and later have no use
+for it. They must learn the lesson and keep up the practice of using
+their muscles sufficiently to dissipate surplus heat, so as to prevent
+this energy from being used up in various ways within the body, with a
+resulting disturbance of many delicate nervous mechanisms.
+
+
+Useless Muscles.--Whatever a human being has to carry round as useless
+can only be expressed by the telling Roman word for the baggage of an
+army, _impedimenta_. Prof. James, in his "Principles of Psychology,"
+sums up the law very well:
+
+  The great thing in all education is to make our nervous system our
+  ally instead of our enemy. It is to fund and capitalize our
+  acquisitions and live at ease upon the interest of the fund. For
+  this we must make automatic and habitual as early as possible as
+  many useful actions as can be and guard against the growing into
+  ways that may be disadvantageous to us as we should guard against
+  the plague.
+
+An over-developed muscular system, with its tendency to manufacture
+heat and its craving to be used, and the consciousness it is so apt to
+produce of ability to stand various dangerous efforts, is a
+disadvantage rather than an advantage.
+
+
+Useless Fat.--This reminds us very much of the attitude with regard to
+children in the acquisition of fat. Chubby babies with rolls of fat
+all over them and deep creases near their joints are considered to be
+"perfectly lovely." Mothers are proud to exhibit them. They are
+supposed to be typical examples of abounding good health. Neighborly
+mothers come in to coo over them and, in general, the main aim of
+existence for children in their early years would seem to be to make
+them as fat as possible. Such children, as is brought out in the
+discussion of the subject in the chapter on obesity, are not healthy
+in the true sense of the word, are well known to be of lower resistive
+vitality than thinner infants, and easily succumb to diseases.
+
+
+
+Resistive Vitality.--One reason for the early deaths of many athletes
+is the fact that, confident of their strength, they allow themselves
+to become so overwhelmed by an infection, before they confess that
+they are sick and take to bed, that often the cure of their affection
+is hopeless. Ordinarily neither pneumonia nor typhoid are likely to be
+fatal diseases for men between twenty and fifty. If a man's heart and
+kidneys are in good condition during this {202} period, an attack of
+either of these diseases, while a serious incident, is likely to be
+only a passing loss of time. Rather frequently, however, strong and
+healthy men without any organic defect that may be considered
+responsible for the fatal termination, succumb to these diseases. The
+reason for the fatality is that they are not willing to admit that
+they are ill enough to be in bed, they have a large reserve force of
+strength on which they call and which enables them, for a good while,
+to resist the weakening influence of disease. Doctors know and dread
+these cases. A young man in the flower of youth, with magnificent
+muscular development, comes into the office breathing very rapidly and
+with a laboring pulse. Almost exhausted, he sinks into a chair,
+confesses that he is nearly "all in," and wonders what is the matter.
+At times the physician will find practically a whole lung solidified
+by pneumonia, and at times both lungs are seriously affected. The
+wonder is how the young man succeeded in holding out so long.
+Sometimes the doctor is summoned to see him because he has fainted in
+his home, or in his office, and his friends are alarmed. These cases
+are almost invariably fatal. Any one who continues to be up and around
+until the third or fourth day of pneumonia will have so exhausted his
+vitality, no matter how great that may be, that he will have no
+reserve force for the life-struggle that must come before the crisis
+is reached.
+
+Nearly the same thing is true for typhoid fever in the same class of
+persons. A young athlete, who considers it babyish to confess to
+illness, complains of feeling out of sorts but nothing more, until
+some morning he is literally unable to leave his bed, or has a
+fainting fit after going up-stairs. He is found by the physician with
+a temperature of 104°, or near it, and with evident signs of being in
+the middle of the second week of typhoid fever. The termination of
+such a case is generally fatal.
+
+The ordinary man knows his limitations better; he recognizes the fact
+that he may be ill, and gives in quietly and rests, so that nature may
+employ all her energies in conquering the infection. Most of the
+long-lived people of history have been rather delicate and have
+learned young the precious lesson of caring for themselves. This care
+has not been exaggerated, but it has consisted in avoiding danger, in
+resting when tired, in not overdoing things, and above all in yielding
+to the symptoms of disease before these become serious.
+
+
+Regulation of Exercise.--Each man must be a law unto himself as to the
+amount of exercise that is necessary for him. He must take enough to
+use up the energy supplied by the food he eats, just as, on the other
+hand, he must eat enough food to make up for whatever waste there is
+in his body. There are many men who eat over-heartily and then have to
+take exercise to use up this material or else suffer for it. This is
+one of the compensations that the hearty eater must pay: he overfeeds
+and becomes obese, or, if he succeeds in keeping down his weight to
+the normal, it is only by the expenditure of time in securing such
+muscular action as will use up surplus energy. Many men find it
+difficult to control their appetites, and prefer to take exercise
+rather than to deny the appetite which they created during their days
+of indulgence in athletics. It is for such men to decide just what
+seems preferable. If the fuel is supplied to the heat engine, which
+all human beings are, it must be used for the production of energy or
+else it will exert {203} itself in accumulating certain waste in the
+tissues, just as over-abundant fuel serves merely to clog up the
+fire-box of an engine without doing any work.
+
+
+Air and Exercise.--It is easy to deceive one's self in the matter of
+exercise. With regard to air such a mistake is almost impossible. As a
+rule, it is air rather than exercise that people need when they have
+the restlessness and nervousness which comes from over-abundant
+nutrition. Fresh, pure air enables the individual to burn up nutritive
+material to the best advantage by the encouragement of oxidation. It
+is a surprise to those who are not accustomed to it, to see how
+tuberculosis patients who come to sanatoria with very little appetite,
+soon acquire an appetite and are able to consume large quantities of
+food, to sleep well and become restful--all as the result of living
+constantly in the open air during the day, and also having an
+abundance of fresh air at night. This is particularly true if the air
+in which they live is rather cold, and, above all, if it has a large
+difference of temperature every day, so that there is an upward and
+downward swing of the thermometer of from thirty to forty degrees.
+This varying temperature seems to use up nutritive material, and keeps
+all the natural processes going.
+
+
+Gymnastics.--The very opposite to this plan of open air life is that
+followed by those who take gymnastic exercises for health's sake, with
+the idea that the use of certain muscles is necessary to keep the
+bodily economy in equilibrium. Such gymnastics are usually undertaken
+indoors, sometimes in stuffy quarters, and the movements are commonly
+repeated with such continued routine that absolutely all interest is
+lost. That there are many who advocate this form of exercise, it has
+nearly always seemed to commonsense physicians an entirely wrong
+solution of the important question of the encouragement of oxidation.
+It is like running an engine, not for the purpose of having it do
+something, but simply in order to have it oil itself, and consume the
+fuel that has been put into its boiler and that must be used up
+because more will be put in to-morrow. It would be much better, either
+to limit the amount of fuel or to give the muscular exercise some
+useful purpose, above all connect it with some interest that furnishes
+diversion of mind at the same time that the muscles are used. This
+last is the most important consideration, for, after a time,
+gymnastics pall in spite of artificial incentive.
+
+Dr. Saleeby, in "Health, Strength and Happiness," has expressed very
+forcibly what has come to be the feeling of many physicians with
+regard to gymnastics, especially indoor gymnastics:
+
+  The natural spontaneous exercise having been forbidden, and the bad
+  consequences of no exercise having become conspicuous, there has
+  been adopted a system of factitious exercise--gymnastics. That this
+  is better than nothing, we admit; but that it is an adequate
+  substitute for play we deny. . . . The common assumption that, so
+  long as the amount of bodily action is the same, it matters not
+  whether it be pleasurable or otherwise, is a grave mistake. . . .
+  The truth is that happiness is the most powerful of tonics. . .
+  Hence the intrinsic superiority of play to gymnastics. The extreme
+  interest felt by children in their games and the riotous glee with
+  which they carry on their rougher frolics, are of as much importance
+  as the accompanying exertion. And as not supplying these mental
+  stimuli, gymnastics must be radically defective.
+
+  Granting, then, as we do, that formal exercises of the limbs are
+  better than nothing--granting further that they may be used with
+  advantage as supplementary aids, we yet contend that they can never
+  serve in place of the exercises prompted by nature. For girls, as
+  well as boys, the sportive activities to which the instincts {204}
+  impel, are essential to bodily welfare. Whoever forbids them,
+  forbids the divinely appointed means to physical development.
+
+
+Play and Exercise.--There has been a distinct tendency in modern times
+to think that gymnastic exercise can be a substitute for play for
+growing young folks. When certain of the instruments and methods of
+the modern systems of gymnastics which have been introduced into
+schools, and are supposed to be so wonderfully beneficial, are put to
+the test of the psychology of exercise, the conclusions are likely to
+be very different from the theories under which they were introduced.
+Dr. Saleeby has expressed these differences rather strikingly:
+
+  Anyone who will consider for a moment the natural constitution of
+  man and the principles of natural education, must agree that the
+  deplorable thing called a dumb-bell offers an exquisite parody of
+  what exercise should really be. The cat, as she exercises her
+  kittens along the lines of their natural proclivities and needs,
+  never telling them that this is exercise for the sake of exercise,
+  and certainly prepared, if she could, to turn up her nose at any
+  artificial implement we might offer her--should be our model in this
+  respect. It may be imagined that some unfortunate girl, brought up
+  on early Victorian lines, having never been permitted to wear
+  comfortable garments, or to stretch her arms, would welcome and
+  enjoy the dumb-bells when first introduced to them. But any one who
+  has had a natural childhood and who has been taught to play, and who
+  has taken his or her exercise naturally, or incidentally in the
+  course of pursuing some mental interest--any such person may be
+  excused for saying that a pair of dumb-bells should be deposited in
+  our museums as indications of what was understood by exercise even
+  as late as the earlier years of the twentieth century. All exercise
+  for the sake of exercise is a mistake--or, at any rate, a second
+  best. You may do your mind--and body, too--more harm by sheer
+  boredom than you may gain good from the exercise you go through. The
+  dumb-bell symbolizes the fact that the most elementary and obvious
+  truths of psychology are still unrecognized, though the play and
+  games of every natural child--if you object to be instructed by
+  kittens--should be perfectly sufficient to teach us what indeed
+  nature taught us ages ago, if only we would listen to her.
+
+
+Indoor Sport.--Indoor sport is another thing. In wintry weather it is
+impossible to play outside conveniently, and indoor games have their
+place. Unfortunately they are usually associated with dust, and when
+played before crowds of spectators, the participants suffer also from
+the disadvantage of rebreathed air containing, too, the emanations of
+those who are looking on. It must not be forgotten that these two
+factors are the most prominent predisposing causes of tuberculosis.
+Those who have any tendency to tuberculosis, by which is meant
+specifically all those who are associating with tuberculosis patients,
+whether those patients are related to them or not, or who are more
+than 20 per cent. under the weight that they should have for their
+height, should not be allowed to take part in indoor sports where
+these drawbacks are sure to be encountered.
+
+Sport, because of the diversion of mind involved, is an ideal form of
+exercise. An exercise that becomes a mere routine and that can be
+eventually gone through with so mechanically as to leave abundant room
+for thoughts of business or study or worries of other kinds, loses
+sight of one of the principal purposes of exercise as nature demands
+it.
+
+
+Horseback Biding.--It is because of the complete diversion of mind
+that is necessarily involved in it, that horseback riding makes such a
+magnificent exercise for the busy man. The old expression "the outside
+of a horse is the {205} best thing for the inside of a man" is founded
+even more on the mental influence of horseback riding than its
+physical quality. The same amount of exercise in the open air, taken
+otherwise, often does not accomplish so much good, because a man's
+thoughts may continue to run on his business or be occupied with his
+worries, or he may not be able to divert his thoughts from himself and
+his digestion or his ills. A horseback rider must pay attention to the
+other animal, rather than himself, and that represents the complete
+diversion of mind so necessary for the health of most people. Just as
+soon as man rides an old favorite animal on whose back he can throw
+down the reins, allowing it to saunter on as it will, while he
+occupies himself with other things, then horseback riding loses its
+efficacy and falls back into the class of bicycle riding or carriage
+riding or walking in the open air unless there is diversion of mind in
+the scenes, or the necessity for care at street crossings, to banish
+preoccupation of mind. Unless business troubles and worries are
+necessarily excluded by its conditions, or are deliberately eliminated
+from the mind during the course of any exercise, it may even become a
+renewed source of worrisome thoughts, rather than a renewal of energy,
+mental and physical.
+
+It is doubtful whether horseback riding should ever be recommended for
+those who have not been accustomed to it from their youth. To ask a
+man past forty to learn to ride horseback for the sake of exercise is
+nearly always a mistake. It becomes a trial rather than a recreation,
+and may thus do harm rather than good. On the other hand, horseback
+riding is one of the things that may be, and indeed often is, much
+abused. The old English fox-hunting squire would never have lived out
+his life even as long as he did, consuming the amount of proteid
+material that was his custom, and drinking his three or more quarts of
+port at dinner every day, but that the excessive drain upon his system
+by long days of hard riding in the hunting field made calls upon his
+nutrition which kept even this amount of food and stimulant from doing
+immediate harm. Just as soon, however, as long spells of severe
+exercise become excuses for the consumption of big dinners, and
+exercise is used as a factor to enable one to overeat with more
+comfort than would otherwise be the case, a vicious circle is formed,
+and one serious abuse is counterbalanced by another. What many
+well-to-do people of leisure need is not so much more exercise as less
+eating.
+
+
+Walking.--Perhaps the best and most readily available form of exercise
+for most people is walking. It has one disadvantage. As soon as the
+walk becomes too much of a routine, and the ground gone over has lost
+its interest, or is even of such a nature as to permit or, indeed,
+tempt introspection and occupation with other things, rather than with
+the surroundings, then walking loses most of its efficacy as a form of
+exercise. Walking in the country, for instance, becomes monotonous,
+though at first it is a great source of pleasure. Walking in a large
+city, however, has little of this objection and as large city life has
+grown more and more strenuous in recent years, the good effect of
+walking to and from the office or walking in the busy parts of the
+city has been increased. Between the trolley and the automobile, and
+the hustling commercial traffic of the streets, it is impossible for a
+man to walk through the busier portions of any large American city
+without keeping his wits thoroughly intent on what he is doing, nor
+without requiring all of his {206} attention for his transportation.
+An abstracted man will in the course of a half hour have so many
+narrow escapes from being run down in a busy quarter that he will
+either eschew walking in that particular neighborhood, or give up his
+habits of mental abstraction, or else he will come to himself some day
+in a hospital.
+
+Besides, the passing show in city life is itself of surpassing
+interest. It is not things but men that interest us most. There are so
+many phases of human life to be seen on busy city streets, so many
+things happen in the course of even a short walk to bring out
+prominently traits of human nature that, if a man is at all
+sympathetic, he finds much to occupy his attention, to distract him
+from his own worries and take him away from his business cares. The
+long walk to and from the office may thus become an efficacious source
+of thoughts that are different and of profound pleasure. All depends
+on the man and his mood. Men who try it whole-heartedly soon find a
+renewed interest in life. An hour of daily walking in the open air
+with the distractions of city life all around, provided the walking is
+done briskly and faithfully, is of infinitely more hygienic value than
+an hour of gymnasium work. There is only one thing that hampers this
+form of exercise--there are so many excuses to tempt one not to keep
+it up. If one gets to a gymnasium there is an instructor or director
+who keeps tabs on one's hours and so helps a weak human will, and
+excuses are easier made to one's self than to others.
+
+
+Massage as Exercise.--This curious tendency of men to take their
+exercise far more regularly, provided some other is concerned in their
+taking it so that it cannot be neglected without explanation, is
+illustrated in many of the experiences of the doctor in modern life. A
+number of forms of massage have come into vogue as wonderful
+cure-alls. It is comparatively easy for some men, and above all for
+many women, to take their exercise by means of massage rather than in
+some more vigorous way that requires their own initiative. A man who
+is working hard, and who feels the need of exercise, will not take the
+easy natural way of getting up half an hour earlier, having his
+breakfast half an hour sooner and then walking down to his office four
+or five miles, but he hears of someone who gives vigorous massage and
+he engages him to come every morning and exercise him for half an hour
+or an hour. In order to do so, he has to get up an hour earlier, but
+the fact that he has the engagement with someone else, rather than
+with himself, makes it more difficult for him to make excuses, and so
+morning after morning, in spite of the fact that he may have been up
+late the night before, perhaps to a big dinner, he gets up to be given
+his exercise. If he is a heavy eater he will, of course, at the end of
+a week or ten days feel ever so much better for he has been using up
+material that was clogging his circulation and irritating his nervous
+system.
+
+At the end of a month he will probably feel so much better that he
+will conclude that he has found the root of all evil in life, or of
+all disease, in a failure of circulation that can be removed by means
+of massage, manipulation and passive movements. When he gets well
+enough to give it up, he drops straight back into his old troubles,
+because what he needs is a radical change of life that will adapt his
+eating to the amount of exercise that he takes, and his exercise to
+the amount that he eats. If this fails to come, he has had only a
+temporary benefit that has probably tempted him rather to increase
+{207} the amount that he eats normally than otherwise and will
+probably do him harm in the end. This massage brings about a distinct
+reduction in the weight of women, and as most of them are very
+desirous of this, the remedy becomes even more precious to them than
+to men. Here, too, however, it is only a temporary expedient. They are
+tempted to eat more than before, or at least not to reduce their diet,
+and the good that is accomplished is only for the moment, while no
+habits, either of restraint of eating, or of more exercise in the open
+air which so many of them need, have been formed.
+
+
+Passive Movements.--The success of osteopathy has been largely founded
+on this curious peculiarity of human nature. People are not satisfied
+to regulate their eating and exercise in a sensible way. They prefer
+to submit to various methods of exercise, manipulations and passive
+movements which make up for the muscular exertion that should help the
+circulation within the body, but do not accomplish the purpose nearly
+so well as the voluntary exercise of muscles. It requires little
+exercise of will to submit to this treatment, while for many people it
+requires considerable exertion of will power to exercise their muscles
+for themselves. The old particularly, who are likely to suffer from
+achy conditions around joints, always worse on rainy days, which would
+be expelled by enough exercise to stimulate the circulation in these
+structures, find the new remedial measures of vicarious exercise of
+great service to them and consequently osteopathy has gained many
+votaries. Old members of many a state legislature who have been
+accustomed to ride for so long that exercise is almost an unknown
+quantity in their lives, are treated by the osteopath and lose so many
+vague pains and aches and discomforts of various kinds that it has not
+been difficult to persuade them that it is a great new discovery in
+medicine, and so in many of the states the osteopaths have secured
+legal recognition.
+
+
+Summary.--Exercise, as exercise, often does harm rather than good.
+Thin people seldom need exercise, stout people seldom take enough of
+it. No one should be encouraged to exercise merely that he may be able
+to use up material that he has eaten, when it is evident that he is
+eating more than is required for his ordinary occupation. The question
+can never be settled without taking into consideration all these
+individual peculiarities of each case. Properly used, exercise is one
+of the most important therapeutic aids. But it is liable to as many
+abuses as are drugs, and the patient's attitude of mind toward any
+particular exercise is always an extremely important factor. If the
+exercise produces fatigue and disgust, then it will do no good, in
+spite of all that is hoped from it. If it creates true diversion of
+mind, it will surely be precious, even though it may, for other
+reasons, seem unsuitable.
+
+
+
+CHAPTER III
+
+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 {208} 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 {209} 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 {210} 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 {211} 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 {212} 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.
+
+{213}
+
+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.
+
+
+
+CHAPTER IV
+
+TRAINING
+
+One of the most important factors for therapeusis in the sense of the
+amelioration of defective motor conditions, the relief of disturbing
+sensory affections and the restoration of or compensation for
+defective functions of various kinds is training. By this is meant the
+training of the power of attention and its concentration in such a way
+that defects are overcome. There are many examples of almost marvelous
+improvement of function brought about in this way that are familiar,
+but it is well to recall some of them here in order to illustrate the
+uses to which this therapeutic mode may be applied. A blind man is
+able to read by means of his finger tips, and to recognize raised
+letters that seem quite beyond the possibility of tactile recognition
+by {214} ordinary individuals gifted with all their senses. The
+peculiar skill is simply due to the individual being able by
+concentration of attention upon slight variations in touch sensation
+to recognize even minute differences readily and so read raised
+letters with comparative ease and rapidity.
+
+Over and over again it has been shown that neither the congenitally
+blind nor those whose vision has become defective have any better
+sense of touch than the average person. With an esthesiometer, their
+power to recognize the distance between the points of a calipers is
+shown to be no better than that of an ordinarily sensitive individual.
+This is illustrated in other ways. Certain blind persons, even those
+born blind, are known to be able to distinguish colors more or less
+accurately, that is, at least the three primary colors. Their power to
+do this is consequent upon a faculty of recognizing differences in
+heat absorption. The ordinary seeing person going into a room in the
+dark recognizes at once the difference between a pencil and a piece of
+metal of the same shape and size by its weight and the greater
+tendency of the metal to feel colder. When we are not sure whether a
+pillar in a structure is of stone or an imitation, we determine this
+by touch, and the fact that stone absorbs heat rapidly while wood and
+other imitations of stone do not. It is the same faculty for
+distinguishing specific heat that enables certain blind people to
+recognize colors. If pieces of cloth of different colors are put over
+snow when the sun is shining on them, it will be found that black
+absorbs much more heat than the colored cloths, or white, and
+consequently that the snow melts faster beneath the black. After black
+comes red, then green, then blue. It is this difference in the power
+to absorb heat that the blind recognize and thus distinguish colors
+after long patient training of themselves.
+
+
+Obstacle Sense.--An example of the value of training is the so-called
+obstacle sense which has been rather carefully studied in recent
+years. By means of it blind people are able to avoid larger obstacles
+and to know when they are passing an open door or window on a corridor
+or a building alongside a street. Blind children have been known to
+play in a garden where there were trees and other obstacles and
+carefully avoid them even while moving rather rapidly. This sense is
+disturbed whenever there is loud noise in the vicinity. It is not very
+active and yet it is of considerable value to the blind. Its
+disturbance by noise would seem to indicate that it is due to some
+sense faculty in the tympanum, or ear drum. It exists in everybody,
+but remains quite undeveloped except in those who need it and
+therefore learn to make use of it.
+
+
+Touch and Sight.--The triumph of training is to be seen in the cases
+of those who are born blind and deaf and who yet are taught to
+understand through lip and throat reading by the tips of the fingers
+and taught to talk by being shown patiently the method by which others
+accomplish it, though the only avenue to their brain is the dull sense
+of touch which means so little for the ordinary individual. The cases
+of Laura Bridgeman and of Helen Keller illustrate how a sense that is
+usually quite neglected can be made to supply the place of both the
+eyes and the ears by patient, persistent training. Lip reading by
+sight is, of course, a very interesting example of the same principle
+that can be learned by anyone who has good sight in a comparatively
+short time. There are compensations of this kind and powers of
+development latent in every sense and function of the body that can be
+{215} employed to make life interesting and to restore usefulness
+after nearly every form of lesion or defect. Practically all of this
+compensatory power is mental, hence its place in psychotherapy. We do
+not increase the power of the sense but by concentration of attention
+the mind is rendered capable of obtaining definite information from
+sensory stimuli that are present in every person but that are
+ordinarily neglected.
+
+
+Hearing.--One of the most surprising instances of the value of
+training for cases in which favorable results seemed quite out of the
+question, is Urbantschitsch's method of training the deaf to hear.
+After investigating it personally I reported it in the _International
+Clinics_.   [Footnote 24] Patients who could hear but very little,
+indeed, only the loudest noises, were trained by means of loud
+shouting and the hearing of loud notes gradually to catch sounds more
+and more easily until not infrequently they could hear rather well.
+Sometimes even those who were thought to be absolutely deaf to sound
+were found to be able to hear very loud sounds and then it was
+invariably discovered that by practice they could be made to hear much
+more. The secret of the success consisted not in any increase in the
+power to hear, but entirely in training the attention to recognize and
+differentiate sounds so that what seemed at first a confused murmur
+gradually became intelligible. It is exactly the same process as that
+by which a man learns to read with his fingers. He is not able to
+differentiate the letters but after a time it is possible to do so
+without difficulty.
+
+  [Footnote 24: Lippincott & Co., Phila., Vol. IV, 8th series, 1899.]
+
+
+Equilibrium.--There are typical examples of almost as striking
+increase of muscle sensation, or rather of ability to distinguish
+minute differences in muscular sensation, noted in those who train
+this faculty carefully. Acrobats succeed in developing wonderful
+control over muscles and marvelous response to slight disturbance of
+equilibrium. The ordinary individual has comparatively small balancing
+powers, but the slack-rope performer seems almost to defy the laws of
+gravity, because he has learned so to coordinate all muscular action
+as to enable him to maintain his balance. He has trained himself to
+distinguish every variety of message from his semicircular canals. Of
+itself neither of these senses gives us very much information, indeed,
+only as much as we ask for from it, but when we pay careful attention
+to the minute details of the information that it imparts, we are able
+to use it to great advantage.
+
+
+Muscle Training.--It is this power of training to enable us to
+appreciate minute sensations that forms the basis of the Frenkel
+treatment of tabes. For the proper guidance of the muscles the
+muscular sense is all-important, though ordinarily we are quite
+unconscious of the information it conveys. This is seriously disturbed
+by the degeneration in tabes. The patient can, however, be taught to
+use even the slight amount of it that remains to great advantage or
+else to avail himself of some other compensatory sensations which will
+enable him to guide his muscles in various motions much better than
+before.
+
+This same faculty can probably be employed in many other conditions.
+Frenkel has shown that it is applicable in paralysis agitans and
+markedly relieves the rigidity that is so annoying a symptom. It gives
+these patients something to occupy their minds, too, which means a
+great deal for their {216} general condition, for occupation of
+attention saves them from neurotic disturbance of themselves.
+
+Sufferers from infantile paralysis can be taught to do many things
+with their weakened muscles that seem to be quite impossible to them.
+It requires patience to get results, but they mean so much that the
+efforts are well worth while. After cerebral incidents, sometimes
+actual apoplexies, sometimes injuries, occasionally serious effusions
+due to kidney diseases, there may be disturbance of motor functions.
+It is surprising how often training will enable the sufferer to use
+his muscles much better in these cases than at first seemed possible.
+I have seen a man who had lost most of his power for writing after a
+cerebral incident regain it as a consequence of being taught to write
+from his shoulder, instead of from the forearm as had been his custom.
+
+
+Heart Training.--In recent years we have learned that training is not
+only good for the external muscles and enables them to do more work
+without discomfort, but that it is particularly beneficial to the
+heart muscle whenever that organ can respond to it favorably. At all
+of the heart cures in recent years, exercise of some kind or another
+is one of the important features and the failure of physicians
+generally to secure as good results while pursuing all the other
+methods followed at these cures, seems to show that exercise was
+probably the most important factor. Nauheim is the typical heart cure
+and there, besides the resisted movements in the bath, there is the
+graduated exercise of the walks around the town, all of which, owing
+to the situation, lead up hill. Walking up hill, even though it be a
+gradual ascent, might seem to be the worst possible exercise for heart
+patients, yet it proves eminently beneficial.
+
+
+Respiratory Training.--Shortness of breath is often a bothersome
+symptom, especially for stout people, and prevents them from taking
+necessary exercise. When it cannot be traced directly to some
+affection of the heart or of the circulatory apparatus, it is usually
+due to lack of exercise. Much can be done for it by deliberate
+training. In the modern time, with elevators so common, people seldom
+have to walk up-stairs, and consequently one of the modes of exercise
+that was particularly likely to furnish some training in deep
+breathing is absent. Any one who has seen the shallow breathing of
+many of the patients who come to Nauheim and how much it has improved
+by the gradually increased walks up the hills around the valley, will
+appreciate how much training in deep breathing means. This exercise of
+the diaphragm will often give benefit besides in making the bowels
+more regular, and in getting rid of the accumulation of fat in the
+abdomen, which is one of the mechanical causes of the interference
+with the diaphragm and consequent shortness of breath.
+
+
+Training the Appetite.--Just as training may be used for the sensory
+and motor systems that are external, so it may also be used for many
+internal functions analogous to these. There are a great many people
+who eat too little. They are the nervous, irritable persons with no
+fund of reserve energy to draw on when anything happens, and who are
+in their years before middle life likely to be the victims of
+infectious disease. They suffer much from lack of proper covering in
+the winter time and from a certain protection that is afforded to the
+nervous system generally by being up to weight. Often their
+under-weight is a life-story, and occasionally it is a family matter.
+When {217} they suffer from neurotic symptoms a gain in weight nearly
+always does them good. They complain that when they increase their
+diet they have uncomfortable feelings. This is only what is to be
+expected, since the muscularis of their stomach--much more important
+than its secretory function--has not been accustomed to as much
+exercise as is now being demanded of it.
+
+On the other hand, for those who are over-weight, training in eating
+less is the one important therapeutic factor. If their diet is cut
+down suddenly, they soon become discouraged. If there is a gradual
+reduction of food quantities, variety being allowed, so that they may
+eat practically everything they have been eating before, the system
+gradually accommodates itself to less and less food. This is the only
+sensible way of bringing about reduction in weight. It requires
+constant attention over a long period, but it can be done with
+excellent success.
+
+In the same way the bowels may be trained to perform their work
+regularly. Habit means probably more with them than any other factor.
+Our digestive tract, however, is largely dependent on habit. We get
+hungry three times a day or twice a day, according to the custom that
+we have established. Countries differ radically in the matter, and
+nearly always, when a man goes from one country to another in early
+years, he changes to the habits of the new country, though if he comes
+after middle age he usually clings to those that he is used to.
+
+
+Training to Stand Pain.--There are many painful conditions, especially
+involving the muscles in the neighborhood of joints, that are worse on
+rainy days and are spoken of as rheumatism, that can be very much
+improved by training in the use of muscles. As men grow older and gain
+in weight, the lack of exercise in their sedentary lives incapacitates
+their muscles for activities of many kinds. The consequence is that
+where most strain is put upon them, in the neighborhood of joints,
+they readily become tender and painful. It is this class of cases
+particularly that is benefited by irregular practitioners of all
+kinds. Mental healing, osteopathy, Eddyism, the many liniments,
+rubbings and manipulations prove beneficial. What is needed is
+training in the use of muscles so as to enable them to do the work
+that is required of them without discomforting reaction. This is
+particularly true for the leg and foot muscles. Exercises that
+strengthen the muscles of the calf and of the thigh, and particularly
+such as require free movement of the foot, are almost sure to relieve
+these patients of many annoying symptoms. Pains around the ankles and
+in the knee and hip, worse in rainy weather, disappear as a
+consequence of such gradually increased use of these muscles as gives
+them increased nutrition and power. This subject is discussed more
+fully under Foot Troubles and Painful Conditions of the Knee.
+
+There may be a training in bearing discomfort which is of great value
+to over-sensitive patients. Some nervous patients seem to suffer
+merely from their ordinary physiological functions. These are the
+patients who abuse the drugs that are supposed to bring relief. There
+is just one mode of treatment that is successful with them: they must
+be told to bear their discomfort for a while without seeking drug
+relief, but always securing freedom from discomfort by means of
+attention to other things, until gradually they have succeeded in
+diverting their minds from the concentration of attention on their
+functions which is causing their disturbance. The whole programme
+{218} need not be outlined to them or they will perhaps have a
+revulsion of feeling against it that will make its accomplishment
+impossible. They can, however, be made to stand their discomforts for
+a time with the promise that it is for the best, since there will be
+eventually an improvement.
+
+
+Intellectual Faculties.--Nearly every one of our faculties can be
+trained to do much better work than we have any idea of if we only are
+willing to take the trouble and give the attention. I have often shown
+people who came complaining of loss of memory that if they wanted to
+train themselves to remember they could do so. The memory probably
+cannot be bettered any more than can the sense of touch in the blind
+man, but by attention to minute details, in the concentration of the
+mind on certain subjects, it can accomplish results that seemed quite
+impossible before. All systems of improving the memory are founded on
+this method of concentrating attention on what one wishes to remember
+and connecting it with other things that we know by experience are
+readily remembered.
+
+
+
+CHAPTER V
+
+OCCUPATION OF MIND
+
+
+Two classes of patients frequently apply to physicians for relief from
+various discomforts. They are, first, people who have no regular
+occupation and who often are in what is supposed to be the happy
+position of being able to do just what they please. The second class
+consists of those who take their occupations too seriously, so that
+they never get away from them and, as a consequence, disturb their
+physical functions. The feelings that these two classes complain
+of--for, when analyzed, their symptoms prove really to be
+uncomfortable feelings--can usually be "bothered" away and, if not
+entirely forgotten, made to disappear when the patients become deeply
+interested in something other than their usual occupation. The first
+class of patients needs occupation of mind; the second needs diversion
+of mind, and that subject will be taken up in another chapter.
+
+
+Uncomfortable Sensations, Their Location and Causes.--These pains and
+aches, as patients call them, though it is well to remember that they
+are only discomforts, senses of unequal pressure, of constriction, or
+perhaps only unusual feelings, or consciousness of sensation, may
+occur in every part of the body. Perhaps they are most commonly
+complained of in the head. Many of the so-called headaches that are
+more or less continuous consist of these senses of pressure or of
+constriction over a particular part of the skull. Sometimes there may
+be a sense of pressure at the back of the eyes. Very often there is a
+feeling of heaviness at the back of the head that makes the patient
+feel as if relief would come if the head were allowed to drop forward
+and if sleep could be thus obtained. Every other portion of the head,
+however, even within the cavities, may have some of these
+uncomfortable sensations. In some persons, there is a tightness in the
+throat. In others, there is a feeling of fullness of one cheek and the
+dread that they may not be able to use it properly in talking.
+Sometimes the uncomfortable feeling is within the nose. Not
+infrequently the discomfort is in the ear.
+
+{219}
+
+All of these may be due to local conditions which need to be
+corrected, but in most cases nothing is found locally, or at most
+there is some functional disturbance so slight that, though it is
+shared by a great many people in our climate, others do not complain
+of it at all. It seems evident, therefore, that the discomfort must
+result from the sensitiveness of the individual emphasizing the
+significance of some slight disturbance.
+
+Every portion of the body may suffer from these discomforts. The upper
+part of the back, especially below the base of the neck, is a favorite
+location in men, and particularly in those who bend over a desk. The
+lower part of the back is affected in such men as tailors and cutters
+who stoop incessantly at their work. In women, the lower part of the
+back is likely to suffer, and this is usually attributed to genital
+conditions, but constipation may play quite as large a role as the
+genital organs. Some of the stooping occupations of women, at the
+sewing machine or dressmaking, or even harder occupations, as
+sweeping, washing, and the like, may also be responsible. The
+commonest source of discomfort is, perhaps, the upper left-hand
+quadrant of the abdomen. This seems to be due to the distention of the
+stomach, either by gas or by liquid. Vague discomforts may occur
+around the umbilicus, often due to the presence of gas, with or
+without borborygmi.
+
+Generally the local condition is only an occasion, and the real cause
+of the complaint is the lack of occupation of mind and consequent
+concentration of attention on any organ whose function happens to be
+disturbed sufficiently to make one conscious of its action.
+
+
+_Lack of Occupation_.--For all of these cases the most important
+therapeutic factor is occupation of mind and diversion of attention.
+In our time, social conditions allow a large number of people to have
+very little occupation. For instance, many women of the well-to-do
+classes have absolutely nothing that they must do. Various phases of
+this are discussed in previous sections.
+
+As a rule, it is useless to try to relieve these discomforts by
+anodynes. Many an opium habit has been formed by a turning to opium in
+such cases. The coal tar products are greatly abused here, for they do
+not bring relief to queer feelings nor to a sense of pressure or
+discomfort; they rather add to depression. What they are efficacious
+for is acute pain. The coal tar products relieve even toothache or
+neuralgia, as well as a real headache, but I have had patients tell me
+over and over again that the continuous headaches from which they
+suffered were not relieved in the slightest degree by phenacetin or
+acetanilid. Occasionally one hears of hyoscine or hyoscyamus suggested
+for these conditions, but they are quite as useless and as much
+contraindicated as opium or the coal tar products. As a rule, these
+headaches are relieved by lying down; they disappear during sleep. The
+real indication for treatment, however, is found in the fact that all
+of these vague discomforts are much better or even disappear when the
+patient is intensely occupied, or at least pleasurably engaged.
+
+What these people need is occupation that really catches their
+interest and takes attention from themselves. One of the most striking
+expressions of this truth that we have comes from the poor, sad, mad
+poet, Cowper:
+
+  Absence of occupation is not rest;
+  A mind quite vacant is a mind distressed.
+
+
+{220}
+
+And surely poor Cowper, himself the victim of depression, saved from
+himself only by the suggestion that he should put into poetic form the
+thoughts that came so abundantly to him, could well understand the
+depth of wisdom in his couplet. The story of Cowper's life is enough
+of itself to encourage physician and patient to persevere in the
+effort to lift depression by occupation, since the fruits of that
+occupation may prove so valuable.
+
+
+_Mental Short-Circuit_.--The minds of these people must do something,
+and since there is nothing really occupying for them to do, in a very
+expressive modern phrase, they are doing their possessors. As we
+suggest elsewhere, the nearest simile is that of the short-circuiting
+of a dynamo. Mental energy is exerted harmfully within the machine
+instead of in doing work.
+
+See what happens in these cases when by some chance the women, or the
+men, who complain almost constantly are suddenly deprived of the means
+which enabled them to live an aimless life. The physician often has
+patients who have been in affluence but after a financial panic are in
+straitened circumstances. It is interesting to note what an excellent
+tonic effect, in younger people always, in older people very often,
+the change of life has on these chronic valetudinarians. Sometimes
+this is attributed to the simpler life which they lead when poorer,
+occasionally to the lack of responsibility, or other similar reason.
+Nearly always it is easy to see that the real cause of the improvement
+in health is the occupation of mind with serious interests outside of
+self.
+
+
+Regulation of Life.--In the matter of occupation, and especially
+occupation of mind, the formation of habits and the training of the
+will are extremely important. In his book on "The Education of the
+Will," which was so popular that it went through over thirty editions
+in France, M. Jules Payot [Footnote 25] emphasizes the necessity for
+deliberately arranging the details of life so that time shall not hang
+heavily on the hands, he reverts to certain rules of life of the old
+religious orders, and to the habits advised by spiritual directors. He
+counsels that every one should make an examination of the day's
+happenings at the end of it, in order to see just where the failures
+lay and in what accomplishment was made. At the end of this
+old-fashioned examination of conscience, he counsels that a set of
+resolutions for the next day be made and an arrangement of work for
+various times, so that even more may be accomplished.
+
+  [Footnote 25: English translation by Dr. Smith Ely Jelliffe.
+  New York, 1909.]
+
+M. Payot further suggests that a certain time be given up to
+reflection, or as he calls it, meditation, on the significance of life
+and on the consideration whether something valuable is being made of
+it. Without this he insists that it is easy to let one's self slip
+into habits of life in which absolutely nothing is accomplished for
+self or others. If there is no real accomplishment, then pleasure soon
+palls, because pleasure has a place only as an interval in the midst
+of labor and as a relief from effort. These reversions to the old
+modes of life and thought of the monastic communities show how little
+of real advance there is in life, and what excellent conclusions
+serious men came to even in the distant past. Certainly for many of
+the leisure class in modern times only the use of periods of
+reflection and the examination of {221} results obtained will serve to
+prevent that utter waste of time which leads to the intense
+dissatisfaction that is often reflected in the general health.
+
+
+Thought for Others.--After forgetfulness of self, the most important
+factor in psychotherapeutics is thoughtfulness for others. Ordinary
+diversions are quite insufficient to occupy most people. One must have
+a serious occupation that appeals deeply, and then diversions of mind
+will be useful for purposes of recreation. Pleasure, so-called, if
+pursued not as an interruption from work but for its own sake and
+without serious occupation, palls, and after a time its votaries find
+life is scarcely worth living. The pursuit of pleasure as the sole
+interest of life is one of the most fruitful resources of depression,
+discouragement and neurotic symptoms with which modern physicians are
+brought in contact. The only way to be sure of having compelling
+interests is to be so much occupied with other people that one forgets
+self.
+
+  Yet mere flippant excitement and superficial entertainment is
+  nothing but a cheap counterfeit of what is needed. Voluntary effort
+  is needed, and this is the field where the psychotherapist must put
+  in his most intelligent effort. There is no one for whom there is
+  not a chance for work in our social fabric. The prescription of work
+  has not only to be adjusted to the abilities, the knowledge, and
+  social conditions, but has to be chosen in such a way that it is
+  full of associations and ultimately of joyful emotions. Useless work
+  can never confer the greatest benefits; mere physical exercises are
+  therefore psychophysically not as valuable as real sport, while
+  physically, of course, the regulated exercises may be far superior
+  to the haphazard work in sport. To solve picture puzzles, even if
+  they absorb the attention for a week, can never have the same effect
+  as a real interest in a human puzzle. There is a chance for social
+  work for every woman and every man, work which can well be chosen in
+  full adjustment to the personal preference and likings. Not
+  everybody is fit for charity work, and those who are may be entirely
+  unfitted for work in the interest of the beautification of the town.
+  Only it has to be work; mere automobiling to charity places or
+  talking in meetings on problems which have not been studied will, of
+  course, be merely another form of the disorganizing superficiality.
+  The hysterical lady on Fifth Avenue and the psychasthenic old maid
+  in the New England country town both simply have to learn to do
+  useful work with a concentrated effort and a high purpose. From a
+  long experience I have to confess that I have seen that this
+  unsentimental remedy is the safest and most important prescription
+  in the prescription book of the psychotherapist.
+
+
+_Care of Children_.--Probably the most important therapeutic factor in
+the cure of the ills which come to unoccupied women is the finding of
+some occupation that will absorb their hearts as well as their
+intellects, that is, satisfy their feelings as well as appeal to their
+intelligence. That very acute observer and kenner of her sex, Mrs. St.
+Leger Harrison, who is Charles Kingsley's daughter and writes under
+the pseudonym of "Lucas Malet," said in "Sir Richard Calmady": "Feed
+their hearts and the rest of the mechanism runs easy. I have known
+disease to develop in a perfectly healthy woman simply because the
+heart was starved." For most women the only thing that will entirely
+satisfy the heart or keep it from hunger is children. Fortunately an
+interest in other people's children can, under certain circumstances,
+be almost as satisfying as in one's own.
+
+
+_Interest in Others_.--Probably the best possible occupation that a
+childless woman can have is the care of others. Charity in one form or
+another satisfies the emotions as well as creates interest and gives
+varied occupations. Even the frequent disillusions that are
+encountered in charity work only add variety {222} to the experience,
+and do not discourage those who have the real charity instinct. For
+women particularly, as we have said, some charity that brings them
+much in contact with children is the surest preventive of
+over-occupation with themselves and over-emphasis on their feelings
+and sufferings. Many a woman in our large cities owes her freedom from
+the neurotic symptoms to which her sisters are subject, to her
+interest in tuberculous children. There is just enough of suffering to
+arouse all the pity of the visitor, without so much of anguish as
+would deter the more delicate from being interested in the work.
+
+
+_Touch with Real Suffering_,--For patients who think they have much to
+suffer, yet whose complaints are all of subjective feelings of
+oppression and depression, there is no better remedy than to come in
+touch with real suffering. I have known not a few neurotic young
+women, who were preparing for themselves years of suffering by
+over-attention to little pains and aches, saved to a life of
+usefulness and even happiness by having to nurse near relatives
+through the last stages of fatal cancer. When these neurotic persons
+are brought intimately in touch with real suffering, have their
+sympathies aroused, and see how well human nature can bear pain when
+it has to, and yet not be impatient, nor wish to end it all, then a
+renewed life comes over them and they cease to be preoccupied with
+themselves.
+
+
+_Sympathy as a Remedy_.--In former days, when hospitals were not so
+well provided and trained nurses non-existent, all forms of suffering
+had a wider appeal and aroused more active sympathy than at present.
+It is true that patients, in both hospitals and homes, suffered from
+the lack of trained nursing, and that was an even greater
+disadvantage. But it is, nevertheless, too bad that more actual touch
+with suffering does not come to people now, for nothing is so sure to
+make little ills disappear as the sympathy aroused by the sight of
+real suffering. Certainly, our cancer cases might well be a strong
+therapeutic factor for many of the neurotic ills of the world. They
+are, of course, deterrent to many people. It would seem to add
+needlessly to human suffering for some of the delicate to have to be
+in contact with what is one of the most awful afflictions that flesh
+is heir to. If death and suffering were not inevitable, we might try
+to save people from the suffering which sympathy entails. But there is
+no avoiding them; soon or late they are sure to come to everyone. The
+upbuilding of character, consequent upon intimacy with them, is of
+great value, and really brings so much of contentment to people who
+are over-worried about little things that it is worth while to recall
+how valuable this sympathy for suffering is in psychotherapy.
+
+I have spoken of this phase of occupation as if it referred only to
+women. There are many men of whom one may well say that they need more
+human sympathy in their lives and that if they had it their supposed
+ills would drop from them, or seem so slight as to be quite
+negligible. Over and over again, I have seen men who had become too
+occupied with themselves lose their pains and aches in an interest in
+some real charity. Charity, however, not philanthropy, is the secret.
+The sitting on a board of trustees of a charitable institution may
+mean little though even this usually has its good effect; but close
+contact with the poor, intimate personal relations with other human
+beings who are in suffering, are quite as necessary for men
+over-occupied with themselves as for women.
+
+{223}
+
+_Care of the Incurable_.--Mother Lathrop (Hawthorne's daughter) in her
+cancer work prefers not to take patients suffering from incurable
+cancer into the homes that she has for them, if they can in any way be
+cared for reasonably at their own home. Of course, the main reason is
+because there is so much of cancer in the community (one in thirty of
+the population now die of it), that it is impossible to take care of
+all the cases that apply for admission. Another excellent reason is
+that it would be too bad to take out of a home the opportunity for
+self-discipline that is afforded by the care of one of these patients,
+when it does not inflict an intolerable burden on someone already
+overworked. As a rule, the effect of attendance on such a patient does
+so much for character upbuilding, and for a proper realization of
+values in life, that trivial things fall into their right places.
+Anyone who has seen the development of character, And the growth in
+amenity of disposition of those who bear such a burden with patience,
+will realize just what is meant by the expressions used.
+
+
+Finding Mental Occupation.--For many of his patients the physician
+simply must find occupation of mind. Not a little racking of brain is
+needed for this, until experience helps. One form of occupation of
+mind that seemed quite unpromising at first, but that has in a number
+of cases proved of value, is the committing to memory of passages in
+verse. A generation ago it was quite common for people to have their
+memories stored with fine passages from authors which they could
+repeat literally. Latin verse particularly was learned by the school
+boys of fifty years ago. Frenchmen know their classical poets, and
+some of the Italians also know theirs with wonderful fidelity. It is
+said that, even in his advanced years, Pope Leo XIII could repeat long
+passages of Dante and often found a relief from pressing cares of
+state in the ponderings of the great thoughts recalled by the verses.
+I have known half a dozen Italian clergymen who could from memory
+follow up a line of Dante, taken anywhere in the poet's writings, with
+the rest of the passage.
+
+Such well-stored memories furnished much more abundant food for
+thought to their possessors than do those of the modern time. Our
+modern system of education has done away, to a great extent, with
+learning by heart, but as one of those educated under the older system
+and who is still able to recall many passages from Pope, or
+Goldsmith's "Deserted Village," or "The Traveler," or from Virgil or
+Horace, I feel sure that this is a serious mistake. In some cases I
+have deliberately tried to make up for it by having people, even well
+on in years, settle down to memory lessons again. Under disorders of
+memory I suggest the use of this practice as a valuable training which
+serves first to dispel the idea that memory is failing when it is only
+lack of attention and of concentration of mind that is at fault, and
+secondly, because after a time there can be observed an actual
+improvement of the memory faculty. Here I would insist on its value as
+an occupation of mind for those who lack some serious interests. I
+have found it to be ever so much better as a diversion than reading or
+the theater. If the interest in it can be awakened, it represents a
+valuable adjunct in the treatment of some rather difficult cases of
+mental short-circuiting. Lord Chesterfield, in one of his letters,
+suggested to his son that even very brief periods during the
+day--those that are ordinarily used for the fulfillment of bodily
+necessities--might be employed to store the memory with valuable
+quotations, great thoughts {224} greatly expressed, and this should be
+recalled. After a little practice not near so much time is required
+for memory work as might be imagined, and the effects are excellent.
+
+Much of this may seem too trivial for the physician to occupy himself
+with and quite apart from his duties as a practitioner of medical
+science. But it must not be forgotten that medical science is as yet
+quite imperfect and the practice of medicine is an art. What we have
+to do, is to treat individual patients rather than cure cases, for
+that is why medicine is a profession. Each affected individual who
+comes to us is quite different from any other. In spite of our
+grouping them under certain heads, the diseases of the race are as
+distinct from one another as the features of the individuals affected.
+
+
+
+CHAPTER VI
+
+DIVERSION OF MIND--HOBBIES
+
+
+There are two classes for whom diversion is of the utmost value. The
+first are over-occupied with themselves; and the second group are so
+occupied with some one interest in life, or with one narrow set of
+interests, that it becomes an obsession, never leaving them. Constancy
+of mental occupation with one set of thoughts proves seriously
+disturbing after a time, especially if the only amusements available
+are so superficial that they do not really act as a diversion. Many of
+the so-called neurasthenic or psychasthenic states (I would prefer to
+call them conditions of nervous weakness and of psychic impotency,
+because the simpler names carry with them no suggestion of a definite
+ailment) are really the consequence of this lack of any true
+diversion. The patients do not get any genuine rest.
+
+The typical example of such lack of diversion is the business man who,
+contrary to the wisdom of the ages, takes his business home with him.
+If we accept Ramon y Cajal's theory of attention, by which whenever a
+particular portion of the brain is occupied with a subject the
+capillary blood vessels in that particular part are pulled wide open
+by the contraction of the neuroglia cells, certain of the brain
+tissues in these cases are constantly in a state of congestion. It is
+not surprising that such men suffer from insomnia. It is scarcely less
+to be wondered at if their digestion suffers, since that function is
+so important that it requires most of the nervous energy that a man
+can provide at certain times. Besides his brain cells are never really
+resting. If a man goes to sleep with a thought and wakes with it, even
+though he may not be quite conscious of the fact, his mind has been
+occupied with it. Brain cells need definite periods of rest. These
+cells are not getting such rest--hence the development of many
+pathological conditions.
+
+I have described the extreme case, but it is not exaggerated. Writers,
+editors, scientific investigators and generally those whose work does
+not bring them much in contact with others, are likely to thus suffer.
+Contact with others, even on business matters, seems to have a
+relaxing effect. Social amenities and personal interests prevent
+absolute concentration of mind over long periods. In some people even
+milder degrees of preoccupation with a {225} single subject may work
+harm. Some people are able to stand concentration of mind for many
+hours a day for years. Others cannot. We have come to recognize that
+more than eight hours a day is a mistake, but there are many people
+who cannot work more than a four-hour day. The sooner this is
+recognized and diversion of mind provided, the better for them. This
+is one of the most important benefits that psychotherapy can confer on
+many of the so-called neurasthenics.
+
+
+Possibility of Diversion of Attention from Ills.--The necessity for
+diversion of attention from one's ills is best realized by considering
+what happens in the opposite direction. Headache, toothache, and many
+other uncomfortable feelings, especially discomfort associated with
+abdominal disturbances, can be entirely banished from the mind by
+pleasant association with friends, by an interesting play, by a game
+of cards, or, indeed, by almost anything that takes up the attention
+completely. It is well understood that the severer forms of pains can
+not be thus banished, but discomforts that make life miserable for the
+patient may be entirely relieved for the time being. If this power of
+mind to divert attention from the ills of the body means so much, it
+is not hard to understand that if this mental influence be directed in
+the other way, that is, to emphasize the ailment by attention to it,
+it will not be long before symptoms become quite unbearable.
+
+
+Hobbies.--A hobby is the physical salvation for a man who wants to
+work hard, yet not become so absorbed in his work that it becomes an
+obsession. Unfortunately, it is not possible to create a hobby for a
+man or a woman in a short time. It must be a growth for many years
+until it has become a portion of one's life. It must, as far as
+possible, be something to which one turns with as much interest as to
+one's regular occupation, so that the time taken from it, even for the
+necessary vocation of life, is more or less resented. If a man has two
+occupations that are intensely interesting, then he gets the best
+possible rest. Otherwise it will be necessary in many cases for the
+physician to help him in the choice of another interest in life. It is
+not enough that there should be a vacation once a year, or a
+conventional day off on Sunday. There must be much more than this,
+deliberately planned and faithfully carried out.
+
+
+_Gladstone_.--Men with hobbies have done some of the best of the
+world's work; busy for many hours every day, they have yet lived to be
+eighty and even ninety years of age, and have been industrious to the
+end. A typical example in our generation was Gladstone, the great
+English statesman. Few men had their minds occupied with more serious
+problems than he for nearly forty years of a busy existence. In spite
+of this, he found time to make a study of Greek literature and of
+ecclesiastical writers; He acquired even more authority perhaps in
+these subjects than in political science, doing the work of several
+men, yet he lived to be an extremely old man. He welcomed the
+opportunity to get away from one kind of work in order to devote
+himself to another, but this occupation of an entirely different set
+of brain cells gave those that had been previously at work opportunity
+for complete rest. Very probably, except at times of special crisis or
+stress of anxiety, his political problems did not disturb his studies
+of Greek literature, not because he insisted on keeping them away, but
+because this other interest was so absorbing that it required no
+special effort to occupy his mind completely with it.
+
+{226}
+
+_Virchow_.--For more than a year I lived close to the great German
+pathologist, Virchow, and found that his varied interests were
+probably the secret of his power to devote himself to work for many
+hours a day, take only a small amount of sleep and yet live healthily
+and happily for over eighty years. Frequently he did not leave the
+Prussian legislature until 1 a. m., or even later, and yet he seldom
+failed to be at his laboratory before 7:30 o'clock in the morning,
+though it was several miles from his home and took over half an hour
+to get there. Besides pathology, he was deeply interested in
+anthropology and in most of the biological sciences, and his favorite
+hobby was the practical care of the health of the city of Berlin. From
+the time when Berlin, just after the Franco-Prussian war, began to
+grow out of the half-million provincial town that it was, into the
+great world capital that it became, a transformation that took less
+than twenty years, Virchow had charge of the health of the men engaged
+on the sewer farms of the city. Berlin, unlike other great capitals,
+is not situated on a large stream that will carry off its excreta, and
+consequently a new problem in sewage disposal had to be met. The
+sewage was spread over fields outside the city and proved, as might be
+expected, a magnificent fertilizer. The whole cost of sewage disposal
+was recouped from the sale of the farm products.
+
+Prophecies of dire disaster of many kinds were made when this system
+was first proposed. It was said that the men engaged on the farms
+would suffer from all sorts of disease, especially respiratory and
+intestinal diseases, that the farm products would be insanitary, and
+the whole plant would be such a disease producer for the city as to
+become a nuisance. Virchow was put in charge of the sanitary side of
+the project, and how well he fulfilled his obligations is shown by the
+statistics. The people who worked on the farms were healthier than the
+average inhabitants of Berlin, and were especially free from
+intestinal disease. Every phase of disease that occurred among the
+workers on the farms, and there were many thousands of them with their
+families, was reported to Virchow. Every night, the last thing before
+he went to bed, he looked over this report and if there were any
+suspicious cases, made arrangements for the prevention of the spread
+of disease.
+
+This of itself might seem work enough for one man, but it was only a
+diversion for Virchow, turning his mind away from his other
+intellectual work completely during certain hours of the day. His
+visits to the farms, his planning for the prevention of the spread of
+disease, his deep interest in the reports and the constant improvement
+of conditions, instead of hampering his other intellectual activity by
+wasting brain force, probably proved restful by diverting the blood
+stream away to the cells that occupied themselves with this other and
+very different problem, and so proved a benefit, not an evil. Perhaps
+other men might not have had the store of nervous energy to enable
+them to carry on work in this way, but for those who have, this is the
+ideal arrangement. There are many others whose names might be
+mentioned here. John Bigelow and Pope Leo XIII are typical recent
+examples. Great workers are usually long livers, barring accident, and
+all of them have had variety of occupation.
+
+
+Necessity for Diversity of Occupation.--Even for those of lesser
+intellectual capacity, it is advisable to have, in a lower order of
+intellectual occupation, two very different things in which there is
+intense interest. The blasé {227} attitude in which the individual
+finds no interest in anything and nothing worth doing, makes it
+impossible to secure such relaxation as will give relief from worry.
+So long as nothing happens to call for special resistive vitality,
+such people may go on nursing their unhappiness. It is from this
+class, however, that the suicides come. The mind becomes occupied with
+the worries that it cannot get away from, sleep is interfered with;
+the worries become an obsession, and brain exhaustion results. It is
+usually said that suicides are insane, and to this extent certainly
+the expression is true. Certain brain cells have so long been occupied
+with a particular subject, because the mind has no other interest to
+divert attention and blood supply to other portions, that these cells
+are overborne and become utterly beyond the control of reason and
+will.
+
+
+Intervals in Work.--The old university rule of long ago was that no
+one should do more than two hours of intellectual work continuously at
+the same subject. Certain of the monastic orders required scholars and
+students to take a break from an intellectual occupation for a
+measured interval at least every two hours. The modern business man,
+and even the literary man or reporter, would think this preposterous.
+The rule is, however, founded on good common sense, for it relieves
+the tension and keeps conditions of strain from inveterating
+themselves in such a way as to do harm.
+
+As a matter of fact, better work is accomplished if it is done in
+two-hour intervals, with a break of fifteen minutes to a half-hour
+between, than if the attempt is made to work longer. This may not be
+true for certain forms of creative literary work, where, when the mood
+is on, it is easier to finish things than if a break occurs, but these
+are exceptional cases, and even here there may be serious abuse. Many
+of the men who work late at night eventually get into habits that
+seriously impair their sleep. This system of rest prevents such a
+strain from being put upon the physical organs underlying attention as
+will prevent them from promptly relaxing when the call upon them has
+ceased.
+
+There are, of course, men for whom no such rules as these seem to be
+needed, because they apparently thrive on work. These are exceptions,
+however, that prove the rule. They will usually be found on
+investigation to have been men who lived very simply and permitted
+themselves very little excitement. There is great danger in imitating
+them because most of them had a superabundant vitality which expressed
+itself in longevity as well as in a noteworthy capacity for work. They
+had superabundant brain power to run their business (even though it
+was deeply intellectual), but then, too, these men were careful not to
+throw extra burdens upon their digestive organs, nor to abuse
+stimulants, nor to permit a regular routine of work to be disturbed.
+When symptoms of nerve weakness begin to show themselves, even the
+exceptional men must be warned of the danger. The causes of the
+exhaustion of nervous vitality should be pointed out, and an
+improvement of habits insisted upon.
+
+
+Amusement and the Mind.--The theater, as it is at the present time,
+affords very little opportunity for mental relaxation. Most of our
+theatricals are mere show that occupies the eye but does not seriously
+catch the attention, especially after a certain number of types of
+these performances have been attended. The humor of the comedians of
+our musical comedy may, for {228} a certain number of people, mean
+something as a diversion of mind, but it does not last. Unfortunately,
+practically all their humor runs along the same line, most of it is
+extremely superficial, much of it is borrowed and wears signs of its
+origin, not a little of it is mere horse-play, which may divert
+children but not grown men, and so the theater as a mental relaxation
+has lost nearly all of its effect. Other diversions are sometimes more
+hopeful. For baseball enthusiasts, attendance at a game may be such a
+complete occupation of mind as to furnish thorough relaxation.
+
+The kind of work that provides mental relaxation for others often
+proves exhausting to those who do it. Humorists, especially those who
+have to grind out paragraphs or columns of humor every day or every
+week, are usually melancholy men. The story of Grimaldi illustrates
+how serious may be the effect of work that seems mere play if pursued
+too singly. This humorist on one occasion consulted a specialist in
+mental diseases, for certain symptoms of nervous breakdown and
+depression that were causing him much annoyance and even more
+solicitude. The specialist believed in diversion of mind, and, having
+been to see Grimaldi the night before and enjoyed him hugely, though
+he did not recognize him off the stage, counseled him to go and see
+that humorist and have his "blue devils" banished for good. "If
+Grimaldi won't cure you of your depression," he added, "I don't know
+anything that will." "My God!" the humorist said, "then don't leave
+me in despair. Man, I am Grimaldi!"
+
+
+Sports.--Unfortunately in our modern life we have to a great extent
+lost the idea of sport. The conventional make-shifts of life in a camp
+that is really a luxurious country house, or on a luxurious yacht, do
+not replace the complete diversions that came with real camping,
+hunting, fishing, sailing and the like. People now go to the country,
+but take the city with them. They live in country hotels and make five
+changes of clothing in the day, if not more. If men are interested in
+hunting and fishing and can go into the forest (unfortunately even the
+Adirondacks can scarcely be so designated now and we have to go into
+the Canadian wilderness to get away from the pall of regular life and
+civilization), complete recreation is secured. This makes a real
+vacation which does not mean absolute freedom of mind, but freedom
+from other cares so that one may with complete absorption apply
+himself to something different. During the year sports for grown-ups
+are difficult to obtain. Some men continue well on in middle life to
+play tennis, hand-ball, and certain other games, _O fortunati nimium_,
+that make the best kind of diversion. Fortunately, in recent years
+golf has become a favorite and for many makes a genuine diversion.
+
+
+Children's Diversions.--In recent years we have so interfered with the
+normal natural development of the child that there is need to
+emphasize certain details in this matter. The modern child is apt to
+be precociously occupied with books and adult interests, because he is
+brought so much into the foreground of family interests. True play for
+some city-bred children is almost an anomaly. Exercise and air they
+get. They are conducted solemnly to the park by a nursemaid, who is
+instructed to see that they do not play with other children unless
+quite as well dressed as they are themselves, and their dress is often
+so elaborate that it is quite impossible for them to think of any real
+play. There is absolutely no recreation for the child in this
+procedure: on {229} the contrary, a new effort of will is required to
+walk with the stately propriety that is expected of it. Then the child
+is preoccupied with the thought of its clothes. Relaxation of mind is
+often quite out of the question, and yet we wonder why children are
+nervous and do not sleep well, why they have night terrors and do not
+digest their food properly, while all the time they are living
+unnatural lives that give no proper outlet for their energies and
+little diversion for their mind.
+
+Games are important, but their true spirit has gone out in recent
+years. There are still a few young people who play for the sake of the
+sport, but everything now seems to be a preparation for some sort of
+contest. Only those are engaged in these contests and the preparation
+for them whose muscular development is such as to suggest that they
+will help to win. Winning, and not sport, has become the purpose of
+our games. This makes the participants worry about the games and
+associate them with dread of errors and ill chances. It is true that
+the interest for the contestants during the game is sufficient to make
+up for this and make the game valuable as relaxation; but those who
+need such relaxation most--the boys and girls who are underdeveloped
+muscularly--must sit and watch the contests, and this, after one has
+become accustomed to it, like newspaper reading and the theater,
+constitutes a poor apology for the complete relaxation of mind and
+diversion of brain-cell energy that used to come with sports when they
+were freely indulged, for the sake of the sport and not for the sake
+of winning.
+
+
+
+CHAPTER VII
+
+HABIT
+
+
+Few people realize how powerful a factor for physical, as well as
+moral, good and evil is habit. The old expression that habit is second
+nature is amply illustrated in the most familiar experiences. The
+child, unable at the beginning to make any but the most ill-directed
+movements, learns during its first two years to make the most complex
+co-ordinated movements--first with difficulty, then with ease, and
+finally with such facility that there is no need for it to pay any but
+the most perfunctory attention to their execution. Walking requires
+the co-ordination of a large number of muscles so that the absolute
+position of every muscle in both the legs and in the trunk, at least
+as far as the shoulders, must be definitely known and their activity
+properly directed. Perhaps nothing brings out more clearly the
+difficulty of walking, though it depends on only one factor, the
+co-ordination of the two sides of the body, than the story of the
+Italian Tozzi twins. They were born with two heads and shoulders and
+with only one pair of legs. It was found that each head ruled the leg
+on its own side of the body. It was impossible for the creatures to
+walk. They lived to adolescent life, yet never succeeded in walking.
+The intimate association of the lower parts of their trunk and the
+long years of companionship of their brains, did not enable them to
+accomplish what seems to us so commonplace a co-ordination of movement
+as walking.
+
+
+Formation of Habits.--The co-ordination of the two limbs is after all
+only a small portion of walking. The body must be held erect, the
+curve of {230} the spine must be managed so that the center of gravity
+is kept well within the base, and gluteal and femoral and calf muscles
+must all be co-ordinated with one another. In a few months a child
+learns to do all this, and in a couple of years it executes all the
+co-ordinate motions with such certainty that walking becomes not only
+an easy matter but an absolutely unconscious accomplishment that can
+be carried on while the mind is occupied with something else or while
+it becomes so abstracted that surrounding objects are not noticed.
+
+A far more difficult co-ordination is required for talking. It is only
+when we analyze how nicely adjusted must be every movement, in order
+to pronounce consonants and vowels properly and to combine them in
+various ways, that we realize how complex is the mechanism of talking.
+A difference of a hundredth of an inch in the movement of the tongue,
+or less than that in the movements of various muscles of the larynx,
+makes all the differences between clear articulation and a defect of
+speech. In the course of the years up to seven, the child learns this
+wonderful co-ordination apparently without difficulty, but really at
+the cost of constant well-directed effort. There is no time in human
+existence when the child really learns so much as during the first
+four years of its existence, even if it learns nothing else except to
+walk and to talk. The foolishness of obtruding other things,
+information and study of various kinds, on the child's attention at
+this time should be manifest.
+
+
+_Unconscious Regulation of Muscles_.--What is thus prefigured in early
+life invades every activity in later years. The boy who learns to ride
+a bicycle must at first devote all his attention to it, but after a
+while rides it quite unconsciously, his muscles having learned by
+habit to accommodate themselves automatically to all the varying
+positions of his machine. Anything well learned by habit is never
+forgotten. How hard it is to learn to swim, yet, after years away from
+the practice of it, the art comes back at once. The same is true of
+skating, and of the nice adjustments of muscles required in various
+games. Such is the influence of habit in forming a second nature. It
+is no wonder that Reid, the Scotch philosopher, should have written:
+
+  As without instinct the infant could not live to become a man, so
+  without habit man would remain an infant through life, and would be
+  as helpless, as unhandy, as speechless, and as much a child in
+  understanding at threescore as at three.
+
+Commenting on this Prof. J. P. Gordy, in his
+"New Psychology," [Footnote 26] says:
+
+    [Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.]
+
+  Strong as this statement seems, it is probably an understatement of
+  the truth. Without habit, we should rather say, a man would be as
+  helpless, as speechless, as unhandy at three-score as at birth.
+  Habit is the architect that builds the feeble rudimentary powers of
+  the child into the strong, developed powers of the full-grown man.
+  If a child's vague, purposeless movements give place to definite
+  movements performed for definite purposes, if his sensations become
+  more definite, if his perceptions become clearer, if his memory
+  becomes more accurate, if he reasons more and more correctly and
+  logically, it is because of habit.
+
+
+Law of Habit.--The law of habit is that every time we perform any
+action, mental or physical, or allow ourselves to be affected in any
+way, we have more proneness to, and greater facility in the
+performance of that action or in {231} experiencing that affection
+under similar circumstances, than we had before. In the chapter on
+Tics, I call attention to the fact that all the curious gestures by
+which we are individualized, are due to the law of habit. It is
+infinitely amusing to watch a group of people and note the endlessly
+different habits of which they have become the victims. There are
+tricks of speech and tricks of gesture eminently characteristic and
+often quite laughably individualistic. We imitate, especially those of
+whom we think much. Sometimes it is only when a father's attention is
+called to them in his sons that he realizes the ludicrousness, or at
+least laughableness, of some of the things he does, and he proceeds to
+correct both generations of their faults.
+
+
+PHYSICAL HABITS
+
+
+Habit and Food.--Most of our likes and dislikes for food are neither
+physical nor physiological, but simply habitual. We have become
+accustomed to certain things, and so we like them. We are unaccustomed
+to them, and do not care for them. It is amusing when people put
+forward these lacks of habituation as if they were physiological
+idiosyncracies. Many thin people do not like butter and milk. The real
+reason for this is not any peculiarity of digestion, or any gastric
+incompatibility, at least in 99 cases out of every 100, but the mere
+fact that they are not habituated to their use. That is one of the
+reasons why they are thin. Our tastes for curious foreign foods are
+nearly all deliberately acquired. Not one in ten ordinary Americans
+likes olives or caviar when first tasted. Nearly every curious article
+of food is "caviar to the general" at first trial. Later it becomes
+impossible to understand how we could have had any objection to them.
+At times, even an actual craving for them asserts itself as a
+consequence of the habitual use, and then deprivation means positive
+discomfort.
+
+
+Slow Eating.--One of the most valuable habits that a man can
+cultivate, but one of the most difficult to acquire in our time, is
+that of eating slowly. Most Americans bolt their food to a degree that
+would be quite appalling to them if they realized what they were
+doing. Pieces of potatoe as large as the end of the thumb are
+swallowed. Bread and milk may be eaten so hurriedly as to be as potent
+a source of digestive disturbance as fried onions. There seems no
+doubt from what we know of Fletcher's experience and Chittendan and
+Follin's studies that a man derives more nutrition from food that is
+masticated properly, that he can get along and do his work on less
+material and that, above all, there is not the same tendency for him
+to put on weight that is so common among people after reaching middle
+age.
+
+Sir Andrew Clarke used to have his patients chew a definite number ol
+times on each bite--say thirty times. Even so great a man as Gladstone
+submitted to this rule and gradually learned to accustom himself to
+eating very slowly. Fletcher's system of chewing the food until it
+passes down the esophagus of itself without any swallowing effort is a
+better rule. It is a surprise to most people how unconsciously
+swallowing can be accomplished in this way and how little liquid is
+needed in order to prepare food to be swallowed. The formation of the
+habit, however, is not an easy one. Persistence and frequent reminders
+are needed, or else the beginnings of the habit are soon dissipated
+and old bolting habits reassert themselves.
+
+{232}
+
+
+Water Drinking.--In drinking, habit is as supreme as in eating. The
+majority of people who work outside and perform muscular labor crave
+and take an abundance of water. Many of those who live indoors,
+especially in steam-heated houses, may need it quite as much if not
+more, but get out of the habit of drinking water. As we need about
+three quarts of water per day for use in our economy, this no water
+habit often becomes a serious factor in the production of
+physiological disturbances. We have replaced water drinking and the
+milk drinking of the olden times by tea and coffee, and as these are
+stimulants, habits form very readily with regard to them. I have known
+people who were sure they would be miserable without their half-dozen
+cups of tea or coffee each day, and who actually would be miserable
+for a few days, when deprived of it. They were seriously impairing the
+efficiency of their nervous system by so much stimulation.
+Unfortunately, it is just those whose nervous systems have least
+stability, and are already the subjects of more stimulation by
+conscious introspection than is good for them, that are most likely to
+form the tea and coffee habits, and who are most harmed by them,
+though they find it hard to understand the reason therefor.
+
+
+Air and Exercise Habits.--Habits with regard to exercise and fresh air
+are particularly important. In this matter it is only habit that can
+be really helpful. To work at high pressure indoors for several days,
+and then, when one is quite on edge, to take a lot of severe physical
+exercise is not good. Every human being should go out between meals. I
+am not one of those who believe much in exercise for exercise's
+sake--what is needed is fresh air. Our sanatorium patients who sit
+out-doors all day have fine appetites. The advice to a busy man that
+he must form the habit of being out between every two meals for from
+half an hour to an hour would usually evoke a strenuous protest, but
+all he needs to do is to get up half an hour earlier and walk down to
+his office, and if he will walk back in the evening he will have
+plenty of air and exercise between his meals.
+
+
+Change of Habits.--Patients do not want to change their habits. They
+come to a doctor to be treated. They want some medicine that will,
+without further inconvenience, rid them of certain discomforting
+symptoms. At the beginning, at least, patients resent interference
+with their habits. They are quite satisfied, and to modify them
+requires an effort that must be continued for some time. The changing
+of old habits and the formation of new habits are most important for
+the ordinary ills to which mankind is prone. Modifications of habit
+constitute real hygiene and are not mere corrections of symptoms,
+permitting the habits that have led up to them to go on.
+
+Patients may conclude that it is too much trouble to change their
+habits. We all know persons who feel that they can not give up their
+coffee. As to whether or not the modification of a habit is worth the
+trouble it involves, the patient must be the judge after the case is
+put properly before him. It is possible that he may learn to endure
+the inconvenience given him by his symptoms rather than to stand the
+inconvenience of changing a nicely settled habit, and forming a new
+one. The reward should be put very plainly before him, however, and
+besides, the consequences of his habit in the future should be
+suggested so that he may realize just what it will lead to.
+
+{233}
+
+
+MENTAL HABITS
+
+It is evident from the foregoing that physical habits have much to do
+with making life easier and saving expenditure of nervous energy, but
+just this same thing holds good for mental states. With care, a proper
+habit of mind and of the mental attitude towards difficulties in life,
+can be so cultivated as to ward off many of the discouragements, and
+most of the causes of depression that weigh heavily on some people.
+The natural disposition can not be entirely overcome, but habit, as a
+second nature, can modify the personality so as to make conditions
+much better than before.
+
+With this wonderful power in habit, it is too bad that its force for
+good is not used. It is especially important that its force for evil
+shall not allowed to dominate human actions so as to make them harder
+of accomplishment. Many people, who are greatly troubled by the
+inconveniences and discomforts necessarily associated with human life,
+worry over it to such a degree as to make themselves sick. The
+expression I have quoted elsewhere of the old man who said, "I have
+had many troubles but most of them never happened," is a typical
+example of what the habit of looking at things from a wrong standpoint
+means to many people. They are confirmed pessimists. Their one
+consolation, when a small evil happens to them, is that perhaps this
+may be sufficient to ward off the greater evil that fate surely has in
+store.
+
+
+Pessimism.--Pessimism has been defined as sticking one's nose in a
+dungheap and then asking, "How is it that it smells bad around here?"
+Some people are always nursing a grievance. No matter how many times
+they may happen to have been undeceived, still the next time the
+opportunity occurs they are sure that fate or friends or someone has
+it in for them and that the worst may happen at any time. In the
+expressive words of a recent slang phrase, they have a "perennial
+grouch." This state of mind toward the environment not only prevents
+the physical and mental good that cheerfulness brings with it, but it
+unfavorably influences physical conditions within the body. People
+suffering from indigestion are usually morbid, petulant, and hard to
+get along with. Many a dyspeptic makes this an excuse for his bad
+temper. Anyone who has had to study these cases much soon comes to the
+conclusion that the beginning of the digestive disturbance was the
+gloomy outlook on life, which flowed inward to disturb the digestion
+and all the other animal functions.
+
+
+Depression of Mind and Body.--Patients suffering from melancholia
+nearly always lose in weight. As a result of their lowered vitality,
+there is a suppression of the nervous impulses which rule over
+nutrition, with a consequent loss of weight. In cases where there are
+only tendencies to depression and gloom, the effect upon the digestive
+system is not so marked but there is no doubt that there is some
+effect, and that the indigestion in these cases is more often than not
+a result of the depressed state of mind, rather than the depression of
+mind the result of the indigestion.
+
+
+Moodiness.--The habit of looking at the gloomy side of things is
+easily formed and, once acquired, it becomes very forceful. Many a man
+who was quite cheerful when young, becomes moody as he grows older.
+Nearly everyone permits moods more than is good for him. The attitude
+of mind that should be cultivated is one in which it is realized that,
+though there may be {234} many sources of evil in the world there is a
+preponderance of good even in the worst environment, and that
+opportunities for making the best of things will be found by any
+cheerful disposition. _Mrs. Wiggs of the Cabbage Patch_ is a typical
+example in fiction of the optimism that counts. Miss Helen Keller in
+real life is a typical example of how the most untoward circumstances
+can not crush the spirit of man if he only wishes to be cheerful--if
+he only tries to lift himself above his surroundings, no matter how
+discouraging they may seem to be. No one is without discouragement and
+causes for unhappiness. "Happy he who has least," the Greek dramatist
+said.
+
+The difference between the optimistic and the pessimistic point of
+view is much more a matter of habit than is usually thought to be the
+case. Indeed, there is good reason for assuming that it is so largely
+a matter of habit, that other factors count for little. We all know
+individuals who, after having, been cheery, bright, hopeful and
+helpful, have had some incident sour them and then they have been just
+the opposite. This did not come all at once; it was a growth. They
+felt hurt and aggrieved, and then began to look at things through dark
+glasses, and after a time could see nothing on its brighter side. Not
+infrequently, as doctors well know, the growth of such a moody
+disposition has been the signal for the development of a series of
+complaints, if not of actual symptoms, and men and women who have not
+been in the doctor's hands before now become valetudinarians. This new
+physical condition is often attributed by their friends, by
+themselves, and even by complacent physicians, to the effect upon them
+of the trial or disappointment that struck them. Only too often it is
+wholly due to the cultivation of a habit of pessimism consequent upon
+a shock that for the moment pushed their cheerfulness into the
+background. Strong characters will not be thus easily affected, but
+weaker characters need not suffer such a change of disposition and
+with it a deterioration of health or well-being unless they so will
+it.
+
+
+MANNERS AND DISPOSITION
+
+Habit can modify nature so much as to make what is practically another
+man. We all know how the dancing master can transform a country gawk
+into a refined, courteous society man (not gentleman, for that is
+something else) of graceful carriage and even handsome bearing. He
+cannot do this for all the pupils that come to him, for it is
+impossible to make a silk purse out of a sow's ear, but for anyone
+that comes with good will the revolution in manners is often a
+revelation to those who have known the man before. When the exterior
+can be changed so much, the interior attitude toward other people
+certainly can be greatly modified.
+
+Persons of a melancholic disposition may be surprisingly cheerful, and
+even gay, with comparative strangers when they make the effort to be
+so. For many people, meeting with strangers is an excellent remedial
+measure. It stirs them up to present the best side, and it occupies
+attention to the exclusion of themselves in a way that is extremely
+beneficial. If people would only form the habit of being as courteous
+to their own folks as they are to others, the disposition involved in
+this would often save them from certain symptoms, and save their
+physicians from many complaints.
+
+{235}
+
+Happiness is the basis of good health. The phrase is often put the
+other way: Good health is the basis of happiness. Without health there
+is no happiness. But every physician knows that many a patient
+suffering from real organic ills, and having much physical pain to
+bear, still has many hours of happiness in working for others. This
+happiness reflected back upon his physical life is not able to cure
+his ailments, but does so lessen the significance of the symptoms as
+to make the ailment more bearable.
+
+
+THERAPEUTIC IMPORTANCE OF HABIT
+
+The most important therapeutic element in the formation of good
+habits, mental and physical, is that habit does away with the
+necessity for conscious regulation of many details of life. Without
+habits of doing things, we have to make numerous decisions and keep on
+making them under conditions that require special effort and waste of
+energy. When habit asserts itself, there is little or no difficulty.
+Habits of living in airy rooms, of taking exercise, of food regulation
+as to quantity and quality, of methods of taking food as regards
+mastication, the quantity of fluid ingested, the hours of meals and
+the like, can all be formed and then followed without effort. Just
+inasmuch as life can be ruled by habit, nerve force is conserved. This
+is as true for our attitude towards life, our disposition and
+consequently our satisfaction with life, as for anything else that we
+do. Habitual cheerfulness, habitual readiness to make allowance for
+others and to be helpful to them, habitual self-control--all of these
+things can be cultivated. Properly cultivated, they save much of the
+wear and tear of life, and make for contentment and happiness much
+more than many of the things for which men strive so anxiously because
+they seem to promise happiness.
+
+
+
+CHAPTER VIII
+
+PAIN
+
+Pain, while always a dreaded symptom of disease, seems, with the
+increase of comfort and the gradual abolition that has come in our
+time of many of the trials of existence, to have had its terrors
+increased. Even a slight pain or ache is dreaded, and if continuous or
+frequently repeated, becomes for many people a trial that is almost
+impossible to bear. This is all the more to be deplored because
+ability to stand a certain amount of pain, with reasonable equanimity,
+is almost a necessary condition of rapid recovery from disease or
+injury. Placidity of mind favors the flow of nerve impulses for
+reconstructive purposes, while over-reaction to pain inhibits the
+natural processes of repair. According to Shakespeare's heroine:
+"There was never yet philosopher that could endure the toothache
+patiently." Pain is usually supposed to be an essentially physical
+phenomena for which mental influence can be of little, if any,
+benefit. As a matter of fact, however, the mental attitude towards
+pain modifies it to a considerable degree. I have quoted Hippocrates'
+declaration that a greater pain drives out a lesser pain. Any strong
+preoccupation of mind will greatly lessen pain at any time.
+
+{236}
+
+Pain is not, after all, in the nerves, nor in the central nervous
+system, but in the consciousness. Just as there is no sound unless the
+waves in the air arouse recognition in the consciousness, so there is
+no pain unless the disturbance of nerves finds its way above the
+threshold of consciousness. Nerves may be racked, yet no sensation may
+be felt. There may be pain in the mind apart from the nerves, and
+slight nervous affections may produce severe pains. The whole question
+of the treatment of pain involves the individual much more than it
+does the affliction which causes the pain. What seems unbearable pain
+to many may be little more than a passing annoyance to others. What
+would be, under ordinary circumstances, intolerable torture,
+especially to sensitive people, may, because of intense preoccupation
+of mind, remain absolutely unnoticed. Maniacal patients sometimes
+inflict what would normally be extremely severe pain on themselves by
+burning or mutilation without any manifestation of pain. In the
+excitement of a panic men may suffer what would, under other
+circumstances, be excruciating agony, and yet not know that they are
+hurt.
+
+To a mind that is without serious interest, even slight pain, if
+continuous, soon becomes unbearable. The course of pain, where there
+is no diversion of mind, is an interesting study. While suffering, we
+seem always able to bear the pain of the present moment, and it is
+only the cumulative effect of the pain that is past and the
+anticipation of the discomfort to come, that make the pain unbearable.
+Nearly, always it is much more the dread of what the pain may mean,
+and the lack of power to endure which gradually develops as a
+consequence of suffering, that constitute the worst features of pain.
+At the beginning of a period of pain we stand it well, as a rule, but
+its continual nagging debilitates us and heightens our susceptibility
+until we cannot nerve ourselves to further endurance. If our power of
+endurance were not thus gradually lessened the pain would not seem
+severe. There are many neurotic people whose susceptibility to pain
+has been so much increased by their lack of self-control and their
+tendency to react easily to pain, that even slight pain becomes a
+torment. Psychotherapy should gradually train these people to a power
+of endurance.
+
+
+Pain from Over-Attention.--Much of what is called pain is really due
+to such concentration of mind on a particular portion of the body that
+the ordinary sensations of that part, usually accomplished quite
+unconsciously, become first a source of uneasy discomfort and then an
+ache or pain. There may be some slight physical disturbance which
+calls attention to the part, but there is no really serious
+pathological condition. While such pains are spoken of as imaginary it
+must be remembered that this does not mean that they are non-existent.
+On the contrary they may be much more real to the patient than
+physical ailments. A pain in the mind is a much more serious condition
+than having it in the body.
+
+While pain may be thus created by concentration of attention, it must
+not be forgotten that what the mind can do in increasing pain is even
+more important than in originating it. Slight discomforts by
+concentration of attention on them may be made insupportable. It is
+this element in pain, above all, that the physician requires skill to
+alleviate. Habits of introspection and the lack of serious occupation
+of mind of many people leave them the victims of over attention to
+themselves. In trying to relieve their pain it may be {237}
+comparatively easy to alleviate their physical condition, but the
+mental condition, once aroused, may remain, and may easily tempt to
+the use of habit-forming drugs or others that may do serious harm. The
+story of the evil effects of headache powders in recent years, and of
+the opium habits formed in olden times, are a significant commentary
+on this fact. It is probable that in most of these cases, the
+discomfort for which remedies were frequently taken was of a kind that
+should have been treated only partly, if at all, by drugs. It is more
+important to lessen susceptibility than to try to cure the pain.
+
+The relation of the mind to what is often considered severe physical
+pain, has come to be generally recognized in recent years. Neuralgias,
+for instance, have often been reported as recurring after fright, or
+strong emotion, or worry. It is at moments when patients are much run
+down in health that pains are particularly likely to be unrelievable,
+and during periods of emotional strain that anodyne drugs are most
+called for and are most likely to be abused.
+
+
+Rest and Pain.--In any study of pain and its relief, one must always
+recur to that classical contribution to medicine, now in the fiftieth
+year of its publication and still as important as when it was written,
+Hilton's "Rest and Pain." He calls attention to the fact that what he
+wrote was only a development of what many practical physicians had
+thought long before his time. He quotes a prize essay of the French
+surgeon, David, written in 1778. Hilton's development of the idea that
+pain is usually a signal on the part of nature for rest, and that rest
+will usually enable her to overcome the pathological condition and so
+relieve the pain without recourse to drugs, is, and ever must be, the
+basic element in the therapeutics of pain. How many forms rest may
+take can only be judged by a careful reading of Hilton's book. The
+oftener one reads it, the better one realizes how much of precious
+common sense and acute clinical observation there is in it. It is
+essentially a book of psychotherapy. It treats the patient's mind
+first and then through that changes his habits, persuades him of the
+need of rest, directs how that rest should be taken and so leads up to
+his natural cure.
+
+Every treatment of pain must include rest of mind as well as body.
+Hilton has particularly dwelt on the rest of body. Rest of mind is
+just as important. Many pains could be easily borne were it not for
+the worry that accompanies them. A slight pain becomes greatly
+annoying because the patient's general condition makes it impossible
+to stand discomfort with equanimity, and there has been no training in
+self-control. In spite of all our advance in medicine, we are not
+likely ever to make life so free from pain that people can go through
+it without needing self-control. Training in self-control is an
+important psychotherapeutic prophylactic. If, with a certain amount of
+capacity to bear discomfort, there goes such rest of mind as does not
+exaggerate or emphasize the condition, then many of the pains of life
+lose their power to annoy, all of them are distinctly lessened and the
+relief of them by accessory physical methods becomes easier.
+
+
+Pain in Its Relation to Life.--There is an unfortunate tendency to
+exaggerate the significance of pain. We have cultivated irritability
+in the physical sense, rather than the power of endurance. Patients
+should, as far as possible, be lifted out of this condition of
+over-delicate sensitiveness and put into a state where the idea of
+pain is not so serious. Only in this way can {238} the more or less
+inevitable discomforts of life be borne without such reactions as
+seriously interfere with health. It may be said to be other than the
+physician's business to secure this magnanimity, but as magnanimity is
+needed in our patients, and there is no one else to respond,
+physicians must start its cultivation. The necessity for learning to
+bear minor discomforts, at least without exaggerated reaction, need
+not be presented to the patient directly, but can be gradually made a
+part of the system of treatment. By absorption in other interests, the
+consciousness of these discomforts disappears without the necessity
+for recourse to drugs.
+
+
+Self-Denial.--Many thoughtful people are sure that what is needed to
+make a large number of our generation more happy, or at least less
+miserable, is training in self-denial and in self-control. The word
+self-denial has come to have a very distant sound for most of our
+generation. From early childhood anything that is unpleasant is
+shunned and anything that is difficult is likely to be shirked. The
+head-master of Eton College has recently insisted that too much is
+being done to please young folks and too little to stimulate them to
+activity. He declares that, as a rule, any undertaking begins to be
+useful just where it ceases to be simply pleasant. Unpleasantness is
+avoided to such a degree that the habit of thinking that it has no
+part in life comes to be a second nature. As a consequence, the
+reaction to any continued unpleasantness is likely to be exaggerated
+and make the subject very miserable, and sometimes disturbs and
+discourages, whereas it should have the effect of stimulating to
+reactive efforts, to bring out the best that is in us.
+
+Hinton emphasizes the fact that an ingredient of pain is necessary to
+all health or pleasure. The fatigue and the hardship associated with
+mountain climbing is a portion of the essence of the pleasure in it.
+All healthy, pleasant exercise has an accompaniment of fatigue and
+some aches and pains. What is needed, then, in our time is the
+training to do things for the sake of doing them. We should be
+neglectful of the discomfort that may be associated with them, or we
+should even consciously rejoice in the fact that this very discomfort
+is of itself a sign that functions are being used to such an extent,
+that their limits are being expanded, their limitations overcome.
+
+It may well be said that it is not the physician who, as a rule,
+should do this; it should be accomplished in the early years by the
+teachers and trainers of the young. True enough. But physicians can at
+least help in reforming the tradition in this matter so as to
+neutralize the present state of mind which seems to look upon pain as
+an evil. Pain is always either a conservative sensation or an actual
+stimulus to function. Besides, many of the present generation who come
+to us, having had no training in the precious qualities of self-denial
+and self-control under difficulties and discomforts, must have this
+knowledge supplied for them as far as possible by suggestions of
+various kinds. It is more difficult to accomplish much in this matter
+for the adult, but even in apparently hopeless cases of over-attention
+to self and incapacity to bear discomfort, much can be accomplished by
+patience and persistence.
+
+The common dread of suffering is quite unwarranted by what we know
+about the effect of pain. There are many motives that may be adduced
+to make it seem less terrifying than it now is to many people. The
+effect of pain upon character is always excellent. The difference
+between two brothers, as we have said, one of whom has had the
+discipline of pain or suffering and {239} the development of sympathy
+that comes with it, and the other who has not had the advantage of
+this great human experience, is likely to be marked. In the one there
+is a depth of human nature that enables him to appreciate and even to
+express the meaning of life better than his apparently more fortunate
+brother. Practically all the men who have ever got close to the heart
+of the mystery of life, and expressed it in poetry or other form of
+literature or art, have gone through suffering as a portion of their
+training. Even the suffering that comes from ill health is never
+wasted. Men have gone through it who have thought that the ecstasy of
+relief following it made the experience worth while.
+
+Men are not deterred from action by the prospect of even severe pain.
+Probably no greater physical suffering can possibly be invited than is
+sure to come to those who go on Arctic expeditions, or who undertake
+prospecting in Alaska. Of course, many of the prospectors find
+themselves in the bitter cold of the North without having realized
+what they would have to stand. But Arctic explorers, as a rule, know
+exactly what they have to expect. Most of of them have been through it
+all before, yet they deliberately choose to go again for rewards that,
+to an average man's eyes, seem trivial. The memory of past pain is
+rather pleasant. Virgil's "Perhaps it will be pleasant to recall these
+trials at some future time" is not poetic exaggeration.
+
+
+_The Discipline of Pain_.--There is only one way to learn how to bear
+pain, and that is by practice in it. There might be no necessity for
+this in case life were arranged differently. But all men must die, and
+death inevitably involves a painful process. Suffering is practically
+unavoidable for the majority of men. Even in the midst of every
+possible material comfort, cancer may come with all its hideous
+connotations. It is important, then, that everyone should be prepared
+to stand some pain. Certain suggestions help in bearing special pains.
+
+
+Pain Diffusion.--Pain along one nerve may readily become diffused.
+This diffusion will sometimes cause discomfort, and even tenderness,
+at a distance from the original seat of the pain. Such diffusion tends
+to produce in the patient's mind the idea that the underlying
+pathological condition is spreading, though it is only a sign that the
+nervous system is becoming irritable and easily responding to sensory
+disturbance. Dr. Head's investigations ("Brain," 1893), should be
+known to physicians, and the conclusions that flow from them should be
+presented to patients who are sometimes suffering quite as much from
+their apprehension of the spread of pain, and its significance, as
+from the discomfort itself. Dr. Head says:
+
+  If I have an aching tooth, the pain is at first localized to the
+  tooth affected. The longer the toothache continues the more I become
+  worn out, and the pain is rapidly accentuated by a "neuralgia," that
+  is, a pain in the face. The neuralgia is soon accompanied by
+  distinct cutaneous tenderness over a definite area on the face
+  corresponding to the tooth affected. If I am anemic, or if the pain
+  remains untreated until my bodily health is affected, I no longer
+  have a localized area of tenderness, but the pain, and with it the
+  tenderness, spreads until the whole of one-half of the head and even
+  the neck may be intensely tender. Thus at last the pain of an aching
+  tooth has produced tenderness over areas which bear no relation to
+  the affected organ.
+
+As pain can be suppressed by diversion of mind, or concentration of
+thought on something that creates great preoccupation, it must not be
+{240} forgotten that pain may almost be created by concentration of
+attention on certain areas of the body, or certain nerve tracts.
+Over-attention will actually make sensations intolerable that are at
+first quite indifferent, or at least very easy to bear. Sensitive
+people, in the ordinary meaning of that term, are those who are much
+given to paying attention to their sensations, and who therefore have
+much to complain of them. There is much in modern life that has the
+tendency to produce this sybaritic condition in which even slight
+discomforts become the sources of almost unbearable annoyance.
+
+Even where there is no good physical reason for the occurrence of
+pain, thinking may produce discomfort. The one thing that Freud's work
+has made clear is that in neurotic persons the memory of a mental
+shock or strain may be transferred to some portion of the body related
+in some way to the shock, and then prove to be the source of
+hysterical pains and also of hysterical palsy. The case told by him in
+which the young woman massaging her father's limbs allows them always
+to rest on her own lap during the process, and after his death suffers
+from an hysterical, painful condition in this region, is a typical
+illustration. Her sympathy for her father, accentuated by his
+subsequent death, and her sorrow at a time when her nursing efforts
+made her particularly susceptible, led to an explosion of nervous
+energy along those nerves which had always felt the impress of his
+legs. The hysterical condition resulted. This is an extreme case. In
+milder forms it would be possible to explain many otherwise
+inexplicable pains and aches in sensitive young people along these
+same lines.
+
+More than once I have seen young women, who had been asked to rub
+father or mother with liniment, complain of tingling pains in their
+fingers which were followed by some redness so that one would be
+tempted to think of Weir Mitchell's disease, though evidently the
+pathological cause at work was the slight disturbance of the vasomotor
+system due to the liniment and the rubbing, emphasized by the
+sympathetic feelings, and by the over-attention which this brought
+about. Whenever women have, for a prolonged period, to nurse others in
+whom they are deeply interested, and have to perform some habitual
+action that is somewhat fatiguing for them, after the death of the
+patient there will not infrequently be the development of hysterical
+or neurotic over-sensitiveness in the parts employed. This may give
+rise even to an hysterical joint, or to severe neurotic pains. Once
+these cases are recognized, the attention can be diverted from
+themselves and they can be made to understand that their grief and
+sympathy are being concentrated on the part and by transfer are
+producing physical manifestations. The pain is not imaginary, but the
+condition will improve as soon as the mind is diverted from it.
+
+
+Neurotic and Organic Pain.--The distinction between pain due to a
+neurosis and to a definite lesion is often difficult to make. If there
+is a definite localization of pain, it is almost surely not neurotic,
+but organic. If there are certain positions in which pain is felt
+while it disappears in others, there is some local inflammatory or
+congestive condition and not mere hypersensitiveness of nerves at the
+bottom of it. These positions of maximum pain are important. When pain
+radiates a great deal, even though there may be complaint of a
+particular region, it is usually neurotic. If patients are asked to
+tell exactly where their pain is, and they indicate its location by a
+wave of the hand, it is probable that the condition is neurotic. When
+there is a definite {241} localized point of tenderness with the pain,
+even though there may be radiations, usually the condition is based
+upon some organic trouble. It must not be forgotten, however, that
+slight local troubles may by concentration of mind on them, become
+exaggerated and that, in spite of the fact that there is or was at the
+beginning a definite localization of pain with some tenderness, the
+neurotic elements may, after a time, become manifest and prove to be
+much more important than the others.
+
+Pain that is definitely influenced by motion, as by the jarring effect
+of walking, or by bending and stooping, is practically always organic.
+The best differential diagnosis between neurotic abdominal conditions
+and organic trouble can be made by the help of information obtained in
+this way. If the appendix is inflamed, or the gall bladder infected,
+or contains a calculus, or if the kidney has a calculus, these are all
+made worse by movements, by jarring, by stooping as in tying the
+shoes, by riding on rough roads, and the like. If patients who suffer
+from obscure abdominal conditions associated with pain of which they
+complain much, can, at certain times, indulge with impunity in these
+exercises and motions, it is probable that their attacks are neurotic
+in character. Especially is this true if the indulgence in these rides
+and motions is without effect when they are in pleasant, agreeable
+company, though there may be some complaints when they have to ride
+alone, or under conditions that are less pleasant. If a hint of this
+distinction by which the physician differentiates one form of pain
+from another is given a neurotic patient, the suggestion will serve
+the purpose of producing complaints whenever the opportunity presents
+itself. Such patients take such suggestions, as a rule, without
+wishing to deceive, but they become persuaded that their sufferings
+are of the character asked for.
+
+
+{242}
+
+SPECIAL PSYCHOTHERAPY
+
+SECTION VI
+
+_THE DIGESTIVE TRACT_
+
+
+CHAPTER I
+
+INFLUENCE OF MIND ON FOOD DIGESTION
+
+
+With the progress of biological chemistry, digestion came to be
+considered a purely chemical process. Now we realize that even more
+important than the chemical factors of digestion is the individual
+liking for particular kinds of food, and the mental attitude of the
+patient toward digestion.
+
+Not only may mental factors interrupt or hamper digestive processes
+generally but, as the investigations of Pawlow at the Imperial
+Institute of St. Petersburg show, they may modify very materially the
+chemical processes within the stomach. If, for investigation purposes,
+a stomach pouch be experimentally segregated in a dog from the rest of
+the stomach, and the dog be fed food that he has a particular liking
+for, the gastric juice manufactured will be especially strong and
+effective. If the food given be less to the dog's liking, the gastric
+juice is not nearly so efficient in its activity. Finally, if food be
+consumed for which the dog does not care, but which he takes because
+hunger compels him, the gastric juice manufactured for its digestion
+is quite weak and the process of digestion is slow. If this is true
+for an animal like the dog, whose psyche is comparatively of much less
+importance than that of human beings, the corresponding influences in
+men and women will be even more emphasized. This is only what common
+experience has always shown us. The human stomach is not a test-tube
+in which mere chemical processes are carried on, but its vital
+activity is of great importance. That vital activity depends to a
+large extent on the state of mind, on the relish with which food is
+eaten, on the individual likes and dislikes, and on the emotional
+condition during digestion.
+
+
+Prejudices and Digestion.--Perfectly good food materials may become
+difficult or impossible of digestion as the result of learning
+something about their mode of preparation. In the country this is
+often noted, with regard to butter, milk, and even eggs. The story of
+the farmer's wife who wanted to trade her own butter for an equivalent
+amount made by someone else illustrates the influence of mind over
+relish for food. She was candid enough to say that the reason she
+wanted to exchange the butter was that a mouse had been seen in the
+cream, and her children could not, therefore, eat it. She took {243}
+back home with her exactly the same butter in another crock, and there
+was no further difficulty, though before this the children would have
+been actually sick if compelled to eat the butter. I once saw a family
+of three women who had vomited because they heard that the dishes had
+been washed in a slop pan, though this proved to be a mistake. Such
+occurrences emphasize the necessity for properly predisposing the
+mind, and for removing unfavorable suggestion, if digestion is to
+proceed properly.
+
+
+Mental States and the Stomach.--The typical example of the influence
+of the mind on the digestive tract is to be found in the experiences
+of Flaubert, the French novelist, while writing "Madame Bovary." When
+he was writing the scene in which he describes the effects of the
+arsenic which Madame Bovary takes, he himself suffered from
+practically all the symptoms due to the drug. In order to describe it
+faithfully he had studied it carefully. He had the pains, the
+vomiting, the burning feeling and even the garlicky, metallic taste in
+his mouth. Such an incident is extremely exceptional, yet its
+possibility is recognized, and it illustrates how sensitive some
+people are to the action of mental states upon the body, and how large
+a role a strongly excited imagination can play in producing definite
+physical symptoms. There are many more such realistic imaginations
+than we have, perhaps, been inclined to suspect. It is over these
+particularly that the psychotherapeutist can exert his influence by
+helping to modify the cause of their symptoms, the mental attitude
+which exists, rather than by trying to change the symptoms which are
+only effects, for diseases must, as far as possible, be treated in
+their causes.
+
+
+_Disgust and Disturbance of Digestion_.--Max Müller's story, told in
+his book on "Language," to show how language might have been a human
+invention from imitation of natural sounds, illustrates the influence
+of an unfavorable state of mind in disturbing digestion. An
+Englishman, traveling in China, fearful lest he should not be able to
+obtain food that he cared for, because of his lack of knowledge of the
+language of the country, was rather surprised on his first day's
+journey into the interior, to be served with a stew made of some kind
+of dark meat that tasted very well indeed and with which he was so
+much pleased that he asked for a second helping. Just as he was about
+to eat the second portion, he thought it well to ask the waiter what
+sort of meat it was, as he wished to be able to obtain the same kind
+at other places. Calling the waiter to him, he said, pointing to the
+dish of meat with a questioning tone, "Quack, quack?" The waiter at
+once shook his head and said, "Ugh! bow wow!" The Englishman pushed
+the second portion away and got up from the table.
+
+Tinder the same circumstances nearly everybody would feel the same
+qualmishness--at least all who had been brought up according to our
+Western notions. Reason has little or nothing to do with it. It is a
+question of feeling. The dog is much more cleanly in its habits than
+the hog, but we in the West are used to the idea of eating hog-meat
+just as they in the East are used to eating dog-meat. The objection,
+of course, might be urged that the difference between the hog and the
+dog is that we do not eat carnivorous but only herbivorous animals.
+But the slop-fed hogs from the neighborhood of our large cities,
+constituting a goodly portion of those brought to market, eat meat
+quite ravenously. They certainly are not exclusively herbivorous.
+There is no {244} principle behind our objection to dog meal
+then--only the unfamiliarity of the idea of eating it.
+
+The treatment of patients with digestive disturbances requires a
+careful analysis of the conditions of mind towards foods. If prejudice
+exists with regard to certain foods, there will be no relish for them,
+and unless these prejudices can be removed, the foods either will not
+be taken, though they represent important nutritional elements, or
+else they must be taken in such small quantities and digested with so
+much consciousness of their presence and such difficulty as to be a
+disturbing factor for health. Persuasion, the custom of the country,
+habit, training, mean much for this modification of mental attitude.
+
+
+_Custom and Food_.--In recent years many parts of animals, not
+generally eaten before, have come to be consumed with a relish because
+of the removal of prejudices against them. It might be thought that
+organs like the kidney, the essential function of which is excretory,
+and through which so much of the offensive waste products of the body
+pass, could not be a relished article of food. But it has become quite
+a dainty. The liver, owing to the peculiar nature of its function, its
+very special flavor, and the staining with bile, might be expected to
+be objectionable. It is not, but, strange to say, a third organ of the
+abdominal cavity, the spleen, which has none of the external
+objectionable features of kidney or liver, is not yet eaten, and most
+people would probably find it rather difficult to eat it. This
+difficulty would result, not because of anything in the organic
+substance itself, but because of the lack of accustomedness to it.
+There are a number of people who now have trained themselves to eat
+it. Such apparently impossible portions of the animal as the
+intestines, even those of the hog, are eaten with relish by a great
+many people, though there are others who have never been able to get
+used to them. The dainties of some peoples are utterly repulsive to
+others. The French like brains and other special portions of animals
+that are not much eaten by Anglo-Saxons. Fried brains in black butter
+sauce are enough to turn the stomach of some people by the very
+thought of it, though it is a highly prized dish in the south of
+France.
+
+In Italy most visitors eat snail soup with relish before they know
+what it is. It seems to be a special kind of gumbo soup. Down at
+Marseilles, gourmets occasionally eat angle-worms and find them to be
+a very appetizing dish. In all of these things the question of relish
+and peaceful, happy digestion depends entirely on the attitude of
+mind. The first men who ate eels must have been looked upon with
+considerable suspicion by their neighbors as viper eaters, and
+probably they themselves were not comfortable over the feat. It has
+been said that the first man who ever swallowed an oyster performed as
+great a feat as any of our important inventors or discoverers.
+
+
+_Gastric Antipathies_.--To the great majority of mankind the idea of
+eating horseflesh is repulsive. Numbers of people in various parts of
+Europe have found, however, that after the initial repugnance is
+conquered, it is quite as pleasant to eat as cow's meat. To my taste,
+at least, it is much more palatable than venison or bear meat. At the
+beginning, its sweetish taste has a curious reflex effect. Taken in
+connection with the thought that this is horse meat, the taste is apt
+to produce a sensation of nausea. This is readily overcome, though the
+first time it is necessary to keep constantly inhibiting {245} the
+mind from acting unfavorably upon the stomach during the course of
+eating and digestion. Custom, I learned from many, soon made it quite
+as savory as beef.
+
+
+_Food Varieties and the Mind_.--How easy it may be to overcome many
+prejudices in the matter of food digestion under the stress of
+necessity and the influence of example, was well illustrated during
+the siege of Paris. The Parisians, though a most delicate people in
+the matter of eating, were able to accommodate themselves to the
+conditions, and practically every kind of animal was eaten with a
+relish. Before the siege, to most of them it would have seemed quite
+impossible, that they should sit down with complacency to the dishes
+which afterwards were so appetizing. At the beginning there was a
+definite attempt to conceal the eating of rats, mice, cats and dogs
+under various names, and by various modes of preparation. But it was
+not long before there was an end of this pretense. The animals in the
+zoological garden proved a veritable life-saving store of meat. Every
+one of them was eaten, people were glad to get them, and paid high
+prices for them. Camel steaks, elephant cutlets, lion and tiger stews,
+appeared under their own names, even at the banquets of the wealthy.
+
+What is true of the mental attitude for meats influencing not only the
+relish for them, but their digestion, is also true for many
+vegetables. There are unfavorable suggestions in the minds of many
+with regard to the supposed indigestibility of potatoes, turnips,
+carrots, beans and occasionally with regard to tomatoes, lettuce, or
+the like. A few definite physiological idiosyncrasies against these
+vegetables, or certain of them, do actually exist. The attitude of
+mind, however, is largely responsible for the discomfort that occurs
+after the consumption of most of them. Patients who ought to consume
+more starchy substances, or whose bowels need the residual materials
+that are contained in these vegetables, for the sake of their effect
+upon peristalsis, should be persuaded to take these vegetables, first
+in small quantities and then in gradually increasing amounts. Many of
+them can thus be brought to a diet at once more nutritious and more
+likely to help out intestinal function. Their objection to them is
+usually but a fancy.
+
+
+Genuine Food Idiosyncrasies.--There are certain genuine idiosyncrasies
+with a physiological basis which prevent the taking of certain kinds
+of food, or cause disturbance if they are taken, but these are rare.
+Their presence should never be considered as demonstrated by
+subjective signs alone for these are eminently fallacious. In certain
+cases, however, so rare as to be almost always curiosities in medical
+practice, there are definite objective symptoms of the idiosyncrasy.
+These consist of urticarial rashes, tendencies to vomiting, or
+diarrhea, or both. Sometimes these result from the most bland and
+nutritious of foods. I have notes of the cases of two children--whose
+father could not eat eggs without vomiting--and to whom fresh eggs fed
+at the age of two and three years, always produced this same effect.
+Even small portions of egg would cause it. It mattered not how the egg
+was prepared, nor even whether it was carefully concealed in custard
+or in cake provided there was a certain amount of it, the food eaten
+with it would be vomited. There are many such idiosyncrasies for shell
+fish, cheese, and such fruits as strawberries, pineapples,
+pomegranates and the like, but they are demonstrated by objective
+signs. But by far the greater number of food dislikes are entirely
+{246} subjective and the subjective feelings can probably always be
+overcome by habit and training.
+
+
+Food Dislikes.--_Milk_.--Nothing makes more clear the absolute
+dominion of the mind over the stomach than the likes and dislikes of
+people for various kinds of milk. Most Americans can take cow's milk
+with good relish, though there are a few to whom it is distasteful. In
+this country we have not had much experience with the milk of other
+animals. Even goat's milk is not commonly used. The very thought of
+taking it disturbs many people, and to take it with other food would
+almost surely produce disturbance of digestion. I have seen people
+while traveling quite upset over the discovery that goat's milk had
+been put into their tea or coffee. Mare's milk is commonly used in
+some parts of Europe and in many parts of Asia, but it would be quite
+impossible to most of our people. Sheep's milk is used in some places.
+Ass's milk is commonly used in parts of Asia and may be obtained in
+Spain and is said to be less likely to disagree with children in
+summer than cow's milk. Most American mothers would rather not hear of
+it.
+
+The same thing is true of the milk products. Some people find certain
+kinds of cheese quite out of the question though other people relish
+them. It requires special training, not of stomach but of mind, to
+enable one to eat certain cheese, though once the habit has been
+acquired such articles are delicious. It is only in recent years that
+some forms of cheese with greenish tints have become popular in
+America. To serve them at a dinner a generation ago disgusted many
+people. Now a dinner does not seem complete without them.
+
+The beverages of various countries illustrate this same principle. The
+wines the Spaniards care for are not palatable to the Italians, and
+_vice versa_. Beer, as the result of familiarity, is now drunk
+everywhere in Europe, but when it was first introduced into Italy from
+Germany, it was considered impossible to understand how anybody could
+take it and pretend that its taste was pleasant. The question is said
+to have been once asked of one of the Congregations at Rome whether it
+was permissible to take beer on fast days. The Cardinals who tasted it
+declared that not only did it seem to them permissible but that it was
+a mortification to drink it and therefore it was proper Lenten
+exercise.
+
+
+_Eggs_.--Many people have a supposed natural repugnance for eggs which
+they are sure indicates that these are not good for them. As a result,
+the physician gets all sorts of stories with regard to the supposed
+effects of eggs. One person tells you that more than two eggs a day
+makes him bilious. Another will tell you that they are too heavy for
+him. A third will tell you that they are distinctly constipating. A
+fourth will tell you that they produce a tendency to diarrhea. Here,
+as with regard to milk, the experience of the tuberculosis sanatoria
+has shown that there are but few people who cannot, when properly
+persuaded and when eggs are given in various forms, take from four to
+six eggs in the day without injury, and even without inconvenience. In
+these cases, it is largely a matter of mental attitude towards the
+food. In many instances, it will be found that the disinclination
+began in some experience in childhood when an egg was not very good,
+or when it was served insufficiently cooked, or when, perhaps, eggs
+always cooked one way were made a staple of the diet for a
+considerable period. There are over one hundred {247} ways of cooking
+eggs and this variety of preparation will often make them palatable,
+and nearly always digestible.
+
+Over and over again I have seen people who had thought that eggs made
+them bilious, and who accordingly had for long refused to eat them,
+put in circumstances (from tuberculosis, diabetes, or obesity) where
+eggs had to form a considerable portion of the diet. Then there was no
+difficulty about eating and digesting eggs. In three cases in my
+experience patients with an objection they thought constitutional,
+developed glycosuria, and then nearly all their desserts were
+custards, and eggs became a standing dish in their daily diet. In
+every case not only was there no trouble, but they got to like the
+eggs and wondered why they should ever have had any prejudice against
+them. Two of the patients were women, the third a man who had not
+touched eggs for many years. His wife's comment was: "Eggs always made
+him bilious when he did not take them, but now that he is taking them
+freely they no longer make him bilious."
+
+
+Mental Changes and Digestion.--The change that has come over the
+public mind with regard to sour milk is a typical illustration of how
+much a difference in the mental attitude towards a food product may
+mean for its satisfactory consumption by many people. Sour milk,
+though many farmers and working people thought it a pleasant acid
+beverage, was for long looked upon as a product fit at most to be fed
+to the pigs, if, indeed, there might not be question even of the
+advisability of this. Only the very poor who craved the nutritious
+value there was in it, continued to take it to any extent. Even if the
+milk still tasted sweet, but broke when it went into the tea, that was
+enough to make it quite impossible for many sensitive stomachs.
+
+
+_Lactic Acid as a Bactericide_.--Then came Metchnikoff's announcement
+that his studies showed sour milk to be an extremely valuable food
+material, but much more than that, an important auxiliary for the
+lessening of microbic life in the intestines. He seemed to be able to
+demonstrate that a great many bacteria, whose products, absorbed from
+the intestines, hastened that process of deterioration in the tissues
+that we call old age, were inhibited when sour milk or lactic acid
+bacteria were present. The general health of the person who took sour
+milk was, as a consequence, much better. Not only this, but processes
+of deterioration being lessened, prolonged life and even old age could
+be promised to those who drank sour milk in sufficient quantities.
+Metchnikoff had been brought to the study of this question by what he
+had seen on the Steppes of Russia. Among the nomad tribes a principal
+part of whose diet consists of soured mare's milk, he found a large
+proportion of very old people. In looking for the reason for this
+disproportionate longevity, he came to the conclusion that the sour
+milk had something to do with it. Then laboratory observations and
+experiments as to the influence of the bacillus, that causes the
+souring of the milk, on the growth of other bacteria, and especially
+such bacteria as are usually found in the human digestive tract,
+seemed to show that the lactic bacteria had a strong inhibitory effect
+on nearly all the pathologic flora of the intestines.
+
+As the result of these studies, all the world is now quite willing to
+take its share of sour milk. We no longer hear the complaint that
+uncomfortable feelings in the digestive tract are the result of taking
+milk that was a little sour.
+
+{248}
+
+Since this doctrine of Metchnikoff's has come to be popularly known,
+fewer patients have insisted that they could not take milk in such
+quantities as the physician thought desirable for them. Before that, a
+persuasion with regard to the ease with which milk becomes
+contaminated with microbes, and the dread that it might thus be a
+source of disease, or at least of disturbance of digestion, made it
+very difficult of digestion for many people. Now that they have a good
+authority who insists that, even if it should become somewhat soured
+in the ordinary way, this, far from making it a pathological article
+of diet, rather adds to its value from a therapeutic standpoint, has
+changed the attitude of mind of these people.
+
+We need a similar feeling with regard to eggs in order that they may
+be eaten by many people who now refuse them because they fear the
+possible evil results of taking even a slightly tainted egg. Our
+recent pure food investigations have shown that the bakers in our
+large cities have been for many years using canned eggs, and that
+these would be quite impossible of consumption except disguised as
+they are in the midst of baker's products. Sometimes these eggs have
+been kept for several months before being canned. All the cold storage
+eggs that cannot be disposed of otherwise are thus treated. In spite
+of the common use of these canned eggs by a large proportion of the
+city population no serious results have come from them. The change
+that comes over eggs in time does not apparently spoil their nutritive
+quality, but only disturbs their taste. The main element in the change
+is the production of hydrogen sulphide. This gas has a very unpleasing
+odor, but its presence is not of pathological significance. This gas
+is a common ingredient in those mineral waters that are known as
+sulphur waters, and that have a reputation for curing many forms of
+digestive disturbance, especially chronic cases of nervous
+indigestion. What is true of sour milk, then, would seem to be true of
+eggs that have been, to some degree, spoiled, and at least no serious
+results may be expected from them. If serious results were to be
+expected, we should have had many evil reports of them in recent
+years. Whether considerations of this kind will help patients, who
+need to get over qualminess with regard to eggs, because they are
+always suspicious lest they should not be fresh, will depend a good
+deal on the suggestive value of such information as presented by the
+physician.
+
+
+_Another Organic Acid_.--Sauerkraut has shared the fate of sour milk,
+and because of its acid bacteria has been accepted by Metchnikoff as
+an ally. Yet sauerkraut used to be thought quite out of the question
+for invalids, especially those suffering from digestive disturbances.
+I recall the case of an old German shoemaker who had lived very much
+on sauerkraut when he was a young man and then, having made money in
+the manufacture of shoes, had not had much of it for thirty years,
+pleading with me, when he was old and it was rather hard to get
+anything to stay on his stomach, that he should be allowed to have
+sauerkraut. On the principle that what a man craves is usually what
+does him good, I allowed it. The physician with whom I was in
+consultation was perfectly sure there would be trouble, and the family
+were confident that his physicians evidently had given up all hope and
+were quite ready to yield to his caprices and let him take anything
+that he cared for. He not only took the sauerkraut without any
+trouble, though I must confess to some misgivings myself (for I am of
+those who unfortunately do not care for it and, therefore, {249} was
+prejudiced), but after having eaten a large plateful of sauerkraut
+twice a day for several days, he began to crave other things that
+would not stay down before, retained them well, digested them without
+difficulty, and got over that attack of indigestion and lived for
+several years afterwards. His own mental attitude was a better index
+than our supposed knowledge, though science has now come to confirm
+his state of mind.
+
+
+_Bacon and a Change in Suggestion_,--Another food material with regard
+to which there has been a complete change of view in recent years, is
+bacon and hog products generally. Pork in all forms used to be
+considered quite indigestible, and was one of the first things that
+people suffering from indigestion--or the fear of it--eliminated from
+their diet. Now we know how valuable a food product it is, especially
+for those inclined to suffer from constipation, or who are under
+weight. Many people still look surprised when advised to eat it
+regularly. Here we have a typical example of the change in the mental
+attitude toward a particular article of food bringing about a
+corresponding difference as regards not only the appetite for it, but
+also its digestibility. Many persons, who used to have no appetite for
+breakfast, now find that after eating a crisp piece or two of bacon,
+they develop an appetite for other foods. Bacon has become a fetish
+for some people and is considered a help, not a detriment to
+digestion.
+
+I recall a case in which I had very nearly the same experience with
+bacon as I related with regard to sauerkraut. The patient was an
+elderly woman, probably nearly ninety years of age, who, because of a
+crippling deformity, had not been able to get outside of the house for
+many years. She sat in a wheel chair, transported herself from one end
+of an apartment to another, spent most of her time by the window, but
+was very helpful in many little things about the house and occupied
+her hands with knitting and sewing. In spite of her condition, she was
+cheerful, pleasant, happy, and all her life had had a good digestion,
+her only trouble being a tendency to asthma as she grew old. I came
+back to the city after a summer vacation to find that she was not
+expected to live because nothing would stay on her stomach. She was
+sinking, and the end seemed not far off. I was asked to see her more
+because I had been her regular physician for some years, and it was
+thought that it would console her to see me than with any real hope of
+betterment. It had been extremely hot weather and this seemed to be an
+unfortunate circumstance. At my visit, I asked her if there was
+anything that she cared for. She shook her head and yet there seemed a
+hesitancy. I urged her to tell me if there was anything that she
+wanted, but only after considerable urging did she venture to say that
+there was something, only that she knew that she could not have it.
+Putting her thumb on the top of her little finger, she said, "Oh, I
+would like so much to have just a teenie-weenie bit of bacon." I said
+that she should certainly have it. Then taking courage, she asked if
+she could not have a little cabbage with it. I said, "Certainly." Her
+friends thought that it was just a yielding to one of the last wishes
+of an invalid with the idea that nothing could much harm her, since
+she was so near the end. She had eaten cabbage and bacon all her life;
+she ate it again with a relish, and in spite of the heat kept it down
+and digested it well. She had bacon and cabbage next day, and for
+several days; she gradually got strong and lived several more years of
+her happy contented life.
+
+
+{250}
+
+
+CHAPTER II
+
+INDIGESTION AND UNFAVORABLE STATES OF MIND
+
+
+Indigestion is the characteristic disease of our time. There are few
+men or women over thirty who have not suffered from it. The working
+classes are spared the most, but with the frequent suggestions in the
+newspapers and the introspection which has become so common,
+indigestion is often complained of even among them. Sedentary
+occupations, involving mental work and little physical effort, seem
+especially to predispose to some form of indigestion. Few of those who
+live what is called the intellectual life escape suffering from some
+of its symptoms. Not infrequently men have been hale and hearty
+specimens of muscular manhood when they took up some profession which
+compels them to be indoors, yet before long, they begin to complain of
+discomfort after eating, of tendencies to constipation, of headaches,
+of depression, of incapacity for mental effort after meals, and all
+these symptoms are attributed to the almost universal disease,
+indigestion.
+
+It is possible for the general attitude of mind to have a great effect
+on digestive processes, and the symptom-complex which is called
+indigestion, or dyspepsia, is probably much more dependent on the mind
+than on any other factor. In many cases it is primarily due to
+over-concentration of attention on digestion. In others it is due to
+over-occupation with business, worry, or serious thought at times when
+the digestive processes need all the energy. In many cases so-called
+dyspepsia is due to an unfavorable state of mind toward digestive
+processes in general, because of unfavorable auto-suggestion.
+Normally, stomachic sensations reach our consciousness only under
+special circumstances. When, however, much attention is paid to them,
+even the slight sensations that occur with normal digestion may rise
+above the threshold of consciousness and become subjects of
+solicitude. If they do so, then the increased attention likely to be
+paid to them surely interferes with function and changes what may be
+merely physiological into pathological processes.
+
+
+Disease Suggestions.--An unfortunate state of the public mind with
+regard to indigestion in general has been cultivated by many
+publications on the subject. People dread its occurrence, and fear
+that the first sign of discomfort in their gastric region is a signal
+of the beginning of a progressive affection. They fear the worst, and
+the consequence is a reaction quite out of proportion to the gravity
+of the ailment. So much has been said particularly of mistakes in diet
+that just as soon as they feel, or often rather think they feel, the
+first symptom of beginning dyspepsia they begin to study how to modify
+their diet so as to prevent its progress. They begin to eliminate
+various supposedly indigestible foods. Usually among the first things
+that are greatly reduced in quantity, or are entirely eliminated, are
+the fats and certain of the starchy vegetables. Because of expressions
+heard and read as to its harmfulness, the fearful ones also are
+usually timorous about taking fluid at meal times. As this is about
+the only time when they are likely to take fluid, unless it be summer,
+they soon suffer for lack of it. Eating only food that {251} leaves
+little residue and taking insufficient fluid leads to constipation.
+This reacts still further to disturb digestion, and to interfere with
+appetite.
+
+This leads to further reduction in the amount and variety of food,
+with the consequence that insufficient nutrition to supply energy for
+bodily needs is taken. The digestive system gives up to the body as
+much as it possibly can, not only of the food materials to be
+consumed, but of its own substance. Thus it weakens its own vitality,
+with a lessening of appetite and of digestive power. Hence, a vicious
+circle of change is instituted, the consequences of which are easy to
+see. After a time the patient is taking only the blandest foods,
+constipation has become an important element in the case, and the mind
+is constantly occupied with solicitude over the digestion and the
+choice of materials at meals.
+
+
+Contrary Suggestion and Digestion.--Hudson, in "The Law of Mental
+Medicine," insisted on the necessity for not suggesting to children
+the possibility of indigestion of various substances, for that is
+almost sure to disturb digestive functions. Children sometimes hear
+the remark that father or mother cannot take a certain article of food
+because it disagrees with them. The imitative faculty of the child is
+sure to be aroused, with the consequence that this particular food is
+not eaten with relish nor given a fair show for digestion, and will be
+the source of some stomach disturbance. Not infrequently substances
+thus spoken of are among those that are especially likely to do
+children good, such as milk or eggs, or occasionally butter. The harm
+done by the remark may, therefore, even be serious, for these foods
+should constitute a large proportion of the child's diet. Indeed, an
+excellent prophylactic in the matter of indigestion is to prevent as
+far as possible all conversation at table about the indigestibility of
+food. Unfortunately, this has, in late years particularly, become a
+favorite subject of table conversation.
+
+
+Transferred Feelings.--Professor Cohnheim called attention to the fact
+that many uncomfortable feelings are likely to be mistranslated
+because they are referred to organs with which there is nothing wrong.
+Whenever this function is hampered in any way, there are many
+uncomfortable feelings associated with the digestion of food. The
+custom has been to refer the origin of all these to the stomach.
+Cohnheim thinks that it is much more likely that they really originate
+in the intestines, though the rule has been to take the patient's
+feelings as an indication and to treat the stomach. It is not an
+unreasonable thing for patients to be deceived as to the exact
+location of discomfort. Even in so acute a process as toothache it is
+possible to mistake the particular tooth that is giving trouble, and,
+as dentists know, a perfectly quiescent tooth is sometimes blamed for
+pain that is coming from another. Fillings have been removed, teeth
+have been treated, good teeth have been extracted, because patients
+insisted on the significance of their feelings in such cases. The
+stomach must not always be blamed. Sometimes the only source of
+supposed gastric discomfort is the constipation present which is
+usually easy to relieve.
+
+
+_Gastric Reflexes_.--While the mind may serve to disturb digestion and
+produce gastric discomfort by over-attention, there are many reflexes
+that center in the digestive tract, the origin of which may be in
+distant organs. Fright often produces a sensation as of cold at the
+pit of the stomach. Looking down from a height has the same effect in
+some persons. Discordant noises {252} have the same effect on people
+of sensitive hearing and certain reactions to touch may be similarly
+reflected. There are a number of affections which produce
+uncomfortable reflex sensations in the gastric region. This is the
+hypochondrium of the olden time. Whenever feelings were complained of,
+for which there was no actual basis in the hypochondriac region, it
+came to be spoken of as hypochondriasis, a word that has an innuendo
+of imaginativeness about it. Dr. Head's studies with regard to the
+transfer of sensations from one portion of the body to the other, show
+us that there is a good physical reason in reflexes for many of these
+complaints. An explanation of this to patients will often relieve
+their minds greatly and make their discomfort seem much less serious.
+Dr. Head said:
+
+  With orchitis or prostatitis, we also occasionally find that the
+  patient complains of a pain at the epigastrium, representing the
+  stomach area. This is put down to hypochondriasis and if it occurs
+  in a woman as a consequence of ovaritis, she is said to be
+  hysterical. But this phenomena is no more "hysterical," whatever
+  that may mean, than is the reference of the pain and the tenderness
+  of an aching tooth to the back of the head or the shoulder.
+  [Transfers which have been observed actually to take place.]
+
+  This is the phenomenon I have been accustomed to call
+  "generalization" of visceral pain and tenderness, and is of such
+  common occurrence as to form a very important factor in the clinical
+  picture of many diseases.
+
+  The order in which generalization takes place, leads one to speak of
+  the relative "specific resistance" of the centers for the sensory
+  impulses from various organs. No very definite rule can be laid down
+  to govern every case, but each case must be considered on its
+  merits. However, the area which appears most easily on a woman, as a
+  secondary affection, is the tenth dorsal; then, perhaps the sixth
+  dorsal, or inframammary, and then the various gastric areas,
+  beginning first with the ensiform or seventh dorsal. In a man the
+  tenth dorsal appears rather less readily while the ensiform appears
+  with great ease.
+
+Affections of other organs within the abdomen may produce like
+reflexes. A chronic appendicitis, for instance, will often be
+reflected in the stomach area. So will the presence of gallstones, or
+of disturbances of the biliary mucosa. Loose kidney often produces
+stomach reflexes. Any disturbance of the intestinal function will
+produce gastric irritation and inhibition of digestion. Most of the
+other primary conditions are more serious. Often the patient is aware
+of their existence, and it is a relief to him to find that the stomach
+symptoms are not the index of further pathological development, but
+only reflex conditions. This of itself does much to make the condition
+more bearable.
+
+Patients who are suffering from symptoms of indigestion often have
+areas of their skin surface that are at least very sensitive, if not
+actually tender. They feel the pressure of their clothing over a
+particular portion of the body, usually on the left side of the
+abdomen somewhat above, though at times also below the umbilicus.
+Though not painful, as a rule, it is decidedly uncomfortable and
+produces a constant desire to loosen the clothing, or lift it from the
+part. Mere loosening, it is soon found, does no good, because the
+clothing continues to touch the skin and it is not the constriction or
+pressure but the contact that produces the discomfort. Sometimes there
+is a distinct lesion of the stomach. This cutaneous hyperasthesia may,
+indeed, rise to the height of extreme tenderness in cases of gastric
+ulcer, or the like. But there is no {253} doubt that a certain amount
+of this sensation is present with all functional disturbances of the
+stomach and that the reflex sensitiveness of superficial nerves is
+only what might be expected from what we now know of this subject.
+
+
+_Discomfort and Digestion_.--Just as certain food materials disagree
+because of the state of mind, so certain feelings in the gastric
+region, even in the skin surface, sometimes disturb digestion and lead
+to changes of the diet unwarranted by the condition. Patients conclude
+that, if the skin is so tender, then the underlying organs, the
+disturbance of which causes this tenderness, must be in a serious
+condition. For these patients the explanation of the present state of
+our knowledge as to reflex disturbance of sensory nerves will be of
+therapeutic value. They must be taught that pain is reflected from one
+nerve branch to another, and is not communicated by continuity of
+tissue, or by sympathetic affection from the stomach mucous membrane
+through the stomach wall, and then from the abdominal wall to the skin
+surface. This knowledge will prove reassuring.
+
+
+Division of Energy.--After this mental occupation with digestion
+itself, which by consuming nervous energy lessens the amount available
+for digestive purposes, probably the most common factor in the
+production of indigestion is the concentration of mind on serious
+subjects, while digestion is proceeding. An old English maxim is that
+some people have not enough brains to run their liver and their
+business. The liver in old-time pathology was considered the most
+important of the abdominal organs and was taken by metathesis for them
+all. Most of us have only a limited amount of vital energy and,
+usually, we can accomplish only one thing well at a time. If we try to
+do intellectual work while digestion is going on, both the
+intellectual work and the digestion suffer. If we persist in
+attempting to do both, we will surely disturb the digestive organs and
+we may bring about grave neurotic disturbances in the central nervous
+system. We may be able for a time to accomplish the two things at the
+same time, but it will not be long before evil results will be seen.
+Nervous, high-strung people should be reminded of Lincoln's anecdote
+of the little steamboat on the Mississippi which had not steam enough
+to blow its whistle and run its paddle wheels at the same time, so
+that whenever the engineer wanted to blow the whistle he stopped the
+boat.
+
+Indeed, much of the indigestion that we see is due to this dissipation
+of energy through the attempt to do two things at the same time. Those
+who live the intellectual life are the most frequent sufferers.
+Worries and anxieties that are allowed to trouble the mind during
+digestion time are sure to disturb digestion eventually because they
+use up energy that is needed for physical purposes.
+
+A change of environment that takes us away from the ordinary cares of
+life, is often sufficient to make all the difference between ease of
+digestion and extremely uncomfortable dyspepsia. By worry the mind
+apparently becomes short-circuited on itself and uses up a large
+amount of the available energy in nervous impulses that do not find
+their way outside the central nervous system at all, but are used in
+disturbing associated nerve cells. Just as soon as a change of scene
+and occupation calls for a different set of thoughts and other
+feelings, energy is released for work outside the central nervous
+system itself, digestion begins to improve, and in a comparatively
+short time what seemed to be a serious gastric disturbance, disappears
+almost completely.
+
+{254}
+
+_Lack of Sleep Repair_.--In my own experience one of the most
+characteristic stigmata of these cases of indigestion which are due to
+exhaustion through other channels of vital energy, is that they feel
+much better in the evening than in the morning. They are, therefore,
+tempted to stay up late and so do not get the necessary rest. Their
+excuse for late hours is that they need recreation. To that excuse I
+have no objection. They do need more recreation; they need more hours
+during which their minds are absolutely free from business cares; but
+these hours must not be taken from their sleep, for they need rest
+even more than recreation.
+
+
+_Worries and Irritations During Meals_.--The presence of worries or
+irritation during meals or shortly after, as well as unfavorable
+states of mind towards digestion itself, and occupation of mind with
+serious affairs during digestion, are likely to be sources of serious
+disturbance of digestion. A fright, a fit of anger, nagging,
+irritation, or any disturbing emotions, may hamper digestion. An
+experiment that is sometimes performed in the physiological laboratory
+on the cat nicely illustrates this. If the laboratory cat is fed some
+dainty that it likes, mixed with bismuth in order that its stomach and
+intestines may be made opaque to the x-rays, and then be examined by
+means of the fluoroscope, the peristaltic processes of digestion by
+which food is mixed in the stomach, passed out into the intestines,
+and by which intestinal digestion is stimulated, may be seen to go on
+very interestingly. If, now, the cat is made to arch its back, and
+manifest the usual signs of extreme irritation, the process of
+digestion is interrupted, and will not be resumed till some time after
+the cat quiets down. The lesson is obvious.
+
+
+
+CHAPTER III
+
+PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS
+
+If discouragement and solicitude make a healthy stomach digest
+imperfectly, the same mental factors will play an even more serious
+role with a diseased stomach. Certainly without the mind's aid, there
+can be little hope of such a reactive vital resistance as will enable
+the organ to recover from the organic ailment.
+
+So many cases of indigestion are due to mental persuasion alone, that
+after a time there is danger that the physician may be over-confident
+in his diagnosis, and may occasionally overlook serious organic
+lesions. Before attempting psychotherapy in these cases, the physician
+must assure himself that no organic lesion is present. This is
+particularly true for cancer in the middle-aged and ulcer in young
+women. At times these lesions are latent except for certain vague
+digestive symptoms. After careful consideration it is generally
+possible to make a definite decision, and then the indications are
+clear. Even when an organic lesion is present, a modification of the
+mental attitude will often be of great service to the patient.
+Suggestion will even make a cancer patient gain in weight, though one
+must be careful of that very fact because the apparent improvement may
+occasion delay until the case becomes inoperable.
+
+Once the presence of these serious organic lesions of the stomach can
+be {255} excluded, the bringing of influence to bear on the patient's
+mind for the improvement of his digestion is indicated. It is true
+that there are certain reflex disturbances of the digestive tract
+consequent upon affections of other abdominal organs. Chronic lesions
+of the appendix may produce stomach symptoms as will also pathological
+conditions of the biliary tract. A floating kidney, various affections
+of the pelvic organs, especially in women, and of the urinary organs
+in men are sometimes said to produce seriously depressing effects upon
+the stomach. Where this occurs, the first indications undoubtedly are
+to put the patient into as good condition as possible before making
+any decision. Where a lesion of the stomach itself exists suggestions
+with regard to the increase of diet may do harm. They will not do harm
+in the reflex conditions, and so patients can be brought into better
+physical condition. As a consequence of this, their symptoms in other
+organs will often disappear. In case the symptoms do not disappear the
+patients are in better condition to stand and react from operative
+intervention.
+
+Before concluding as to the character of the stomach symptoms we must
+make sure that other important organs are not affected. Most cases of
+tuberculosis begin with stomach symptoms, which often make their
+appearance before there is cough or any definite localizing symptom of
+the disease. Often there is only a disturbance of pulse, and perhaps a
+slightly increased range of temperature. If the patient has been
+exposed to tuberculosis, a careful investigation of the lungs should
+be made. Any disturbance of the liver or pancreas (especially cancer)
+will almost surely give rise to stomach symptoms. Latent cancer in any
+part of the body, however, will, by its depressing toxemia, produce
+loss of appetite, consequent loss of weight, and a number of symptoms
+that are sure to be referred to the stomach. I have seen cancer of the
+prostate, without disturbing urination, produce such symptoms for
+months before it was recognized. I have seen cancer of the rectum in a
+comparatively young woman treated as piles, without an examination,
+the development of the piles being attributed to the gastro-intestinal
+symptoms which were consequent upon the presence of the cancer.
+
+
+MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION
+
+It is often said that this teaching as to the effect of the mind on
+digestion and its eminent usefulness for the treatment of dyspeptic
+conditions, is due to the attention that has been attracted to this
+subject as a consequence of the prominence of Eddyism, New Thought,
+Mental Healing, and the like. There are absolutely no good grounds for
+any such assertion. Here in America, more than twenty-five years ago,
+before there was any question of the modern mental healing movements,
+our greatest medical clinician, Dr. Austin Flint, expressed himself
+very emphatically with regard to mental influence over digestion, and
+to solicitude of mind as one of the most frequent etiological factors
+in dyspepsia.
+
+Dr. Flint was thoroughly scientific in his medical observations, was
+no seeker after notoriety, and he was reading his paper before the
+older physicians of the period, and all of those who took part in that
+first meeting of the New York Medical Association strove to make their
+papers of scientific value. His words, then, must carry great weight:
+
+{256}
+
+  Dyspepsia formerly prevailed chiefly among those who adopted, to a
+  greater or less extent, the foregoing maxims [the finicky rules of
+  dyspeptics which he deprecates and corrects as quoted later in this
+  chapter]. It was comparatively rare among those who did not live in
+  accordance with dietetic rules. The affection is much less prevalent
+  now than heretofore, because these maxims are much less in vogue.
+  The dyspeptics of the present day are chiefly those who undertake to
+  exemplify more or less of these maxims. It seems to me, therefore, a
+  fair inference, that dyspepsia may result from an attempt to
+  regulate diet by rules which have for their object the prevention of
+  the affection which they actually produce. It is to be added that an
+  important causative element involved in the practical adoption of
+  these rules is the attention thereby given to digestion. It is by
+  introspection and constant watchfulness of the functions of the
+  stomach, that the mind exerts a direct influence in the causation of
+  this affection.
+
+
+
+Dietetic Rules of a Former Day.--In order to make definite just what
+were the views of the olden times which he deprecates, he stated them
+briefly and forcibly:
+
+  The views generally entertained, at the time to which I have
+  referred, largely by physicians and almost universally by
+  non-medical sanitarians, may be summed up in a few maxims as
+  follows: Eat only at stated periods, twice or thrice daily, and
+  never between meals, no matter how great may be the desire for food.
+  Never eat late in the evening or shortly before bedtime. In the
+  choice of articles of diet, carefully select those which reason and
+  personal experience have shown to be best digested; and never yield
+  to the weakness of eating any article of food simply because it is
+  acceptable to the palate. In order to avoid the temptation of
+  overeating, let the articles of food be coarse rather than
+  attractive, and eschew all the devices of the cuisine. Always leave
+  the table hungry. Study personal idiosyncrasies, and never indulge
+  in kinds of food which, although wholesome for most persons, are
+  injurious to a few who are peculiarly organized. With reference to
+  this last maxim, bear in mind that "what is one man's meat is
+  another man's poison." In order to secure, as effectually as
+  possible, a proper restriction in the quantity of food, it was
+  recommended by some physicians and to some extent practiced, that
+  every article be carefully weighed at meal times, and that a certain
+  quantity by weight be never exceeded. Vegetarianism or Grahamism was
+  advocated and practiced by many. Total abstinence from drink was
+  considered by a few as a good sanitary measure, compelling the body
+  to derive the needed fluids exclusively from fruits, vegetables, and
+  other solid articles of diet. Restriction in the amount of drink, as
+  far as practicable with regard to the power of endurance, was very
+  generally deemed important, so as not to dilute the gastric juice.
+
+When to his question, "Do you regulate your diet," the patient
+answered promptly and often emphatically in the affirmative, Dr. Flint
+insisted always: "This is a good reason for your having dyspepsia; I
+never knew a dyspeptic get well who undertook to regulate his diet."
+When the patient asks then, "How am I to be guided," the reply is,
+"Not by theoretical views of alimentation and indigestion, no matter
+how much they appear to be in accord with physiological and
+pathological doctrines, but by the appetite, the palate and common
+sense." He then goes on to answer certain other objections that
+patients are wont to urge, and says:
+
+  But the patient will be likely to say, "Am I not to be guided by my
+  own experience and avoid articles of food which I have found to
+  disagree with my digestion?" The answer is, that personal experience
+  in dietetics is extremely fallacious. An article of diet which may
+  cause inconvenience of indigestion to-day may be followed by a sense
+  of comfort and will be readily digested to-morrow. A variety of
+  circumstances may render the digestion of any article of food taken
+  at a {257} particular meal labored or imperfect. As a rule articles
+  which agree with most persons do not disagree with any, except from
+  casual or accidental circumstances, and from the expectation, in the
+  mind of the patient, that they will disagree. Without denying that
+  there are dietetic idiosyncrasies, they are vastly fewer than is
+  generally supposed; and, in general, it is fair to regard supposed
+  idiosyncrasies as purely fanciful. Patients not infrequently cherish
+  supposed idiosyncrasies with gratification. The idea is gratifying
+  to egotism, as evidence that Providence has distinguished them from
+  the common herd by certain peculiarities of constitution.
+
+
+Dietetic Instructions.--Finally Dr. Flint has a series of instructions
+for those suffering from indigestion:
+
+  Do not adopt the rule of eating only at stated periods, twice or
+  thrice daily. Be governed in this respect by appetite; and eat
+  whenever there is a desire for food. Eat in the evenings or at
+  bedtime, if food be desired. _Insomnia is often attributable to
+  hunger_ [italics ours]. In the choice of articles of diet, be
+  distrustful of past personal experience, and consider it to be a
+  trustworthy rule that those articles will be most likely to be
+  digested without inconvenience which are most acceptable to the
+  palate. As far as practicable, let the articles of diet be made
+  acceptable by good cooking. As a rule, the better articles of food
+  are cooked, the greater the comfort during digestion. Never leave
+  the table with an unsatisfied appetite. Be in no haste to suppose
+  that you are separated from the rest of mankind by dietetic
+  idiosyncrasies, and be distrustful of the dogma that another man's
+  meat is a poison to you. Do not undertake to estimate the amount of
+  food which you take. In this respect different persons differ very
+  widely, and there is no fixed standard of quantity, which is not to
+  be exceeded. Take animal and vegetable articles of diet in relative
+  proportions as indicated by instinct. In the quantity of drink,
+  follow nature's indication; namely, thirst. Experience shows
+  abundantly that, with a view of comfortable digestion, there need be
+  no restriction in the ingestion of liquids.
+
+
+Removal of Solicitude as a Remedial Measure.--Many dyspeptics have no
+subject that they occupy themselves with more seriously than their
+digestion, and they thus divert blood needed for digestive purposes as
+well as nervous energy that would help in it from the stomach to the
+brain, in order to exercise surveillance over the process. As has been
+well said, "Probably much more than half of the indigestion is really
+above the neck." This does not mean that there are not cases that need
+definite stomachic treatment, or even that patients who have succeeded
+in functionally disturbing their digestion by thinking over much about
+it, will not need gastric remedies.
+
+The explanation of the many fads and remedies that _cure_ indigestion,
+real or supposed, is exactly this tendency of the suggestive influence
+of such remedial measures to lessen the patient's solicitude about
+digestion. Any change in diet that carries with it the persuasion that
+for any reason digestion ought to be better, will, because of this,
+make digestion better. Any habit of taking warm or cold water before
+meals, or of chewing in a particular way, or of taking a particular
+kind of food different from what is usually taken--exclusively cereal,
+uncooked, largely fruit, vegetarian, etc.--will lift the concentration
+of attention on the digestive process, and so give the stomach a
+chance to do its work without interference from the brain.
+
+Du Bois has quoted some striking testimony in this matter from Baras,
+who wrote on the "Gastralgias and Nervous Affections of the Stomach
+and the Intestines" as early as 1820. Baras had himself been a
+sufferer from {258} gastric discomfort, fullness after eating,
+eructations of gas, constipation, and general depression. He consulted
+most of the distinguished medical practitioners of his time. With one
+exception they were convinced that he was a sufferer from chronic
+gastro-enteritis. They added more and more to his concern about his
+stomach, and furnished him with numerous sources of autosuggestion. In
+spite of all that they did for him, his condition grew worse and
+worse, he lost in weight, and was sure that his case was hopeless. He
+was cured in a single day. His daughter was attacked with consumption,
+and "in the moment my attention," says Baras, "was centered entirely
+upon my child, I thought no more of myself, and I was cured."
+
+
+Brain Workers and Indigestion.--Perhaps the best proof of how
+necessary it is that people should not continue to occupy their
+intellect seriously during the time when digestion is going on, is to
+be found in the frequency with which complaints of indigestion occur
+in literary folk. The complaints are heard most from literary folk
+because they are more likely to tell their stories. They have their
+work, and thoughts of it, always with them. So there is a constant
+call for nervous and mental activity and for much blood in the brain
+tissues. This subtracts from the nervous energy necessary for
+digestion, and makes it impossible to conduct it with that perfection
+which comes naturally to people who banish all other thoughts and keep
+their minds free for the pleasures of the table and social intercourse
+at meal time.
+
+Nervous indigestion is so common among literary folk, teachers and
+scientific workers, that various causes have been suggested for it.
+Dr. George Gould, in his "Biographic Clinics," calls attention to it
+and suggests that the cause is probably the need of properly fitted
+spectacles. In our own time, when we are much more careful in the
+matter of eyeglasses, and when most writers and professors wear
+scientifically adapted glasses, the complaints still continue. The
+reason is evidently something associated with the almost continuous
+work that they do. Such people, too, are much more self-conscious than
+others. They think more about their digestion and what they eat. They
+often think that they differ from other people and have special
+idiosyncrasies for food. These thoughts are sure to culminate in
+nervous indigestion.
+
+
+Food Faddists.--Literary folk and people who live the intellectual
+life are very prone to take up with fads of various kinds and find
+surcease from their sorrows in all sorts of out of the way dietaries,
+modes of eating, food limitations and specializations. They constitute
+a majority of the food faddists. Some of them--sure that they should
+not eat meat--are strenuous vegetarians. Others confine themselves
+entirely to food the life of which has not been completely destroyed
+by cooking. They are fruit faddists, nut faddists, milk-product
+faddists, and the like. Some of them try to persuade the world that it
+eats too much; others that it eats too frequently. Some of them take
+but a single real meal a day and have apologies for the other meals.
+All want to lead people to their particular mode of life, as if all
+the world had been wrong until they came to set it right. Some want
+the rest of the world to chew seventy-times-seven before they swallow
+and to adopt other exaggerations of attention to eating that are quite
+contrary to instinct, the most precious guide that we have in the
+matter of food choice and food consumption.
+
+These intellectuals are always improved by their fads, no matter what
+they {259} may be. The reason is apparent. Their original digestive
+disturbance was due to over-occupation with intellectual work. Then
+they began to worry about their digestion and feared that nearly
+everything they ate would disagree with them. This fear and solicitude
+still further interfered with digestion. Next they acquired the new
+fad. They became persuaded that they could eat certain things in
+certain ways. They no longer disturb their digestion by anxiety about
+it, but, on the contrary, help it by favorable suggestion. Now under
+the new regime everything will surely go on well. Besides, they
+usually learn the lesson of not doing intellectual work close to their
+meals, and of spacing their work better. They learn to do a daily
+stint of work and no more. One of the fads that goes with most food
+fashions is abundant outdoor air. This always does good. Between the
+favorable mental influence, the lessened work, especially just after
+meals, and the increased outdoor air they get better and then they
+attribute it all to their special fad about food. The _"cure"_ is due
+to psychotherapy and common sense, and not in any way to the special
+fad.
+
+
+Worry.--Worry of any kind will have the same effect as the
+over-attention of the literary man or teacher to his work. Anyone who
+brings his business home with him is likely to suffer and, unless he
+has a superabundant supply of energy, will impair his digestive
+function as a consequence of attempting to do business after dinner,
+perhaps also stealing some of it in before and during breakfast.
+
+
+PREVENTION AND CORRECTION
+
+The important rule with regard to the mental attitude of the patient
+toward uncomfortable feelings due to digestion must be, first to
+correct all other possible sources of the trouble, and only after
+these have been proved not to be factors in the case, should there be
+any question of modification of diet. This is just the opposite rule
+from that which obtains, and by which patients begin to meddle with
+their diet at the slightest symptom, or supposed symptom, of
+indigestion. My custom is to tell patients at once that there is
+probably something else besides their diet at fault. It is not that
+they eat too much, nor too great a variety, but that perhaps they eat
+too rapidly. Without reducing their diet, and above all without
+eliminating supposedly indigestible things from it, there should be
+formed a habit of eating more slowly. This will usually result in the
+reduction of the quantity eaten, but the variety of food should be the
+same, and the patient should not be permitted to limit his diet to a
+few supposedly bland, unirritating materials. In that event,
+constipation will assert itself, particularly if there is limitation
+of the amount of fluid taken.
+
+
+Longevity of Dyspeptics.--There is one consolation that may be given
+to nervous dyspeptics, though in the midst of their worst symptoms
+they may not be sure whether it is a genuine consolation or not. It
+has been noted that many of those who live to extreme age tell the
+story of having suffered from nervous dyspepsia in middle-life. Their
+solicitude about themselves makes them safe against over-indulgences
+of many kinds in food or drink that might prove hurtful to them. Much
+of their discomfort is indeed due to the fact that they do not eat
+quite enough. If they succeed in avoiding the {260} pitfalls of the
+infectious diseases, and especially tuberculosis during their earlier
+years, and most of them are likely to because of the great care they
+take of themselves, they often live to old age. Certainly of two men,
+one of whom eats very heartily and the other very sparingly, the
+latter is much the more likely to attain old age. There are those who
+declare that the valetudinarian life, "half dead and alive," which
+even Plato satirized nearly 2,500 years ago, ever renews the question
+as to whether life is worth living or not. It is particularly
+dyspeptics who seriously discuss this question--yet with all their
+complaints, they actually do live longer lives.
+
+
+Pharmaceutic Remedies.--This insistence on the importance of mind in
+the treatment of indigestion does not imply that tonic remedies, and
+especially such substances as strychnin, which stimulate appetite and
+add tone to the muscles of the stomach, should not be used when duly
+indicated. They are always helpful. Alone, these remedies give but
+temporary relief and after a short time the system becomes accustomed
+to them. If prescribed in connection with changes in the patient's
+habits, and especially such as divert his attention from his digestive
+tract, and from wrong persuasions as to food taking, the good they
+accomplish will be lasting. Nervous people usually have an increase of
+acidity. They are liable to overdo everything, and even the stomach
+overdoes its acid forming function. For this, alkaline remedies such
+as rhubarb and soda will do good. But, just as with strychnin, the
+benefit is but temporary unless the patient's habits and attitude of
+mind are modified so as to eliminate their solicitude as a constantly
+disturbing factor.
+
+
+Circumstantial Suggestions.--There are many changes of habits that are
+of great value in the treatment of nervous and allied forms of
+indigestion. These changes often make a great difference in the
+general health of the patient and thus help to improve digestion.
+Besides their influence as alteratives, they are valuable from the
+mental influence which they exercise. It requires a definite exertion
+of will many times, perhaps, each day to bring about the omission or
+performance of certain actions, and this act of the will is
+accompanied by the repeated suggestion that this will cause
+improvement in the digestion. Many of the cures effected by special
+diet. Habits of exercise, health resort regimes and the like, owe
+their efficacy to this accompanying repeated suggestion of acts for
+the formation of new habits or the breaking of old ones.
+
+
+Physiological Measures.--There are, of course, certain details with
+regard to digestion in which the patient's mental attitude needs to be
+changed by instruction rather than persuasion, by knowledge of
+physiology rather than by psychology. In the taking of food itself,
+chewing is, of course, the most important consideration after its good
+preparation by the cook. If patients are told to chew their food
+carefully, however, without further directions than this, it will
+usually be found that they begin to chew their meat a great deal and
+their vegetables scarcely more than before. It is, however, vegetables
+that must be chewed particularly. The meat-eating animals bolt their
+food. They have only cutting and tearing teeth. Their instinct is
+correct, for the saliva has nothing to do with the digestion of meat,
+and therefore no chewing is necessary. On the other hand, the
+vegetable-eating, and especially the grain-eating animals, chew
+carefully. Most of them are ruminants, that is, after a preliminary
+thorough chewing of their food, they swallow it, and then {261}
+afterwards at their leisure bring it up once more into the mouth and
+chew it again.
+
+
+_Mastication and the Stomach_.--If food is not chewed well, and occurs
+in large masses in the stomach, not only is it not dissolved easily,
+but the work of passing it out to the intestine is delayed. The reflex
+which brings about the opening of the stomach and the ejection of food
+into the intestine is best brought about by the liquefaction of the
+stomach contents. During the mixing process all the food, as far as
+possible, becomes fluid and then is passed on. Large pieces of any
+kind are delayed, however, hamper the emptying of the stomach and
+interfere with stomach motility. The stomach is only a thin-walled
+membranous viscus which finds difficulty in dealing with food in
+lumps. It is different from the stomach of the hen, which, having no
+teeth, swallows grains of all kinds without chewing, but also by
+instinct swallows small stones which, in its thick-walled, muscular
+gizzard, are used for grinding up the food.
+
+
+_Exercise_.--The taking of exercise is an important habit that needs
+to be changed in the case of dyspeptics. Many of those who live a
+sedentary life, and are much occupied with intellectual or business
+matters, are almost sure to take little or no exercise. If earlier in
+life they were accustomed to take much, the lack of it leads to
+serious disturbances of nutrition. They have formed certain habits as
+to the amount of food they eat, and these continue, so that they
+consume more heat-making material than they can use. In the process of
+dissipating it, there is likely to be much nervous energy wasted,
+usually to the discomfort of the patient. This is likely to be
+eventually reflected back to the stomach, with disturbance of appetite
+and digestion.
+
+We now know that the motor function of the stomach is much more
+important than its secretory function. Its main purpose is to mix the
+food and pass it on in small quantities, at intervals, to the
+intestines. When patients have a sense of uncomfortable fullness in
+the gastric region after a hearty meal, or of discomfort after the
+taking of food, especially if much liquid is taken with it, they are
+prone to attribute these feelings to imperfect secretion not
+completing digestion as it should, and permitting fermentation with a
+production of gas and consequent stomach distention. The real reason
+for their discomfort is not secretory, but motor. It is due to a delay
+in passing on the food and to stomach distention because the gastric
+muscle is not in good tone.
+
+People who have been used to taking exercises have their muscular
+system in good tonic condition. This includes the involuntary muscles,
+as well as the voluntary, and if they are neglecting air and exercise,
+the whole muscular system becomes flabby. Hence the uncomfortable
+sense of distention, because the stomach walls do not contract readily
+for the expulsion of food. A second important factor is also
+present--the muscles of the abdomen. Ordinarily they support the
+abdominal organs without any sense of effort. If by lack of exercise
+they have diminished in tone, however, when a hearty meal is eaten,
+the abdominal muscles have to support this additional weight since the
+stomach itself sags, and the consequence is a feeling of pressure on
+the left side of the abdomen about the level of the umbilicus. To
+relieve this feeling the tendency of the patient is almost always to
+lessen the amount eaten. If he is not distinctly overweight this will
+do harm rather than good. Instead he {262} needs to take sufficient
+exercise to tone abdominal muscles and reflexly also tone even
+involuntary muscles, and with them the gastric muscularis.
+
+
+_Air_.--Almost more important than exercise is an abundance of fresh
+air, and without this muscles soon fail to respond to voluntary or
+involuntary impulses. If people do not spend two or three hours in the
+air every day, they are likely to develop an over-sensitive condition
+in which all nervous sensations are exaggerated. The reason men and
+women differ so markedly in their reaction to pains, aches and
+discomforts, is mainly that their habits of being out in the air
+differ correspondingly. Men are out much and, as a rule, stand
+discomfort better. Women are out little and are more sensitive to
+pains and aches. The more a man is out, the less is he likely to
+notice discomforts and aches that he would otherwise complain about.
+
+
+_Sleep_.--Another important factor is the amount of sleep. Over and
+over again I have found that patients who were beginning to complain
+of discomfort, which they associated with the word indigestion, were
+taking too little sleep, and as soon as I persuaded them to add an
+hour or more to their sleep their gastric symptoms began to improve.
+It is easy in our large cities to acquire the habit of shortening the
+hours of rest. This is sometimes done so gradually that the individual
+scarcely realizes how much he has cut into his sleeping period. Some
+people who have to get up at seven or half-past seven in the morning
+go to bed about twelve, but really do not get settled for sleep until
+nearly one o'clock. Sometimes people read interesting books just
+before going to bed, or while in bed, and it is nearly two o'clock
+when they get to sleep.
+
+Many people have the habit of reading themselves to sleep. This may be
+an excellent way to get rid of bothersome thoughts, provided the
+reading selected is not of too absorbing a character, and provided
+also as soon as sleepiness comes its call is heeded. Some write
+letters late at night. Writing always keeps one awake, though reading
+may be helpful for sleep. If this abbreviation of sleep becomes
+habitual, the first organs in the body to set up an objection is the
+digestive tract. It is one of the hardest worked systems in the body,
+having to dispose of its quantum of food three times every day, and if
+the organism does not receive due rest, the digestive tract suffers
+first. People who get insufficient sleep often have no appetite in the
+morning, and suffer from uncomfortable feelings in the gastric region.
+What they are too prone to do is to meddle with their diet, and this
+practice always does harm.
+
+
+
+CHAPTER IV
+
+APPETITE
+
+
+Two classes of patients come to the physician complaining of lack of
+appetite. The first and more important class consists of those who are
+eating too little, who are consequently under weight, and who must be
+made to eat more. The other class consists of those who eat enough but
+complain that they do not relish their food. Careful questioning
+usually elicits sufficient information to enable one to decide that
+most of these latter are eating too {263} much, or unsuitable food,
+and at too frequent intervals. They are usually overweight, and there
+is need to reduce the amount they eat. In both of these classes the
+physician is tempted to conclude that medicines should form the
+principal part of the treatment. We have a number of tonics and
+stimulants that undoubtedly initiate a desire for food, or at least so
+increase the circulation in the stomach that patients feel much more
+inclined to eat than they otherwise would. There are a number of
+remedies, also, the so-called anti-fat group, which produce a
+disinclination for food.
+
+
+Power of Mind Over Appetite.--Appetite, whether in deficiency or in
+excess, is best regulated through the patient's mind. Patients
+frequently state that they cannot eat more than they do, that they
+have no inclination for food, and yet, after a little persuasion, they
+can be made to increase the amount they have been eating, and then
+that can be gradually raised until they are taking what is for them a
+normal quantity. There are many things that we swallow without caring
+for them. Most medicines we not only do not like, but positively
+dislike. We put them down, they accomplish their purpose, and food
+will act nearly in the same way. There are few cases where food is
+positively rejected. Patients can be persuaded to eat more, and after
+a time will be surprised to find that their desire for food increases
+with the habit of taking it. On the other hand, patients can be made
+to see that they are taking too much food really to enjoy its
+consumption. Their appetites are perpetually cloyed, and to them food
+has none of the pleasant flavor that exists when it is taken in
+moderation.
+
+
+_The Will to Eat_.--In various parts of this book there is emphasized
+the necessity for the exercise of the human will in order to aid in
+the accomplishment of even physical functions. The basis of many
+nervous symptoms is a lack of sufficient nutrition to steady the
+nervous system. Some people not only lack will power, but also
+judgment in the matter of eating; they prefer to err on the side of
+insufficiency lest they should over-eat. For these people the
+important remedial measure is to dictate the amount that they shall
+eat, and gradually to increase it until they are eating enough for
+their nutritional purposes.
+
+When this advice is given to patients, they are willing to agree that
+a gain in weight would be good for them, but they cannot understand
+how they can eat more since they are now eating all they can, or
+certainly all they care to. Appetite grows by what it feeds on, and
+increase in appetite is a function of the habit of eating.
+
+But some patients, after having tried the prescription of eating more,
+are still in the same condition, and find that they cannot put on
+weight. What is needed in such cases is an inquiry into all the
+conditions of the daily life, their habits of eating and the amount of
+time that they take for their meals. They are probably eating one good
+meal a day, their dinner in the evening--but they confess that the
+other meals are not satisfactory. If their habits are rearranged, the
+will to eat does the rest. Sometimes they complain of uncomfortable
+feelings after eating and this makes them eat less at the next meal.
+There are various mental elements that disturb the efficacy of the
+will to eat, consequently these patients do not get on. What they need
+is emphatic insistence on the necessity for persistent effort in
+regular eating day after day, meal after meal, and it is not long
+before improvement comes not {264} only in weight, but also in
+appetite. I have known patients to gain five or six pounds a week
+after having tried weeks in vain to gain a single pound.
+
+
+_Sitophobia_.--Many people read much of the possibilities of evil in
+overeating, and they conclude that a limitation of diet would be
+better for them. After a time some of these people of nervous
+constitution acquire an actual dread of over-eating and develop what
+has been called sitophobia, or dread of food. Before anything can be
+done with them, this dread must be removed. The problem is discussed
+more fully in the chapter on Weight and Good Feeling, but here it
+seems necessary to emphasize that it is often quite impossible by
+ordinary medical means to produce an appetite in these patients. Their
+mental persuasion with regard to food must first be removed. If it
+cannot be removed, improvement is usually out of the question. No
+medicines are sufficiently powerful to overcome a fixed unfavorable
+idea with regard to food. The same is true as to sleep, or any other
+natural function--it comes and must go through the mind.
+
+
+Disturbance of Mind and Its Influence on Appetite.--The basis of the
+psychotherapy of the digestive tract is the fact that appetite is a
+function of the state of mind rather than of the state of body. We all
+know how easy it is to lose the appetite by emotional disturbance. We
+may come into the house after a brisk walk, when we know that dinner
+is going to be better than usual, quite ready to anticipate the
+pleasure we are to have in eating it and with appetite craving that
+dinner shall not be delayed, we find a telegram announcing the death
+of a friend or the illness of a relative or some other bad news, and
+in an instant our appetite has disappeared. It makes no difference to
+us for hours whether we eat or not. What we eat gives us no
+satisfaction. It will be taken entirely from a sense of duty and
+without pleasure and will digest slowly, even if it does not produce
+discomfort.
+
+
+_Feelings and Appetite_.--There is no need for a serious stomach
+condition to develop, to diminish, or eliminate appetite. The sight of
+an accident on the street, especially if blood is shed, will entirely
+take away the appetite of many persons. Now that suicide beneath the
+wheels of subway trains has become a rather frequent way of going out
+of life, physicians note that nervous patients who happen to see these
+sad affairs have no appetite, not alone for the next meal, but
+sometimes for several days. Some people have no appetite at all if
+there is a dead body in the house where they live. I have known people
+who felt it almost a desecration to eat under such circumstances. Even
+much less than this may serve to diminish appetite. An offensive odor
+of almost any kind is quite sufficient to take away the appetite of
+many people. For some the odor of cooking food, if they have been in
+it for some time, is almost sure to cloy any desire for food.
+
+Cooks suffer from loss of appetite for this reason. The sight of a
+disagreeable stain on a tablecloth, or of a waiter's thumb in the
+soup, or of some unpleasant characteristic of the waiter, may be quite
+enough seriously to disturb the appetite of sensitive people.
+
+We know all this very well, and yet we are prone to think of appetite
+as something regulated by instinct, and representing the real needs of
+the organism in its cravings and the limitations of the necessity of
+food by its satisfaction. In our sophisticated modern life instinct
+will often fail entirely to fulfill these purposes. Appetite for those
+who live much indoors is a question of {265} habit and regulation
+rather than of instinct. It has to be voluntary to a large extent, not
+only as regards the quality but also the quantity of food. We eat the
+things that we care for, but how much of them we shall eat is another
+matter. That depends on how we happen to be disposed at the moment,
+and whether there is any good reason for eating more or less at the
+given time.
+
+
+Appetizers.--There is a whole group of substances recommended as
+appetizers, most of which are effective, but their effect is likely to
+be temporary, and to fail particularly in those cases where an
+appetite is most needed. Anything that will increase the circulation
+in the stomach will usually add to appetite; consequently warm drinks,
+alcoholic liquors and spices of various kinds have this effect. In
+vigorous people, a dash of cold on any portion of the body, is
+followed by a strong reaction of the circulation. Cold drinks,
+therefore, will sometimes serve as an appetizer, especially in hot
+weather. Almost anything that has a certain peculiarity of taste, and
+that is taken with the definite suggestion that it will produce an
+appetite, will almost surely have that effect. All sorts of articles
+of diet have in various countries acquired a reputation as appetizers.
+Fermented mare's milk is effective in central Europe; a glass of
+buttermilk in Ireland; some very hot soup with one of the strong
+spiced sauces in it in England; and various curious combinations of
+fruit and other materials in the shape of what are called cocktails,
+in America. Anything that stimulates the stomach a little unusually,
+and is accompanied by the idea that it is likely to increase the taste
+for food, almost surely adds to appetite.
+
+This question of appetizers is as yet a mystery to us. It is eminently
+individual and yet much depends on racial customs, the habits, the
+environments and the family training. It is surprising what curious
+materials serve to excite the appetite. Caviar, in spite of the
+distaste of "the general," is undoubtedly a good appetizer for many
+people. Bismarck herring, or kippered herring, acts in the same way.
+In the old days men used to take what were called red herrings and
+undoubtedly found in the eating of them a renewal of desire for food,
+when there had been absence of appetite. There are some people in whom
+a little taste of cheese serves the same purpose. Bitter tastes
+usually increase appetite. Salt under certain circumstances has a
+similar effect. Acid fruits sometimes stimulate a jaded desire for
+food. Nearly always the effect of these various appetizers is
+increased by the attitude of expectancy. They have the reputation of
+being appetizers and so, though often at first somewhat disagreeable,
+they eventually prove to be helpful stimulants.
+
+
+Appetite and Habit.--For those who live an indoor life, and have that
+nervous disposition that disturbs instinct, the only safeguard for
+nutrition is a definite formula for eating which must be followed
+strictly, especially by those who are below the normal in nutrition.
+In the chapter on Weight and Good Feeling I discuss the failure of
+appetite following a diminution of the amount of food. The stomach may
+be described as unselfish, and in times of scarcity it gives up to
+other organs more of the nutrition that comes to it than it should. As
+a consequence, it is not so well able to fulfill its functions of
+digestion and of craving for food, which is part of its function, as
+it would otherwise be. It is the people who are eating a proper amount
+and have been eating it, whose digestive tracts are in a condition to
+crave the proper {266} amount of food. Those whose habits have
+unfortunately led them into eating amounts too small, also suffer in
+not having the proper desire for food.
+
+Nervous people particularly are likely to lack appetite in the early
+morning. Those who are under weight will almost invariably confess
+that they take little breakfast. Their reason for so doing is that
+they have no appetite. For most of them what is really true is that in
+the early hours of the day their will has not yet taken properly hold
+of their economies and everything is in a depressed state. These
+patients usually confess that they wake feeling not rested but tired,
+fearing the day, and wondering now they will be able to get through
+it. Only toward the middle of the day do they feel like themselves,
+while towards evening they wonder how they could have been so
+depressed in the morning. What these people need is the rousing into
+activity of their functions. Occasionally, especially in summer, a
+cold sponge on rising in a room into which an abundance of air is
+admitted will do much for them. Often a walk of even ten minutes
+before breakfast will make all the difference between appetite and
+lack of it. Above all, however, they should be made to feel that if
+they want to eat they can eat--if they want to they can reestablish
+the habit of taking breakfast, and then it will be a pleasure instead
+of a burden.
+
+
+_Food and Caprice_.--Those complaining of lack of appetite should
+learn not to let caprice rule them in the matter of eating. There are
+people who by habit eat too much. What they must do, as pointed out in
+the chapter on Obesity, is to unlearn the habit of overeating, and
+that is almost as hard to break as the habit of taking stimulants.
+Most nervous people undereat, but they must take themselves in hand,
+eat three meals a day, and reestablish the habit of taking as much at
+these meals as they ought. What each one should consume is eminently
+individual, depending altogether on the sort of heat engine that each
+one is. Family traits mean much in this. Some must eat much more than
+others to keep up their weight and strength, because they are wasteful
+heat engines. As a rule, tall, thin people must eat more in proportion
+to their weight than shorter individuals of stout build. They expose
+more surface for heat dissipation. In this each person must learn for
+himself his own necessities. When there is a question of regulating
+eating by reason, the rule must be remembered that there is a tendency
+in people living indoors to take too little rather than too much.
+
+
+_Appetite and Food Preparation_.--There are many curious things with
+regard to the formation of the habit of eating that show how easily
+the appetite or instinct is vitiated. Women, for instance, are nearly
+always prone not to eat enough if they have to prepare their own
+meals. When a mother and daughter or two sisters live together, they
+usually prepare one good meal, but the other two meals are likely to
+be picked up any way. The presence of a man in the household makes all
+the difference in the world. Meals are prepared regularly for men.
+Even for a boy of five to fifteen, meals are regularly prepared, and,
+as a rule, the presence of a child makes for regularity in eating.
+
+
+_Habit of Overeating_.--On the other hand, it is easy to form habits
+of eating that go quite beyond appetite and vitiate the desire for
+food quite as seriously in the opposite direction. Many stout people
+take snacks between meals; women, already too heavy, indulge in the
+afternoon tea habit with a surprising amount of substantial food taken
+with the tea; many a stout man {267} takes a glass of beer
+occasionally and never fails to take something to eat at the same
+time, mainly with the idea, as he says to himself, that by taking
+something to eat the beer will be less likely to do him harm. Stout
+children are likely to form the habit of eating too frequently. When
+they come home from school they have a piece of something; before they
+go to bed they have a glass of milk, and a piece of cake, and
+sometimes are encouraged in these bad habits by their parents. Any
+child who is more than ten per cent. above weight, should be kept
+strictly to its regular meal times, and should not be allowed to put
+on additional weight, for this will be very hard to get off in adult
+life. To carry more than ten per cent. of over-weight is a burden, and
+not a benefit.
+
+
+Frequent Eating as an Appetizer.--Thin people should be encouraged to
+indulge in some of these between-meal privileges. Very often a thin
+person who has been accustomed to take comparatively small amounts at
+meal times, will find it easier to gain in weight by indulging in
+luncheons between meals than by increasing the amount of each meal.
+Large meals on stomachs unaccustomed to them, and somewhat less
+vigorous than they ought to be because of lack of nutrition, may be
+the cause of considerable discomfort if abundant meals are taken where
+small ones have been habitual. In this case, multiple feeding at
+shorter intervals will gradually increase tissue strength. After the
+patient has come up to normal weight, regular intervals between meals
+may be determined and sufficient quantities taken at each meal. Nearly
+all thin people sleep better, and are more comfortable if they take
+something shortly before going to bed. Most people will eat their
+breakfast better after such an indulgence than if fourteen hours
+elapse between the evening and the morning meal.
+
+
+Nervous Loss of Appetite.--Nervous patients often say they have no
+appetite, that, even though they eat, their food has no taste. Such
+people have often lost their eating instinct to a certain degree. They
+eat merely from routine, or because food is placed before them. They
+would usually just as soon not eat and they have no instinctive
+directions as to quantity. If a number of courses are presented to
+them, they eat such as they care for and take a conventional amount of
+each kind of food presented, but they have no particular feeling to
+guide them in the matter of quantity. There are moods in which these
+patients care to eat. There are others in which eating seems a hard
+task. If they are in reasonably poor circumstances and have not to
+prepare a meal for others they are likely to neglect the preparation
+of one for themselves, take almost anything that happens to be at
+hand, and then consider that they have eaten.
+
+
+Instinct and Natural Life.--If one expects the natural guidance of
+one's instincts then one must give these instincts a proper
+opportunity. Instinct is a part of our animal nature, and unless other
+portions of our animal nature are given rather free play, or at least
+the opportunities for their natural life, we cannot depend on any
+single one of the instincts to be a safe guide. Man was meant to live
+much outside. He was meant to take considerable exercise and to have
+to get his food by severe exertion. We have changed this. We live
+indoors to a great extent in an equable temperature, we very seldom
+tire ourselves by exercise, and it is not to be wondered at if we have
+not that craving for food that comes to the man who lives a more
+animal existence. The {268} Scotch surgeon, Abernethy, once said that
+the best possible tonic for the appetite was "to live on a shilling a
+day and earn it"--of course, he meant by manual labor. He talked at a
+time when the English workmen got but three shillings a day for
+fourteen hours of work.
+
+
+Application of Principles.--What is needed for the mental treatment of
+patients with defective appetite, is that they should be made to
+realize that appetite is a function of habit, rather than of absolute
+natural craving in the conditions in which men and women live at the
+present time. The most important physical factor for appetite is not
+exercise, as has often been thought, because this, by consuming
+material, is naturally supposed to increase the craving for material
+to renew the tissue, but air, for it is oxidation processes that
+stimulate metabolism and make the call for a fresh supply of
+tissue-building material. People without an appetite must be made to
+understand that they should spend a considerable portion of the time
+between meals in the open air. Sitting in the open air is often even
+more effective than exercise under similar conditions, especially in
+weak people. The reason is exercise exhausts energy, and sometimes
+does not leave enough vitality for digestion, or even for the craving
+for food. Exercise is, of course, excellent for those of stronger
+constitution, and especially those who have been accustomed to it.
+
+Those who need to eat more, must keep constantly before their minds
+the suggestion that if they want to eat they can, and that if they
+actually do eat more, satisfaction with eating grows, and appetite is
+restored to its normal place of influence. This is as true for those
+who are convalescing from some ailment, or who are in the midst of
+some progressive disease such as tuberculosis, as it is for the merely
+nervous persons whose lack of will and inefficiency of judgment have
+disturbed their eating habits. The will to eat is the most important
+appetizer that we have. The old Scotch physician's rule that if food
+stayed down it would do good, and that if the residue of it passed
+through the intestinal tract there was nothing very serious the matter
+with the patient, applies to the majority of patients who come to be
+treated for obscure ailments, especially of a chronic character,
+whenever they are associated with or developed on a basis of lack of
+normal weight.
+
+
+
+CHAPTER V
+
+CONSTIPATION
+
+
+To judge by the frequency of advertisements for laxatives of various
+kinds, constipation must be an extremely common affection. At least
+one out of every three city dwellers suffers, it is said, from
+constipation. Proper regard for the taking of food calculated to help
+this important function, the formation of appropriate habits, and the
+proper disposition of the mind so as to relieve worry and anxiety,
+will cure the majority of these patients. There are some who need
+additional treatment, pharmacal or mechanical, but these are few.
+Undoubtedly the mind plays the most important role in the therapeutics
+of the affection. It is influenced partly through instruction, {269}
+partly by the modification of unfortunate auto-suggestion, and partly
+through auxiliary favorable suggestions of one kind or another.
+
+
+Prophylaxis.--What is needed in most cases is such instruction as will
+lead to a better observance of certain common-sense laws of health,
+rather than the addition of remedies which eventually only complicate
+conditions.
+
+Many people believe that unless they have an ample movement of the
+bowels every day all sorts of serious results are likely to follow. If
+they do not have the expected movement before noon, they suffer during
+the afternoon from headache that is probably due more to worry than to
+any physical cause. Ordinarily it is quite out of the question that
+the retention of the contents of the lower bowel for a few hours
+should produce any such serious effects as these patients immediately
+begin to feel. Especially is this true when on the day previous there
+has been, as is often the case, a sufficient movement of the bowels,
+due to the use of medicine. Some people have become so anxious in the
+matter that they foster the development of feelings of discomfort both
+in their abdominal and intracranial regions.
+
+This over-anxiety is all the more important because recent
+observations have made it clear that over-occupation of mind actually
+hampers peristaltic movements of the intestines, and thus prevents the
+muscular action which would gradually pass the excrementitious
+material on to the lower bowel, to be evacuated in the normal way. _It
+cannot be too often repeated that nature resents too close
+surveillance of her functions and operations_. Just as soon as the
+over-anxiety is relieved, and patients are made to appreciate that if
+they do not have a movement to-day they may wait without serious
+solicitude till they have one to-morrow, the amount of medicine
+required to bring about movements of the bowels is at once reduced.
+
+
+The Mind and Peristalsis.--Analogous to Pawlow's ingenious
+experiments, with regard to digestive secretion in the stomach, are
+Kronecker's experiments at Berne upon the motor function of the
+intestinal tract. Pawlow showed that the appetite depended, not on
+physical conditions so much as on the mental state of the animal and
+its desire for a particular kind of food. Kronecker, by isolating a
+loop of intestine in which a metal ball was placed, showed that it was
+possible to modify peristalsis very materially by affecting the
+psychic condition of the animal. There was a distinct difference in
+the movements of the intestine, in the passage of a metal ball, when
+the animal was called and expected to go for a walk with its master,
+than when it was threatened with punishment or rendered depressed for
+some other reason. In animals, the psyche plays a very subordinate
+role in inhibition and stimulation compared to that exercised by man's
+higher nervous system, since in him this portion of the organism is so
+much better developed than in the animal. The condition of the human
+mind in its possibilities of unfavorable influence over the intestinal
+function, is, therefore, extremely important.
+
+The more one knows about the curious power of the mind even over so
+material a function as intestinal peristalsis and movement, the more
+is one convinced of the necessity for a properly disposed mind toward
+intestinal function, if it is to be accomplished with regularity and
+without disturbance. Many persons thoroughly under hypnotic influence,
+who are told that they will have a movement of the bowels at a certain
+hour the next day will have it. Indeed, this constitutes one way of
+treating certain forms of constipation in nervous, {270} preoccupied
+people. There are many stories that illustrate the influence of
+auto-suggestion upon the bowels. We have already mentioned Flaubert's
+suffering as a consequence of realistic absorption in "Madame
+Bovary's" poisoning by arsenic when he was writing that scene in the
+book. Boris Sidis has told the story of a man who used to have a
+disturbance of the bowels at every new moon, as the result of his
+memory, acting unconsciously, reminding him of his mother's habit of
+giving him a purgative about that time. These may be and doubtless are
+exceptional cases, yet they illustrate the influence of mind and show
+how much it must be the effort of the physician to use this effective
+adjuvant just as much as possible in this very common and often
+obstinate affection in which drugs so often fail, or are
+unsatisfactory.
+
+
+So-called Intestinal Auto-intoxication.--Those who are anxiously
+interested in the subject are likely to have read so much of
+intestinal auto-intoxications, of which a great deal has been written
+in recent years, that they will be quite sure the slightest delay in
+intestinal evacuation may be serious, or at least may profoundly
+disturb their economy. As a consequence, just as soon as the hour at
+which they should have a movement passes, they begin to worry about
+it. In a couple of hours they feel tingly all over, and they know that
+there most be poisonous substances in their circulation. After two or
+three more hours, they begin to have a headache. Then they have to
+give up work, and still more devote themselves to concentration of
+attention on the disturbed condition. Their sleep will be disturbed,
+perhaps will be delayed; they wake unrested and fearful of the awful
+effects of intestinal auto-intoxication. In most people this state of
+feeling is entirely due to suggestion.
+
+So much has been said in recent medical literature of the influence of
+absorption of poisonous substances from the intestinal tract--the
+so-called intestinal auto-intoxication--that it is a surprise to learn
+how little we know, definitely and absolutely, about this subject, and
+how many theories have come and gone. Arthur Hertz, in his
+"Constipation and Allied Intestinal Disorders" (Oxford Medical
+Publications, 1909), reviews the whole subject very interestingly but
+shows that we are entirely without any definite conclusive evidence
+for what has been talked about so much. The idea had often occurred,
+and been expressed vaguely, in medical literature in the old time, but
+began to have its great vogue when the high-sounding Greek term
+copremia (literally "excrementitious-substances-in-the-blood") was
+invented, toward the end of the first quarter of the nineteenth
+century. Naturally this had a strong suggestive effect. Bouchard took
+it up a generation later, and then intestinal auto-intoxication,
+another mouth-filling term, came to occupy much attention as an
+explanation for various vague conditions, and especially nervous
+discomforts of many kinds. Bouchard's method of proving his theory by
+showing how much toxic material was reabsorbed from the intestines,
+using the urine for injection into animals, was open to many
+objections. Now it has been quite discredited.
+
+Bouchard's disciples exaggerated and theorized even beyond their
+master, until intestinal auto-intoxication became the same sort of a
+refuge for the puzzled physicians of our time--like rheumatism or the
+uric acid diathesis, for those of a score of years ago. Various
+methods of demonstrating the toxicity of substances absorbed had a
+vogue for a time, but they have now lost their significance. There are
+only a limited number of people who seem to suffer {271} from the
+symptoms attributed to such reabsorption. Some people who are quite
+constipated have none of the symptoms at all, while a delay of an hour
+or two in the evacuation seems to affect other people very much. These
+latter are especially nervous persons. It now seems very clear that
+the liver acts as a safeguard against the absorption of poisonous
+materials from the intestinal tract, and that neither degenerate
+proteid materials, nor bacterial toxins, are allowed to affect the
+system to any serious degree. After all our study, as Dr. Hertz
+insists, we have as yet no evidence that poisons are absorbed.
+
+
+Reassurance as an Element in Treatment.--The most important element in
+the rational treatment of constipation is to make patients understand
+that under ordinary circumstances the symptoms of auto-intoxication,
+of which so much is said, do not develop until there has been
+long-continued accumulation of excrementitious material and under
+conditions favoring absorption. Even then nature learns to protect
+herself against untoward conditions. We have some very striking
+examples of good health in spite of even very rare movements of the
+bowels.
+
+
+_Examples of Intestinal Tolerance_.--There is the famous case of the
+French army officer who, from his earliest years, did not have regular
+movements of the bowels, but secured evacuations of them by artificial
+aid once every two months or more. He lived to the age of past fifty,
+and then died from an intercurrent disease not connected with his
+intestinal condition, having in the meantime enjoyed good health. He
+was able to accomplish his duties as an officer without any special
+allowances, and he was on the sick list much less than many brother
+officers whose intestinal condition left nothing to be desired. This
+remarkable man succeeded in doing his life work without his condition
+being known by others to any extent, and it was only inconvenience,
+and not serious illness, that he suffered from. After his death, it
+was found that certain folds of the lower bowel were so large as to
+meet across the lumen of the bowel, making shelves and pouches in
+which fecal material gathered, preventing the movement of all material
+above.
+
+In the Orient, it is said that many people, especially of the better
+class, do not expect to have movements of their bowels every day. Some
+of them, indeed, do not encourage intestinal evacuations oftener than
+once a week, sometimes even more seldom. As their diet is more largely
+vegetable than ours, this is all the more surprising. This custom does
+not contribute to their good odor, but this they compensate for by
+using various Eastern perfumes. The average length of life of such
+people is not much below the Occidentals and the difference is
+probably accounted for to a great extent by other unhygienic
+practices, rather than this failure to have regular movements of their
+bowels. In the meantime, they do not suffer any particular
+inconvenience, and live life quite as free from the ordinary pains and
+aches as do the people of the West. Of course, in such cases the
+custom has been established early, and nature has grown accustomed to
+it. Nature seems to be able to stand almost anything, if she can only
+survive it long enough to neutralize its effects by some of her
+marvelous means of compensation.
+
+A case under my observation some years ago deeply impressed upon me
+how thoroughly the human system can learn to get along in spite of
+extremely unfavorable conditions in the matter of intestinal
+evacuation. The case was that of a young woman suffering from some
+internal trouble and there was {272} a possibility of the growth of a
+tumor. Some charitable people had been interested in her case, and the
+question had arisen whether the tumor might not be physiological. Her
+story was a very curious one. She and her sister worked in a mill.
+They came from a family that had been reduced in circumstances, and
+were much more sensitive, as regards the decencies of life, than were
+their fellow workers. In order to get to the toilet, the working girls
+had to pass a window of an office where a number of men were at work.
+The other girls did not seem to mind it, but these two girls were so
+sensitive that they preferred not to use the toilet room at the
+factory. They had to leave home shortly after six o'clock in the
+morning. They did not get home until nearly seven. For a time, they
+succeeded in accomplishing their intestinal functions during the hours
+of their stay at home. Gradually, however, this habit was broken, and
+at first they went two or three days without an evacuation, then four
+or five days, and finally a week. It then became their custom to take
+a large dose of epsom salts on Saturday night and spend most of the
+day on Sunday getting rid of the accumulated excrementitious material
+of the whole week.
+
+They taught Sunday School in the afternoons, and as the elimination of
+the accumulation of week-long material interfered with this, they
+gradually acquired the habit of doing their Sunday School work on
+alternate Sundays, each taking the other Sunday for evacuation
+purposes. It might be expected that this serious abuse of function
+would soon lead delicate girls, compelled to work full eleven hours a
+day, into rapid serious breakdown. But it did not. This state of
+affairs continued for more than a year. Then finally one Sunday, the
+more delicate of the two girls found it impossible to open her bowels
+at the end of two weeks, and though she stayed at home the next Sunday
+found it likewise impossible. Had not the directress of the Sunday
+School, who had become interested in them, succeeded in gaining their
+confidence, it is possible that they would not have consulted
+physicians even for some time longer, though about three weeks had
+passed without an evacuation.
+
+Probably every physician in active practice has women patients who
+have been constipated for successive periods of three or four days at
+a time, for several months, without much disturbance of the general
+condition. While, then, there are many nervous persons who are quite
+sure that they begin to notice definite symptoms within a few hours
+from the failure to have a motion of the bowels at the time when they
+had been expecting it, it seems certain that this is generally rather
+the result of anxiety and nervous worry than consequent upon any
+actual absorption of toxic materials--intestinal auto-intoxication--as
+these patients, with a naïve liking for nice long names, find such
+satisfaction in describing their condition. A simple explanation of
+the complete lack of inconvenience that is found in so many cases of
+constipation, will neutralize the unfavorable auto-suggestion that
+exists, and make these people much less likely to suffer.
+
+
+_Individual Variation_.--Another suggestive item of information that
+should be given those who are over-sensitive and anxious in the
+matter, is that different individuals vary very much in the need for
+intestinal evacuation. Perfectly healthy people have lived long and
+happy lives, having an intestinal evacuation only once every two days.
+Whether it may not in exceptional cases be rarer than this without
+serious injury, immediate or remote, {273} experience has not
+definitely settled. Many of these people with infrequent intestinal
+movements, have gone on utterly unconscious of the frequency or
+infrequency of the calls of nature, paying no attention at all to the
+matter until by some chance remark or a newspaper health item, it is
+brought forcibly to their notice. They have not had a symptom before
+of any kind, but now they begin to note all sorts of symptoms because
+they try to order their lives after the supposed rule that they have
+heard or read.
+
+
+_Anatomical Peculiarities_.--On the other hand, some people normally
+have two evacuations a day, and seem to require them if they are to
+remain in the best physical condition. While daily evacuation is to be
+considered normal, individual departures from it in either direction
+must be respected as quite within the bounds of good health. Sometimes
+there are anatomical reasons, as the capacity of the large intestine.
+Sometimes there are physiological factors, as the amount of food
+taken, or the fullness or rapidity of function in the digestive tract.
+
+
+Amount of Food as a Causative Factor.--Frequency, or infrequency, of
+bowel movements seems to depend to a great degree on the amount eaten.
+It is well known that two men of the same weight and doing the same
+work often seem to require quite different amounts of food to enable
+them to accomplish their tasks. This is what might be expected, since
+it holds true also for the consumption of fuel in heat machines.
+Engines built in exactly the same way often require quite different
+amounts of fuel in order to release the same amount of energy. Where
+men are large eaters, the amount of excrementitious material left will
+usually provoke, if not actually demand, more frequent evacuation than
+where the amount eaten is small. Variety of food also has an important
+bearing. Men who live largely on beef, milk, eggs and food materials
+that do not leave much residue, do not require, indeed they cannot
+have, frequent evacuations. Those who live almost exclusively on
+vegetables, with large amounts of residue, will require more frequent
+evacuation of the bowels. Certain other dietetic habits, as the amount
+of fluid taken with the meal, or whether food is eaten in the solid
+state or cooked into purees, stews and the like, make a decided
+difference, the reasons for which are obvious.
+
+
+Habit in Treatment.--For the regulation of the bowels and the proper
+treatment of constipation in nearly all cases, more weight must be
+given to the directions laid down for the patient's attitude of mind
+and habits of life than to drug treatment. The patient must be made to
+realize that the directions given to him are much more important for
+the effective relief of his condition, than is the medicine
+prescribed. As a rule, medicine is meant only to afford relief from
+immediate inconvenience, in the hope that after a short time new
+habits will be formed which will remove the habitual constipation by
+correcting certain hampering conditions that have unfortunately become
+established.
+
+
+_Habitual Evacuations_.--By far the most important element in the
+treatment is to make the patient realize that habit plays the largest
+role in the regular evacuation of the bowels. A child, even under two
+years, can, by tempting it at certain times to evacuate its bowels, be
+gradually brought to establish a habit that will save much
+inconvenience for nurses and the family. This has actually been done
+for most human beings now alive, and this same thing can be done at
+all stages of life. If a particular time be chosen, and the {274}
+individual habitually goes to the toilet at that time, results may be
+confidently expected. It is rather important that the time chosen be
+one when there is not much hurry nor anxiety, and when it is
+reasonably certain that the same time can be taken every day. It is
+surprising how much so simple a bit of advice as this will do for many
+people who have considered that they have been suffering great
+discomfort from habitual constipation. Between the persuasion that an
+occasional failure to have a movement is not serious and the definite
+habit of journeying to the toilet room at a particular time, whether
+the desire is felt or not, many cases of habitual constipation will
+disappear with, perhaps, only the necessity for the administration of
+such drugs as will prove laxative to a slight degree during the first
+two or three weeks.
+
+
+Ingestion of Fluids an Important Influence.--After the suggestion of a
+habit and its extremely efficient influence, the most important idea
+that a patient suffering from constipation must be made to grasp, is
+the necessity for fluids. That there shall be easy movement of
+excrementitious material in the digestive tract, there must be fluid
+enough ingested to keep the residue, after digestion, thoroughly
+moist, so as not to allow it to become dry and compact. To secure
+this, a reasonable amount of liquids must be taken. So much has been
+said in recent years about the actual and possible harm of taking much
+fluid with meals, because of the danger of diluting the gastric juice,
+dilating the stomach and the like, that many persons who eat under the
+control of their reasons rather than their instincts, have very
+materially lessened the amount of liquids taken at meal time. This is
+undoubtedly one of the reasons why constipation has become more common
+in the last half century. In the olden time considerable quantities of
+fluid were taken at meals. With people in our time deliberately
+diminishing the quantity, there is often not enough fluid ingested to
+keep the human economy in proper working order. Prof. Hawk's work
+shows how utterly wrong was this limitation.
+
+The ordinary excretion of water through the kidneys should be at least
+three pints, another pint is exhaled from the lungs--the quantity is
+even more than this in steam-heated houses where no provision for
+moistening inhaled air is made--and probably still another pint is
+needed for other purposes, perspiration, nasal and ocular secretion,
+and the like. Two quarts and a half to three quarts of liquid must be
+daily ingested then, and unless special care is taken to see that this
+amount is consumed the system may have to get on with much less, but
+as can readily be understood, not without difficulty. The ordinary
+glass of water does not contain half a pint; the ordinary tea cup
+probably holds not more than from four to six ounces. A glass of water
+and a cup of tea or coffee is about the limit of consumption of fluids
+at meals for ordinary people, and some take even less. Except in hot
+weather, comparatively few regularly take any fluids between meals. At
+the most, then, three or four pints of liquid is taken, instead of
+five or six, and the consequence is that the intestinal contents are
+deprived of their fluids by the call of the system for more liquids.
+Peristalsis has, therefore, to overcome the sluggish movement of the
+excrementitious material, which usually does not contain as much
+liquid as would make its movement easy and normal.
+
+
+Residual Material.--The next most important consideration after the
+amount of fluid in the intestines, is the amount of the residuum which
+the lower bowel has to move. Evacuation of the intestines is to a
+great degree {275} a mechanical arrangement. When sufficient material
+is contained in the lower bowel, it pushes on ahead of it the matter
+that has been gathered there during the immediately preceding time,
+and so leads to an accumulation in the rectum that brings about reflex
+evacuation. It is only indigestible material that is thus excreted. If
+sufficient indigestible material is not taken with the food, there
+will not be sufficient residue left after digestion to call for the
+exercise of the evacuant function of the intestines, and the
+consequence will be sluggishness and failure to bring about daily
+movements. Originally nature provided food materials so arranged that
+the amount of indigestible material was sufficient for the exercise of
+peristaltic function; or rather perhaps, the regularity of peristaltic
+movement is of itself a development from the habits that were
+gradually formed in moving the residue that is normally left from food
+materials in the state in which they are produced by nature.
+
+Food materials are no longer taken to any great extent in the form in
+which they are provided by nature. We have learned to eliminate the
+coarser indigestible portions. Bread used to be made of the whole
+wheat, and of rather coarse flour, leaving a large residue for
+peristalsis to exercise itself on. Now only fine white flour is used,
+leaving a minimum undigested. Vegetables used to be taken with much
+more waste material attached to them than is the case now. After being
+baked, potatoes were often eaten with the skins on, apples and other
+fruits were eaten unpared and many of the coarser vegetables, turnips,
+carrots, beets, and greens of various kinds that leave large
+proportions of waste were much more commonly used. Movements of the
+bowels depend on this residue. If it is not present the bowel
+movements will not take place with the regularity observed when food
+with more residue is consumed.
+
+
+Diet--Prof. Otto Cohnheim, in his lecture before The Harvey Society in
+New York, December, 1909, emphasized the necessity for a mixed diet.
+The less vegetables are taken, the less cellulose remains undigested
+to stimulate peristalsis. Liquids find their way through the
+intestines by a system of percolation, and do not excite peristaltic
+movements. Meat, if well digested, is almost entirely dissolved in the
+stomach and becomes a fluid. Vegetables are passed on to the
+intestines as a rather thick paste. Occasionally, in the midst of this
+paste there are portions of food of good size. Those excite
+peristalsis; hence the necessity for vegetables in the diet, if
+peristaltic movements and regular evacuations are to take place. This
+physiological law is poorly understood. Patients have heard so much
+about the indigestibility of starches, that whenever they have any
+uncomfortable feelings in their abdominal region, supposed to be due
+to indigestion, they commonly eliminate vegetables from their dietary
+with the consequence that their disturbed condition is likely to be
+emphasized rather than improved.
+
+
+_Limitation of Diet_.--Just as soon as a patient's attention is
+attracted forcibly to any tendency to constipation, he is almost sure
+to conclude that this is a symptom of indigestion and he proceeds to
+put into practice all the rules which he has heard and read for the
+treatment of indigestion. The first of these is elimination from the
+diet of all indigestible food products, including most of the
+vegetables. The result is a vicious circle of cause and effect by
+which constipation is rendered worse than before. This needs {276} to
+be explained to intelligent patients in order to make them understand
+that some of the new habits which they have been forming and which
+they are prone to think highly hygienic, of cutting off all food
+containing indigestible material, are really important factors in the
+causation of further intestinal disturbance. It will often be found
+that the real reason for patients' inability to have daily evacuations
+of the bowels, is that they have become persuaded that various forms
+of food are either indigestible on general principles, or else are
+indigestible for them. For this reason they have eliminated from their
+diet most of nature's ordinary and quite natural provocations to
+intestinal evacuation, only to have to substitute artificial means to
+the same end in the form of the various laxatives.
+
+It is important to talk this matter over with patients; otherwise the
+true cause of their constipation may be missed. For instance, from the
+very beginning of human life an excess of fat acts as a lubricant of
+the intestine, and as a material by means of which other and more
+concentrated objectionable matter that needs to be eliminated is
+carried out with as little friction as possible. Mother's milk
+contains from one-fourth to one-third more fat than the baby can use
+in its economy. This is meant to furnish a lubricant for the large
+intestine. It is a residue that will aid in securing movements of the
+bowels at regular intervals.
+
+
+_Fats_.--Many people who come to their physicians complaining of
+habitual constipation have been told, or have read, that fat is rather
+indigestible, and, as a consequence, they have eliminated from their
+dietary all fatty materials. Even butter they use but sparingly, and
+they exchange the cream in their tea or coffee for plain milk; they
+carefully remove as much as possible of the fat of meat and they
+abstain from all sauces in which fat is employed. Such practices make
+normal, natural, regular evacuations of the bowels extremely
+difficult.
+
+
+_Sugars_.--Another food material that is a valuable aid to nature for
+the stimulation of peristalsis is sugar. In its digestion, a certain
+amount of fermentation takes place, and the gas from this stimulates
+peristalsis. Of course, there may be excessive fermentation, and then
+harm rather than good, is done. Ordinarily a certain amount of sugar
+is demanded by nature and practically all the food materials, even the
+meats, contain it. All the starches from vegetables have, as the end
+products of their digestion, various forms of sugary material. These
+are just the classes of foods that many nervous persons, suffering
+from constipation and anxious about their digestion, eliminate from
+their diet under the mistaken notion that they are indigestible, or
+are productive of undesirable fermentations. When they do so, it is
+not surprising that their constipation should be emphasized and that
+they should have to ingest other irritant materials, laxatives, to
+replace the sugars. It is probable that where constipation exists in
+the bottle-fed infant, the addition of a little brown sugar to the
+water with which the milk is diluted, is the safest and most natural
+way of correcting the sluggishness of the intestines.
+
+
+_Supposed Idiosyncrasies_.--The physician will in many cases meet with
+the objection that some of these materials that he is recommending
+disagree with his patient. Most of the presumed idiosyncrasies in the
+matter of food are founded on extremely insufficient evidence.
+
+Not infrequently young persons who are thin and inclined to be {277}
+constipated, and who need to take fats plentifully, do not care at all
+for butter. Sometimes this is founded on nothing more than the fact
+that at some time or other the butter provided for them was rather
+poor, and they got out of the habit of eating it. Now they assume that
+their disinclination is physiological. In this regard, as with milk, a
+little careful persistence will usually convince the person that there
+is no natural obstacle and no good reason why they should not partake,
+in moderate quantities at least, of this extremely valuable article of
+food.
+
+Often the supposed idiosyncrasy against a food is due to no better
+reason than that on a single occasion it disagreed, owing to its
+preparation, the circumstances under which it was eaten, or the
+materials with which it was associated. An aversion, for instance, to
+so nutritious and so valuable a food-stuff as hog-meat will be
+acquired for no better reason than that fried ham or bacon disagreed
+with the patient on one or more occasions. Such people when told that
+ham, boiled so thoroughly that it crumbles in the fingers, is a
+favorite mode of giving meat to convalescents in European hospitals
+and that it agrees very well with them, will often be tempted to try
+it. Then they find they have been harboring an illusion as to their
+supposed idiosyncrasy for hog-meat. Nearly the same thing is true of
+bacon. A trial or two of crisp bacon, with the fat so thoroughly
+cooked out of it that it may be eaten out of the fingers without
+soiling them, will often convince those who doubt of their ability to
+eat it, how tasty a nutriment it is. Bacon is one of the most precious
+dietetic adjuvants in the treatment of constipation.
+
+
+Exercise.--There is always a serious difficulty in the treatment of
+constipation in stout people. To counsel fats and starches and liquids
+in the quantities necessary to bring about regular natural movements
+of the bowels, through the mechanical presence of a sufficient amount
+of residue, will often add greatly to their weight. For them,
+exercises are needed. Not exercise in general, for many a man who
+takes abundant exercise may be constipated. I have patients with this
+complaint who are letter carriers, expressmen, even stevedores, and
+the like. The mere absence of a sedentary occupation will not
+guarantee against constipation. Motormen and conductors not
+infrequently suffer from it. What is needed particularly is exercise
+directed to the strengthening of the abdominal muscles, and the
+increase of peristalsis.
+
+For this certain leg exercises that can be readily and easily done in
+less than five minutes each day will be found useful. A patient may be
+directed to lie on his back, lift up the leg as high as possible in
+the extended position, and do that with each leg an increasing number
+of times every day. At the end of a month he is able to lift each leg
+up forty or fifty times at each trial. This exercise twice a day,
+morning and evening, just before and after sleep, will usually relieve
+the constipation. The bringing up of the thigh on the abdomen as far
+as possible, not only acts as a sort of massage upon the abdomen
+itself, but the bellying of the large muscles within the pelvic and
+abdominal regions mechanically helps the movement of the intestinal
+contents. If, in addition to this, the patient gradually accustoms
+himself to rise to a sitting from a lying position, the constipation
+will almost invariably yield. In stout people, the presence of fat in
+the abdominal wall seems to weaken the muscles so that the intestines
+are not compressed as they should be in ordinary conditions, and
+peristalsis seems to be thus interfered with.
+
+{278}
+
+A heavy wooden (bowling) ball rolled on the surface of the abdomen,
+beginning low down in the right lower quadrant up towards the liver,
+across just above the umbilicus, and then down on the left is often
+advised. It is a good remedy but not better than the simple exercises
+of the leg and abdominal muscles suggested. The use of the ball has
+the advantage of novelty, and of distinctly adding to the suggestive
+value of the exercise treatment. It is particularly valuable for
+women. All of these exercises have a distinct value from their
+suggestive side. If thus twice a day for three minutes people are made
+to recall while doing the exercises the necessity for taking an
+abundance of fluid, forming a habit with regard to movements of the
+bowels and eating so as to encourage peristalsis, a definite good
+effect will be produced. In the treatment of stout people
+particularly, it is important to remember that the use of sufficient
+salt, and then of certain of the natural salts, as Carlsbad or Hunyadi
+Janos, may be of distinct advantage for their obesity. If taken
+regularly in small amounts, that is, just enough to help to a movement
+of the bowels, and if varied from time to time and occasionally
+interrupted while some other form of laxative is taken, much good may
+be done. It is as well to take simple irritants of this kind as some
+of the irritant foods that will have a tendency to add to their
+accumulation of fat, though they may increase peristalsis.
+
+
+Influence of Position.--Little things may mean much in the matter of
+the regular movements of the bowels. In my student days in France, our
+little hotel in the Quartier had the old-fashioned water-closets
+consisting of a hole in the floor in one corner, and a place to put
+one's feet properly beside it, thus reverting to the old-fashioned
+natural method of bowel evacuation. Some of the American students
+found it an uncomfortable proceeding at the beginning, but, on the
+other hand, some of them who had suffered from constipation in America
+were no longer troubled that way. I have found in quite a few cases of
+younger men that the suggestion to revert to this natural mode of
+evacuation helped in the formation of the habit of having bowel
+movements at a regular time. How much of the effect was physical and
+how much was mental seemed hard to decide. The suggestion was
+particularly valuable in my experience with patients of the better
+educated classes.
+
+
+
+CHAPTER VI
+
+NEUROTIC INTESTINAL AFFECTIONS
+
+
+There is a whole series of intestinal affections dependent on nerve
+influence that get worse and better under stress of emotion or relief
+from it. Probably the commonest of these is constipation, which is
+dealt with in a separate chapter. Often these nervous intestinal
+conditions are associated with other neurotic manifestations. On the
+other hand, patients are seen who are absolutely without any other
+sign of the neurotic habit, and have nothing like hysteria, yet who
+suffer severely and rather frequently from intestinal neuroses. Most
+of the people who react symptomatically to the eating of strawberries,
+or of shellfish, or of pork in any form, or cheese or other milk
+products, also have a definite tendency to certain skin neuroses and
+to suffer from intestinal troubles as a consequence of emotional
+states. It is hard to trace {279} real causation in many of these
+cases, because it is so easy to accept the patient's expressions that
+they must have taken cold, or they must have eaten something that
+disagreed with them.
+
+
+Neurotic Diarrhea.--But it must not be forgotten that nervousness
+alone, without any additional factor, may produce a disturbance of the
+functions of the intestines, and may even increase peristalsis and
+bring about severe diarrhea. Anyone who has observed students going to
+examinations has surely seen many examples of this. There are some
+individuals--fortunately they are rather rare--who always suffer from
+diarrhea when they have to take a serious examination. Some of these
+cases are pitiable because the effects are quite beyond control, and
+make it almost impossible for them to do justice to themselves.
+
+
+_Fright and Loss of Bowel Control_.--Severe disturbance, such as
+fright, may bring on this paralysis of proper regulation of
+peristalsis, with consequent imperative intestinal evacuation. A
+classical case in history is that of James II, for whom the Irish
+soldiers invented a special name because of the tradition that he
+suffered from an intestinal accident in one of the battles with
+William of Orange. The imputation of cowardice on the last of the
+unfortunate Stuarts has been completely wiped out by the investigation
+of recent historians, and James' character for bravery has been
+thoroughly vindicated. The fact that the story should have gained
+credence shows that there is a general persuasion and popular
+tradition that such intestinal incidents do occur from fright. An
+incident told of the Franco-German War illustrates this, though I do
+not vouch for the facts. Wishing to test the bravery of some soldiers
+whom he was to send on a very dangerous expedition, and above all to
+try how they would bear up even before the threat of instant death, an
+officer of the French troops is said to have asked that half a dozen
+brave men be sent to him. Without a word, he announced that there had
+been treason in the ranks, and that the army needed an example. They
+were condemned to be shot. A platoon of soldiers was drawn up, the men
+were placed with their backs to a wall and they were asked whether
+they wished to be blindfolded. They refused though they protested that
+they did not know why they were being put to death. Then the word fire
+was given. All of the men, excepting one, fell down, though the guns
+of the firing party had been loaded with blank cartridges. The one who
+remained standing was told that he was the man who would be selected
+to go on the expedition, which, though perilous, was also of great
+glory for himself and profit for his country. He said that he was
+ready to go, but he asked permission to be allowed to change his
+clothing, as he had not been able to keep as good control over his
+intestinal muscles, as he had over his muscles of station.
+
+Fright often has this effect in children. These stories and traditions
+illustrate the influence of the mind and of deep emotions over the
+intestines, and while only profound mental disturbance will produce
+the most serious effects, there seems no doubt that lesser emotions do
+interfere with normal function. This phase of the subject serves to
+strengthen the contention that over-attention to the bowels may bring
+about constipation by causing increased inhibition of peristalsis,
+just as severe emotional disturbance may paralyze inhibition and so
+bring about increased peristalsis with consequent diarrheal symptoms.
+
+{280}
+
+Habitual Diarrhea.--There are certain forms of chronic diarrhea,
+usually considered most intractable, that owe their origin and
+continuance to neurotic conditions of the intestine, rather than to
+any gross organic lesion. In these cases the bowels acquire the habit
+of emptying themselves two or three or more times a day, and the
+stools are seldom formed. All sorts of physical treatment are employed
+for these conditions, usually without avail, but whenever the
+patient's mind can be set at rest, and his attention distracted from
+his bowels by thorough occupation with some interesting work, the
+intestinal disturbance gradually becomes less annoying. Ordinarily,
+when stools have been frequent for a prolonged period, the case is
+considered more or less unamenable to treatment. So far as ordinary
+drug remedies go, this is true. What is needed is attention to the
+patient's mind, to his habits of life, and to his worries, and the way
+that he takes them. The illustrations given of the influence of the
+mind over the bowels should make it clear that this therapeutic
+principle can be of far-reaching significance and must be applied
+deliberately and with confidence in the results.
+
+
+_Worry as a Factor_.--Very often it will be found that the diarrhea is
+particularly bothersome on days when the patient is worried. In a
+clergyman friend and patient who was building a church, the approach
+of days on which bills and notes became due, was always the signal for
+a diminished control over his bowels, and there were frequently three
+or four stools in the day. On his vacations, when eating unusual
+things, drinking unaccustomed water, exposed to changes of
+temperature, all the factors that give many people diarrhea, he was
+perfectly regular because the worries had been lifted from his mind.
+In another case, where for fifteen or twenty years a writer living
+much indoors had had tendencies to diarrhea, always made worse by
+worries, self-discipline and the refusal to let troubles occupy him by
+always turning to something else, did him so much good that he
+considered himself cured. In his case the return of a manuscript from
+a magazine would always affect his bowels unfavorably. If, as
+sometimes happened, he found that the manuscript had been returned
+only for some corrections, there would be an immediate relief of his
+condition.
+
+
+Change of Mode of life and Intestinal Control.--An interesting phase
+of the neurotic or mechanical disturbance of peristalsis is found in
+the interference with regular movements of the bowels when persons are
+aboard trains for long distances, or for more than twenty-four hours.
+There are very few people who are not bothered in some way by such a
+journey. Those of a nervous temperament are likely to suffer from
+diarrhea. This is usually attributed to catching cold because of
+drafts, but in recent years, when well guarded Pullmans eliminate
+drafts to a great extent, the bowel disturbance continues. For the
+majority of people, however, constipation results. The cause of it
+seems to be due to a disturbance of peristalsis in the line of
+inhibition because of the vibration and jolting of the train. The more
+or less conscious assumption of definite positions of the muscles of
+the abdominal region in order to save the body from the action of the
+unsteady movement of the train, seems to be reflected in the sphere of
+peristalsis with consequent constipation. There are other features,
+such as a lessened consumption of food and water and absence of
+exercise, that seem also to have an influence. If the journey is for
+several days patients should be advised to walk out during the longer
+stops.
+
+{281}
+
+Mental Influence and Indifferent Remedies.--The best evidence that we
+have of the influence of mind upon the intestinal tract, and the
+importance of employing that factor for therapeutic purposes, is found
+in the number of cases of various intestinal disturbances, often
+apparently chronic in character, which have been cured by the
+administration of quite indifferent remedies. Dr. Hack Tuke in his
+"Influence of the Mind on the Body" reports a number of cases in which
+bread pills were used with good effect. _Pillulae micarum panis_ were
+not an infrequent prescription in preceding generations. They are
+usually supposed to have been effective only against the curious
+symptoms that develop in hysterical women, but it must not be
+forgotten that neurotic manifestations connected with the abdominal
+region may occur very freely in men, and that treatment by suggestion
+in connection with some remedy, real or supposed, is the most
+efficient cure. The "British and Foreign Medical Review" for January,
+1847, has a series of cases among naval officers which were reported
+by a surgeon of long standing and wide experience. These cases include
+painful intestinal psycho-neuroses, occasionally accompanied by
+diarrhea, and sometimes by constipation and sometimes even by
+dysenteric movements, all cured by bread pills when these were
+administered in certain definite ways, and the patient's attention
+concentrated on their expected effects. Bismuth lost its effect in one
+case of repeated colic, opium was beginning to lose its effect. The
+patient was then told that on the next attack he would be put under a
+medicine which was generally believed to be most effective, but which
+was rarely used on account of its dangerous qualities, and that would
+not be used unless he gave his consent. At the first sign of his next
+attack, a powder containing four grains of ground biscuit was
+administered every seven minutes while within the hearing of the
+patient the greatest anxiety was expressed lest too much should be
+given. The fourth dose caused an entire cessation of pain. On four
+other occasions, the same remedy was employed with equal success for
+the same sort of attack. In a seaman who was suffering from obstinate
+constipation which resisted even the strongest purgatives, including
+Croton oil, pills consisting of two grains of bread were administered
+every seven minutes, and the patient watched with very apparent
+anxiety lest an overdose should be given. Within two hours he began to
+have nausea at his stomach, which had been foretold as one of the
+symptoms to be expected, and his bowels were freely open almost
+immediately after. Apparently the administration of the bread pills
+eventually cured his constipation.
+
+
+Skin and Intestinal Sympathy.--Curious intestinal conditions are, as I
+have said, often associated with neurotic manifestations of other
+kinds. Attacks of hives and other neurotic skin disturbances are
+common in association with nervous diarrhea. Sometimes the attack of
+hives precedes the intestinal disturbance; sometimes it accompanies
+it. Soon after eating the offending material, the skin manifestations
+may begin and other symptoms follow. Only a few minutes elapse, even
+when the patient does not know that the offending material has been
+eaten, because it is concealed in some combination, yet the reaction
+takes place evidently not from digestive absorption, but from
+intestinal reflex. Very often there is vomiting, as well as diarrhea.
+It is not hard to understand that in these cases there is produced an
+irritation of the intestinal mucosa, corresponding to that seen in the
+skin. Whenever {282} this occurs, it is not surprising that there
+should be evacuation of the contents of the digestive tract in every
+way that nature has provided for removing irritating material. The
+simple nervous diarrhea is often spoken of as an "intestinal blush,"
+as the neurotic disturbance of the bladder which causes frequent
+urination is spoken of as a "vesical blush." Blushing is certainly the
+external manifestation that corresponds most closely to the
+disturbance that is probably the basis of these curious
+manifestations.
+
+
+_Urticaria and Diarrhea_.--Patients who suffer from urticaria readily
+are almost sure to have other neurotic disturbances, and their
+intestines seldom escape. On the other hand, those who have an
+idiosyncrasy for certain kinds of food are almost sure to have other
+nervous neurotic disturbances, which emphasize the fact that these
+curious idiosyncrasies are of reflex nervous origin, rather than due
+to any chemical irritation.
+
+Some of these lesions of the intestinal tract related to urticaria may
+affect, either primarily or secondarily, the biliary structures. Under
+these circumstances there may be symptoms resembling true biliary
+colic with some jaundice and pain that radiates toward the right
+shoulder. Whether these bile symptoms are due to the occurrence of
+actual urticarial lesions in the bile duct, or so close to the papilla
+of entrance of the gall passages into the intestine as to occlude it,
+is doubtful. Practically all the symptoms of the presence of biliary
+calculus may be thus simulated. The differential diagnosis can only be
+made by the rapid clearing up of the symptoms, and by the history of
+the case. As a rule, where there is the story of repeated attacks of
+neurotic intestinal disturbance, the physician and especially the
+surgeon, should be slow to conclude as to the presence of a serious
+pathological condition anywhere in the intestinal tract, unless the
+symptoms are absolute. This is all the more necessary because now, in
+patients' minds, the words appendicitis or biliary calculus are
+associated with the thought of operation. This thought sometimes gives
+rise to so much dread as to seriously disturb the appetite and still
+further predispose the patient to the repetition of neurotic
+intestinal trouble.
+
+In the chapter on Abdominal Discomfort, the necessity for absolute
+assurance of some definite lesion before there is any question of
+operation, is insisted on. Here the disturbing mental influence of
+suggestion, with regard to certain serious abdominal conditions, may
+be emphasized. Many painful conditions in the abdomen are either
+primarily or secondarily due to appendicitis. Most of these are quite
+acute, and practically all amenable to definite diagnosis. There is,
+however, a tendency to exaggerate the place that this organ holds in
+the pathology of chronic cases. Many women who suffer from nothing
+more than hysterical abdominal conditions are told by someone that
+they have recurrent attacks of appendicitis, though there is nothing
+except their suggestive complaints of pain on which to found such a
+diagnosis, and then it becomes extremely difficult to remove this idea
+from their minds, and contrary suggestion applied over a long period
+is the only therapeutics that favorably affects them.
+
+
+Intestinal Idiosyncrasies.--I have had the opportunity to see a series
+of cases of intestinal idiosyncrasy in a family that has been an
+interesting study for many years. One of the members has the most
+exquisite case of susceptibility to various articles of food that I
+think I have ever seen or heard of. {283} Even the eating of a little
+unrecognized pork in sausage will give rise to a diarrhea so intense
+that there is no peace for hours, and slight movements take place
+every few minutes. Towards the end of the attack, there is always
+considerable blood in the stools. Often the attack is preceded by
+vomiting. While in most people the idiosyncrasy is limited to one
+article of food, this patient has it for all of the articles that are
+usually the subjects of idiosyncrasy. Besides pork, shell-fish will
+produce vomiting and diarrhea within a few minutes, strawberries act
+detrimentally at once, and cheese produces an almost immediate
+reaction.
+
+The most interesting feature of this case is that occasionally an
+attack of diarrhea that is extremely severe, will occur merely as a
+consequence of a strong emotional stress. Any great anxiety will have
+this effect. The knowledge that someone has a telegram for her whose
+contents she can not ascertain for a time, will act as a cathartic.
+She also has other neurotic manifestations, especially of an
+urticarial character, that are equally interesting. On a number of
+occasions, when she has particularly prepared for some special event
+such as a wedding or reception, for which a new gown has been provided
+and preparations made with considerable solicitude to the end that she
+shall appear at her best, she has suffered from a severe attack of
+angio-neurotic edema affecting either her lips or her eye-lids so that
+it was absolutely impossible for her to be present at the social
+engagement. This has happened to her over and over again. On the first
+two occasions, one eye was closed completely by the edema. In each
+case she attributed it to the sting of an insect. There was no sign of
+any sting, there was no itching or inflammation, the condition
+presented all the signs of angio-neurotic edema, had come without
+warning, and disappeared in from 36 to 48 hours without leaving any
+mark or trace of its origin.
+
+There is absolutely not a sign of hysteria in this individual, nor is
+there any tendency to what would be called an emotional neurotic
+condition. On the contrary, she is lively and sensible, the life of
+her friends when they are ill, their consolation when they are in
+trouble, and she herself has shown the power to bear trials and
+difficulties. It is only the peripheral circulation in the intestinal
+mucosa, and in the skin, that passes from under her control. She
+neither laughs nor cries without reason and she has no other
+exaggerated nerve reactions. Even more interesting is the fact that
+the angio-neurotic condition can be traced in the preceding
+generation, while the tendency to an intestinal neurosis complicated
+by diarrhea exists in a sister in this generation. Examinations are
+always a source of grave distress to the sister. Although she is a
+bright intelligent woman she does not do justice to herself because of
+her nervousness. Usually she has a vomiting spell in the morning
+before the examination, and rather serious intestinal disturbance
+during the day. That this is entirely neurotic is clear from its
+constant disappearance immediately afterwards, and its constant
+reappearance whenever there is this form of emotional stress.
+
+In certain of these cases of supposed neurotic, intestinal troubles,
+one cause of the condition sometimes fails of recognition. Many of
+these people are found on inquiry to be taking much more salt than
+usual. It is hard to understand how this occurs, but I have seen it in
+a number of cases, sometimes in men, but much more frequently in
+women. Some sort of a vicious {284} circle has been formed: probably
+their original tendency to diarrhea led to a craving for salt, because
+of the excessive serous evacuations. Somehow, then, the habit of
+taking more salt was formed and its presence reacted to produce
+irritative conditions in the patient, which, combined with neurotic
+tendencies, produced the intestinal disturbance. I have seen chronic
+diarrhea, mucous diarrhea, and even mucous colitis, associated with
+the over-free taking of salt. When salt was eliminated from the diet
+the cases at once improved. We now realize the value of a salt-free
+diet for many conditions disturbing osmosis, and the presence of serum
+where it should not be. It is probable that most people take more salt
+than is good for them.
+
+
+Intestinal Troubles Due to Air.--One of the most annoying intestinal
+troubles due to a neurosis is the passage of air from the intestines,
+or in some people a rumbling through them, which is distinctly of
+neurotic origin. It is increased under emotional stress or whenever
+there is anxiety with regard to it. This is much more common in the
+old than in the young, as if relaxation of tissues had much to do with
+it. Old men seldom complain of it to their physicians, but for obvious
+conventional reasons, we are rather often asked to control it in older
+women, and are occasionally asked to treat poignant cases of it in
+young women. The older women are often stout, of flabby constitution,
+and one has almost to accept the conclusion that the real trouble is
+such a relaxation of the intestinal walls that the empty intestines do
+not fall together as they used to, but rather tend to lie apart from
+one another with the production of spaces into which gases, perhaps by
+diffusion from the blood, find their way and are expelled. Usually
+these patients were stouter than they now are.
+
+Often after these patients have walked outside for some time,
+especially if they have become quite tired, and then sit down inside
+and become warm, the expansion of the air in the intestines leads to
+some rumbling and the production of flatus. This experience is so
+common with elderly people, when they come in in cold weather, that
+they do not feel quite right unless it actually happens. The odor of
+the flatus is seldom offensive.
+
+
+_Air Swallowing_.--There seems to be no doubt that a certain amount of
+air is swallowed, that it finds its way along the intestines, and
+then, with the change of temperature on coming into the house,
+expansion takes place and the air finds its way out. In certain
+patients the habit of swallowing air may grow, and the necessity for
+its evacuation, either by eructation or flatus, may be a source of
+great discomfort. The latter form of relief may be impossible owing to
+conditions, though it is quite as natural as other forms of the
+evacuation of the bowels, and it must not be considered pathological
+unless it becomes too frequent. People of other civilizations than
+ours are not so sensitive in this matter. A late distinguished Chinese
+Ambassador to this country relieved himself of an accumulation of gas
+in his lower bowel quite as indifferently as he would have of gas in
+his stomach--but without so much as "by your leave" and evidently
+without a thought of anything unseemly in the act--apparently to his
+own great satisfaction, though sometimes to the consternation of the
+bystanders. Utterly failing to understand why he should not permit
+himself this satisfaction, he peremptorily refused to conform to our
+Western refinements in this matter.
+
+In many of these cases habit may add to the necessity for relief of
+this {285} kind, and habit may require considerable self-discipline
+and training of organs to overcome it. To attempt to control this form
+of intestinal trouble by ordinary intestinal remedies, and especially
+by carminatives, is almost sure to increase it rather than do any
+good. It is the patient's mental attitude toward the affection that
+must be modified, and the intestinal bad habit must be brought under
+control.
+
+
+_Intestinal Uneasiness_.--In young women the cases are much more
+serious, for the presence of gas in the intestines sometimes leads to
+such dread of physical events over which they fear they may have no
+control, that it makes it impossible for them to carry on their
+ordinary occupations, hinders their conformance with social usages, or
+even their association with any but very near friends. The cases are
+not frequent, but are poignant when they occur. Many young women
+suffer from rumblings in the intestines whenever more than four hours
+have passed since their last meal. This phenomenon is not likely to
+manifest itself unless they are nervous, excited and worried over
+something, but is particularly likely to be troublesome when they are
+with persons whom they are most solicitous to impress favorably. The
+manifestation is undoubtedly associated with emptiness of the
+intestines and relief will usually be afforded by taking something to
+eat, even something so simple as a glass of milk and some crackers,
+shortly before the time when the rumblings are usually heard. Dread of
+this annoyance plays a large role in it, and it is due to an
+exaggeration of peristalsis with the consequent crowding into larger
+masses of small quantities of air that ordinarily would find their way
+much more slowly along the intestinal tract. Milk of bismuth will do
+more than anything else, though the presence of a certain quantity of
+food is probably the best prophylactic and remedy.
+
+Besides these cases, there are some that are even more annoying. These
+occur in young women who have all the symptoms of an approaching
+intestinal evacuation, and then find when they have excused themselves
+that there is nothing but gas to be passed. This gas is nearly always
+quite inoffensive, and is evidently air that has been present in the
+intestines for some time, and has in the midst of the excitement of
+peristalsis been forced on into the rectum and gives the sensation of
+an approaching stool. These cases are coming into notice much more
+commonly since young women have taken up business occupations. The
+symptoms are worse in those who are constipated, though sometimes in
+these cases there are recurring attacks of diarrhea showing that the
+normal function of the intestine is disturbed. It is more annoying
+just before and during menstruation than at any other time.
+
+
+_Physical Basis_.--Whenever the patients are run down in weight there
+is a distinct exaggeration of the condition. Whether the loss of
+weight, by removing fat from within the abdomen, does not tend to make
+the intestines more ready to take up air and to produce these
+manifestations is a question worth considering. The most annoying
+cases that I have seen were in people who had lost considerable weight
+and though there had been some tendency to the condition before they
+lost weight, it was doubtful whether the symptoms were greater than
+those often seen and which are not productive of special annoyance
+except in very sensitive people. In three of these cases that have
+been under my observation in recent years, improvement came promptly
+when weight was put on. The presence of an abundance of fat in {286}
+the abdominal cavity seemed properly to balance the intestines and to
+dampen peristalsis.
+
+Reassurance, absence of worry, occupation of mind with interests that
+keep it from putting such surveillance on the intestinal tract as will
+surely be resented, must be the chief care of the physician. Without
+these any relief afforded will be only temporary. With psychotherapy
+relapses will occur, for these individuals are in a state of unstable
+intestinal equilibrium, but practically all the successful remedies of
+the past have been founded on it and its effect may be renewed over
+and over again under various forms.
+
+
+
+CHAPTER VII
+
+MUCO-MEMBRANOUS COLITIS
+
+Probably the severest, certainly the most interesting of the neurotic
+conditions of the intestines, is muco-membranous colitis. The only
+lesions discovered are those which point to a functionally increased
+secretion of tenacious mucus from the lower bowel. No definite
+pathological changes are known. The colic seems to be due to nothing
+more than the effort of the large intestine to push off the thick
+mucus which has been secreted, and which in many cases clings to the
+bowel walls. This may be of such consistency that it is passed from
+the bowel in the shape of tubular casts. These casts have often been
+seen in place in the lower bowel. While the word membranous used in
+connection with the disease has produced the impression that this
+might be a form of diphtheritic affection, it is now known that it is
+only due to an abnormally increased function, and not to any
+structural pathological condition or infection of the lower bowel. The
+membranous material is often gelatinous, and so the casts may hang
+together in long pieces.
+
+
+Neurotic Etiology.--It might be thought that such a cast could not be
+formed, remain in situ in the lower bowel for a considerable period,
+and then be passed as a whole, or in quite long portions, without
+causing serious tissue disturbance in the mucous membrane. As Sir
+William Osier says, in spite of the apparent improbability, the
+separation may and usually does take place without any lesion even of
+the surface of the mucous membrane. The epithelium seems to be left
+intact. Owing to the curious nature of the stools, the disease has
+been recognized for a long time and the descriptions of this disease
+by the older authors are very interesting. Muco-membranous colitis
+occurs mainly in nervous individuals, and is much more frequent in
+women than in men, but it is not limited to women. Some of the
+severest cases have occurred in men, and Woodward, in the second
+volume of "The Medical and Surgical Reports of the Civil War," has an
+exhaustive description of the disease as it occurred among soldiers.
+It is particularly those who are worried and run down from overwork
+and excitement who are likely to suffer from it, but it occurs
+typically in people who, _faute de mieux_, worry about themselves.
+Most of its victims are self-centered, though not hysterical.
+
+
+Recent Increase in Number of Cases.--According to all the authorities,
+there has been a considerable increase in the number of cases in
+recent years. {287} At one watering place in France, Plombiêres, which
+has acquired the reputation for relieving, or even curing the disease,
+about 400 cases had been under treatment during the course of about
+two years. This increase was attributed by Boas of Berlin to two
+causes. First the struggle for life has become much more intense in
+our day, and the nervous conditions which are practically always the
+basis of muco-membranous colitis, have as a consequence become more
+frequent. Not only this, but mild cases that were not called to the
+attention of physicians in the past, have become so emphasized by the
+nervous worries of the strenuous life that now they seldom escape the
+physician's attention. Besides our generation is getting away from the
+old-fashioned idea of patiently standing many pains and aches, and
+refusing to call in a physician unless the condition persists or seems
+to be producing serious results. There are more cases of the disease,
+but physicians also see more of the cases than formerly because
+patients come for treatment for slighter causes.
+
+Dr. Boas considered that, besides the strenuous life, there was
+another prominent factor in the increase of the disease. This is the
+abuse of laxatives and purgatives. Many of these have their principal
+effect on the lower bowel. In consequence the nervous mechanism of
+this structure has been irritated to a point where occasionally
+explosions of nerve force take place. This causes an increase of the
+secretion, and a tendency to cramp-like contractions. While there is
+undoubtedly much of truth in this, there is no doubt that the most
+important factor in the disease is the patient's nervous condition.
+Only those who are inclined to be introspective, to worry much about
+themselves, and who are constantly examining their stools for the
+presence of mucus, suffer severely from the affection.
+
+Very few cases have been seen among the working classes. Most of the
+cases have hypochondriacal symptoms that sometimes go to the extent of
+real melancholia and the full persuasion that they have an incurable
+disease, a visitation on them for some real or fancied lapse from the
+laws of health in earlier years. The affection usually lasts a long
+time, or has been in existence for some years when the physician is
+asked to see it, and patients are made most miserable by it.
+
+Unfavorable Suggestion and Over-attention.--The pathological
+physiology of this disease, for, as has been said, it has no pathology
+in the proper sense of the word, is in many cases a problem of mental
+influence. For some reason, the patient gets his or her lower bowel on
+his or her mind. There is so much talk of constipation and its evil
+effects in the newspapers, in advertisements and by suggestion from
+bill-boards and in the magazines as well as, sad to relate, in
+parlors, drawing-rooms and even dining-rooms, that it is easy for
+those who are introspective and nervous about themselves, and who have
+some little tendency to constipation already, to become much worried
+about it. If, then, as was suggested by Boas, they take laxatives in
+profusion, the irritation set up further fixes the attention on this
+portion of the body. After a while, in these people, a goodly portion
+of the waking hours are spent in thoughts with regard to the lower
+bowel. The morning thought is the possibility of a stool to-day,
+followed by conjecture as to its character. After the stool has taken
+place, if there seems anything abnormal about it, comes a morbid dread
+of the consequences of having such stools.
+
+{288}
+
+This constant attention sends down a lot of impulses to the lower
+bowel. Anyone who has studied the psychology of attention knows how
+much influence can be exerted on the skin, or on the mucous surface by
+mental influence. Hyperemia is produced, and this leads to over-action
+of the glands of the large intestine. These glands secrete a glairy
+mucus which is necessary to protect the bowel from the offensive
+material that is always present, and from the hardened material that
+is so often there when there is a tendency to constipation. This mucus
+is secreted in large quantities, while at the same time a hyperemia of
+the colon tends to interfere with peristalsis and consequently to
+delay the passage of contents and to keep the mucus in place. An
+accumulation goes on for some time, until irritation is set up by the
+presence of such a large quantity of material in the intestine, and
+then colicky efforts for its removal are occasioned. All of this
+process is accompanied by suggestive reactions upon the mind that
+further complicate the case. This story of the affection points out
+the indications for treatment. Unless the patient's mind can be
+diverted from its constant attention to the lower bowel, the
+possibility of cure is distant, and even after such diversion any
+return of attention is likely to bring on a relapse.
+
+
+Treatment.--The treatment of this affection emphasizes its neurotic
+origin. We have had any number of cures for it and each one has
+actually relieved many patients. The more trouble the cure involves,
+and the greater the impression produced on the patient's mind the more
+likely is there to be a relief of symptoms. All sorts of drugs have
+been employed. Many of them have for a time been heralded as more or
+less specific. The important thing, however, was that the patients
+should come predisposed to believe that they were going to be
+improved, and then that suggestion should be made at frequent
+intervals--a combination of auto-suggestion through the administration
+at regular intervals for a long period of simple remedies with the
+confident suggestion of the physician that the patient will get
+better. Local treatment of various kinds has been reported to bring
+about improvement. The more difficult this is, and the longer it
+takes, as well as the more bother it involves for the patient and the
+attendant, the better the response to it is likely to be. Long rectal
+tubes were found beneficial in many cases, though they failed in many
+others, and most physicians have seen relapses occur in spite of the
+continuance of the treatment that at first did much good. High
+injections of water containing various drugs, and of olive oil
+sometimes bring improvement though they afford no guarantee against a
+relapse. Mineral waters do good only in the suggestive environment of
+the spring.
+
+
+_Surgery and Suggestion_.--The symptoms have sometimes been so severe
+and the complaints of the patients have been so great that even
+surgery of serious character has been recommended and tried in some of
+these cases. The making of an artificial anus in the right inguinal
+region, so that for a time the feces are not allowed to pass over the
+colon mucous membrane has been tried. This gives decided relief from
+the symptoms, but when the artificial anus is allowed to close,
+recurrences often take place. It has been suggested, therefore, that
+the artificial anus should be allowed to stay open for months, but
+even this seems to afford no guarantee against a relapse. In recent
+years the appendix has been taken out through the opening in the right
+inguinal region, and a portion of it allowed to remain through which,
+when {289} fastened to the abdominal wall, injections might be made
+into the colon. In these cases ice-water has been found probably of
+more effect than any drug solutions. This rather serious surgical
+procedure is, however, as yet on trial, and we do not know enough
+about the after-course of the cases to be sure that it has any
+permanent effect.
+
+A strong suggestion is involved in the removal of the appendix, and
+the use of the stump of it as an irrigating tube. When the treatment
+consists of something that is so strongly excitant of feeling as
+ice-water, applied directly to the colon, it is easy to understand
+that suggestion reaches the limit of its possibilities. No wonder
+these cases improve, though we are not sure as yet what happens after
+the appendix opening is allowed to close, or is deliberately sutured.
+I should expect a recurrence of symptoms, if ever a time came when the
+patient was run down in weight and worried by external conditions,
+introspection, and above all by concentration of attention on the
+intestines.
+
+
+_Direct Suggestion_.--The question is whether suggestion can be used
+to advantage in these cases without employing any of the radical
+measures that have been suggested. There is no doubt that at certain
+watering places where a specialty is made of this disease, and to
+which patients go, sure that they are going to be much better than
+before, and where they see patients all round them who are improving,
+they often get complete relief. This is only what might be expected.
+Whether a similar effect can be produced by simple suggestion when the
+patient is thoroughly convinced that the physician understands the
+case, and that if they will respond he can cure it, remains to be
+seen. I know that mild cases improve rapidly under simple hygienic
+measures, with a renewal of confidence in the possibility of relief,
+and with the diversion of the patient's mind from the intestinal
+difficulty. This is the most important factor in the treatment, as it
+is the most important factor in pathology. If the patient's nerve
+centers can be kept from sending down impulses causing exaggerated
+action of the glands, then there is some hope of relief. A habit has
+been formed in the matter, and a habit can only be broken by a series
+of acts, just as it was formed. It is not effort for a few days nor a
+week that counts in these cases, but diversion of mind for long
+periods, until normal function is restored. It is usually quite
+impossible to keep up this improvement constantly in nervous patients.
+There are setbacks, but then this is true in every form of nervous
+affection. It is, then, that the renewed suggestion of the physician
+is needed.
+
+
+_Resort Cures and Suggestion_.--Physicians often tell patients that
+muco-membranous colitis is incurable, or at least emphasize strongly
+that it is very refractory to treatment, and that it is prone to
+relapse even after improvement. After a certain number of physicians
+have insisted on these points, it is inevitable that patients should
+not respond readily to treatment, and that they should be solicitous
+about themselves, even when improvement does come.
+
+It is most important then to bring about the neutralization of these
+unfavorable suggestions. This is what is particularly accomplished at
+the health resorts where muco-membranous colitis is successfully
+treated. At these the patients see other sufferers from the disease
+who proclaim how much better they are and some at least who are
+entirely cured. The waters {290} used at these health resorts are not
+nearly so efficient when used at a distance because of this lack of
+additional suggestion.
+
+The most efficacious treatment of muco-membranous colitis then is to
+bring the patient up to normal weight, for they are often thin people,
+quiet their solicitude about themselves, give them a bland and
+irritating diet and get them away from worries or anxieties about
+themselves or others. I know cases in physicians where the effect of
+worry of any kind can be traced very clearly in the increased symptoms
+of their colitis and the greater frequency of attacks. It is
+particularly important not to give habit-forming drugs in these cases
+for they always do harm. Where the pain is much complained of the
+coal-tar anodynes are useful, but ice in the rectum or even
+suppositories of gluten, or of cocoa butter without any medication
+often prove useful. Most of these patients watch prescriptions that
+are given them rather carefully and make up their mind beforehand
+whether they are likely to do them good or not and the event usually
+follows their premonition. They often have habits of self-drugging
+which must be stopped and always carefully inquired into for they will
+sometimes continue to take things for themselves in spite of being
+under the doctor's care. If they have heard of surgical treatment for
+their affection they are likely to think that they will have to come
+to it eventually and this prevents a favorable attitude of mind
+towards their affection. Unless this is secured no treatment will
+prove efficient. With it almost anything that keeps up the suggestion
+will greatly relieve and often will actually cure the condition.
+
+
+
+CHAPTER VIII
+
+OBESITY
+
+Obesity, popularly considered to be an over-accumulation of fat, is
+sometimes thought to exist only when there is the large development of
+abdomen which is more properly designated corpulency. In its strictly
+scientific sense it represents excessive over-weight, that is, above
+twenty per cent. more of weight than is normal for the height of the
+particular individual. (See table of weight for height in chapter
+Weight and Good Feeling.) The Latin derivation of the word gives also
+its etiology. Ob-ese means having eaten too much. It is a question of
+failure of due proportion between the taking of nutrition and the
+oxidation processes within the body. More food being taken than is
+needed, there is an accumulation of it in the form of fat, and this is
+deposited by natural preference in certain places, such as the
+abdomen, the breasts and in the _panniculus adiposus_ beneath the
+skin. The fats and starches are most readily converted into this fat,
+but under certain circumstances proteid material may be turned into
+fat, and then a true pathological condition develops resembling
+diabetes in certain ways.
+
+The metabolism of fat is rather simple, but this may be disturbed by
+bad habits. When such large quantities of sugar-making materials are
+taken that they are beyond the power of the normal metabolism to
+dispose of, they are excreted in the urine with the production of what
+is known as physiological {291} glycosuria. In the same way, the
+eating of a superabundance of fat-forming food leads to the deposition
+of fat in the tissues where, when in excess, it is just as much wasted
+as if it were excreted. Physiological glycosuria is, however, usually
+considered to be dangerous, inasmuch as its frequent occurrence may
+disturb the normal metabolism of sugar, and lead to diabetes. In the
+same way, the over-consumption of fat-forming materials may disturb
+the fatty metabolism, and lead even to the changing of proteid
+materials into fat. This represents a real disease requiring careful
+management, while ordinary obesity needs only the exercise of the
+patient's will to secure such proportion between the amount of food
+taken, and the amount of exercise and fresh air, as will not only
+prevent accumulation of fat but will lead to the reduction of any
+accumulation that may, through neglect of this care, already have
+taken place.
+
+
+Over-eating.--The putting on of weight depends on the individual's
+craving for food, and his satisfaction of his appetite. While it is
+not ordinarily looked at from this standpoint, this craving for food
+and the habit of satisfying it which is developed, is not very
+different from the craving for stimulants and the habit that forms
+with regard to them. People insist that they can not eat less--that
+their appetite simply requires them to eat. We have all heard this
+story over and over again from the man who craves alcoholic
+stimulation. Usually the obese can be persuaded more easily than the
+inebriate to break off their habit, but they relapse into it even more
+easily than he does. It is comparatively easy to limit the appetite,
+or rather to forego the satisfaction of eating abundantly, for a week
+or two weeks or even a month, but the effort finally becomes appalling
+and the consequence is a relapse. If the patient really wants to lose
+weight, in nine cases out of ten it is a comparatively simple matter.
+The trouble is that they want to lose in weight without giving up the
+satisfaction of eating.
+
+
+Under Exercise.--The second factor in obesity--lack of sufficient
+exercise, is even more important than the habit of over-eating. This
+is illustrated very well by the cases of certain animals who, without
+any tendency to fat accumulation by nature, but rather the contrary,
+acquire fat to a marked degree, owing to the habits that are forced on
+them by their relations to human beings. A typical example is the pet
+dog. Dogs living their natural active lives, have little tendency to
+put on superfluous flesh. Kept in the house in cities, they
+practically always put on weight until, after some years, many of them
+are quite incapable of moving except in an awkward waddle, often
+comically symbolizing their mistresses in this respect. Besides the
+inactivity, the dog is subject to the influence of the other cause of
+obesity, the over-eating of fat producing material. Another typical
+example, and one that provides evidence of the pathological tendency
+to fat accumulation, is found in the Strasburg geese from whom the
+fatty goose livers for _pates de foie gras_ are obtained. Geese are
+placed in a warm underground room, in a mass of cement that gradually
+hardens round their feet keeping them almost completely inactive, and
+then they are fed abundantly with fat-forming materials. The absence
+of light and air, and the immobility, leads to the production of the
+fatty changes, eventually producing the enlarged fatty livers, which
+delight the gourmet's palate.
+
+What is true of the dog and the goose is exemplified in the lives of
+all other {292} animals. The fattening process is well understood by
+butchers--keep the animal inactive and supply an abundance of
+fattening food. The inactivity is even more important than the food.
+
+
+Prophylaxsis.--Of course, if obesity is to be successfully treated,
+cases must be seen early and before there has been a large
+accumulation of fat. When people are more than 10 per cent. over
+weight they are in the danger zone, and with 20 per cent. above the
+normal, decrease must come or the condition becomes inveterate. It is
+between these two points and not when they are forty or fifty pounds
+over weight that they need the advice of a physician and the careful
+institution of regular life to prevent further fat accumulation. After
+the body has carried thirty or forty pounds over weight for some time,
+it has acquired the habit of accumulating fat, rather than using it,
+and this, once acquired, is hard to break. Every additional pound
+tempts to the formation of lazy or sluggish habits because of the
+additional weight that has to be carried around. Everyone knows how
+hard it is to walk a few blocks a little briskly carrying a suit case
+that weighs thirty pounds. Even twenty pounds soon proves to be a
+burden. Fat in the tissues, though it seems to be a portion of the
+individual, is really quite outside of him and consists of extra food
+material that the body is carrying round, having accumulated it for
+the purpose, apparently, of using it at some time when it should be
+necessary. While carrying this burden, people have little inclination
+to an active life. Inactivity lowers oxidation processes and leaves
+them with an additional tendency to fat accumulation because of lack
+of oxidation. In a word, a vicious circle of cause and effect is
+formed. Accumulation of fat prevents the taking of proper exercise,
+and lack of exercise leads to further accumulation of fat!
+
+Not only should the treatment of obesity begin early in a particular
+case, but, in families where there is a recognized tendency to take on
+fat, it should begin early in life.
+
+Children should not be so fed that they become mere specimens,
+illustrative of how early fat accumulation may occur, and to what a
+degree it may go. Just as soon as baby shows signs of an accumulation
+of fat above its normal weight for age and size, there should be just
+such a regulation of its diet as would be considered necessary if it
+were an older person, and showed the same unfortunate tendency. This
+is particularly important if the parental relatives on either or both
+sides of the house show tendencies to fat accumulation. We are sure
+that in diabetes the over-eating of starchy and sugary substances
+produces what is, at the beginning, an alimentary or so-called
+physiological glycosuria, though it is doubtful whether any glycosuria
+is ever absolutely physiological. This may lead to a pathological
+glycosuria and the production of a true diabetes. So, also, the
+tendency to accumulation of fat, as the result of what might be called
+alimentary obesity, may lead eventually to the production of an
+essential obesity in which even the proteid materials of the food may
+be changed into fats, just as in the case of diabetes they are changed
+to sugar. This fat is then stored up in the tissues though there is no
+need at all for such an accumulation, and the food stuff is wasted
+quite as much as in diabetes.
+
+
+The Will in Treatment.--The important element in the treatment of
+obesity is the readiness of the patient to follow directions. Nine out
+of every {293} ten stout people are thoroughly able to control the
+accumulation of fat and even to bring themselves down to about normal
+weight, if only they _will_ to do so. This is no easy matter. It is
+not an affair of a few weeks, or even a few months. Just as in the
+case of over-indulgence in alcohol, it will probably be a life
+struggle. It is well worth the while, however, for life is longer and
+is larger without the accumulation of fat, which is not only so
+uncosmetic, but is so preventive of real enjoyment of life.
+Unfortunately, the cosmetic side of it, that is, the absurdity of
+going round among one's friends with a very prominent abdomen, or with
+noticeable protuberances, is the particular motive that appeals to
+most people. While women may be quite ready to stand many discomforts
+for cosmetic effect when dictated by fashion, they are not ordinarily
+persistent enough in their efforts to prevent fat accumulation to be
+successful in this much more important purpose.
+
+Such patients make the rounds from physician to physician, and from
+quack to quack, and go from patent medicine to patent medicine, to
+find something that will enable them to lose weight without the
+necessity for their taking any trouble. It is the old, old story that
+the nerve specialist who is known occasionally to treat his patients
+by hypnotism has so often presented to him. Patients who are sufferers
+from alcoholism, or drug addiction, or some other vicious habit,
+present themselves and ask if they cannot be hypnotized and then lose
+their tendency to fall back into the old habit. There is no
+possibility of this. If they are willing to cooperate, all of these
+habits may be overcome, but a constant effort will be required and,
+even after the habit is broken, there always remains a distinct danger
+of relapse. Patients suffering from obesity want to transfer the
+burden of working it off to someone else's shoulders, or they want
+some specific remedy that will bring about reduction in weight yet
+permit them to indulge in all the pleasures of their artificially
+excited appetite. They follow directions for a few weeks, often
+half-heartedly, and then give up the struggle.
+
+
+_Food Temptations_.--With obesity, as with indulgence in alcohol, the
+main difficulty is the occasion. Most of these fat people are placed
+in circumstances in which tempting food passes them three times a day,
+and it is hard to refuse it. If a hot punch or a fragrant cocktail
+were several times every day passed under the nose of a man with a
+tendency to inebriety it would be beyond the bounds of reason to hope
+that he should withstand his craving. Just as soon as those who want
+to reduce in weight are put in conditions in which only simple food,
+though there may be a reasonably good variety of it, is presented to
+them, the difficulty of limiting the amount they eat is comparatively
+easy. This necessitates, as a rule, refusing invitations to dinner at
+friends' houses, especially at the beginning of a reduction cure,
+avoiding hotel _menus_ and giving up various social functions. It may
+even involve changing home customs from those of luxury back to
+simplicity. The question is whether this is worth while or not. When a
+husband is likely to indulge over much in alcoholic liquors a wife is
+apt to consider it easy to deny herself the privilege of such liquors
+on her table and of avoiding places where he is likely to be tempted.
+The rest of the family are usually quite satisfied to stand some
+self-denial so that unfortunate results may not follow.
+
+Where father or mother are suffering from obesity this same thing may
+be necessary with regard to rich and highly seasoned foods. This would
+be a {294} hardship to inflict on the family were it not for the fact
+that the health of all the members will be distinctly benefited and a
+return to simple food, nutritious and with a variety that makes it
+eminently wholesome, will be good for them as a prophylactic measure.
+
+
+_Motives for Self-Control_.--The task of keeping the weight down is so
+difficult that very few people with a tendency to over-weight are
+equal to it. They need the help of every motive possible for
+encouragement. It is well to make these persons realize that
+over-weight, according to the statistics carefully gathered and
+collated by the large insurance companies in recent years, is a
+serious bar to great expectancy of life. In a large series of cases it
+was found that not a single individual recorded as being more than
+twenty per cent. over the normal weight that he should have for
+height, died of old age. Furthermore no one of over-weight attained
+the age of eighty years, though 44 under-weights passed this age, and
+two of them even reached the age of ninety. Death from nearly every
+known cause is more frequent among the over-weights than in the normal
+population, except in the single instance of tuberculosis.
+
+What was thus demonstrated from statistics, carefully gathered in
+modern times, has been a commonplace in medicine since the earliest
+days. Hippocrates summed up Greek experience in the aphorism "persons
+who are naturally very fat are apt to die earlier than those who are
+slender." Practically all the commentators since his time have agreed
+with him. In early years thinness may be quite as dangerous.
+
+If there were no other reason but the greater frequency of _diabetes_
+among the obese, this of itself would be sufficient to act as a strong
+deterrent motive. It may well be used as such, especially in families
+where a tendency to diabetes has been manifest. Diabetes figures as a
+cause of death in life insurance statistics five times more frequently
+among those who are over-weight than in the general population. Those
+who are under-weight suffer from the disease in fatal form less than
+one-half as frequently as the average. Hence, obesity and diabetes are
+evidently closely related. As we have suggested, the disturbance of
+metabolism due to the failure to use sugar properly in the system and
+to its consequent elimination, corresponds in some, as yet not well
+understood, way to the other metabolic disturbance by which
+unnecessary fat is accumulated in the system. It is probable that the
+over-eating of starchy foods and fats which leads to obesity, causes
+in some people a breakdown of metabolism in the matter of the proper
+disposal of sugar, and this initiates diabetes which becomes a
+pathological condition, after a time quite beyond control.
+
+
+Sleep and Exercise.--After the reduction of diet, the most important
+feature of any successful treatment of obesity must consist of an
+increase in the amount of exercise. Both of these can be accomplished
+only through the patient's will, and by frequently repeated
+suggestion, and auto-suggestion, of the necessity for constant
+surveillance in both these matters. Any form of exercise that is
+pursued faithfully is beneficial. Exercise in the open air, because it
+encourages oxidation, is preferable to gymnastic exercises, but the
+care of a trained instructor, the influence of example, the habit of
+taking it at regular hours, make gymnastic exercise of value in this
+condition. A regular walk every day is invaluable if it can be
+secured. Women can be tempted {295} to walk even three or four miles,
+if the habit is gradually formed, and if they realize the necessity
+for it. It is important that too much sleep should not be indulged in.
+One of the difficulties with pet animals is that they sleep so much
+more in domesticity than in the state of nature. Sleep must be
+absolutely regulated for the obese. The old monastic rule "seven hours
+for a man, eight hours for a woman and nine hours for a hog" must be
+emphasized.
+
+
+Heredity.--There always remains in these cases the influence of
+heredity. Many people are sure that because they come from families
+with the tendency to obesity, it is impossible for them to overcome
+this assumed heredity, and that the only thing for them is to bear the
+affliction with equanimity. They usually do this while indulging their
+taste for the luxuries of the table rather freely. This question of
+heredity, however, has come in recent years to occupy a very different
+position in the minds of biologists from that which it held a
+generation ago. We know now that the evidence for acquired characters
+being transmitted is so trivial as to be quite negligible.
+
+The children of stout parents are likely to acquire their parents'
+habits as to the consumption of food, in such quantity and quality as
+will almost inevitably put fat on them. It is this habit much more
+than any hereditary element, which is the underlying cause of the
+obesity. There may be some influence of heredity, but it is much less
+than has been thought, and even where it exists, it is not so
+inevitable as has been considered. There are cases in every
+physician's experience where the children of stout parents who, for
+some reason, have been brought to habits of spare eating, have been
+thin all their lives. On the other hand, anyone who has seen the
+change that has come over the sons of spare, lanky farmers, in whom
+both father and mother were of the thin type, yet who in the midst of
+the luxury of city life have taken on weight, will be convinced that
+personal habits mean much more than any influence of heredity in the
+production of obesity.
+
+Where there is normal occupation of mind and body with strict
+regulation of the hours of sleep, and simple though abundant food,
+there is little tendency for people to become obese, even though there
+may seem to be hereditary tendencies. In a considerable experience
+with religious communities I have often noted that the member of a
+family who enters a religious order often goes but slightly above
+normal weight, even though other members of the family may become
+distinctly fat. This is not because of rigid self-denial in the matter
+of food, that is to such an extent as to take less food than is
+necessary, for most members of the religious communities work too hard
+for this to be possible, but because they live the regular active life
+and have the simple food of the community. This is true in spite of
+the fact that their indoor life would seem to predispose them to the
+accumulation of fat. After fifty most of them put on weight because
+this is the physiological accompaniment of that period of life, but it
+is not this form of fat accumulation that the physician is called upon
+to treat as a rule, but that in people between the ages of twenty and
+forty.
+
+If the prevention of over-weight is taken up in time, if habits are
+broken before they become tyrannous, if proper self-control is
+cultivated early in life, there are very few people that need fear the
+oncoming of obesity. There are some pathologically obese families in
+which this will not be true, but they are as rare as diabetic
+families. The most important element in any {296} treatment is the
+rousing of the patient's mind and his will to take up seriously the
+task of unlearning habits of overeating and not allowing sluggishness
+of life to gain control. This can be done best, not by removing all
+sorts of articles for which there is special taste from the diet, but
+by a general reduction in the quantity of food eaten, by the
+introduction of food material that does not put on weight yet
+satisfies the craving, by the replacing of many of the starchy
+vegetables by greens of various kinds, by replacing many of the
+desserts by gelatine products and cheese, and by additions to the
+exercise. But there must be no extremes in the reduction of food or
+the taking up of exercise. Patients should not be permitted to lose
+five pounds a week--at most two or three pounds--and they should be
+made to understand that it is a life work and the formation of lasting
+habits that they have before them. They should be made to understand,
+also, after a time the satisfaction that comes from a more active life
+will give them even more pleasure than the satisfaction of their
+appetite did before.
+
+
+Principles of Treatment.--Many systems of treatment of obesity have
+been invented. All of them are supported by cured cases. Some of them
+are founded on a reduction in the amount of fluids, some on a
+reduction of the amount of vegetables eaten, in some cases going to
+the extreme of an almost exclusively meat diet. Most of them modify
+the diet very extensively. It is doubtful, however, whether any of
+these systems, when successful, have owed their success so much to the
+physical effect as to the suggestive influence exercised on the
+patient's mind, that he must at the same time limit his eating and
+increase his exercise. In the matter of fluids particularly, some of
+the systems are absolutely contradictory of one another, yet success
+follows their application. There is one serious difficulty in the
+application of these systems. After a time the patient becomes very
+tired of the monotony of diet suggested, and growing discouraged,
+relapse into old habits. If suggestion can be used with as much force
+without such extreme modifications of diet, the results are as good,
+and are always more lasting. The important factor is a reduction in
+the amount eaten, without necessarily denying any but the very rich
+foods. In this way patients can very soon be induced to take half
+portions of what they have been previously eating and thus secure a
+prompt reduction in weight.
+
+It is important that the bowels of obese patients be kept freely open.
+Tendencies to constipation seem to disturb metabolism in the direction
+of fat deposition, and even fatty degeneration. Many of the cures at
+watering places include the taking of laxative salts, or waters of
+various kinds, and undoubtedly this is helpful at the beginning. But
+the continuance of such treatment may seriously disturb peristalsis so
+that it is important to have intervals of rest for the bowels, during
+which, while there is a regular daily evacuation, there are no
+tendencies to diarrhea. The suggestive influence of the taking of
+salts has meant much for a great many so-called obesity cures. They
+should be employed carefully, but must not be abused.
+
+For fat already accumulated, only exercise will serve as a sure
+remedy. For fat within the abdomen, the various leg exercises which
+may be gone through in bed, and the trunk movements, especially those
+of sitting up from a lying position, when frequently repeated, will
+soon serve to dissipate accumulated fat. They will also encourage the
+taking of outdoor exercises, as {297} well as relieve the patient from
+many muscular discomforts, difficulties of breathing and heart
+palpitation, which were not only annoying before, but discouraged the
+taking of exercise.
+
+
+
+CHAPTER IX
+
+WEIGHT AND GOOD FEELING
+
+
+Probably the most important single condition for the maintenance of
+good health and _good feeling_ is the carrying of weight normal for
+the height and age of the individual, or slightly in excess of normal.
+Popular expressions contain many proofs of this. The proverb "laugh
+and grow fat" is undoubtedly due to the recognition by all the world
+that stout people are nearly always laughers, and as a consequence,
+perhaps placing the effect for the cause, laughing has been regarded
+as a factor in putting on flesh. [Footnote 27]  There is no doubt that
+the exercise for the diaphragm afforded by hearty laughing, with the
+stimulation of the intra-abdominal circulation consequent upon
+vigorous diaphragmatic movements, is an important element in producing
+a healthy state of the important organs of the human economy contained
+within the abdominal cavity. Dr. Abrams in his book, "The Blues,
+Causes and Cure," attributes this disturbing condition of depression
+so familiar to those who have much to do with nervous patients, to a
+disordered blood and nerve circulation in the splanchnic area, and
+calls it scientifically, splanchnic neurasthenia. This undoubtedly
+sums up one important element in the causation of a great many
+depressive conditions. Most of them are banished by frequent hearty
+laughter which, with its exercise of the diaphragm, tends to stimulate
+splanchnic blood vessels and nerves.
+
+  [Footnote 27: Those who are interested in fossil words will find many
+  curious confirmations of the connection between weight and good
+  health and good humor. A typical illustration is the word _buxom_,
+  derived from the German _biegsam_, which means "ready to obey," from
+  the original significance of being ready to bend, that is bendsome.
+  In our day it has come to have quite a material rather than an
+  ethical significance. A buxom woman is one who is round and full of
+  form and while she usually also is cheerful and tractable, the two
+  ideas are not necessarily connected. It is curious that what was
+  originally the obedient wife should now have become the stout and
+  healthy wife, as if stoutness and healthiness were somehow
+  inseparably connected with the preceding idea so that gradually one
+  portion of the meaning was lost sight of and now only the physical
+  significance remains.]
+
+
+Thinness and Discontent.--In general, it is well understood that thin
+people are likely to be more gloomy and discontented than those of
+stouter build. The pessimists of the world have usually been lank and
+lean. Shakespeare, in "Julius Caesar," has the great Roman declare
+that he likes not "the lean and hungry Cassius," and that "discontent
+is bred in such bodies." The issue shows his prophetic power.
+Discontent with life is much more likely in thin people than in stout.
+Most suicides are under-weight. Where nutrition is under the normal,
+digestion is sure to be poor because the digestive organs themselves
+suffer even more than others from lack of food, apparently giving up
+some of their own substance at the call of other tissues; sleep is
+nearly always disturbed, constipation is almost the rule, and muscular
+action becomes distasteful. While in our day we hear much of people
+overeating, the nervous specialist finds that many of his patients are
+undereating. {298} These patients grow out of many discomforts,
+dreads, and symptoms that often seem, even to the physician, to be due
+to organic change, when they take on enough weight to relieve them
+from the incessant calls for more nutrition to which insufficient food
+has made them subject.
+
+
+Physical Disadvantages of Thinness.--There are many dangers that go
+with thinness besides the tendency to that irritability of the nervous
+system which we have come to associate with neurotic symptoms. It has
+long been known that a person who is under weight is much more likely
+to contract tuberculosis than a normal individual. From carefully
+selected statistics, the large insurance companies have determined,
+that it is far more dangerous to insure a man who is twenty pounds
+under weight and who has no family heredity of tuberculosis than to
+insure a man with a family history of tuberculosis on both sides of
+the house, provided he is well up to or above the normal weight, and
+is not living in special conditions of danger from contagion. It is
+contagion and not heredity that plays the most important role in
+tuberculosis, and the element that is still more important is that of
+vital resistance. Every adult of thirty years or over has probably at
+some time had tuberculosis, for traces of its presence are found in
+the bodies of all adults who come to autopsy. Seven-eighths of the
+human race are, however, able to resist, and among these seven-eighths
+by far the greater proportion are those who are above normal weight.
+
+Of course, this matter of the relation of normal weight to good health
+did not escape the acute observation of the old physicians.
+Hippocrates, to take the first and greatest of them, realized that
+while excessive eating and drinking was serious, there were many
+people who suffered from not eating enough. One of his aphorisms runs,
+"A slender and restricted diet is generally more dangerous [manifestly
+he means to both the well and the ill] than one a little more
+liberal." He appreciated, too, the fact that while the old may
+restrict their diet with more or less impunity, this practice may be,
+and indeed is likely to be, more serious in young people. He has
+marshaled the ages and stated the effects of a low diet on them very
+definitely:
+
+  Old persons endure fasting most easily, next adults; young persons
+  not nearly so well, and infants least of all, especially those who
+  are of a particularly lively disposition.
+
+
+_Discomfort Due to Lack of Fat_.--Many of the vague discomforts of the
+internal organs seem to be due to a lack of fat cushions round them,
+and fat blankets to keep them from being too much subjected to the
+vicissitudes of external temperature. Anyone who has noted in a series
+of cases the difference between the condition of patients suffering
+from a slightly movable kidney when they are well up to weight, and
+when, on the other hand, they are considerably reduced in weight, will
+have the significance of the first of these conditions brought home
+very clearly. Most of the people who suffer much from cold in winter
+are greatly benefited, as might be expected, by a blanket of fat. It
+is rather easy to grow accustomed to carrying ten additional pounds of
+fat when ten additional pounds of clothes would be an insupportable
+burden. Some fat people are prone to complain of the cold. These are
+not the plethoric but the anemic. This latter class often have a
+sluggish circulation, besides a lack of hemoglobin. As a consequence
+of this their {299} oxidation processes are slow and imperfect, and
+this is one of the reasons for the over-accumulation of fat. The
+healthy individual with normal heart and normal blood-making apparatus
+will always be ever so much more comfortable with a reasonable
+panniculus adiposus and fat cushions and coverings for the internal
+organs.
+
+
+_Muscular Weakness and Discomfort_.--There are a number of pains and
+aches occurring in lean persons that are due to nothing else than the
+weakness of muscle consequent upon the poor nutrition of their
+muscular tissues. Muscles which do not receive as much nourishment as
+they should, must necessarily be weak, and if asked to do much work
+they will resent it. Ordinarily it is not realized how much work is
+required even for such common muscular efforts as those that are
+needed to hold the body erect, or to keep it in a stooping position at
+a definite angle, or to move around on the feet.
+
+I have seen patients lose their aches and pains, and become quite
+capable of standing weather changes and ordinary hard muscular labor
+without discomfort, simply as the result of a decided gain in weight.
+All that was needed was the persuasion to eat more, and especially to
+eat a full breakfast, the meal likely to be neglected. In some
+persons, appetite will only return after the correction of
+constipation and insistence on a certain amount of outdoor air every
+day, not necessarily exercise--for bus riding or the open cars are
+excellent appetizers.
+
+
+Eating Enough.--It is very difficult to persuade some people to eat
+enough! They have all sorts of excuses. They rather pride themselves
+on the fact that they do not eat much. Persons who are twenty pounds
+under weight will calmly tell you that they do not need more than they
+eat. They are actually in debt to that extent to their tissues, yet
+they are persuaded that they are paying nature's claims in full.
+Sometimes the excuse is that they have heard, or read, of how much
+harm is done by overeating; they have taken to heart the phrase that
+people are digging their graves with their teeth, and so they are
+actually cultivating the habit of undereating instead of allowing
+their instinct for food to manifest itself. Many are found to be
+following the good old saw of getting up from the table hungry. The
+inventor of it is not known, but quite unlike the inventor of sleep,
+it would have been a great blessing if he had kept it to himself by
+patent right.
+
+After a time habit for these people becomes second nature, and it is
+hard to get them to eat enough. When people undereat it is the
+digestive organs that, in my experience, always suffer the most. As a
+consequence, the appetite decreases because of gradually acquired lack
+of vitality in the digestive system, its nutrition having been lowered
+by drafts upon it from other portions of the body. Quite contrary to
+what is told in the old fable, the stomach apparently is not selfish
+and does not keep the lion's share for itself. The decrease in the
+amount of food brings on a decrease in digestive power.
+
+
+Weight for Height.--The physician who wants to help patients by
+suggestion must keep before him weight tables for height, as they have
+been determined by statistics. When people are under weight, it
+matters not what they may be suffering from, improvement will come if
+they are made to gain in weight. To be able to show them that they are
+considerably below the normal and to point out what this probably
+means in lack of surplus energy, suffices of itself to make many
+people understand the necessity for {300} effort in the matter and to
+give them a strong suggestion as to probable relief of their symptoms.
+The following tables are the best-known averages for men and women:
+
+ADJUSTED TABLE OF WEIGHTS FOR INSURED WOMEN, BASED ON 58,855 ACCEPTED LIVES
+
+         15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Combined
+                                                                     Ages
+4' 11"   111   113   115   117   119   119   122   125   128   126   118
+5'  0"   113   114   117   119   122   122   125   128   130   129   120
+5'  1"   115   116   118   121   124   124   128   131   133   132   122
+5'  2"   117   118   120   123   127   127   132   134   137   136   125
+5'  3"   120   122   124   127   131   131   135   138   141   140   128
+5'  4"   123   125   127   130   134   134   138   142   145   144   131
+5'  5"   125   128   131   135   139   139   143   147   149   148   135
+5'  6"   128   132   135   139   143   143   146   151   153   152   139
+5'  7"   132   135   139   143   147   147   150   154   157   155   143
+5'  8"   136   140   143   147   151   151   155   158   161   160   147
+5'  9"   140   144   147   151   155   155   159   163   166   165   151
+5' 10"   144   147   151   155   159   159   163   167   170   169   155
+Combined 123   126   129   132   136   136   139   142   145   142   133
+Heights
+
+
+The average shoes of the average woman will raise her about 1-1/2 to 1-3/4
+inches.
+
+
+DR. SHEPHERD'S TABLE OF HEIGHT AND WEIGHT FOR MEN AT DIFFERENT AGES
+
+        15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
+
+5'  0'  120   125   128   131   133   134   134   134   131
+5'  1'  122   126   129   131   134   136   136   136   134
+5'  2'  124   128   131   133   136   138   138   138   137
+5'  3'  127   131   134   136   139   141   141   141   140   140
+5'  4'  131   135   138   140   143   144   145   145   144   143
+5'  5'  134   138   141   143   146   147   149   149   148   147
+5'  6'  138   142   145   147   150   151   153   153   153   151
+5'  7'  142   147   150   152   155   156   158   158   158   156
+5'  8'  146   151   154   157   160   161   163   163   163   162
+5'  9'  150   155   159   162   165   166   167   168   168   168
+5' 10'  154   159   164   167   170   171   172   173   174   174
+5' 11'  159   164   169   173   175   177   177   178   180   180
+6'  0'  165   170   175   179   180   183   182   183   185   185
+6'  1'  170   177   181   185   186   189   188   189   189   189
+6'  2'  176   184   188   192   194   196   194   194   192   192
+6'  3'  181   190   195   200   203   204   201   198
+
+
+
+Correction of Underweight.--Underweight is undesirable for many
+reasons, and gain in weight is often the solution of many problems in
+ill feeling. It is well to bear in mind that most patients who are
+under weight can be made to gain in weight by an appeal to their
+reason and by proper directions and care in seeing that those
+directions are carried out. Patients have told me that they could not
+eat more and yet I have been able to persuade them that they must eat
+more, and they have done so. Anyone who has much to do with
+tuberculous patients knows that utter repugnance for food can be
+overcome by will-power, when it is once made clear to the patient that
+they {301} must eat if they want to live. The most interesting event
+in the process is that with the increase in the amount of food taken,
+instead of the appetite becoming more and more satiated, as patients
+are likely to anticipate, and instead of the repugnance for food
+growing, the appetite grows stronger, and the repugnance gradually
+disappears. There is only one way to gain in weight; that is by eating
+more than one has been accustomed to eat. Persons who are twenty
+pounds under weight ought easily to gain three pounds a week, half a
+pound a day, if seriously intent on doing so, but in order to do this
+they will probably have to increase the amount they eat by double this
+quantity. That means that a solid additional pound of food, quite
+apart from the watery elements of the food, must be taken every day.
+
+In the correction of under-weight details are all-important. Patients
+must be given specific directions as to what and how much of the
+various foods they should take. With regard to supposed idiosyncrasies
+against such nutritious substances as eggs, milk and butter, enough is
+said elsewhere to make it clear that, as a rule, these are merely pet
+notions, beginning in some unfortunate incident and cherished until
+they have become a mental persuasion strong enough to disturb the
+digestion of these substances. What is true for quality of food is
+true also for quantity. People must be made to understand that the
+amount of food is to be increased. The results attained by this method
+are well worth the efforts required for it. Of course, the bitter
+tonics, especially strychnin and cinchona, will do much to help. Just
+as soon as patients begin to gain in weight many of their neurotic
+symptoms leave them. Their tired feelings are no longer complained of
+and when they are up to normal weight they are quite other
+individuals, both in good humor and efficiency.
+
+If for years patients have been eating less than they should, then
+they will have discomfort when they begin to eat more. They will have
+no more discomfort, however, than would be occasioned if they took
+more exercise than they had been accustomed to. The stomach and
+intestines must be gradually accustomed to the new task of disposing
+of more food. Unfortunately, the usual impression among these patients
+is that discomfort in the abdominal region, by which they mean any
+sense of fullness, proceeds from indigestion, and indigestion
+signifies developing dyspepsia with all the horrors that are supposed
+to go with it. In reality the slight discomfort which comes from
+increased eating is usually not manifest whenever the patients are
+occupied with something reasonably interesting. After a time the
+organs will become accustomed to it, and then the discomfort will
+cease.
+
+
+_Nervous Patients_.--One of the strongest suggestions that we have in
+our power for thin nervous patients, suffering from many and various
+ills, is to have them gain in weight. Many of them will be found to be
+distinctly under weight for their height. They insist that they cannot
+eat more, that they are eating as much as they care to, and that they
+have no appetite, that when they eat more they have discomfort, etc.
+It must be made clear to them that their one easy road to health is to
+gain in weight. If they are under weight this makes a very definite
+purpose to put before their minds. The objection so often urged, that
+they come from a thin family, must not be listened to. The unalterable
+purpose to make them gain in weight must be insisted upon. If they can
+be made to eat more than they have been {302} eating before, they will
+surely gain in weight. To see themselves gaining in weight is a daily
+renewal of the suggestion that they will be better when they get up to
+their normal weight. It is much better than electricity or the rest
+cure, or anything else that I know; it is perfectly natural and, above
+all, because it may be made an auto-suggestion, it does not leave the
+patient after a time dependent on anyone else.
+
+
+
+CHAPTER X
+
+VAGUE ABDOMINAL DISCOMFORTS--LOOSE KIDNEY
+
+
+After the vague pains around joints so commonly called rheumatic, and
+which occur so frequently that probably there is no one over forty who
+is quite ready to confess that he has not had rheumatism, the most
+important source of vague discomfort is the abdominal region. This
+occurs particularly in people who are engaged in a sedentary
+occupation which prevents much exercise, keeps them indoors, and gives
+them abundant opportunity as a rule for introspection and dwelling
+upon their sensations. There are few people who live the intellectual
+life who have not suffered from some of this abdominal discomfort,
+which they presumed must mean some definite lesion, or portend some
+serious development, and yet, as a rule, they have lived for years
+afterward without any of their fears proving true.
+
+Physicians are not spared from this source of worry and discomfort.
+They suffer from it even a little more than others. Their knowledge of
+the possibilities of serious pathological developments within the
+abdomen, especially after the age of forty, makes them a little more
+concerned as to the significance of these vague discomforts.
+
+At least half a dozen times a year, for the last ten years, I have
+heard physicians say that they were sure that some organ or other
+within was not performing its function properly, and that there was
+probably some organic lesion. The thought has usually been in their
+minds for months, sometimes for years, and they have come to be
+thoroughly examined. Sometimes they rather expect to be told that they
+should go to a surgeon. They are usually half concealing a question as
+to how soon they should set about putting their affairs to rights and
+how serious the outlook is. As a rule, I am able to dismiss them
+without any further treatment than the injunction not to think so
+persistently about certain obscure feelings which they are allowing to
+occupy their consciousness. Sometimes I know they take the
+advice--even oftener, perhaps, I know they do not. Once it has got
+hold of us, it is hard to get away from morbid introspection, and I
+sometimes hear of them consulting others. All of these patients are
+improved for a time after their consultation by the reassurance that
+so long as they have a good appetite--which is the case with all of
+them--and their bowels are regular--which unfortunately is not the
+case with most of them--and so long as they sleep well and have no
+acute pain, there is little likelihood of any serious latent abdominal
+condition.
+
+Such reassurance cannot be given until the abdominal region is
+carefully palpated, and especially the right side explored as
+thoroughly as possible. {303} Here lies the appendix, the head of the
+colon, which is sometimes the seat of trouble not necessarily
+originating in the appendix. Just above them one may find a loose
+kidney, for the right kidney is more likely to be movable than the
+left, because of the overhanging liver, and finally the gall-bladder,
+and the bile passages, so likely to be the seat of serious trouble. If
+none of these organs are tender on deep palpation, if the kidney does
+not come down when the patient is examined in the standing position,
+if there are no serious derangements of digestion, except such as can
+be attributed to nervous indigestion, and if there is no dilatation of
+the stomach, and no enlargement of the spleen, there is no reason why
+one should do anything but try to get the patient's mind off himself.
+
+There is always the danger of overlooking an abdominal cancer, in
+these eases, though with the care in diagnosis I have suggested this
+is minimal. The best therapeutic test that I know to determine this,
+if there should be any doubt, is to put the patient on an increased
+diet and watch the scales. If he is able to digest the added food
+well, and without trouble, and if he proceeds promptly to gain in
+weight, there is much less than one chance in a hundred that he is the
+subject of latent cancer in the abdominal region. The old farmer's
+maxim is: "A sick hog don't get fat." When human beings properly
+respond to increased feeding, it is probable, not only that there is
+nothing serious the matter with them, but that the symptoms of which
+they complained before may very likely have been due to lack of
+nutrition. The digestive organs not having enough to occupy them, were
+tempted to digest themselves, or at least to have their function
+disturbed by the short circuiting of nervous energy looking for
+something to do.
+
+I have seen a number of these cases that had been operated on for
+vague discomfort--some whose appendices had been removed, some whose
+kidneys had been fastened up because they were slightly movable, some
+whose gall passages had been examined for adhesions that were supposed
+to exist, or perhaps for a stone that it was thought might be found
+there, and except where some actual organic lesion was found and
+relieved, none of them was materially improved when seen several years
+after operation. I have heard reports of cures of these cases by
+surgeons who felt that the removal of an appendix presumed to show a
+catarrhal process, or a hyperemia, or an adhesion at its tip, had
+meant the cure of vague abdominal discomfort which had continued for
+many years and made the patient profoundly miserable. But these
+reports were founded on the patient's condition at the end of
+convalescence after the operation, and not on the condition that
+established itself some months, or perhaps a year, later. Operations
+on the abdomen, except for very definite indications, have, in my
+experience, always done more harm than good, and I have seen serious
+conditions--hernia, displacement of organs and disturbance of the
+peristalsis of the intestines--develop subsequent to them.
+
+I have in mind two typical cases. One was a physician whom I had seen
+on a number of occasions, and who complained of vague discomfort,
+mainly in the right side of the abdomen, though never acute, never
+accompanied by fever, nor even by any disturbance of pulse when he was
+not in an excitable mood. His bowels were not always regular, and he
+had had some disturbance of circulation as the result of thrombosis of
+veins on that side after an {304} attack of typhoid fever. My opinion
+was that his discomfort was entirely due to the disturbance of
+circulation. There was probably some interference with the normal full
+circulation to the large intestine, in its ascending portion, that
+gave him a feeling of uneasiness, or of consciousness of its function.
+Eventually he became convinced that he was suffering from a chronic
+form of appendicitis. After considerable persuasion he convinced a
+surgeon friend that his appendix should be removed, and the operation
+was done. I saw his appendix afterwards. It was supposed to be
+thickened, but considering the normal limits of size of the appendix,
+I could not think that it was beyond them in any marked way. At most
+there was but a slight catarrhal inflammation.
+
+For a time after operation he was much improved. He felt confident
+that all his trouble has disappeared, and he took some pains to
+impress me with the supposed fact that in these vague cases of
+discomfort there was always some underlying organic lesion that needed
+surgical treatment. During convalescence he had gained in weight, and
+was looking very well. When I met him a year and a half later he said
+that some of his discomfort had returned. He had grown thinner and was
+feeling discouraged. Six months later he was about to submit to
+another operation, this time for the breaking up of adhesions in the
+neighborhood of his gall-bladder. He had become convinced that this
+must be the seat of the difficulty. After this operation he was sure,
+beyond peradventure, that his trouble was gone never to return. Two
+years later I found him preparing to have his right kidney sewed up. I
+had known that his right kidney was slightly movable, but it did not
+move sufficiently to cause any disturbance of kidney function, and
+certainly not enough to justify serious surgical intervention.
+
+After this operation I met him once casually and he assured me that
+now everything was surely all right. I have since heard that he
+submitted to an operation either for the breaking up of some adhesions
+around his stomach or in order to tuck up that organ for ptosis. It
+had not been quite decided whether an adhesion caused a slight
+hour-glass constriction of the stomach, with some dilatation of the
+splenic end of the fundus, or whether there had been some actual
+sagging. I am sure that after this operation, as after preceding ones,
+with the strong suggestion that he ought to be better and an increase
+of weight during convalescence, he lost his vague abdominal discomfort
+for a time, though I have no doubt that it either has or will return.
+When he gets something to so occupy his mind that he does not dwell
+too much on his discomfort, he will not increase it to the extent that
+makes it intolerable. Then he will remember that most people have some
+discomfort, and he will learn to distract his mind, rather than allow
+it to dwell on the thought of his particular ailment until it becomes
+intolerable.
+
+It has taken twelve years or more to develop this case to the point
+where it is as instructive as it now is, and it is a typical example
+of what may happen even to a physician. There are other cases in my
+notes that are quite as instructive, two of them occurring in
+thoroughly educated men, clergymen who were of good intellectual
+capacity, but who became too much occupied with themselves. One of
+these had more operations done on him than my friend the physician. He
+first had his appendix removed, and was better for a time. Then his
+kidney was fastened up, and improvement once more took place. After
+this he lost in weight considerably and suffered so much {305} from
+headaches that a friendly surgeon suggested that there must be
+adhesions between his dura and his brain. Accordingly a trephining was
+done, and these adhesions, real or supposed, were broken up. For a
+time he seemed to be better. Then he had some urinary trouble. A long
+prepuce, though one that was never tight or adherent, and only
+required a little attention to cleanliness to keep it from giving
+bother, was removed. Some disturbance of his appetite led him to limit
+his eating for a time, and then he suffered from constipation. This
+was diagnosed by a specialist in rectal troubles as due to abnormally
+developed valves in his rectum, and these were cut. He still
+complained very much of abdominal discomfort at times. This was
+diagnosed as ptosis of his organs, and an operation was done to tuck
+these up. After this he developed a large ventral hernia, which had to
+be relieved by a subsequent operation.
+
+I had followed the case carefully during many years, seeing him at
+times, and I was always opposed to the idea of operation and fully
+confident that none of the operations were really needed. He could not
+be persuaded that what his case needed most was occupation of mind
+with something besides his condition. Whenever I could persuade him of
+this I had seen him gain in weight, get into much better spirits and
+be almost able to take up his work again. Then he would become
+discouraged, and before long I would hear of another operation that
+was planned, or was about to be performed. During the course of one of
+his many progressive losses in weight as a consequence of depression
+of mind, he developed tuberculosis. He resisted this very well, but
+eventually died rather suddenly of an empyema. A careful autopsy
+showed nothing but the traces of former operations, and no reason why
+they should have been done.
+
+Another case: A friend, also a clergyman, had three operations done,
+one of them circumcision, the second an appendectomy and the third on
+a supposed floating kidney. None were indicated, so far as I could
+see, by any definite symptoms, or justified by his condition. He had
+vague abdominal discomfort, and this continued to bother him in spite
+of treatment by various specialists, and his mind became so much
+occupied with it that he was ready to submit to anything in order to
+be rid of his burden of discomfort. At no time was it an ache, nor did
+he ever speak of it as a pain. He had some tendency to dilatation of
+the stomach and at times, when much occupied with indoor work and
+neglecting muscular exercise, there was probably some delay of
+digestion. His appetite was good whenever he would let it be; his
+bowels were regular whenever he was eating sufficient to stimulate
+them to normal function; he slept well, except when unnerved by
+something, but the presence of this abdominal discomfort disturbed
+most of his waking hours. He could stand it so far as it had gone, but
+he was sure that it would become so much worse in the future that it
+would be unbearable. He dreaded that cancer or some other awful
+development would come after a time.
+
+As a matter of fact, the main portion of the discomfort in these cases
+is the dread of what may happen. It is a dread, just as misophobia or
+claustrophobia or acrophobia or any of the other dreads that we
+discuss in the chapter on that subject. The constant occupation with
+this dread apparently inhibits to some degree the flow of nerve
+impulses to the abdominal organs, and digestion, already disturbed, is
+still more impaired. Indeed, the whole {306} of the discomfort seems
+to be a consciousness of stomach and intestinal function rather than
+anything more serious. The stomach will take two or three pounds or
+even more of mingled liquids and solids at a meal and pass them on to
+the intestines without forcing itself into the field of our
+consciousness. Anyone who is aware what a thin-walled membranous bag
+the human stomach is--what it most nearly resembles is perhaps the
+familiar bladder of the cow--may well be surprised that, though it is
+supplied with many sensitive nerves, it gives so little sign of the
+load that is often placed in it. It may, however, be brought rather
+poignantly into the sphere of consciousness by concentration of
+attention on it.
+
+The intestines function usually with the same lack of reflex. They
+proceed to pass on this quantity of food, store up two or three days'
+rations, digest what is nutritious and eliminate what must be
+rejected, without rising into consciousness. If either stomach or
+intestines once begin to attract attention, then it will be difficult,
+unless care is exercised to distract the mind from them, to replace
+and keep them back in the sphere of the unconscious once more.
+Peristaltic movements are constantly taking place in the digestive
+tract. Various things may interfere with peristalsis, and the
+disturbance of it will almost surely cause some sensation. It may not
+be serious, and digestive processes may continue, yet there may be
+discomfort. If there is delay in the passage of food, gas accumulates
+in the stomach, presses up against the diaphragm and interferes with
+the heart action. This will give rise to many bothersome sensations,
+some of which are felt in the heart region itself; others much lower
+down on the left side, where it is rather hard to recognize just what
+the real seat of them may be. A good deal of the abdominal discomfort
+of which people complain, is due to such functional disturbances,
+emphasized by the fact that digestive action has come into the sphere
+of consciousness and now attention is being concentrated on it, to the
+detriment of digestion itself, as well as to the increase of the
+annoyance which the discomfort may occasion.
+
+Operations for abdominal discomfort are quite contra-indicated, unless
+there are very definite localizing symptoms of some pathological
+lesion that can surely be relieved by operative intervention. To
+operate on general principles is sure to emphasize the patient's
+concentration of attention on his abdominal discomfort, if it does not
+relieve it, and in most of these cases it utterly fails. The strong
+suggestion of an operation will relieve for the time being, just as
+operations for epilepsy seemed to relieve when that procedure was
+first introduced, though now, unless there are definite localizing
+signs, there is no question of such an operation.
+
+
+Toxic Factors.--_Tea_.--A very interesting phase of abdominal
+discomfort seems to be associated with the taking of nerve stimulants.
+I have frequently found that patients who complained of vague
+abdominal uneasiness, sometimes rising particularly at night to the
+height of colicky feelings but always on the left side, were indulging
+to excess in tea or coffee. In one case, a woman was taking, she
+thought, about a dozen cups of tea a day. Just how much more than this
+she actually was taking I do not know, for it is almost incredible the
+amount of tea that middle-aged women who are alone may take. I once
+found by actual count made for me, that a woman was taking almost a
+score of cups of tea in each twenty-four hours.
+
+{307}
+
+Just as soon as there is a reduction in the amount of tea taken in
+these cases, relief is afforded the patient. This relief will not,
+however, be absolutely satisfactory because the craving for the tea
+stimulation makes the patients irritable, and it takes but very little
+to cause them to complain that they still have their old discomfort.
+In the course of three or four days they realize that the root of the
+trouble has been reached. If the discomfort has continued for a good
+while, a sort of habit seems to be formed, and the attention of the
+mind gives a sense of uneasiness, if not discomfort, in the left
+abdominal region. Usually it is in the upper left quadrant and seems
+to be stomachic in origin. The discomfort is apparently due to the
+presence of air, or gas, which is not properly expelled because of
+some lack of co-ordination of muscles, and then the warmth of a room
+or of the bed at night, or the presence of some slightly irritant
+substance makes the discomfort more noticeable. In the patient's
+over-stimulated condition, there is inability to withstand it
+patiently. In none of these cases is there a fever, though in all
+there is some disturbance of the pulse as if the heart's action were
+interfered with and the organ resented it.
+
+
+_Coffee_.--In some cases the same vague abdominal discomfort occurs as
+a consequence of taking too much coffee. This is seen in men more than
+in women. The tea topers are nearly all women, though my attention was
+first called to this vague discomfort, that made life miserable for a
+tea tester, who spent most of his day tasting tea, though drinking
+very little of it. With regard to coffee, individual idiosyncrasy is
+an extremely important matter. Some men seem to be able to take five,
+six or even more cups of coffee in the day without inconvenience; some
+cannot take even a small cup of coffee after six o'clock at night
+without being kept awake for several hours; others cannot take a large
+cup of coffee in the morning without having considerable discomfort,
+which is usually attributed to indigestion. I have known large, strong
+men, who were much better for not taking any coffee, or at the most a
+tablespoonful of it in a cup of milk in the morning to satisfy the
+taste.
+
+
+Loose Kidney.--Movable kidney is responsible for many of these cases
+of abdominal discomfort. Where it exists to a marked degree it may be
+relieved by operation. It occurs much more frequently in women than in
+men because, for physiological reasons, the kidneys are normally more
+movable in women and this is particularly true of the right kidney,
+which would otherwise perhaps be injured by pressure between the
+pregnant uterus and the liver. It is probable that many of the cases
+of the kidney of pregnancy are really due to an abnormal fixity of the
+kidney to a particular place, so that the growing uterus interferes by
+pressure with its circulation and its function. Slight movability of
+the kidney, then, should not be considered pathological.
+
+I have seen a number of these cases. They seem to occur particularly
+in women who have lost weight. The fat around the kidney is somewhat
+absorbed during the course of loss in weight, and this leaves this
+organ more movable and also less protected and consequently more
+liable to irritation. One sees it rather frequently in many unmarried
+women who have some strenuous occupation. Many of these young women
+come back from their vacation at the end of the summer having gained
+fifteen or twenty pounds in weight. If there has been any kidney
+sensitiveness or movability before, {308} both have usually
+disappeared. The kidney is well held in place because there is much
+more fat within the abdomen, all the organs are better cushioned, yet
+without any interference with their function.
+
+During the course of the year these patients, school-teachers,
+stenographers, and daily workers of various kinds, lose in weight.
+When they have lost ten pounds the kidney begins to be sensitive again
+and somewhat movable. By the time they have lost fifteen to twenty
+pounds there is serious complaint in the right upper quadrant of their
+abdomen extending at times over toward the navel, and the kidney
+becomes quite movable. At this time the treatment must consist in
+holding the kidney as firmly in place as possible, for dragging
+downward will be followed by reflex symptoms in the stomach and
+intestines. Disinclination to food, loss of appetite, and even the
+occurrence of some nausea, as well as some constipation, are easily
+traced to kidney reflexes. During the night there is no trouble,
+because while the patient is lying down the kidney falls into its
+proper position. On arising in the morning the kidney drops down out
+of place. If a corset is put on at this time the kidney may be forced
+still further out of place, giving rise, after a couple of hours, to
+considerable discomfort. New shoes can be borne at first, but after a
+time the pressure they produce shuts off circulation and causes
+intolerable discomfort. To a less degree this happens to the kidney if
+thus compressed and this explains the course of symptoms in many
+cases.
+
+
+_Mechanical Treatment_.--If the corset is adjusted before the patient
+rises, and fits reasonably snugly, but not too tight, the contents of
+the abdomen will all be kept in place, and the kidney will maintain
+its normal position. When the corset is not sufficient to retain the
+kidney in place, a simple pad, a towel or a napkin or, if there is
+much sensitiveness, something more elaborate, especially adapted to
+conditions, can be placed over the kidney, and when held firmly by the
+corset will keep the kidney in its place. At first the kidney is
+usually sensitive to this on account of having been pressed upon
+during the preceding weeks or months. The patient must bear some
+little inconvenience at first, must get accustomed to the new
+conditions in which the kidney is kept in place, and must not expect
+complete relief at once. Any improvement must be considered a step
+forward, and further amelioration can be confidently promised. As in
+all other cases of the use of apparatus or mechanical
+aids--spectacles, false teeth or crutches--the patient must be content
+to grow used to the new order of things, before expecting satisfying
+relief.
+
+This is the palliative treatment. The natural treatment of many of
+these cases is to have the patient maintain such weight as will hold
+the kidney in place, because of the fat within the abdomen, without
+any necessity for external aids. This can be done more readily than is
+often thought to be possible. These patients insist that they lose
+their appetite when they settle down to work, but what they really
+lose is the habit of eating a definite amount at stated intervals.
+Very often it will be found that breakfast, which they took abundant
+time to eat during vacation, is rushed. The luncheon suffers in the
+same way and is small in quantity. They take only one good meal, and
+one good meal is not sufficient to maintain normal weight.
+
+
+_Question of Operation_.--When a kidney is so movable as to deserve
+the adjective "floating," so that it moves considerably from its place
+and, perhaps, even sags and may be felt in the subumbilical region, it
+should be fastened up {309} by surgical means. There is a choice
+between two evils. The fastening of the kidney in the loin does not
+restore the normal condition, but puts it in an artificial condition.
+The kidney supports are of such a kind that it was evidently meant to
+be slightly movable. When it is fastened firmly in the loin, it is
+likely to feel every jar, and certain post-operative cases that I have
+seen, in which firm adhesions had supposedly taken place, complained
+considerably of the discomfort occasioned by this. In a certain number
+of cases, even after the operation, the kidney is still somewhat
+movable, because the adhesions yield and some of the old distress
+returns. All this must be realized before there is any question of an
+operation. There must be not merely a little discomfort, but enough of
+actual ache and of reflex disturbance that can be traced directly to
+the kidney to warrant the operation.
+
+No floating kidney should be operated upon in a patient who has lost
+much in weight and has developed a sensitiveness of the kidney since
+the reduction of weight. Definite efforts should first be made to
+bring about increase in weight, so as to see whether this will not
+restore the previous condition of reasonable comfort. At times it is
+said that the disturbance of the stomach, that is reflex to such a
+floating kidney, prevents the patient from taking and assimilating
+enough food to restore normal weight. This will be true if attention
+has been called to the condition very seriously, and if the patient is
+persuaded that this is the reason why there is no appetite and poor
+digestion. Ordinary palliative measures, such as a binder, or a
+specially made corset, will be sufficient to prevent the kidney from
+producing reflex disturbance of the stomach, and will exert a strong
+suggestion to this effect under the influence of which the patient
+will usually gain in weight.
+
+
+_Intermittent Discomfort_.--The discomfort that comes with a loose
+kidney may be quite intermittent. I have known patients to be bothered
+by it for months, and then quite free from it for several years, only
+to have their discomfort renewed so that they become quite worried.
+Some definite local or mechanical condition can generally be found for
+these variations in feeling.
+
+In thin people a jolting ride over a rough road or stepping off a car
+will occasionally be the beginning of the trouble, and as this also is
+likely to cause a stone in the kidney to give its first
+manifestations, there may be serious suspicion of a more grave
+pathological condition than is really present. If this discomfort
+continues only the X-ray can absolutely decide the question.
+
+Once the mechanical conditions which cause the discomfort are
+understood by the patient, the actual ache becomes much more easy to
+bear. Apprehension makes it almost intolerable. Attention exaggerates
+it, and makes diversion of mind difficult. Understanding helps all the
+conditions and lessens the pain, not actually but mentally, until
+after a time very little attention is paid to it.
+
+
+{310}
+
+SECTION VII
+
+_CARDIOTHERAPY_
+
+
+CHAPTER I
+
+THE HEART AND MENTAL INFLUENCE
+
+
+The heart is an organ so vitally important that we might expect it to
+be carefully protected by nature from any interference with its action
+through mental influence, emotional conditions, or voluntary or
+involuntary feelings. As a matter of fact, it is extremely susceptible
+to mental influence, stimulant or depressive, and to emotions of all
+kinds. Psychotherapy, that is, the removal of inhibiting influences
+originating in the mind, and the suggestion of favorable mental
+influences, is probably more important for the heart than for any
+other organ in the body. The law of reserve energy has its most
+noteworthy applications with regard to it. When we are apparently so
+completely fatigued that we cannot do anything more, a purely mental
+stimulus may so enliven the heart as to give the body a new supply of
+strength and energy. A man wandering through a desert, or swimming for
+his life at sea, may be so exhausted as to be quite ready to give up
+entirely, and be brought to the conviction that he has absolutely no
+strength left for further effort, when a flash in the distance, or a
+sound that indicates that help is near, or some other mental
+incitement, will give renewed energy. It is probably through the heart
+that there comes to us most of our power to accomplish things when we
+are already so tired as to seem exhausted. On the other hand, it is
+the failure of circulation in muscles, because of a slacking heart,
+that produces the sense of exhaustion. Muscular work is easy or even
+pleasant when we are in good spirits, while, whenever exertion is
+undertaken in the midst of discouragement, we cannot accomplish nearly
+so much as when conditions are so framed as to give stimulus and
+encouragement.
+
+If a perfectly normal heart can be so affected by mental conditions
+and emotions as to be seriously disturbed in its work on the one hand,
+or greatly stimulated into new activity on the other, it is to be
+expected that a heart affected by disease will be similarly affected
+and probably even to a greater degree. It is clear, then, that our
+cardiac patients have to be guarded against unfavorable mental
+conditions, and have to have all their reserve energy called out for
+them by encouragement and by the best possible prognosis for their
+reflection. This is especially true as regards the removal of the many
+unfavorable suggestions which, because of ignorance, have in the past
+gathered round most forms of heart disease.
+
+{311}
+
+Emotion and the Heart.--The mental and emotional influence over the
+heart's action was the truth that lay at the basis of the old fallacy
+with regard to the physiology of the heart. The literature of all
+countries testifies that the heart was long supposed to be the seat
+and origin of the emotions. Every one has experienced how the heart
+jumps when something unexpected happens. People have fainted from
+excess of joy as well as of grief. The physical side of emotion is so
+generally associated with some modification of the heart beat that it
+is no wonder that emotions were directly connected with the organ.
+When people are in depressed states the heart is apt to beat more
+slowly than usual, while when in states of exhilaration, even those
+dependent merely on mental factors, the pulse is more rapid.
+Melancholic states have occasionally been attributed to the slowness
+of the pulse, but the slow pulse seems to be a symptom connected with
+the mental condition rather than a causative factor. In the maniacal
+conditions, the rapidity of the pulse, which is sometimes quite
+marked, must probably be explained in the same way, as due to the
+mental excitement under which the patient is laboring.
+
+
+The Heart and the Nervous System.--Prof. Von Leyden ten years ago
+recalled attention to the fact that the heart is literally the _primum
+movens_ in man, and that before the central nervous system is laid
+down, or there is any possible question of impulses flowing from
+center to periphery, the heart, or at least its embryonic
+representative, is beating as constantly, regularly, rhythmically, as
+it is to do during all the subsequent life of the individual. Oliver
+Wendell Holmes has expressed it poetically by stating that the angel
+of life sets this heart pendulum going and only the angel of death can
+break into the case and stop it.
+
+
+_Primitive Heart Action_.--The original beating of the heart is
+entirely automatic, and quite apart from any nervous initiative or
+stimulus. The original bend in the primal blood vessel, which is to
+represent the heart in the course of development, begins to pulsate
+very early in the chick and evidently does the same thing in all other
+living things. Notwithstanding this fact that the heart is thus easily
+demonstrated to be the _primum movens_, the first exhibitor of
+vitality, and might thus seem to be one of the organs or indeed the
+one which should be safe from any nervous interference, later on
+powerful connections with the nervous system are made, and heart
+acceleration and inhibition become familiar phenomena. Every emotion,
+as we have said, has its influence on the heart and even a certain
+amount of voluntary control may be acquired. Indian fakirs are said to
+be able to cause the heart to slow and almost to stop. The curious
+phenomenon of suspended animation which they sometimes exhibit is said
+to be due to this. Certain of the well-developed muscular subjects who
+exhibit themselves at medical clinics are able to cause their hearts
+to miss a beat, but this is said to be rather a result of will-power
+over other muscles compressing the thorax, and interfering with the
+heart, than direct influence upon the heart itself.
+
+
+Mental Influence over Diseased Hearts.--Worry produces much more
+serious symptoms in heart patients than in others. Anxiety about the
+heart itself is often a source of serious detriment to a heart
+patient. Most people have such a terror of having anything the matter
+with their hearts that the haunting thought of such calamity is likely
+to have a definite influence in preventing the development of such
+compensation as will enable the heart to {312} do its work to the best
+advantage. It used to be the custom to refrain from telling patients
+suffering from tuberculosis that they had the disease. On the other
+hand, people with heart disease were usually informed of that fact.
+The reason given for the latter course was that heart disease may in
+many cases be the forerunner of sudden death, and the warning
+knowledge was supposed to enable a man to get his affairs in order. No
+worse policy for either disease could well have been imagined. The
+pulmonary patient should be told at once, the heart patient should, as
+far as possible, be saved the depressing knowledge of his condition.
+
+Dr. MacKenzie, whose practically illuminating studies of heart disease
+give him a right to express opinions with regard to it (and when those
+opinions concern the influence of the mind they are doubly valuable
+because of the absolute objectivity of his studies), has some rather
+strong expressions with regard to the importance of modifying the
+mental state in heart cases. He says:
+
+  The consciousness of heart trouble has often a depressing effect on
+  people, whether the trouble be slight or serious. When such people
+  become convinced that the trouble is curable or not serious, their
+  condition at once becomes greatly improved. Cures by faith, whether
+  in drugs, baths, elaborate methods or religion, act by playing upon
+  the mental condition. But our employment of this element in
+  treatment should not be the outcome of blind unreasoning faith in
+  some rite or ceremony, bath or drug, but in the intelligent
+  perception of the nature of the symptoms. The reassurance of the
+  patient of the harmless nature of the complaint goes a great way in
+  curing him. The reassurance that with reasonable care no danger need
+  be feared is extremely helpful. Even in serious cases when there is
+  reasonable hope of recovery or a certain degree of recovery, the
+  encouragement of the patient may and does help forward his
+  improvement.
+
+
+Heart Remedies and Suggestion.--Probably the best evidence we have for
+the influence of the mind over the heart in diseased conditions, that
+is, when there is definite organic change in the heart valves or
+muscle, is to be found in the history of the many remedies that have
+come and gone in heart therapeutics during the past generation.
+Strophanthus, for instance, was very popular a quarter of a century
+ago, and it seems as though in many cases it not only replaced, but
+was more efficient than digitalis. How few there are who use it now
+with confidence, and how general is the impression that it does not
+affect the heart to any extent! The confidence with which the remedy
+was given by the physician was conveyed to the patient and he "took
+heart," as the expression is, and proceeded to get better. Even more
+striking is the evidence afforded by other remedies. For a while it
+seemed that cactus provided a heart stimulant and regulator of value.
+Convalaria also gained a reputation as a heart remedy. Both are now
+practically abandoned. Here, once more, the real remedy, when these
+substances were employed, was, undoubtedly, the suggestion to the
+patient in connection with the regulation of his habits of life, so
+that his heart got a chance to catch up with its work. There are other
+remedies with which we had similar experiences.
+
+Even digitalis has had phases of confidence and distrust in it, that
+are interesting to study in the light of what we now know with regard
+to the influence of the psyche on the heart. One hears at medical
+society meetings reports of the favorable action of digitalis within a
+few hours of its administration. These are not examples of digitalis
+action, but of mental influence. {313} Any heart patient after the
+first visit of a physician in whom he has confidence is sure to
+brighten up at once, heart action is ever so much better and symptoms
+of mental depression, and even of circulatory disturbance, disappear.
+It is this that has made the study of even the efficiency of digitalis
+so difficult. There were times when most physicians employed it in
+rather large quantities for all forms of heart disease. In some heart
+cases it is absolutely contra-indicated. Fortunately many of the
+preparations of digitalis used in the past were quite inert, and so no
+harm was done. The results obtained were psychotherapeutic.
+
+
+Cardiac Inhibition.--The importance of the role of the nervous system
+and of the mental influences which control it in all functions is well
+illustrated by what we have learned during the last half century with
+regard to inhibition in the animal organism. We used to think that
+while the nervous system sent down positive impulses--that is, nervous
+stimuli which brought about the accomplishment of certain
+activities--it had nothing to do with the stoppage of those
+activities. Such interference was supposed always to be due to
+external influences of various kinds, potent for the time, in the
+organism. We have learned, however, that inhibition is one of the
+important functions of the nervous system. The idea has now become so
+familiar that sometimes we are apt to forget how great is its
+significance. Lauder Brunton, in his article on "Inhibition," set
+forth its role as we have come to know it.
+
+  The recognition of the part inhibition plays in vital phenomena is
+  undoubtedly one of the most important discoveries which have been
+  made in physiology since Harvey discovered the circulation of the
+  blood. It throws light upon an immense number of phenomena
+  previously inexplicable and enables us to form theories of a
+  satisfactory nature about many vital problems. It offers an
+  explanation of the nature of hypnotic states, which is at least as
+  satisfactory as that we have of the action of many drugs.
+
+  The nervous mechanism of the heart affords the best and most
+  commonly cited example of inhibitory action, and here it was first
+  studied by Weber and Claude Bernard in 1848. The cardiac ganglia
+  derived from the sympathetic preside over the movements of the
+  organ, and in response to the stimulus of the intra-ventricular
+  blood-pressure cause rhythmical contraction of the cavities. Their
+  action is, however, controlled by the pneumogastric nerve, through
+  which impulses of an inhibitory nature are constantly traveling and
+  acting as a restraining force.
+
+As noted by Lauder Brunton, the late Professor Czermak had a small
+glandular tumor in close contact with the right pneumogastric nerve
+and he was able by pressure on this to compress the nerve to any
+extent he wished, and either "to completely stop the heart or simply
+retard it." He often performed this experiment so that it is not
+nearly so dangerous as might be thought. We have some instances,
+apparently too well authenticated to be doubted, in which the power of
+the human will to inhibit heart action has been as strikingly
+manifested as this mechanical disturbance of Professor Czermak.
+Sometimes these stories of cardiac inhibition through the will are
+dismissed as unworthy of credence, and doubtless many of them are mere
+fiction, or have been exaggerated for sensational purposes, but some
+of them are very suggestive examples of the power of the will over the
+heart. If only a modicum of such power were to be employed, it would
+seriously hamper heart action, and it must be the aim of psychotherapy
+to prevent such inhibition.
+
+{314}
+
+At least one instance of voluntary heart inhibition was observed by
+thoroughly trained and properly accredited scientists. A report of it
+has been published. As a bit of documentary evidence, on a subject
+that is usually considered so vague as to be scarcely worth
+considering, Dr. Cheyne's description of the remarkable power of
+Colonel Tonshend over his heart should be in the hands of those who
+wish to influence hearts through minds and wills.
+
+  He could die or expire when he pleased, and yet by an effort, or
+  somehow, he could come to life again. . . . We all three felt his
+  pulse first: it was distinct, though small and thready, and his
+  heart had its usual beating. He composed himself upon his back and
+  lay in a still posture for some time. While I held his right hand.
+  Dr. Baynard laid his hand upon his heart, and Mr. Skrine held a
+  clean looking-glass to his mouth. I found his pulse sink gradually
+  till at last I could not feel any, by the most exact and nice touch;
+  Dr. Baynard could not feel the least motion in the heart, nor Mr.
+  Skrine discern the least soil of breath on the bright mirror. Then
+  each of us by turns examined his arm, heart and breath, but could
+  not by the nicest scrutiny, discover the least symptom of life in
+  him. We reasoned a long time about this odd appearance, and finding
+  he still continued in that position, we began to conclude that he
+  had indeed carried the experiment too far; and at last we were
+  satisfied that he was already dead, and were just ready to leave
+  him. This continued about half an hour. . . . As we were going away
+  we perceived some motion about the body, and, upon examination,
+  found his pulse and the motion of his heart gradually returning; he
+  began to breathe heavily and speak softly.
+
+Nor must it be thought that the inhibitory faculty can act only in
+slowing the heart. Normally a certain amount of inhibition is
+exercised over the heart's action. If by any chance this should be
+decreased then acceleration of cardiac activity may take place. Lauder
+Brunton called attention to that in discussing another phase of
+pneumogastric function. He said:
+
+  Paralysis of the pneumogastric, of course, does away with its
+  action. And hence we have among other symptoms of this condition
+  increased rapidity of the contractions of the heart from withdrawal
+  of the inhibitory influence.
+
+If slowing of the heart action can be produced through the mind by
+this mechanism of inhibition, so also under other circumstances may
+acceleration occur.
+
+
+Shock and the Heart--How large a role emotion plays in disturbing the
+action of a heart that is already diseased, is illustrated by the
+story told in serious histories, on what seems good authority, of the
+dwarf of the French king, who was frightened to death by what he
+thought were the arrangements for his execution. While we take great
+pains as a rule to impress upon sufferers from organic heart disease
+the necessity for their avoiding every kind of over-exertion, or
+sudden movement of any kind, we do not always impress upon them the
+even greater necessity for the avoidance of shock and fright, and
+profound emotions. It must not be thought that emotional shocks have a
+deleterious effect only in advanced cases of heart trouble. Almost any
+physician will readily recall examples where emotion had much to do
+with the break in compensation which indicates that the heart has for
+a time been overworked.
+
+A case in my own experience illustrates this: The patient, a student,
+had suffered from severe so-called growing pains, undoubtedly
+rheumatic, when he was about fourteen, and probably had acquired a
+heart lesion at that time. {315} It did not, however, disturb him in
+the slightest degree. The patient had never noticed any fatigue on
+running up stairs; he had no shortness of breath; there were no
+symptoms pointing to his heart. One summer while his family were in
+the country he came into town for the day, and missing the last train
+out, he went to the family home to sleep, though it had been closed up
+for the summer. He let himself in without difficulty and was preparing
+to go to bed when he resolved to get a glass of water. There being no
+tumbler nearer than the dining-room, he went there. As he entered the
+dining-room he struck a match. With the flash of the light he found
+himself looking into the barrel of a revolver and a hoarse voice said,
+"Hands up!" His hands went up. The next minute he was in the hands of
+two "plain clothes" policemen who had been watching the neighborhood
+because of recent burglaries. Noticing the light upstairs, they had
+made their way in for the purpose of catching what they thought a
+burglar at work.
+
+The young fellow, who had never before fainted, collapsed almost at
+once, and was unconscious for some minutes. The next day he was rather
+prostrated and tired on movement. By resting a good deal for the next
+week this passed off to a considerable degree, but then his physician
+found that he was suffering from a serious heart lesion, with a
+decided break in compensation. I saw him several months later. His
+heart had never regained its old power, and his mitral valve was quite
+unable to fulfill its function. Just what the mechanism of the almost
+sudden break in compensation was after he had been for so long quite
+immune from any effects of the rheumatism, is hard to say, but the
+lesson of the case is easy to understand.
+
+
+Place of Psychotherapy in Treatment.--The role of psychotherapy, then,
+in heart cases consists in the recognition of the part that the mind,
+the will and the emotions play in their influence over this important
+organ. These psychic factors may produce disturbed conditions of
+various kinds. The more experience the physician has with cardiac
+cases of all kinds, organic as well as functional, the more powerful
+does he recognize the influence of the mind over the heart to be. The
+expression that a man is living on his will is no mere figure of
+speech. Some cases we have cited seem to show that a favorable
+attitude of mind keeps up heart action, where an unfavorable attitude
+would almost surely allow the heart to fail. It is this very potent
+influence then that must be used to as great advantage as possible in
+the psychotherapy of cardiac patients.
+
+Undoubtedly the most important phase of it is in prophylaxis. As far
+as possible we must save our heart patients from emotions. The effect
+of emotion on the heart is known. When that organ is already crippled,
+emotion may produce a serious strain on it. It is as important to save
+heart patients from joyful emotions as from those of contrary nature.
+Many a son who, after years of absence, thought to surprise a dear old
+mother by suddenly presenting himself to her, has learned to his cost
+that an old heart may break from joy, almost as easily as from sorrow,
+and may be as unfavorably affected by the glad emotions as by terror
+or fright. We must also save heart patients from the unfavorable
+influence of a bad prognosis, and of too serious a diagnosis, both of
+which may be quite unjustified, for the rule is that the longer a man
+has been studying the heart, the less likely is he to be confident in
+his diagnosis, or unfavorable in his prognosis.
+
+{316}
+
+The curative place of psychotherapy is in the obtaining, as far as
+possible, of placid easy lives for these patients. This does not mean
+that they are to give up their occupations, for very often the
+internal emotional life, which develops when they have nothing to do
+but think about themselves, will be more serious in its effect upon
+the heart than the ordinary vocation. Exciting incidents in life work
+must, however, be avoided. If men are in occupations that require
+exposure to excitement, then it may be advisable to change their
+occupations. Brokers, speculators, actors, sometimes public speakers,
+on whom appearances in public in spite of apparent placidity are often
+a severe strain, may have to be guided into quieter paths of life. In
+general, in every attempt to treat heart disease, and the neurotic
+symptoms which develop in connection with it, the patient's mind must
+be considered as one of the most important therapeutic factors.
+
+
+
+CHAPTER II
+
+DIAGNOSIS AND PROGNOSIS IN HEART DISEASE
+
+
+The more carefully heart disease, and particularly individual patients
+affected by various heart lesions, have been studied in recent years
+the more it has come to be appreciated that the most important element
+in the treatment of organic heart disease is the definite recognition
+of the difficulty of exact diagnosis of most cardiac conditions and
+the unfortunate tendency to make the prognosis worse than it really
+is. Many heart affections are quite compatible with long life. In the
+past both of these problems of diagnosis and prognosis have been only
+too often solved unfavorably to the patient, to the serious detriment
+of his power of physical reaction against the ailment. Many a patient
+has been seriously disturbed and even his power of compensation
+lessened by having a diagnosis of an organic affection of the heart
+made with the usual prognosis, or at least strong suggestion of early
+death that goes with it, when there was no justification for such an
+unfavorable opinion.
+
+
+Mental Attitude of Patient.--We do not pretend to cure tuberculosis,
+but we do relieve its symptoms and bring about a remission in the
+progress with a shutting in of the lesions. In heart disease something
+of the same kind can very often be accomplished. This does not mean
+that in advanced cases of heart disease much good can be accomplished
+any more than in advanced cases of tuberculosis, though in both a
+change of the mental attitude may lift the patient from what seems
+almost a death-bed into renewed activity for a prolonged period.
+Probably heart disease is more serious in its prognosis than
+tuberculosis, yet undoubtedly the lives of many patients could be
+prolonged nearly as much as in the pulmonary affection and a large
+amount of suffering saved through mental influence. We do not hesitate
+to change the occupation and the place of abode of the patient
+suffering from tuberculosis. There is even greater reason for doing
+this same thing when it seems advisable with patients suffering from
+heart disease.
+
+With regard to heart disease, the best authorities are now agreed that
+it is better, as a rule, not to tell the patient himself unless it is
+absolutely {317} necessary to do so in order to get him to take the
+precautions that will prevent further deterioration of his cardiac
+condition. The depression incident to the knowledge that one has a
+serious heart lesion is not reacted against, and especially not during
+a threatening break in compensation, and a more favorable time must be
+waited for to reveal his condition to him. The danger of sudden death
+in valvular heart disease is much less than is popularly supposed.
+Only sufferers from aortic heart disease are likely to die without
+warning, and this form of the disease is comparatively rare. The death
+of the patient suffering from mitral disease is likely to be
+lingering. Mitral disease is the commonest form of heart disease, and
+the prognosis of it in ordinary cases is by no means so grave as is
+usually supposed. I have seen a patient still alive with a mitral
+murmur who told the story of having had his affection originally
+diagnosed as mitral regurgitation by Skoda, the distinguished Vienna
+diagnostician, over forty years before. This patient at the time I saw
+him was nearly seventy years of age, still had the mitral murmur, but
+his apex beat was scarcely if at all displaced and there was neither
+enlargement of the ventricle nor apparently any degeneration of the
+auricle.
+
+
+The Apex Beat and Heart Murmurs.--In this regard an expression of
+Prof. Carl Gerhardt of Berlin deserves to be recalled. That
+distinguished clinician used to say that if the apex beat was not
+displaced there was no good reason for thinking that any heart
+affection which might be present was serious enough to require active
+treatment. Heart murmurs have been made entirely of too much
+significance and any man of considerable experience is likely to have
+seen a number of patients who, because they had a heart murmur, had
+been seriously and needlessly disturbed by having a physician tell
+them that they had heart disease, with an air of finality that seemed
+to the patients to say that they might prepare for the worst very
+soon. Patients suffering from diseased hearts have to care specially
+for themselves, but not to the extent of living such maimed lives as
+is likely to be the case if they are depressed by an unfortunate
+exaggeration of the seriousness of their condition.
+
+Our best authorities in* heart disease have at all times proclaimed
+their uncertainty as to the diagnosis of heart conditions from
+murmurs, while mediocre men of comparatively slight experience have
+not hesitated to declare their certainty in this difficult matter. It
+is not an unusual thing to hear of a supposed expert having declared
+upon the witness stand and under oath that he could tell whether a man
+had heart disease by _listening_ to his heart, and some have even gone
+the length of making their decisions in this matter while listening
+for a few moments sometimes even above the clothing of the patient!
+Needless to say, this is quite unjustifiable in our present knowledge
+of the status of heart affections and only men of small experience and
+over-confidence in themselves make any such declarations. The more
+experience a physician has had in heart disease, the more careful he
+is not to make positive declarations. One or two examinations may very
+easily be deceptive unless there are signs quite apart from those in
+the heart itself. Indeed, it is much more the state of the individual
+than the state of the heart itself, or anything that can be found out
+about it, except after a prolonged and repeated study, that enables us
+to make definite decisions. Probably no one during the nineteenth
+century had studied hearts more carefully than Prof. William Stokes,
+whose books on the subject were so widely read. He wrote:
+
+{318}
+
+  We read that a murmur with a first sound, under certain
+  circumstances, indicates lesion of the mitral valves. And again,
+  that a murmur with the second sound has this or that value. All this
+  may be very true, but is it always easy to determine which of the
+  sounds is the first, and which is the second? Every candid observer
+  must answer this question in the negative. In certain cases of
+  weakened hearts acting rapidly and irregularly, it is often scarcely
+  possible to determine the point. Again, even where the pulsations of
+  the heart are not much increased in rapidity, it sometimes, when a
+  loud murmur exists, becomes difficult to say with which sound the
+  murmur is associated. The murmur may mask not only the sound with
+  which it is properly synchronous, but also that with which it has no
+  connection, so that in some cases even of regularly acting hearts,
+  with a distinct systolic pulse, and the back stroke with the second
+  sound, nothing is to be heard but one loud murmur.
+
+  So great is the difficulty in some cases, that we cannot resist
+  altering our opinions from day to day as to which is the first and
+  which the second sound.
+
+  To the inexperienced the detailed descriptions of such phenomena as
+  the intensification of the sounds of the pulmonary valves; of
+  constrictive murmurs as distinguished from non-constrictive; of
+  associations of different murmurs at the opposite sides of the
+  heart; of pre-systolic and post-systolic, pre-diastolic and
+  post-diastolic murmurs, act injuriously--first, by conveying the
+  idea that the separate existence of these phenomena is certain, and
+  that their diagnostic value is established; and secondly, by
+  diverting attention from the great object, which--it cannot be too
+  often repeated--is to ascertain if the murmur proceeds from an
+  organic cause; and again, to determine the vital and physical state
+  of the cavities of the heart. . . .
+
+There are too many cases in which murmurs have no such serious
+significance as was often attributed to them when first studied, and
+yet it used to be almost a universal custom among physicians, and the
+custom still obtains with many, to tell a patient rather emphatically
+whenever a heart murmur was present, that he had heart disease. Above
+all, too much significance has been ascribed to murmurs in initial
+cases of heart disease and these are just the cases that should not be
+disturbed by unfavorable suggestion. The louder the murmur the less
+likelihood there is of there being heart disease in the ordinarily
+accepted sense of the term, that is, that the heart is so affected as
+to be incapable of doing its work properly, for where loud murmurs are
+present this is almost never the case. A murmur that may be heard a
+foot distant is usually associated with perfect compensation.
+
+If this were remembered by those who examine hearts generally, there
+would be much less disturbance of heart action by unfavorable mental
+influence. A great many more who are suffering from certain
+symptomatic conditions of the heart not surely or necessarily
+dependent on organic lesions, are plunged into depression by
+unfortunate, premature or exaggerated expressions on the part of their
+physicians. It is almost a rule to have men and even women patients
+say that it makes no difference to them, that they should be told the
+exact truth as to what their condition is. The future has been
+mercifully hidden from us in most things and there is no doubt that
+this plan is the better for human comfort and accomplishment
+generally.
+
+The truth is not easy to find and oftener in these cases lies on the
+side of favorable prognosis and refusal to think the worst than the
+opposite. In this there has been a great difference between the German
+and the Irish schools of medicine. The three great Irish physicians,
+Graves, Stokes and Corrigan, insisted on the place of the individual
+and upon how much depends upon the general conditions in pulmonary and
+cardiac disease. Our teaching in {319} America in this matter has come
+not from the conservative British schools of medicine, but from the
+German school, and that has had a notable tendency to exaggerate the
+significance of heart signs over the general condition.
+
+What a great distinction there is between this mode of looking at
+these diseases and the German method was pointed out by Prof. Lindwurm
+of Munich, when he translated Prof. Stokes' work on the heart into
+German. Prof. Lindwurm said:
+
+  Thus our modern German works are to a greater or lesser extent only
+  treatises on the physical diagnosis of organic affections of the
+  heart. Stokes, on the contrary, resists this one-sided tendency
+  which bases the diagnosis solely on physical signs and disregards
+  the all-important vital phenomena; he lays less weight on the
+  differential diagnosis of lesions on the several valves and on the
+  situation of a sound than on the condition of the heart in general,
+  and especially on the question as to whether a murmur is organic or
+  inorganic, and whether the disease itself is organic or functional.
+
+
+Broadbent on Cardiac Diagnosis.--What Stokes taught the
+English-speaking world so emphatically in the first half of the
+nineteenth century Sir William Broadbent was just as insistent about
+in the latter half. It is evident, then, that clinical experience has
+not changed its viewpoint in these matters in spite of all our study
+of the heart in the interval. In his paper on "The Conduct of the
+Heart in the Face of Difficulties" he has many suggestions that will
+prevent the physician of less experience from taking too pessimistic a
+view of heart symptoms. He said:
+
+  Moreover, the heart has very special relations with the nervous
+  system; it reflects every emotion, beats high with courage, is
+  palsied by fear, throbs rapidly and violently with excitement, and
+  acts feebly under nervous depression; but it is not only through the
+  cerebro-spinal system that the heart is influenced, it is in
+  immediate relation with the vasomotor nervous apparatus, and in a
+  scarcely less degree with the sympathetic system generally.
+  Normally, afferent impulses are constantly flowing from the viscera
+  to the central nervous system and by this reflex process their blood
+  supply is regulated, and their functional activity is governed.
+  These afferent impulses when perverted by functional derangement or
+  disease may become serious disturbing influences.
+
+  The nervous system in a large and increasing proportion of people is
+  unduly sensitive and excessively mobile, and the reactions to
+  influences of every kind are exaggerated. In some a little emotional
+  excitement gives rise to palpitation, and a piece of bad news or the
+  bang of a door seems to stop the heart altogether. _There is in such
+  subjects no form or degree of cardiac disease which may not he
+  simulated_. [Italics ours.] Add a touch of hysteria on the lookout
+  for symptoms and for someone to give ear to the narration of the
+  unparalleled agonies of the sufferer, and the difficulties of the
+  heart, and it may be added of dealing with them, are complete.
+
+
+Typical Case.--We are prone to think that after the age of seventy the
+existence of definite heart murmurs with some tendency to blueness of
+the lips and of the fingers, with coldness of the hands, surely
+indicates the presence of a serious heart lesion. It is in old people,
+however, that such symptoms may be most deceptive. The outcome may
+prove that physical signs ordinarily presumed to be surely indicative
+of organic disease may be only signs of functional disorder, or at
+most may represent certain organic affections for which even the old
+heart is thoroughly capable of compensation. One such instance in my
+own experience is so striking that I venture to give it in detail.
+
+{320}
+
+This was the case of an old physician friend of some eighty years of
+age. His son had a summer lodge in the Adirondacks. Though for some
+sixty years the father had been living at the sea level in New York
+almost constantly, he went up to visit the son and be with his
+grandchildren at an elevation of nearly 2,500 feet. His heart began to
+bother him almost at once and he could not go up or down stairs or
+take any exercise without considerable discomfort, marked shortness of
+breath and a tendency to palpitation that was almost alarming. He
+continued his stay for several months in the hope that he would get
+used to the altitude, though there were always difficulties of
+circulation manifested by blue lips and finger nails. He returned to
+New York and placed himself under the care of a heart specialist who
+found what appeared to be evident signs of heart deterioration of
+muscular character complicated by valvular lesions. He consoled, the
+old gentleman by the reflection that a heart that had served his
+purposes so well for eighty years could not really be complained of if
+now it should show some signs of deterioration. He also insisted that
+any mental work would be almost sure to be injurious because of the
+calls upon the circulation that it would make.
+
+The old gentleman was ordered South for the following winter with an
+absolute prohibition of any mental work. He had planned to revise an
+historical work on which he had been engaged for many years and which
+had served to keep him in good health perhaps more than anything else.
+This was put away entirely and he proceeded to try to get well doing
+nothing. Almost needless to say with nothing to do he did not get
+well. He had been an extremely busy man all his life, had worked at
+least twelve to fourteen hours a day for most of the preceding fifty
+years, and for him to do nothing would be quite as impossible as for a
+child to be kept in utter physical inactivity. His heart palpitation
+continued and grew worse. He was waked up at night by starts that
+seriously disturbed him and usually kept him from sleep for hours. As
+he said himself, after he had read the morning paper and gone to
+stool, there was nothing else for him to do all day except eat and
+sleep, and these incidents had never occupied any of his attention in
+the past. In spite of the doctor's orders he had his manuscript sent
+to him and proceeded to work. At once he began to grow better. At the
+end of three months he was feeling better than he had felt for several
+years. When I saw him, about his eighty-first birthday, he was looking
+better than he had for some time.
+
+As he said himself in describing his case, his own experience had
+taught him that the more fuss a heart made the less likelihood was
+there of its having anything serious the matter with it, at least of
+such a character as would terminate life suddenly or unexpectedly. The
+serious heart lesions are those which give no symptoms, or but very
+slight ones, and the sudden deaths in heart disease usually come from
+the development of insidious symptoms that do not betray themselves to
+the patient until the fatal termination is on them. The more the
+patient himself has been disturbed by his heart, the less likelihood
+is there of its giving out suddenly. The subjective symptoms are
+usually due to the fact that the heart is actively overcoming external
+interference, or resenting over-attention to it in its work. Certain
+it is, that the neglect of it, so far as that is consonant with
+reasonably regular life, is the very best thing and the most important
+part of any prescription given for symptomatic heart disease, whether
+organic or functional, is to forget it just as far as possible.
+
+{321}
+
+Heart Symptoms in the Young.--In young people particularly it is
+important not to suggest the possibility of heart disease until there
+are definite signs in the circulation apart from the heart which place
+the diagnosis beyond all doubt. The psychotherapeutics of organic
+heart disease that is most important is that of prophylaxis. Patients'
+minds must be guarded as far as possible against disturbance from the
+thought that they have heart disease, for this of itself adds a new
+factor which tends to disturb compensation and adds to the heart's
+labor because worry interferes with the vasomotor mechanism. In this
+matter it seems advisable to repeat once more that there must be a
+complete reversal of the customs that have existed until now with
+regard to tuberculosis and heart disease. Consumptives have from the
+very nature of their disease a tendency to hopefulness which soon
+brings about a favorable reaction against the bad news, but heart
+patients derive no advantage from the announcement and, indeed, if
+they are of the nervous, worrying kind, the effect of it is likely to
+be cumulative. A week after being told the worst a consumptive has
+reacted vigorously and hopefully, and if he has a fair share of
+immunity, the scare will do good by making him take the precautions
+necessary to increase his resistive vitality. At the end of the same
+time a heart patient will be just realizing all the significance of
+the unfavorable diagnosis and prognosis of his case.
+
+It may be urged that heart patients by knowing their condition will be
+preserved better from injuring themselves by over-exertion, but what
+we have said elsewhere about the value of exercise in the treatment of
+heart cases shows how much patients may be injured by having their
+exercise too much reduced and their activity inhibited by the dread
+consequent upon the announcement made to them. It is perfectly easy to
+insist with them that they shall not do sudden things, or take violent
+exercise, or overdo activity, without disturbing them by the dread
+words "heart disease."
+
+
+
+CHAPTER III
+
+CARDIAC NEUROSES
+
+
+If, as all the authorities recognize, the attitude of mind toward
+organic heart disease is extremely important and when favorable is a
+most helpful therapeutic factor, it is easy to understand that in
+neurotic conditions of the heart this is of even more significance.
+The term "heart disease" is bound up with so many unfortunate and
+persistently unfavorable suggestions that it seems advisable not to
+use it with regard to non-organic conditions, even though it may be
+associated with the epithets functional or neurotic. For these the
+term cardiac neuroses, which avoids the implication of heart disease
+in the ordinary sense, seems preferable. Many of the cardiac neuroses
+are quite trifling. Many of them endure for years without producing
+any serious effect or disturbance of the general health. Many
+functional disturbances of the heart action which are extremely
+annoying may disappear entirely with judicious regulation of life. The
+one important condition in all of these cases is to be sure that the
+patient does not worry over the condition, for that {322} hampers
+heart activity and leads to functional disturbances of other organs
+which make the heart's work harder.
+
+
+Varieties.--There are many forms of cardiac neuroses. Indeed,
+functional heart affections are so individual that it is hard to
+classify them. In every case it is extremely important to study the
+individual and recognize just what are the special factors bringing
+about the disturbance of heart action.
+
+
+_Palpitation_.--In a certain number of the cases it will be found,
+indeed, that there is no real disturbance, but that in some way the
+heart action has been brought above the threshold of consciousness and
+has become noticeable to the patient. It must not be forgotten that
+the heart is an intensely active organ. Several gallons of blood are
+pumped through it every minute and yet it accomplishes its work, as a
+rule, with such noiseless, frictionless regularity that most people
+know nothing about it. When the action of the heart becomes conscious,
+it is usually spoken of as palpitation. Patients are sure to think
+that this must mean serious over-action, though, as a rule, no sign of
+over-action or at most a slight exaggeration of the muscular sounds of
+the heart will be found.
+
+
+_Missed Beats_.--A further stage of this cardiac neurosis is the
+missing of beats. This occurs particularly in those whose attention
+has been directed for some time to their heart action by the presence
+of palpitation. It may be due to nothing more than this
+over-concentration of attention. It may be due, however, to mechanical
+disturbances, an over-distended stomach, constipation, or certain
+nervous factors.
+
+
+_Arrhythmia_.--A third stage of cardiac neuroses consists of
+irregularity of the heart action, in which not only are the beats
+missed occasionally, but there may be certain heart sounds much less
+vigorous than others and the spaces between the sounds may be very
+unequal. This condition is usually said to be due to some serious
+condition of the heart muscles, and undoubtedly it often is. There is
+no doubt, however, that great irregularity of the heart may occur
+entirely as a neurotic condition without any organic affection and
+from factors quite extraneous to the heart itself.
+
+
+Etiology.--There are three causative conditions for cardiac neuroses
+that deserve careful study and that can be very much modified by
+changing the attitude of the patient's mind toward his condition. The
+first of these is an over-attention to self such as is particularly
+induced by a life without much exercise and devoted to things
+intellectual. The direct causation is probably intimately connected
+with the second etiological factor in the production of cardiac
+neuroses. This consists of an absence of sufficient exercise for the
+heart itself, when it actually seems to disturb its own activity
+because adequate calls for exertion are not made on it to use up
+accumulated energy. Cardiac neuroses are seen particularly in those
+who having had considerable exercise in earlier years, have settled
+down to a sedentary life in which there are few calls made upon their
+muscular system. The third etiological factor is the most important.
+It is due to cardiac disturbance from the stomach and intestinal
+tract; this will be discussed in a separate chapter.
+
+
+Prognosis.--The prognosis in cardiac neuroses is always worse in the
+patient's mind than it ought to be. If then the physician shows that
+he is uncertain as to the real significance of the affection, some
+hint of this uncertainty will be communicated to the patient with
+resultant unfavorable suggestion. The {323} more carefully neurotic
+heart affections have been studied, the better the prognosis becomes.
+Morgagni in the olden time, Stokes and Corrigan in the early
+nineteenth century, Broadbent and MacKenzie in our time, have all
+emphasized the necessity for favorable prognosis. Even extreme
+irregularity is quite compatible with long life without any symptoms
+of serious circulatory disturbance. MacKenzie has, in his very careful
+studies of heart action, shown that extra systoles may cause marked
+irregularity in many forms without warranting unfavorable prognosis.
+
+Arrhythmia may begin in comparatively early life, persist in spite of
+treatment, and yet continue up to old age. Sir William Osler tells of
+the case of the late Chancellor Ferrier of McGill University who died
+at the age of eighty-seven after having exhibited an extremely
+irregular heart action for the last fifty years of his life. He has
+seen several other patients who have had heart irregularity for many
+years without the slightest disturbance of their general health. His
+experience is not uncommon, and probably every physician who sees many
+cases of heart disease can recall a few of them. Ten years ago I saw a
+man past seventy suffering from distinctly irregular heart action,
+though he gave the history of having had cardiac irregularity for some
+years at least, and he is still alive, past eighty, and with his heart
+irregularity still present. I have a patient over seventy whom I know
+to have had irregular heart action for fifteen years, and he himself
+is sure that it has been present since he was about forty, at least.
+It is cases of this kind, together with MacKenzie's recent studies of
+the subject, that must be before the physician's mind when he makes
+his prognosis for these patients. There must be no hesitancy about his
+declaration. Patients think that physicians are prone to deny the
+significance of heart trouble so as to avoid disturbing their
+patients. The slightest hesitation, then, will be surely looked upon
+as of ominous import.
+
+
+The Intellectual Life and Cardiac Palpitation.--It is curious how many
+people who give themselves to intellectual work and live an almost
+exclusively indoor life have subjective symptoms relating to their
+hearts. Many of the English literary men and women of the last century
+had complaints of this kind. Sir Walter Scott described very vividly
+his sensations as if his heart did not have room to accomplish its
+functions, and said that he used to feel within his chest a fluttering
+as if there were a bird there beating its wings against a cage too
+small for it. Other literary people have told of this sense of
+overfullness in the chest, as if somehow there were not room for all
+the organs. This discomfort is mainly referred to the precordial
+region. In oversensitive, nervous people it may be described as
+painful, though analysis of what they mean by the word pain will show
+that they have only a persistent feeling of pressure which is
+uncomfortable and gives a sense of crowdedness in that region rather
+than any genuine ache. Where the feeling is much dwelt on, however, it
+may be exaggerated into pain, as, indeed, will any sensation, however
+trivial, if attention is concentrated on it. On the other hand, in
+practically all of these cases, just as soon as the mind is strongly
+diverted by any pleasant occupation, the sense of discomfort
+disappears not to reappear again until the patient has time to think
+about himself.
+
+
+Heart Surveillance.--Prof. Oppenheim of Berlin has in his usual direct
+way expressed the power of the mind to influence the heart beat, and
+he does {324} not hesitate to say that certain nervous people who have
+been watching their hearts overmuch, and continually thinking about
+them, are capable of playing all sorts of tricks on themselves and
+sometimes even on their physicians, by this concentration of mind upon
+their heart and its action. Prof. Oppenheim in his "Letters to Nervous
+Patients," writing to a patient complaining of irregular heart action,
+says:
+
+  Whenever you succeed in controlling the action of your heart by
+  means of introspection, there flows from your brain to your heart a
+  current of innervation which disturbs the automatic movement of the
+  organ. You now know what you have to thank for the irregularity in
+  the action of your heart. I have frequently proved this to myself in
+  your case: if I succeeded in feeling your pulse without your
+  becoming aware of it, holding your attention by a conversation which
+  interested you, the action of your heart was always absolutely
+  regular. If, however, I tried it under your control, while your
+  attention was anxiously directed to your heart, its action at once
+  became irregular, and you experienced the very unpleasant sensation
+  of palpitation.
+
+
+Irritable Heart of Athletes.--A curiously interesting form of heart
+neuroses has appealed to me very much because I have suffered somewhat
+from it myself and owing to circumstances I think I have seen a larger
+number of patients suffering from it than usually come to a single
+individual. I refer to the tendency to irritability of the heart which
+is so marked in men who have been athletes when they were younger, and
+have taken a large amount of exercise during the years between fifteen
+and twenty-five. If these men later settle down to a sedentary life
+they almost inevitably suffer from a marked sense of discomfort in the
+precordial region because of palpitation, and are apparently much more
+liable than other people to have an intermittent pulse. Just what
+these symptoms are due to is not always easy to discover, and in
+different individuals there seem to be different accessory causes at
+work. I have seen it particularly in professional men who while at
+college have been on the teams and have played such hard games as
+handball, hockey on the ice, and the like. I do not refer only to
+those who have played an occasional game, but who every day of the
+college year have had some severe muscular exercise.
+
+Whether this irregularity of heart action has not at least been
+predisposed to by over-exertion remains to be determined. Strenuous
+athletics produce curious heart symptoms. Missed heart beats and
+irregular heart action and even leakages at the valves are not unusual
+even in the best of hearts after severe exertion. A careful
+examination of the hearts of those who took part in a Marathon run at
+Harvard some years ago showed that immediately after the race many of
+them were irregular and some of them had leakages at the mitral valve
+which lasted from one to twenty-four hours. These were probably due to
+irregularity in the action of the papillary muscles as a consequence
+of the fatigue. I had occasion to examine the hearts of some
+theatrical dancers a few years ago, immediately after they came off
+the stage. One of them is one of the most successful of modern dancers
+and is able to occupy the better part of an hour in the severest kind
+of exertion before an audience. Her heart was not only very rapid
+immediately after she left the stage, but there were missed beats and
+a distinct disturbance at the mitral valve. It was hard to determine
+absolutely, but the sounds at all the valves were impure and there
+{325} seemed to be imperfect closure or irregularity of action. In
+another case there was a regular missed beat at every sixth or seventh
+pulsation. This seemed to be due to an abortive systole. Usually
+within an hour regularity of heart action is restored and the valve
+sounds become normal. At times when the patient is run down for any
+reason, the cardiac disturbance may persist for many hours, or even
+until after long hours of sleep.
+
+The patients I have mentioned seem to have developed their muscles to
+a noteworthy degree and have enlarged and strengthened their hearts by
+this exercise. Later on their occupation in life prevents them from
+taking any severe exercise, or at least furnishes no opportunity for
+it, and they often settle down to existence that, beyond a short,
+quiet walk perhaps once a day, affords no exercise at all. Under these
+circumstances the muscular development that they secured as young men
+and which kept them in such magnificent health during their adolescent
+years seems to prove a positive detriment to good health, or at least
+to good feeling. The muscular system seems to crave to be kept up.
+Occasionally I have been sure that the intermittent heart action so
+often seen in these cases was due to the fact that the appetite, or as
+I should rather put it, the habit of eating, which they formed while
+they were accustomed to taking vigorous exercise, remains with them
+during their sedentary life and as a consequence they overeat,
+particularly of proteid food materials. The large consumption of these
+materials gives rise to the presence of substances in the blood which
+make all the muscles more irritable than usual, and this seems to add
+particularly to the irritability of the heart.
+
+
+_Dietetic Regulation_.--For many of these people a regulation of diet
+seems to be the best possible remedy. They must be made to eat less
+substantially, since they do not need the same amount of proteid
+material to make up for muscle waste, now that there is no longer the
+old use of muscles. Some of them become very heavy. These, however,
+are mainly individuals who, besides eating abundantly of proteids,
+also consume carbohydrates in large quantities. In these there is a
+distinct disturbance of digestion and a tendency to dilatation of the
+stomach with gas which interferes with the heart action and brings on
+the intermittent pulse so often seen in them. In a certain number,
+however, there are no accessory symptoms of indigestion, but the heart
+symptoms are most prominent.
+
+
+_Exercise_.--For these people the only real relief is afforded by a
+certain amount of exercise every day. They become ever so much more
+comfortable just as soon as their physician insists that they shall
+have an hour's walk at least every morning and every afternoon and
+that this walk shall be brisk and always have some definite purpose in
+it, so that there is no mere sauntering or delaying on the way. Most
+business men to whom this prescription of an hour's walk is given will
+reply that it is impossible. Most clergymen will say that their duties
+are such that they cannot arrange their hours for this purpose. As a
+rule, it is not difficult to show the business man, however, that if
+instead of riding to his business, he should walk every day, and this
+will probably only take twenty minutes to a half-hour longer than if
+he goes by trolley or even by automobile, this walk will provide him
+with a full hour of brisk exercise in the open air. The walk back from
+business will provide the other hour, whenever golf or some other
+diversion cannot be provided instead. In most cities men live from
+three to five miles away from their {326} business, and it is not too
+much to ask them to take this walk. The muscular clergyman must be
+made to understand that there shall be no trolley cars for his
+ordinary clerical calls, or at least that none are to be taken unless
+he has had his full two hours of brisk walk.
+
+There is always the fear in the patient's mind that exercise, by
+calling for heart exertion, is almost sure to make the condition
+worse. This fear of itself further hampers heart action. When exercise
+is first increased in those who have been living sedentary lives the
+heart action for a time is brought more and more into the sphere of
+consciousness and any irregularity that is present is likely to be
+emphasized. A little persistence, however, soon shows that what the
+heart actually was craving was the opportunity to expend some of its
+energy and it was this pent-up force that was disturbing its action.
+There is often the fear in physicians' minds lest the advising of
+exercise should really do harm to the patient. They fear the presence
+of perhaps a fatty condition, or of some obscure muscular condition,
+or of some other heart lesion not easy to detect, yet likely to
+produce serious symptoms. Stokes, who probably knew fatty heart
+disease better than anyone else in the nineteenth century, outlined
+his views of the therapy of it as follows:
+
+  In the present state of our knowledge the adoption of the following
+  principles in the management of a case of incipient fatty heart
+  disease seems justifiable:
+
+  We must train the patient gradually but steadily to the giving up of
+  all luxurious habits. He must adopt early hours, and pursue a system
+  of graduated muscular exercises; and it will often happen that,
+  after perseverance in this system, the patient will be enabled to
+  take an amount of exercise with pleasure and advantage, which at
+  first was totally impossible, owing to the difficulty of breathing
+  which followed exertion. This treatment by muscular exercise is
+  obviously more proper in younger persons than in those advanced in
+  life. The symptoms of debility of the heart are often removable by a
+  regulated course of gymnastics or by pedestrian exercise, even in
+  mountainous countries, such as Switzerland or the Highlands of
+  Scotland or Ireland. We may often observe in such persons the
+  occurrence of what is commonly known as "getting the second wind,"
+  that is to say, during the first period of the day, the patient
+  suffers from dyspnea and palpitation to an extreme degree, but by
+  persevering, without over-exertion, or after a short rest, he can
+  finish his day's work and even ascend high mountains with facility.
+  In those advanced in life, however, as has been remarked, the
+  frequent complications with atheromatous disease of the aorta, and
+  affections of the liver and lungs must make us more cautious in
+  recommending the course now specified.
+
+Perhaps the most important therapeutic suggestion which Sir William
+Broadbent has to make with regard to the cardiac conditions that have
+come to occupy much of the patient's attention is of a negative
+character. He says that "patients suffering from these functional
+derangements of the heart usually make them a pretext for avoiding
+exercise and often for taking stimulants or drugs, whereas exercise
+and fresh air are what they need. The best way to prevent the
+expenditure of superfluous energy on the part of the heart in the form
+of palpitation is to give it a fair amount of legitimate physiological
+work to do." Personally I have found that most of the cardiac tonics
+seem to do harm, in the sense of increasing the subjective symptoms,
+except in cases where the patient is run down in general health
+because of failure to take sufficient food, when strychnin seems to be
+of avail and in the shape of nux vomica acts as an appetizer as well
+as a heart tonic. Sir William Broadbent has warned particularly with
+regard to the use of alcohol in these cases. {327} Most patients find
+that for the moment palpitation is lessened by alcoholic stimulation.
+They pay for it afterwards, however, by an increased sense of
+discomfort that sometimes lasts for 24 hours or more. As Sir William
+Broadbent declared, "To relieve one attack of palpitation or fainting
+by alcohol is to invite another, while the terrible danger of dropping
+into alcoholism is incurred."
+
+Lest it should be thought that even Broadbent is a little
+old-fashioned and not quite to be trusted in the light of our
+present-day knowledge, and above all lest it might be feared that
+these older men made a better prognosis or emphasized the value of
+exercise more than is compatible with our recent discoveries in the
+physiology and pathology of the heart, it seems well to give
+MacKenzie's opinion of these cases in full. This is all the more
+important because, as I have said, the influence of German teaching
+has led to the formation of rather different opinions in America,
+especially among our younger physicians. Prof. Martius in this country
+in his lecture for the Harvey Society gave quite a serious prognosis
+for practically all heart irregularity. He almost went so far as to
+lay it down as a rule of diagnosis that whenever a heart beats
+irregularly there is something the matter with the heart muscle or
+good reason to suspect a myocardial lesion of some kind. MacKenzie's
+view is very different to this and he warns particularly against
+permitting the influence of an unfavorable attitude of mind on the
+part of these patients. He says:
+
+  The most serious thing about these cases is that the consciousness
+  of having an irregularity sometimes makes a patient introspective
+  and depressed. He keeps feeling his pulse, and communicates his
+  doleful tale whenever he find a sympathetic ear.
+
+  As the process which gives rise to it in elderly people is the same
+  as that which produces the tortuous temporal arteries, no more
+  significance should be attached to the one symptom than to the
+  other. I have followed cases for many years, and watched them pass
+  through seasons of sickness and of stress, and have seen no reason
+  to attach any serious import to this symptom. In rare instances the
+  heart, from being occasionally irregular, has after many years
+  become continuously irregular for short or long periods, and in a
+  few the permanent establishment of the nodal rhythm has been the
+  means of hastening the end. But this is infrequent, and in cases of
+  cardio-sclerosis has only happened in advanced life, and the patient
+  should on no account be frightened by being warned of the possible
+  occurrence of this unlikely contingency. In younger and neurotic
+  people I have never seen it lead to any bad results. It may appear
+  in serious affections of the heart, as in febrile complaints, but it
+  does not of itself add to the gravity of the condition, though I am
+  not sure that when due to an acute infection of the heart, as in
+  pneumonia and rheumatic fever, it may not be a sign of invasion of
+  the myocardium by the diseased process.
+
+  If the patient is aware of the irregularity, he should be assured
+  that there is no cause for alarm. It is useless to attempt to treat
+  the irregularity itself. If in other respects the patient is well,
+  then there is no need of any special treatment. If the patient be
+  suffering from conditions which seem to promote irregularity, such
+  as worry, fatigue, dyspepsia, the treatment should be devoted to the
+  removal of the predisposing cause. In people with temporary high
+  blood pressure, who show extra systoles, I find plenty of healthy
+  exercise in the open air specially beneficial, though until they get
+  trained, the extra systoles may at times become more frequent by the
+  exertion.
+
+This last remark of MacKenzie's is particularly important, for at the
+beginning of an attempt to relieve the symptoms by insisting on more
+{328} exercise, the patient is almost sure to be disturbed by this
+symptom of which he will often be conscious, and it takes a good deal
+of experience on the part of the physician to reassure him that
+because of the increased subjective symptoms at the beginning of the
+treatment by increased exertion, he may not be doing harm rather than
+good. As a rule, however, it is not long before the good results of
+the exercise treatment of these cases begin to make themselves felt
+and the patient is reassured. Regulated exercise of body and
+occupation of mind are the two important factors even in the treatment
+of organic heart disease. They are extremely important even in the
+cases with alarming heart symptoms that occur in the very old, once
+the acute symptoms have subsided. In all the functional heart
+affections exercise is the most important therapeutic resource we
+have. It would seem that in the course of muscular exercise some heart
+tonic was manufactured, which in all but the cases of absolutely
+failing hearts is the best possible therapeutic resource for the
+stimulation and steadying of the heart action. Such an internal
+secretion would not be surprising in the light of all that we have
+learned of the physiological nexus of organs in recent years.
+
+Many so-called cures for heart disease probably depend for their good
+effect much more on the graduated exercise that goes with them than on
+many of the other remedial measures, though it is these latter that
+are usually vaunted most highly. We all now recognize how little value
+there is in the Nauheim bath treatment for heart disease away from
+Nauheim itself. The reason is because the resisted movements of the
+early part of the cure and, above all, the graduated exercise of
+walking up the hills around Nauheim, which are such important parts of
+the treatment there, cannot be so well given with the baths at a
+distance.
+
+
+
+CHAPTER IV
+
+CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE
+
+
+Morgagni, whom Virchow greeted as the Father of Modern Pathology, made
+a careful study of the pulse and especially of its irregularities. He
+had learned from the most careful pathological studies that marked
+intermission and even more decided irregularity of the heart may be
+present in life, though there may be absolutely no organic affection
+of the heart itself, either of the valves or of the muscle,
+discoverable at autopsy. In his opinion the most frequent cause for
+such irregularity is flatulency and disturbance of digestion
+generally. He went still farther, however, and seems to have
+understood very well that constipation was often one of the most
+important links in the chain of causes leading up to such heart
+disturbance, itself either a cause or an effect of other digestive
+symptoms. This idea deserves to be borne in mind when there is
+question of the significance of heart symptoms. What Morgagni thus
+determined by precise studies in pathological anatomy had been
+clinically observed by many of the distinguished old-time
+practitioners of medicine, who knew the fatal tendencies of organic
+heart symptoms, yet recognized that many cardiac cases associated with
+gastric symptoms did not have an unfavorable prognosis.
+
+{329}
+
+In spite of the recognition of these conditions by old-time medical
+investigators, there has always been a tendency to fear that heart
+symptoms in these cases might be due to a cardiac affection. This has
+invariably been true for patients themselves to whom the heart
+disturbance became conscious, but has often made physicians hesitate
+as to the diagnosis and rendered their prognosis more unfavorable than
+is justified by actual knowledge.
+
+
+Gastro Cardiac Arrhythmia.--What may be called the gastro-intestinal
+cardiac neuroses usually run a typical course. As a rule, with young
+folks, the beginning of cardiac unrest is found in some stomachic
+symptoms. The distention of the stomach with gas is said to be a
+mechanical reason for interference with the heart action. Whether this
+is really gas that has formed within the stomach, or whether it is to
+a great extent, at least, gas which has been diffused from the vessels
+of the stomach walls in a disordered viscus, or in some cases at
+least, air which has been swallowed because of certain gaspy habits of
+neurotic individuals, is hard to determine. In many cases the absence
+of all odor of decomposition, or of any disagreeable taste, makes for
+serious doubt whether the substance is really due to fermentation.
+Certainly the changes that take place in food in the stomach during
+the course of an hour or two of digestion are not sufficient to
+account for the volume of gas that exerts pressure upon the gastric
+walls and is eructated in large mouthfuls. Fermentative processes are
+slow gas producers, as anyone with experience in the chemical
+laboratory knows.
+
+
+_Mechanical Cardiac Interference_.--Every physician has seen the young
+man who is sure that he has heart trouble when he is really suffering
+from indigestion. Many of the feelings of discomfort accompanied by
+palpitation and irregularity are really phenomena connected rather
+with the stomach than the heart itself. The reason for this is not
+always clear. In many cases there seems to be a mechanical
+interference with the heart's action. This is due to the presence of
+gas in the stomach pressing against the diaphragm. In many cases the
+distention of the stomach by a heavy meal, especially if the heart has
+been rendered sensitive by the taking of stimulants, will have the
+same effect. This is particularly noticeable if the patients lie down
+shortly after the meal, when there is distinct discomfort in the
+cardiac region and noticeable irregularity of the pulse.
+
+The most frequent phenomenon is a missed beat, or often simply a sense
+of discomfort in connection with the heart action that makes its
+beating very noticeable. This palpitation, as it is called, is usually
+entirely subjective. There is nothing abnormal in the sensation
+produced on the hand when the heart is palpated, nothing the most
+delicate finger can detect in the apex beat and nothing uniform in the
+change in the heart sounds produced in these cases. There is usually a
+somewhat over-excited action of the heart, but this is not
+characteristically revealed by either palpation or auscultation. The
+rhythm is interfered with, but the arrythmia affects only an
+occasional beat, usually rather regularly spaced, and does not
+interfere with the heart's rate nor with its action in any way. This
+represents the most familiar form of cardiac neurosis and may, of
+course, be due to such substances as tobacco, or coffee, or tea, where
+these are taken in excess. Excess is always a matter of individual
+idiosyncrasy.
+
+{330}
+
+_Cardiac Reflexes_.--It is thought by some that this heart
+irregularity and palpitation is a reflex action due to irritation of
+the gastric terminal filaments of the vagus nerve reflected back along
+this nerve and affecting the heart. The doctrine of reflexes is not as
+popular, however, as it was, but there can be no doubt of the fact
+that the vagus nerve has terminal filaments in all the large organs,
+yet is so extremely important to the heart that it has a definite
+physiological meaning and doubtless is meant to act in such a way as
+to stimulate the heart when these important organs are overloaded or
+are laboring in their functions, and, on the other hand, to depress it
+or at least to inhibit it somewhat, whenever there is a tendency to
+send too much blood to these parts. In any case, whether the positive
+factor in the production of the heart trouble be mechanical, as it
+surely often is, or whether it be reflex and due to the action upon
+the vagus, it must not be forgotten that in all cases where heart
+symptoms occur with considerable intervals of absolute freedom from
+them and with large subjective elements in the case, the relation of
+the stomach or the digestive organs in general to the heart may serve
+as their best explanation.
+
+
+_Gastric Dilatation_.--In dilatation of the stomach there is likely to
+be an associated tendency to a cardiac neurosis. Unfortunately, enough
+of these cases have not been followed up so as to be sure what the
+outcome is and whether there may not really have been some affection
+of the myocardium with a premature breakdown of the heart. As a
+consequence of the excessive irritation of the terminal filaments of
+the vagus nerve in the stomach wall, or because of the mechanical
+interference with the heart's action as a consequence of the dilated
+stomach pulling upon the esophagus and probably somewhat interfering
+with the action of the diaphragm, an irregularity of the heart action
+is established and a sense of discomfort in the precordia develops
+that is often very marked. These patients sometimes suffer from
+pseudo-angina and still more frequently from cardiac irregularity.
+This cardiac irregularity is sometimes quite marked, and yet in 24
+hours, as a consequence of the emptying of the stomach, will
+disappear, so that only slight intermittency remains, which eventually
+subsides. I have known a heart affected thus to be pronounced
+absolutely without any lesion when examined by a competent heart
+specialist within a month after it had been so irregular as to be
+quite alarming to both patient and physician.
+
+
+_Upward Distention_.--There is sometimes a tendency for the stomach to
+distend upward rather than to dilate downward and toward the left.
+Perhaps this is due to the fact that in certain individuals the
+gastric ligaments are much stronger and more unyielding than they are
+in others. One thing is sure--that there are great individual
+differences in these cases. In some that are without any demonstrable
+gastric dilatation, except that gastric tympany extends higher than
+usual, there is marked interference with the heart action. The
+physician needs to see these cases when they are so irregular that
+there would seem to be absolutely no doubt of the existence of a
+myocardial lesion and then to examine them some months afterwards when
+the stomach had been restored to good conditions, before he is able to
+realize how much interference with heart action is consonant with
+complete return in a comparatively short time to the normal, at least
+so far as heart function goes. This is a very different opinion from
+that held by many heart specialists and {331} especially certain
+German authorities, who insist that any irregularity of the heart must
+be considered as probably representing a muscular lesion; but the
+evidence of careful observers may be adduced in support of it, and it
+is an opinion that very much reassures the patients.
+
+
+Old-time Clinicians--Morgagni, Lancisi.--In this subject it has always
+seemed to me wise to recur to the opinions of some of the old-time
+clinicians who noted symptoms very carefully and studied out
+particularly the connection of symptoms with prognosis.
+
+
+_Morgagni_.--Morgagni, for instance, whose clinical remarks are always
+precious, said:
+
+  Now that mention is made of the intermission of the pulse which
+  approaches more nearly to the nature of an asphyxia than even its
+  slenderness or weakness (for what else is the intermission of the
+  pulse but a very short asphyxia, or what is an asphyxia but an
+  intermission which lasts very long?) the causes of this disorder in
+  the pulse are not to be passed over without examination in this
+  place, as the greater part of physicians are very greatly terrified
+  thereby, often with good reason, yet frequently without any; as when
+  there is some cause of it in the stomach or intestines, which may
+  even vanish away of itself, or be easily removed by the physician.
+  For in what manner a palpitation of the heart may sometimes be
+  brought on by flatus distending these parts, and again carried off
+  by the dissipation of such flatus, I have already said; and in the
+  same manner, or one not very dissimilar, it is also evident, that an
+  intermission of the pulse has sometimes generated, and gone off of
+  itself, in many whom I have known. At another time, in these very
+  same viscera, there is a matter which produces the same effect, by
+  irritating their nerves, with which you know how easily the nerves
+  of the heart consent. And this matter is sometimes of such a nature
+  that it may readily be prevented from harboring itself there. Thus I
+  remember, when I attended to the cure of a young girl who had a
+  fever, and an intermission of the pulse was added to the other
+  symptoms contrary to my expectations, I was not at all deterred from
+  giving such a medicine as I had before determined upon, that the
+  stomach and intestines might be well cleansed; and even that I gave
+  it so much the more boldly; and that on the same day after these
+  parts had been deterged, the pulse returned to its former standard.
+  But you will read even in the _Sepulchretum_ that Ballonius had not
+  only seen this disorder of the pulse, but also that of a languid and
+  small stroke, removed in the same manner. "According to the degrees
+  to which the purging was carried," says he, "the pulse was
+  restored." And, indeed, there is an intermission of the pulse, that
+  is of a far longer continuance as that with which Lancisi says he
+  had been troubled "for the space of six years"; yet if this
+  intermission should be, as it was in him, "from a consent with the
+  hypochondria," it may be entirely and perfectly taken away, by
+  perfectly restoring those parts.
+
+
+_Lancisi_.--Lancisi was another distinguished clinical observer who
+made special studies in neurotic heart disturbance. These studies are
+all the more interesting because he himself was a sufferer from this
+affection for many years. He was inclined to think that his heart
+intermittency was due to disturbance in his digestive organs and
+especially those lying in the upper part of the abdomen. He attributes
+it himself to sympathy with these and said that it came _ex
+hypochondriorum consensu_, as it were a reflex from his hypochondriac
+regions. As Lancisi lived to a pretty good age in spite of noting this
+symptom in early middle life, the significance of it will be well
+understood. It would be perfectly possible to gather a series of such
+cases from among the distinguished physicians of history, and as for
+our contemporaries and colleagues, at least one out of four of them
+will tell you that at some time he has suffered from an affection of
+this kind and has been much worried {332} about it, yet has recovered
+without incident and without any serious development.
+
+
+English Opinion.--The role of the stomach in disturbing the heart is
+only less important than that of the nervous system itself. Of course,
+individual peculiarities, as I have said, are extremely important.
+Some people seem to suffer very little cardiac disturbance from a
+distended stomach, while in others all sorts of heart affections may
+be simulated as the result of the mechanical interference with the
+heart action by the pushing up of the diaphragm. Sir William Broadbent
+in the article on "The Conduct of the Heart in the Face of
+Difficulties," already quoted from, does not hesitate to say that
+heart symptoms secondary to gastric disturbance probably cause more
+suffering than does actual heart disease. Expressions of this kind
+need to be borne in mind when we reassure patients who have all sorts
+of queer, uncomfortable, often even painful, conditions in their
+cardiac region, "Heart disease" has been, perhaps, mentioned casually
+to them and as a consequence worry is adding a nervous element to
+hamper a heart already seriously disturbed by gastric distention. Sir
+William Broadbent's own words are given because they carry so much
+weight in this matter:
+
+  The difficulties arising out of flatulent distention of the stomach
+  or colon or intestinal canal generally, will require some attention,
+  since they are the cause of most of the functional derangements to
+  which the heart is subject, and give rise to the heart complaints
+  which occasion in the aggregate perhaps more suffering than does
+  actual heart disease. The heart often tolerates a considerable
+  degree of upward pressure of the diaphragm, and it is not uncommon
+  to meet with stomach resonance as high as the fifth space, and to
+  find the apex beat displaced upwards and outwards to the fourth
+  space and outside the nipple line, without conspicuous symptoms. But
+  the heart behaves very differently in different subjects in the
+  presence of flatulent distention of the stomach. It partakes of the
+  general constitutional condition of the individual; in the strong,
+  therefore, it is vigorous; in the weak it cannot be anything but
+  weak.
+
+
+Prognosis.--Nothing sends a young person sooner to a physician than
+this cardiac unrest and functional disturbance. He comes all
+a-tremble, as if to hear the worst. Even in middle age and in those
+whose education might be expected to steady them somewhat in the
+matter, even in physicians of long experience, there is a tendency so
+to exaggerate the condition and its possibilities of fatality as a
+consequence of emotion that inhibitory action on the heart becomes
+noticeable. It is a rule with very few exceptions that in these cases
+when the heart is complained of by young persons who have no history
+of rheumatism, the causative condition will be found in the stomach,
+or at least in the digestive tract.
+
+I know a number of physicians who have suffered in this way and who
+have been badly frightened about themselves, yet who have had no
+serious difficulty once they took reasonable care of their diet, and
+paid attention above all to regularity of meals and slowness in
+eating. Indeed, it is rare to find a physician of a nervous
+temperament who has not had some trouble of this kind, and the demands
+made on a busy professional man foster this. Some of them are sure
+that if their cardiac uneasiness does not signify an actual heart
+lesion, valvular or muscular, at least it portends a premature wearing
+out of the heart. There are many evidences to show that this is {333}
+not so. I have had a distinguished physician, now well past his
+seventy-fifth year, tell me of distinct irregularity in his heart
+action as a young man which had rather alarmed him, and as this had
+been preceded by an attack of acute articular rheumatism there seemed
+to be every reason to think that he was a sufferer not from functional
+but from organic heart disease; yet he has lived well beyond the span
+of life usually allotted to man, has accomplished an immense amount of
+work and is now in excellent general health almost at the age of
+eighty. The case is all the more striking because, while rest and care
+of the health and regular life and conservation of energy are usually
+supposed to be essential for these cases, this colleague is noted for
+having made serious inroads on the hours which should have been
+devoted to sleep in order to accomplish certain medical literary work
+while devoting himself to the care of a most exacting practice.
+
+That the good prognosis of these cases which I suggest is not forced
+and is not over-favorable nor the result of the wish to soothe
+patients may be judged from recent studies of the heart as well as
+from the older ones. In discussing extra-systole, MacKenzie in his
+"Diseases of the Heart," [Footnote 28] says:
+
+  [Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D.,
+  1910, Oxford Medical Publications.]
+
+  Dyspeptic and neurotic people are often liable [to suffer from
+  them]. That other conditions give rise to extra-systoles, is also
+  evident from the fact that they may occur in young people in whom
+  there is no rheumatic history and no cardiosclerosis and whose
+  after-history reveals no sign of heart trouble.
+
+It is well to note the frequency of such annoying symptoms in those
+who have gone through rheumatic fever, and where patients have a
+history of this it is well to be cautious, but even in these cases he
+says that the trouble is often entirely neurotic and the one important
+preliminary to any successful treatment is to get the patient's mind
+off his condition, improve his general nervous state, and above all
+relieve as far as possible the gastric symptoms that may be present.
+
+He says further:
+
+  Some patients are conscious of a quiet transient fluttering in the
+  chest when an extra-systole occurs; others are aware of the long
+  pause, "as if their hearts had stopped"; while others are conscious
+  of the big beat that frequently follows the long pause. So violent
+  is the effect of this after-beat, that in neurotic persons it may
+  cause a shock, followed by a sense of great exhaustion. Most
+  patients are unconscious of the irregularity due to the
+  extra-systole until their attention is called to it by the medical
+  attendant. Both being ignorant of its origin, and its being
+  characteristic of human nature to associate the unknown with evil,
+  patient and doctor are too often unnecessarily alarmed.
+
+
+Cardiac Stomach Disturbance.--On the other hand, as a word of warning,
+it seems necessary to say here that later in life acute conditions
+manifesting themselves through the stomach are often of cardiac
+origin. Most physicians have been called to see some old man who had
+partaken of a favorite dish which did not, however, always agree with
+him and who suffered as a consequence from what at first was thought
+to be acute gastritis. The severity of the symptoms and the almost
+immediate collapse without any question of ptomaine poisoning,
+however, usually make it clear that some other organ is at {334} fault
+besides the stomach itself. The real etiological train seems to be
+that a weakened heart sometimes without any valve lesion but with a
+muscular or vascular degeneration hampering its activity is further
+seriously disturbed by the overloading of the stomach. The result is a
+failure for the moment of circulation in the digestive organs with
+consequent rejection of the contents of the tract, nature's method of
+relieving herself of substances that cannot be properly prepared for
+absorption. Unfortunately, the condition sometimes proves so severe a
+shock to the weakened heart that it stops beating, and the physician
+is brought face to face with a death from "heart failure."
+
+In these cases it is important to remember that the gastric
+disturbance may so mask the heart symptoms as completely to deceive
+the physician. The prognosis of these cases, however, is most serious.
+It seems worth while to give a warning with regard to these cases,
+because anything that we may have to say as to the relations of the
+stomach and the heart and the possibility of lessening the cardiac
+depression due to unfavorable mental influence when palpitation occurs
+as a consequence of gastric distention, has nothing to do with these
+acute cases in older patients where the condition is serious and the
+prognosis by no means favorable.
+
+
+Treatment.--The rôle of psychotherapy in this form of cardiac
+disturbance associated with gastro-intestinal affections is, after the
+differentiation of neurotic from serious organic conditions, to give
+the patient such reassurance as is justified by his condition. It is
+surprising how many people are worrying about their hearts because
+their stomachic and intestinal conditions give rise to heart
+palpitation, that is to such action of the heart as brings it into the
+sphere of their consciousness, sometimes with the complication of
+intermittency or even more marked irregularity. The less the
+experience of the physician the more serious is he likely to consider
+these conditions and the more likely he is to disturb the patient by
+his diagnosis and prognosis. Until there is some sign of failing
+circulation, or of beginning disturbance of compensation, the
+attachment of a serious significance to these conditions always makes
+patients worse and removes one of the most helpful forms of
+therapeusis, that of the favorable influence of the mind on the heart.
+On the other hand, unless the patients' own unfavorable
+auto-suggestions as regards the significance of their heart symptoms
+are corrected, these people not only suffer subjectively, but bring
+about such disturbance of their physical condition as makes many
+symptoms objective.
+
+While there are serious affections in which heart and stomach are
+closely associated, these are quite rare and usually manifest
+themselves in acute conditions and in old people. In the chapter on
+Angina Pectoris attention is called to the fact that there are may
+forms of pseudo-angina due to cardiac neuroses consequent upon gastric
+disturbance and without heart lesion. Broadbent has not hesitated to
+say that these forms of angina cause more suffering or at least
+produce more reaction on the part of the patient and are always the
+source of more complaint than the paroxysms due to serious cardiac
+conditions which present the constant possibility of a fatal
+termination.
+
+Where the stomach is the cause of the cardiac neuroses psychotherapy
+is an extremely important element in the treatment. The continuance
+and exaggeration of their symptoms is often due to a disturbance of
+mind consequent upon the feeling that they have some serious form of
+heart disease. Without {335} definite reassurance in this matter all
+the experts in heart disease insist that it is extremely difficult to
+bring about relief of symptoms in these patients. Whenever the general
+health of the individual has not suffered from his heart affection, it
+is quite safe to assume that no organic disease of the heart is
+present, no matter what the symptoms, for, as Broadbent and many other
+authorities emphasize, gastric cardiac neuroses can simulate every
+form of heart disturbance. The older physicians insisted that what
+they called sympathy with the hypochondriac organs might produce all
+sorts of heart symptoms. The patient must be told this confidently.
+The slightest exaggeration of the significance of his symptoms can do
+no possible good and will always do positive harm.
+
+After reassurance, the most important thing is, of course, regulation
+of the diet and of the digestive functions generally. Unfortunately,
+regulation of the diet to many patients and even to many physicians
+seems to mean the limitation of diet. I have seen sufferers from
+cardiac symptoms have these increased by excessive limitation of diet.
+If they are lower than they ought to be in weight they must be made to
+regain it. Above all, there must be no limitation of meat-eating
+except in the robust. Very often the heart seems to crave particularly
+that form of nutrition that comes through meat. It is especially
+important that the bowels should be regular. Fast eating is very
+harmful. Occupation with serious business immediately after eating is
+almost the rule in these cases.
+
+All of these elements of the case need special study in each
+individual patient. The needed suggestions can then be made. Above
+all, the patient is made to realize that his case is understood and
+that it is only the question of a gradual acquirement of certain
+habits, including proper exercise, that is needed for the restoration
+of his heart to normal.
+
+
+
+CHAPTER V
+
+ANGINA PECTORIS
+
+
+The two forms of this affection, known commonly as true and false
+angina, are characterized by pain or anguish in the precordial region
+with reflected pains in other portions of the body. It used to be said
+that whenever the precordial pain was accompanied by reflected pains
+in the neck, or down the arm, or, as they may be occasionally, in the
+jaw, in the ovary, in the testicle, sometimes apparently in the left
+loin, this was true angina and the patient was in serious danger of
+death. We know now that false angina may be accompanied by various
+reflex pains and that, indeed, a detailed description of the anguish
+and its many points of manifestation is more likely to be given by a
+neurotic patient suffering from pseudo-angina than by one suffering
+from true angina. True angina occurs in most cases as a consequence of
+hardening of the arteries of the heart or of some valvular lesion that
+interferes in some way with cardiac nutrition. The definite sign of
+differentiation is that in practically all cases of true angina, there
+are signs of arterial degeneration in various parts of the body.
+Without these, the "breast pang," as the English {336} call it, is
+likely to be neurotic and is of little significance as regards future
+health or its effect upon the individual's length of life.
+
+Besides the physical pain that accompanies this affection there is, as
+was pointed out by Latham, a profound sense of impending death. It
+used to be said that this was characteristic of the organic lesions
+causing true angina pectoris. It is now well known, however, that the
+same feeling or such a good imitation of it that it is practically
+impossible to recognize the true from the false, occurs in
+pseudo-angina. It is this special element in these cases that needs
+most to be treated by psychotherapy and which, indeed, can only be
+reached in this way. Where there are no signs of arterial degeneration
+and no significant murmurs in the heart, it should be made clear to
+these patients that they are not suffering from a fatal disease, but
+only from a bothersome nervous manifestation. Especially can this
+reassurance be given if the angina occurs in connection with
+distention of the stomach or in association with gastric symptoms of
+any kind. In young patients who are run down in health and above all
+in young women, the subjective symptoms of angina--the physical
+anguish and the sense of impending death--are all without serious
+significance.
+
+
+Differential Diagnosis of True and False Angina.--In the diagnosis of
+angina pectoris the main difficulty, of course, lies in the
+differentiation between the true and false forms, that is, those
+dependent on an organic affection of the heart muscle or blood vessels
+and those resulting from a neurosis. The neurotic form is not uncommon
+in young people and is often due to a toxic condition. Coffee is
+probably one of the most frequent causes of spurious angina, though
+the discomfort it produces is likely to be mild compared with the
+genuine heart pang. It must not be forgotten, however, that neurotic
+patients exaggerate their pains and describe their distress in the
+heart region as extremely severe and as producing a sense of impending
+death, when all they mean is that, because the pain is near their
+heart it produces an extreme solicitude and that a dread of death
+comes over them because of this anxiety. Coffee and tea, especially
+when taken strong and in the quantities in which they are sometimes
+indulged in, may be sources of similar distress. Tobacco will do the
+same thing in susceptible individuals, or where there is a family
+idiosyncrasy, and especially in young persons.
+
+For the differentiation of true and spurious angina Huchard's table as
+given by Osler is valuable:
+
+
+
+TRUE ANGINA
+
+Most common between the ages of forty and fifty years.
+
+More common in men. Attacks brought on by exertion.
+
+Attacks rarely periodical or nocturnal.
+
+Not associated with other symptoms.
+
+Vaso-motor form rare. Agonizing pain and sensation of compression
+by a vice.
+
+Pain of short duration. Attitude: silence, immobility.
+
+Lesions. Sclerosis of coronary artery.
+
+Prognosis: grave, often fatal.
+
+Arterial medication.
+
+
+NEUROTIC FORM
+
+At every age, even six years.
+
+More common in women. Attacks spontaneous.
+
+Often periodical and nocturnal.
+
+Associated with nervous symptoms.
+
+Vaso-motor form common. Pain less severe; sensation of distention.
+
+Pain lasts one or two hours. Agitation and activity.
+
+Neuralgia of nerves and cardioplexus.
+
+Never fatal.
+
+Antineuralgic medication.
+
+
+{337}
+
+
+True Angina and Psychotherapy.--One of the most frequent occasions for
+the development of true angina is vehement emotion. The place of
+psychotherapy then in the affection will at once be recognized. A
+classical example of the influence of the mind and the emotions in the
+production of attacks of angina pectoris in those who are predisposed
+to them by a pre-existing pathological condition, is the case of the
+famous John Hunter. He was attacked by a fatal paroxysm of the
+affection in the board room of St. Thomas' Hospital, London, when he
+was about to begin an angry reply with regard to some matter
+concerning the medical regulation of the hospital. He had previously
+recognized how amenable he was to attacks of the disease as a
+consequence of emotion or excitement, and had even stated to friends
+that he was at the mercy of any scoundrel who threw him into an attack
+of anger. Some of the deaths from fright or sorrow at a sudden
+announcement of the death of a relative, or even the deaths from joy
+are due to angina pectoris precipitated by the serious strain put upon
+the heart by the flood of terror or emotion.
+
+Men who are sufferers from what seems to be true angina pectoris must
+be made to understand without disturbing them any more than is
+absolutely necessary that strong emotions of any kind--worry, anger,
+exhibitions of temper, and, above all, family quarrels, must be
+avoided. Not a few of the serious attacks of angina pectoris which
+physicians see come as a consequence of family jars, owing to the
+persistence of a son or daughter in a course offensive to the parent.
+A part of the prophylaxis, then, consists in impressing this fact on
+members of the family and making them understand the danger. The
+disposition that causes the family friction is, however, often
+hereditary and will, therefore, prove difficult of control. It is one
+of the typical cases of inheritance of defeats.
+
+
+_Solicitude and Prognosis_.--The distinguished French neurologist,
+Charcot, had several attacks of what seemed to be true angina
+pectoris. His friends were much disturbed by it. Physicians who saw
+him during the attack feared that he was suffering from an incurable
+heart lesion. He himself, as his son, Dr. Charcot, told me, refused to
+accept this diagnosis, and preferred to believe that what he was
+suffering from was a cardiac neurosis--and, of course, he had seen
+many of them. He was unwilling to have a heart specialist examine him
+very carefully for he did not wish to be persuaded of the worst
+aspects of his condition.
+
+What he said in effect was, "This is either a neurotic condition, as I
+think it is, or it is an organic condition. If it is organic, my
+physicians would be apt to tell me that I must stop working so hard,
+and I am sure that if I should do that I would do myself more harm
+than good by having unoccupied {338} time on my hands. I want to go on
+doing my work. If I am wrong some time I shall be carried off in one
+of these attacks. That will not be such a serious thing, for after all
+I must die some time and my expectancy of life cannot normally be very
+long. I prefer, then, to go on with my work and think the best, for it
+does not seem that I could do anything that would put off the
+inevitably fatal issue if I am to die a cardiac death." He was found
+dead one morning, but he had passed into the valley of death without
+being seriously disturbed and without any of the neurotic symptoms
+that so often develop in discouraged patients. Curiously enough, one
+of our most distinguished heart specialists in this country went
+through almost the same experience and preferred to live "the brief
+active life of the salmon rather than the long slow life of the
+tortoise."
+
+The best possible factor in therapy is secured if patients can be
+brought to the state of mind of these distinguished physicians who
+calmly faced the future, refusing to disturb themselves or their work,
+because they feared that the worry that would come down upon them in
+inactivity would aggravate their disease. Where men are occupied with
+some not too exacting occupation, that takes most of their attention
+and at which they have been for years, it is best to leave them at it,
+though the harder demands of it must be modified. If they can be
+brought to persuade themselves, as did the two physicians--though
+probably only half-heartedly--that their affections may possibly be
+merely neurotic and not true angina, it will always be better for
+them. Death may come, and commonly will, suddenly, but, after one has
+lived a reasonably full life, that is rather a blessing (and not in
+disguise) than the terror which it is sometimes supposed to be.
+
+
+Pseudo-Angina.--The neurotic form of angina is quite compatible, not
+only with continued good health but with long life, and even after a
+long series of attacks, some of them very disturbing in their apparent
+severity, there may be complete relief for years, or for the rest of
+life. Exaggeration of feeling due to concentration of attention plays
+a large role in these cases, and it is evident that the dread of
+something the matter with the heart connected with even a slight sense
+of discomfort may readily become so emphasized as to seem severe pain,
+though many people have similar feelings without making any complaint.
+
+In spite of reassurances attacks of pseudo-angina are likely to worry
+both patient and physician. The only working rule is that in younger
+people discomfort in the heart region, even though it may be
+accompanied by some sympathetic pain in the arm or in the left side of
+the neck, is usually spurious angina. Broadbent goes so far as to say
+that this is true also in many older persons. His method of making the
+differentiation is interesting because so easy and practical that it
+deserves to be condensed here. The earlier attacks of true angina are
+practically always provoked by exertion, while spurious angina is
+especially liable to come on during repose. Any cardiac symptom or
+pain that can be walked off may be set down as functional and due to
+some outside disturbing influence, or to nervous irritability. When
+palpitation or irregular action of the heart, or intermission of the
+pulse, or pain in the cardiac region, or a sense of oppression follows
+certain meals at a given interval, or comes on at a certain hour
+during the night, there need be little hesitation in attributing the
+disturbance, whatever it may be, to indigestion in {339} some of its
+forms. Nightmare from indigestion, Broadbent thought, is not a bad
+imitation of true angina.
+
+In Broadbent's mind acute consciousness of any heart disturbance lays
+it in general under the suspicion of being neurotic in origin. He was
+talking to some of the best clinical practitioners in the world and
+some of the most careful observers of our generation, when, before the
+London Medical Society, he said: "The intermission of the pulse of
+which the patient is conscious and the irregularity of the heart's
+action--though this can be said with less confidence--which the
+patient feels very much, is usually temporary and not the effect of
+organic heart disease." This is particularly true, of course, in
+people of a neurotic character, and Broadbent went on to say that
+"speaking generally, angina pectoris in a woman is always spurious,
+and the more minute and protracted and eloquent the description of the
+pain, the more certain may one be of the conclusion."
+
+I had the opportunity to follow the case of a young woman who had a
+series of attacks of angina pectoris some twenty years ago, so severe
+that a bad prognosis seemed surely justified, and though at times the
+attacks were rather alarming to herself and friends, nothing serious
+developed and for the past ten years, since she has gained
+considerably in weight, they have not bothered her at all. She used to
+be rather thin and delicate, trying to do a large amount of work and
+living largely on her nervous energy. At times of stress she was
+likely to suffer from pain in the precordia running down the left arm
+and accompanied by an intense sense of the possibility of fatal
+termination. With reasonably large doses of nux vomica, an increase in
+appetite came and a steadying of her heart that soon did away with
+these recurrent attacks. These came back later several times when she
+neglected her general condition, but there never were any objective
+symptoms that pointed to an organic lesion. After twenty years she is
+in excellent health, except for occasional attacks of a curious
+neurotic indigestion that sometimes produces cardiac disturbances. Of
+course, such cases are not uncommon in the experience of those who see
+many cardiac and nervous patients.
+
+For the treatment of pseudo-angina, mental influence is all important.
+Of course, the conditions which predispose to the mechanical
+interference with heart action that occasions the discomfort, must be
+relieved as far as possible. The severity of the symptoms, however,
+are much more dependent on the patient's solicitude with regard to
+them, they are much more emphasized by worry about them, than by the
+physical factors which occasion them. Reassurance is the first step
+towards cure. After relief has been afforded from the severer attacks,
+the patient's solicitude as to the future must be allayed and the fact
+emphasized that there are many cases in which a number of attacks of
+cardiac discomfort simulating angina pectoris have been followed by
+complete relief and then by many years of undisturbed life. It is
+important to make patients understand that, in spite of the fact that
+their attacks occur during the course of digestion, as is not
+infrequently the case, this constitutes no reason for lessening the
+amount of food taken. Nearly always these attacks occur with special
+frequency among those who are under weight, and disappear rather
+promptly when there is a gain in weight. Solicitude with regard to the
+heart must be relieved wherever possible and then with the regaining
+of general health the heart attacks will disappear.
+
+
+{340}
+
+
+CHAPTER VI
+
+TACHYCARDIA
+
+Etymologically tachycardia means rapid heart. There are two forms of
+rapid heart, that which is constant and that which occurs in
+periodical attacks. It is for this latter that the term tachycardia
+has been more particularly used, though occasionally the adjective
+paroxysmal is attached to it to indicate the intermittent character of
+the affection. With regard to the persistent type of rapid heart
+something deserves to be said, however, because patients' minds are
+often seriously disturbed by them. Often it has existed for years,
+sometimes is known to be a family trait and probably has existed from
+childhood, yet the discovery of it may be delayed until some
+pathological condition develops, calling for the attendance of a
+physician who may be needlessly alarmed and in turn alarm his patient
+by his recognition of it. The cause for this persistent rapid pulse is
+not well known and is difficult to determine. Heredity, as has been
+suggested, sometimes plays an important role in it. Certain families
+have one or more members in each generation with rapid hearts.
+Whenever persistent rapid heart is a family trait the patient can be
+assured, as a rule, without hesitation, that the general prognosis of
+the case is that of the lives of the rest of the family. Usually the
+symptom seems to mean nothing as regards early mortality or any
+special tendency to morbidity.
+
+
+Favorable Prognosis.--While a rapid pulse often and indeed usually has
+some serious significance, it must not be forgotten that it may be an
+individual peculiarity and be quite compatible with long life and hard
+work. One of the first patients that I saw as a physician had a pulse
+between ninety-six and one hundred. As there was a slight tendency to
+irregular heart action also, I was inclined to think that there must
+be some cardiac muscle trouble. There was apparently no valve lesion.
+He told me that a physician ten years before had noted his rapid pulse
+and had made many inquiries about it which rather seriously disturbed
+him. He had been an extremely healthy man during his fifty-five years
+of life and there seemed no reason to conclude, since his rapid pulse
+had been in existence for ten years, that it meant anything serious.
+He has now lived well beyond the age of seventy and still has a pulse
+always above ninety. Contrary to what might be thought, he is an
+extremely placid, unexcitable individual, who, under ordinary
+circumstances, will probably live for many years to come. He has no
+family history of tachycardia, though there is a history of rather
+nervous irritable hearts in other members for two generations.
+
+An interesting case of this kind came under my observation about
+fifteen years ago in a clergyman whose pulse was never below ninety,
+and who on slight excitement, or after a rapid walk, or after a heavy
+meal, would have a pulse of 120. He knew that it was a family trait,
+his father having had it yet living to be past seventy. He gave a
+history of its having been recognized in his own person more than
+twenty years before. His general health, however, was excellent. He
+took long walks and, indeed, pedestrian excursions {341} were his
+favorite exercise. He was able to go up flights of stairs rather
+rapidly without discomfort. He was the pastor in a tenement house
+district so he had plenty of opportunity for such exertion. Infections
+of any kind, colds and the like, disturbed his pulse very much, if the
+ordinary standard was taken, but it was not irregular and the increase
+in rapidity was probably only proportionate to the original height of
+the pulse in his case. After all, as the normal pulse of sixty to
+seventy rises to between ninety and one hundred even in a slight
+fever, it is not surprising if a pulse normally above ninety should
+rise fifty per cent. to one hundred and thirty-five under similar
+conditions. He is now well past sixty, after over thirty-five known
+years--and probably longer--of a pulse above ninety, yet he is in
+excellent general health and promises, barring accident, to live
+beyond seventy.
+
+Some ten years ago I first saw another of these cases of fast heart,
+with a family history of the affection in a preceding generation. He
+was a man who had not taken good care of himself and had been
+especially over-indulgent in alcohol. This indulgence consisted not in
+rare sprees but in the persistent daily taking of large quantities of
+straight whiskey. In spite of warnings, he has not given up this
+habit; yet at the age of sixty-five he is apparently in good health
+and is able to fulfill the duties of a rather exacting occupation.
+
+Persistent rapid pulse often occurs in connection with some
+disturbance of the thyroid gland. The larval forms of Graves' disease
+occur particularly in young persons, though they are sometimes seen in
+those beyond middle life. They seem to be due to a lack of development
+of the thyroid in consonance with the rest of the tissues, though
+occasionally, especially after the menopause, they seem to be
+connected with some degenerative process out of harmony for the moment
+with other forms of degeneration. When they occur in young persons
+they may, of course, represent the beginning of incipient Graves'
+disease, but they are often only functional and the symptoms may pass
+away entirely. The rapid heart action may come and go, though usually
+the attacks last for some days and oftener for a week or more at a
+time.
+
+
+Paroxysmal Tachycardia.--A rapid heart may not only exist continuously
+in an individual for many years without any impairment of general
+health or shortening of life, but there may be spasmodic attacks of
+this condition with the pulse running up so high as to deserve the
+name of paroxysmal tachycardia; yet the patient may live for many
+years and die from some affection not connected with his heart.
+Perhaps the most remarkable case of this kind on record is that
+reported by Prof. H. C. Wood of Philadelphia. The patient was a
+physician in his later eighties when he came under Dr. Wood's
+observation. His first attack of paroxysmal tachycardia came in his
+thirty-seventh year. These attacks had apparently always been similar
+to those he then suffered and were abrupt in onset and the pulse would
+rise rapidly to 200 a minute. The original prognosis had been, of
+course, very unfavorable. The physician had outlived all the prophets
+of evil in his case, however. When large numbers of these cases were
+studied, it was found that they always last more than ten years, and,
+while heart failure in such cases is reported, it is doubtful if this
+occurs with more frequency in these patients as the result of strong
+reflexes than in the general run of patients, for it must not be
+forgotten that there is a certain average number of deaths from
+so-called heart failure in people supposed to be in good health.
+
+{342}
+
+In connection with these attacks of paroxysmal tachycardia, there
+often come intense feelings of depression and even local disturbances
+of circulation. It is probable that in many cases there is a serious
+factor at work. MacKenzie has suggested that they are due to nodal
+rhythm of the heart in which the heart beat does not start at the root
+of the sinus as is usual, but in some other portion of the musculature
+and as a consequence there is serious interference with the regular
+rhythmic action. In a number of cases of heart failure, tachycardia
+becomes a prominent feature and it is probably due to some such
+disturbance as this. Such cases often look very serious for a time,
+yet frequently recover completely after a brief interval. This must
+not disguise the fact, however, that many of these cases, especially
+where acute dilatation of the heart can be demonstrated, are extremely
+dangerous and may end in a sudden fatal termination. The patient seems
+so much prostrated that occasionally the physician may doubt whether
+it is worth while to put him to the bother necessary in order to
+diagnose the acute dilatation of the heart. It always is, however. If
+it were nothing else but the occupation of the patient's attention
+with the doctor's manipulations, as far as that is possible, the
+effect would be good, besides whatever irritation may be caused to the
+heart muscle itself by percussion of the heart area will probably do
+mechanical good.
+
+The most important element evidently is that the patient shall not be
+allowed to lose courage or to think that nothing can be done for him.
+Something must be done, and a combination of swallowing movements and
+deep breathing, as far as that is possible, with counter-irritation
+through the chest wall should be carried out. Drugs also should be
+employed and the aroma of strong coffee with the irritating effect of
+ammonia upon the nostrils should be employed. These act upon the vagus
+so as to stimulate the heart, but above all they act upon the mind,
+and nothing so stimulates the heart as reawakened hope.
+
+
+
+CHAPTER VII
+
+BRADYCARDIA
+
+
+Bradycardia, or persistent slow pulse, is much rarer than the
+persistent rapid pulse discussed at the beginning of the chapter on
+tachycardia. Cases are, indeed, sufficiently rare to be medical
+curiosities. Prof. Clifford Allbutt has called attention to the fact
+that the status of bradycardia or brachycardia, as Osler (following
+Riegel because of the analogue tachycardia) prefers to call it, is
+very different from that of tachycardia. In the latter, especially, in
+the specific sense of the term, the symptoms occur paroxysmically,
+endure for a definite length of time and then there is a return to the
+normal pulse rate. For this, or at least for the condition known as
+essential tachycardia, there is no well-defined cause and no definite
+pathological lesion. Bradycardia or brachycardia, however, is usually
+present as the result of some known physiologic or pathologic
+condition; it endures as long as the cause continues to act and then
+ceases, usually not to return unless the same cause gives rise to it
+again.
+
+{343}
+
+There are some cases, however, of slow pulse that cannot be traced to
+any definite lesion and in which the pulse is much slower at certain
+times than at others, though without its being possible to trace any
+definite immediate cause. These cases seem to be physiological
+analogues of tachycardia. In tachycardia there is an irritation of the
+accelerator nerves to the heart, in brachycardia of the inhibitory
+nerves.
+
+
+Depressed Mental States.--Occasionally the reason for this can be
+found, though it is rather vague. In depressed mental states, for
+instance, a pulse between fifty and sixty is common. In people who
+suffer from periodic fits of depression it is not unusual to find that
+in the early morning the pulse is not more than fifty-five. I have
+seen patients who were worrying about their hearts present records of
+early morning pulse before they got up that were always below sixty.
+This is probably in a certain number of people quite normal. I
+remember a series of observations made on the attendants in the
+Charite Hospital in Berlin in which it was clear that the normal
+German morning temperature at seven a.m. was below 97 F., while the
+pulses were always below sixty. A reassurance of this kind is helpful
+to patients who have acquired the bad habit of taking their own pulse
+and have been disturbed by finding it so much below what they consider
+normal.
+
+
+Illustrative Case.--A number of cases of persistent slow pulse seem to
+be congenital or produced by some definite pathological lesion, yet do
+not prove serious for the patient. Some years ago I described one of
+these cases in a paper read before the Section on Medicine of the New
+York Academy of Medicine [Footnote 29] and I have had the opportunity
+to follow it for about fifteen years. Though the patient's pulse is
+usually below forty and even after a rapid walk does not rise above
+fifty, she is in reasonably good health and during those years has
+buried two husbands. When I saw her she was compelled to go up and
+down stairs frequently and yet did not experience much difficulty.
+While patients suffering from palpitation would find it impossible,
+because of the discomfort produced, to make the journeys up and down
+stairs that she did, she felt only about as much respiratory
+discomfort as would come to a woman of her size. Her respirations were
+somewhat hurried--22 to 24 to the minute--but her general health was
+very good. Her urine was normal, her liver not enlarged, her ordinary
+organic functions were not disturbed and there was no sign of arterial
+degeneration.
+
+  [Footnote 29: _The Medical News_, November 10, 1900.]
+
+With the pulse rate as low as this one might expect to find the
+patient phlegmatic, slow of movement and not readily moved to emotion.
+On the contrary, she has always been rather nervous and high-strung
+and inclined to be excitable. Her cardiac condition was first noted
+just after the first grip epidemic in this country, though her
+attention was not called to it during the course of the grip. It seems
+probable that the heart condition was acquired as a consequence of
+some irritative lesion affecting the inhibitory nerves to the heart
+that developed at that time. After her heart condition had been
+discovered she was for a time a skirt dancer and frequently danced for
+the amusement of her friends. She was always lively and active and
+after her first husband's death, when it became necessary for her to
+earn her own living, she was on the stage for a time and danced
+without any embarrassment of either {344} heart or respiration. As a
+consequence of running down in weight and general health, owing to
+conditions since her husband's death, she noticed that dancing proved
+exhausting to her and she gave it up.
+
+In general, she considered herself quite as capable as any of her
+friends for the ordinary duties and amusements of life. When I first
+saw her her digestion had been somewhat disturbed by worries and
+unsuitable nutrition taken at irregular intervals and this, I think,
+accounted much more than her heart for her complaint of tiredness on
+exertion. Later, after her second marriage, when she was in better
+circumstances, all her symptoms disappeared and even her heart rate
+rose so that it was seldom below forty, and after exertion always went
+to fifty. What was needed in her case more than anything was a change
+of environment, the satisfaction of mind that comes with freedom from
+worries and the cares of making her own living, and the improvement in
+digestion due to regular meals of good, simple, nutritious food.
+
+
+Compatibility with Health and Activity.--The above case is interesting
+as illustrating mental influence upon such a serious condition as
+bradycardia. Most people who suffer from it are likely to be
+over-depressed and this reacts to disturb digestion and also further
+to disturb the heart itself. What these patients need above all, then,
+is reassurance with regard to their condition. There are some striking
+examples in history and in medical literature of bradycardia or
+persistent slow pulse in persons who are able to accomplish a large
+amount of work and whose general health and capacity for
+accomplishment were not at all disturbed by this physical condition.
+Above all, they were not depressed and did not lack initiative.
+Napoleon I, whose pulse is said normally to have been about forty,
+rising during the excitement of battle to fifty, is a typical example.
+Medical literature records a number of patients with congenital slow
+pulse without any discernible heart lesion who lived long and
+successful lives. One of these was a very successful English athlete.
+The prognosis of these cases is not as bad as it might seem to be and
+the mental state of the patient is more important than anything else
+in the treatment.
+
+
+{345}
+
+SECTION VIII
+
+_RESPIRATORY DISEASES_
+
+
+CHAPTER I
+
+COUGHS AND COLDS
+
+
+Cough under most conditions is so completely a natural reflex due to
+irritation from material which demands expectoration that to talk of
+the application of psychotherapeutics to its treatment would seem
+almost an abuse of words. This is true if we think of the curing of an
+ordinary catarrhal or bronchitic cough by suggestion. We know now,
+however, that, as a rule, we do not cure diseases, we only relieve
+their symptoms and thus enable nature to overcome the affection. The
+ordinary cough remedies do two things: they cause more liquid to exude
+into the lung tissues and thus soften and liquefy thick mucous
+material so as to make it easier to expectorate, or they lessen
+irritation and soothe the cough by making the nervous system less
+reactive. This second function of our remedial measures directed
+against cough can at least be assisted very materially by
+psychotherapeutics. Direct suggestion may be of great help, while the
+first function, that of softening the cough by liquefying the sputum,
+can be materially aided by certain suggestions to the patient of
+natural means and ways by which his cough may be relieved, its
+secondary symptoms modified, and its course abbreviated.
+
+
+Cough and Suggestion.--Much of the coughing indulged in is quite
+unnecessary and might well be dispensed with. At many of the German
+sanatoria for consumption there is a rule that patients must not cough
+at dinner, and no coughing is heard in the refectory. Without such a
+rule the midday meal, if taken in common by the large number of
+consumptives present, would be a pandemonium of coughing. Cough is
+largely influenced by suggestion. Most of the respiratory reflexes
+follow this same rule. To see another yawn tempts us to yawn; to hear
+another cough tempts us to cough. In church or in a theater after an
+interval of interest one cough will be followed by a battery of
+coughs. People who have colds think they have a right to cough, and so
+they often cough much more than is at all necessary. Of course, when
+material accumulates in the lungs it must be coughed up, but not a
+little of the coughing might easily be dispensed with--it is
+unproductive coughing. A distinguished German medical authority who is
+accustomed to talk very plainly once said that it is quite as impolite
+and injustifiable to cough unproductively as to scratch the head
+unproductively. Only results justify either procedure.
+
+Dry coughing, when persistent, is greatly a matter of habit acquired
+by yielding to slight irritation. When children scratch their heads we
+train them {346} not to, and the same thing should be done with regard
+to yielding to reactions from slight irritations of their lungs.
+
+Even when material has to be expectorated there is often much more
+fuss and effort made over it than is needed. Most men a generation ago
+insisted on their right to expectorate in public because it was better
+for them to rid themselves of offensive material than to retain it.
+The difference between men and women in this respect has always been
+distinctive. Women practically never expectorate in public, men do it
+frequently, or rather, let us hopefully say, used to. It seems to be
+thought the exercise of a manly privilege to spit and the boy learns
+the habit. It seemed almost a necessity in the past, yet now we have
+come to a point where, by legal regulation, we prohibit spitting in
+public and it seems likely future generations, not far off, will hold
+it as a rule that instead of the sexes being essentially different by
+nature in this respect, the habits formed by the enforcement of recent
+legal regulations will show their essential similarity and we shall
+have no "expectorating sex."
+
+
+Unnecessary Coughing Harmful.--Coughing, unless it is necessary,
+always does harm. It irritates the mucous membrane, already rendered
+somewhat hyperemic and tender by the inflammatory process at work, to
+have the breath pass over it in such an expulsive way. This is one
+case where nature's indications are not to be followed. It is like
+itchiness in eczema: it needs to be restrained. The cold will get
+better sooner, the inflammatory process will run its course with less
+disturbance and in briefer time than if it was not disturbed in this
+way or disturbed only as little as possible. This is a point that is
+not often explained to patients and most sufferers from colds are
+inclined to think that the more they cough the better, even though the
+cough, like the scratching in eczema, evidently produces a roughening
+and sensitizing of inflamed tissue. Of course, this principle of the
+limitation of cough may be carried to excess and indeed sometimes is
+when opium is administered to quell coughing. This is not the idea,
+however, of the suggestion made here, which is only to restrain the
+cough within the limits necessary for the removal of material that
+should be evacuated.
+
+The history of most of the tuberculous patients who suffer from
+hemorrhage for the first time shows that they had been coughing
+unproductively, and then, after coughing in this way rather severely,
+there came the flow of blood due to the rupture of a minute artery. In
+these cases the tuberculosis process has been at work for some time
+and has prepared the tissue for this arterial rupture, but there is no
+doubt, however, that the coughing itself, far from doing good, rather
+helped in the destruction of lung tissue, or at least made it more
+difficult for natural processes in the lungs to wall off the bacilli
+and prevent further damage. Practically every adult is in some danger
+of lighting up an acute tuberculous process in his lungs if he racks
+them by coughing. There are many similar examples in nosology of this
+possibility of some habit predisposing to or favoring the development
+of disease.
+
+After measles and whooping cough tuberculosis is especially likely to
+develop. In both of these diseases, but especially in the latter,
+coughing is an element of the affection that probably predisposes to
+the implantation of the tubercle bacillus so commonly present in the
+air of our cities. The lesions produced in the extreme expulsive
+efforts of the paroxysm form favorable niduses for the micro-organism.
+Children particularly, if at all encouraged, are likely {347} to cough
+more than is good for them. On the slightest irritation they cough. It
+is almost impossible to restrain them from scratching when they are
+suffering from eczema, yet we take rather elaborate means to do so,
+and quite as much must be done to prevent them from coughing when
+there is no special reason for it. This does not refer to cases in
+which material is being abundantly expectorated. Elimination can only
+be secured by a proper expulsive effort. Very often, however, children
+notice how much solicitude their little dry cough arouses. They like
+to be the objects of attention. They are dosed with various cough
+remedies, more or less pleasant, whenever they cough. Instead of being
+told that they should restrain their cough except when it is
+necessary, they are rather encouraged to cough whenever there seems to
+be the slightest occasion.
+
+
+Reflex Coughs.--There are a number of coughs that are said to be
+reflex because they are not induced by any lesion of the lungs or of
+the larynx, or, indeed, of any of the air passages. In these cases
+some pathological condition is often found in another organ or set of
+organs, usually one of those connected with the vagus nerves. The wide
+distribution of these pharyngo-laryngo-esophago-pulmano-cardio-gastric
+nerves gives ample opportunity for reflexes. We hear much of reflex
+cough. There is a stomach cough and an intestinal cough, a uterine
+cough, an ear cough, etc. These coughs are always dry, though often
+very irritating to patients, and especially may be a source of dread
+and disturbance of mind and health because they seem to signify some
+serious pathological condition. As a rule, these coughs can be
+restrained to a great degree and frequently suppressed entirely by
+suggestion and discipline. In many cases there is some temptation to
+cough consequent upon irritation of nerve endings communicated through
+some devious paths to the nerve supply of the respiratory tract, but
+this tendency is not very strong and can be easily overcome. It may be
+said that this is asking too much of human nature, and that, just as
+sneezing carries with it a certain satisfaction and so is apparently
+worth the trouble of indulging in, coughing should be permitted, at
+least, if not encouraged, but the reasoning is fallacious.
+
+
+Habit Coughs.--An interesting cough that comes to the physician is
+that in which there is absolutely no pathological reason to account
+for it. There is an irritation of the mucous membrane somewhere along
+the respiratory tract but it is very slight and somehow the habit has
+been acquired of yielding to the reflex that it occasions. I have seen
+these coughs in children in cases where I was sure that they were
+nothing but tics. I have seen so-called hacking coughs in girls of
+twelve to sixteen that were explained as ovarian, or sometimes as
+puberty coughs, that were really nothing more than habits. A slight
+hyperemia of the mucous membrane in the upper respiratory tract due to
+an ordinary cold began in a very slight degree the irritation, and
+then the habit of coughing was not given up. Of course, I know the
+danger of treating such cough as habit coughs. Tuberculosis in its
+initial stage may exist for a prolonged period before it produces any
+increase of secretion and at a time when none of the ordinary physical
+diagnostic signs are present, except possibly a little prolongation of
+expiration over the affected area. At this stage tuberculosis will
+sometimes produce gastric disturbance, and, as I have already said,
+these are spoken of as stomach coughs when there really is something
+much more serious than them at work. When there has been no running
+down in {348} weight, and, above all, no special opportunity for
+contagion, then, if there are no physical signs in the lungs, these
+coughs will be best treated as habits and gradually be made to stop by
+suggestion. The limitation of coughing will do good in any case.
+
+
+Coughs as Tics.--Some coughs are not really due to any difficulty in
+the respiratory tract, but are caused by nervous irritability. There
+are certain habits in the matter of clearing the throat that sometimes
+become pronounced and apparently impossible to stop. As I have said,
+these are tics rather than true coughs. Many of these neurotic coughs
+very seriously alarm patients and also their friends. They are dry, as
+a rule, rather harsh and inclined to be brassy. Occasionally they are
+only what is known as "hacks," as if the patient were trying to clear
+the throat of some offending material. Of course, at no time must the
+significance of cough be made light of unless a careful investigation
+of the patient's condition has been made.
+
+
+Diagnosis.--Names for these coughs should not be too readily accepted
+which, by satisfying legitimate curiosity and lessening proper
+apprehension with regard to them, will stop further investigations.
+Besides stomach coughs, one often hears of intestinal and even uterine
+or ovarian coughs. In many cases the real condition is one of an
+incipient tuberculous condition and there may be no sign of this
+except a disturbance of the pulse and perhaps a slight variation of
+the temperature range for the day (two degrees or more Fahrenheit in
+the twenty-four hours). Such coughs should always be carefully
+investigated for the possibility of incipient tuberculosis. At once
+the patient should be warned about coughing without necessity, since
+this only tends to disseminate the tuberculous process and may help to
+break down nature's wall of protective lymph.
+
+Where there is no disturbance of pulse or temperature and the patient
+is not under weight and there are no signs in the lungs, then the
+cough is merely a habit and partakes of the nature of a tic. Sometimes
+these habits are rather difficult to break; always, however, much can
+be done by suggestion, by a habit of self-control, by self-discipline,
+and by thorough persuasion of the patient. Drugs are likely to
+inveterate the condition if not allied with suggestion.
+
+
+Removing Unfavorable Suggestions.--For the ordinary coughs and colds
+of the winter time there are many unfavorable suggestions that deserve
+to be eliminated. For instance, most people are sure that exposure to
+the air will inevitably make their cold and cough worse. This is a
+relic of the olden time when the confinement of patients to their
+rooms was supposed to be the best remedial measure for all respiratory
+diseases. Tuberculosis patients were kept in and died without any
+chance. Now these patients, even while running a temperature, or
+suffering from pleurisy, or the intercostal painful conditions that
+are often serious complications because of the irritability and
+discomfort produced, and which are so often supposed to be due to
+drafts, are put out on the porch, or on the roof of a hospital, or
+allowed calmly to lie in bed between two open windows, without the
+slightest hesitation. They begin to improve under such treatment much
+sooner than if they were confined, and indeed the whole prognosis of
+tuberculosis has been completely changed by the modification of the
+old-time habit of confinement to that of perfectly free access of
+outer air and even cold air that has taken its place.
+
+This principle of treatment must be applied for coughs and colds.
+While {349} patients are running a temperature they must not take
+exercise, they must not be allowed to work, above all they must not be
+allowed to get in crowds nor tire themselves in any way. The room in
+which they are, however, must be thoroughly aired, the window must be
+open all night and, if possible, they must sit in the sun for several
+hours a day. This will cure a cough or a cold quicker than anything
+else. Many coughs that hang on when treated by remedies of various
+kinds, yield at once if the patient is given an abundance of fluid
+diet and gets freely into the air. There is no danger of catching
+another cold, because a cold is not due to a low outdoor temperature,
+but to dust and microbes, and is a real infection.
+
+
+Irrational Remedies.--There are an innumerable number of supposed
+remedies for colds. Scarcely any one who has reached the age of forty
+apparently feels that he or she is doing the whole duty to humanity
+unless they have some remedy for colds to recommend. Most of the
+popular remedies that are employed probably do as much harm as good
+and many of those that are very popular and are sometimes recommended
+even by physicians have no rational standing in present-day
+therapeutics. Perhaps the most popular is a combination of quinin and
+whisky. The effect of this is to give patients, who are unaccustomed
+to whisky and who are susceptible to quinin, about as uncomfortable a
+twenty-four hours the day after they take the remedies as can be
+imagined. Quinin now has no possible specific therapeutic significance
+in the cure of the series of infections called colds. In the days when
+we did not understand malaria and considered it in some way as an
+essential fever due to the absorption of miasmatic material, quinin
+seemed to have a specific influence upon several conditions.
+Accordingly it was employed in all sorts of fevers and, because it is
+comparatively harmless, also in that short infectious fever which we
+call a common cold. No physician now employs it (except in small doses
+as a general tonic) for febrile conditions, unless in malaria. There
+we know that it acts by killing the plasmodium and is a real specific.
+We do not think of it any more, however, as a general febrifuge and
+there is no justification for its use in the slight infective
+conditions we know as colds.
+
+As for the whisky, if taken in stiff doses as it often is, the
+reaction is likely to make the patient quite miserable the next day.
+It seems to be the rule for him to think that if, notwithstanding the
+taking of the quinin and whisky, he feels thus ill, he would have been
+ever so much worse without it. Colds, however, when left untreated so
+far as drugs go but managed by natural means often run a mild course.
+Some of the reputation of quinin and whisky is due to the fact that
+not infrequently persons suffer from chilly feelings that seem to
+portend a cold and take quinin and whisky and the cold does not
+develop. The remedies are then supposed to have aborted or to have
+inhibited the development of the cold. Anyone who has seen a number of
+these cases treated expectantly, however, knows how often it happens
+that the chilly feelings that seem to announce the cold pass off
+without incident after a good night's rest.
+
+
+Rational Treatment.--The old rule of getting the emunctories at work
+must be the basis of any rational therapy of colds. A mild opening of
+the bowels, especially if there is some constipation, a hot drink on
+going to bed so that there is some sweating and perhaps the use of a
+mild diuretic will almost surely affect these cases favorably.
+Patients have to be careful, {350} however, next morning to stimulate
+the circulation in their skin to activity so that the cutaneous
+muscles shall react upon the capillaries and the capillaries
+themselves tonically contract in order that there may not be too much
+blood near the surface of the body, or the patient may easily be
+chilled in cold weather. This chilling of the blood when much of it is
+near the surface seems to lower its vitality and the patient easily
+reinfects himself or, if he goes into dusty or crowded places, catches
+a fresh dose of infectious material. This is the process which is
+called catching a fresh cold.
+
+The removing of the unfavorable suggestions of remedies that do harm
+rather than good and the giving of favorable suggestions founded on
+our present-day knowledge of what a cold is and just what we need to
+do in order to benefit it, is the most important element in the
+treatment. Above all, however, the patient must sleep in an airy room
+and must be sure that he is neither breathing his own expired air nor
+that of anyone else. With thorough ventilation, however, and the
+stimulating effect of the cold air and the confidence due to proper
+directions, colds rapidly get better.
+
+There can be only one reason for keeping patients indoors who are
+suffering from cold. That is, if they are suffering from fever, the
+being out involves exertion. In that case, of course, patients must
+rest and must avoid exertion, but there is no reason why they should
+not have all possible fresh air. The unfavorable state of mind towards
+fresh air and especially night air in these patients was cultivated by
+the profession up to a generation or two ago, but is quite unjustified
+by our present knowledge. Night air is probably a little better than
+day air because it is freer from dust. It is because of malaria that
+night air was supposed to be detrimental, but we have found that the
+only good reason for this was that the mosquito travels at night.
+There are no other constituents of night air that produce any serious
+effect.
+
+As a rule, patients suffering from colds need more sleep than other
+people and above all need more sleep than they ordinarily take, for
+this will increase their resistive vitality and enable them to throw
+off the infection. A good rule is to add two hours of sleep to the
+usual quota. The unfortunate habit of keeping people indoors and of
+keeping fresh outdoor air away from them, because it is feared they
+will catch a fresh cold, often seriously disturbs sleep and delays
+recovery. In a word, many a cold that hangs on does so mainly because
+of unfortunate suggestions of one kind or another that have come to
+occupy a place in the supposed therapeutics of the condition. The
+removal of these and the insistence on just as much recourse as
+possible to the therapeutic means at nature's command constitute the
+basis of successful therapy of these very common infections, which
+probably are the source of more morbidity in the community because of
+their wide diffusion and frequent recurrence than all the other
+infectious diseases put together.
+
+
+
+CHAPTER II
+
+TUBERCULOSIS
+
+
+Tuberculosis, in spite of all our efforts against it, remains in
+Defoe's striking phrase the "captain of the men of death." Pneumonia
+has preempted its {351} place in the statistics of mortality, but this
+is to a considerable extent because tuberculosis at the end
+masquerades as an acute pneumonic exacerbation. Not less than one in
+eight, probably more, of all those who die, die from tuberculosis. It
+is the most serious of diseases. In spite of its eminently physical
+character it probably affords the best possible illustration of the
+place of mental influence in therapeutics. We have had any number of
+new cures for tuberculosis, introduced by serious physicians who were
+sure from the results they had secured that they had found an
+important new remedy. After a few years each of these cures in
+succession has been relegated to the limbo of unused remedies because
+found inefficient. At the beginning they produced a beneficial
+influence because of the suggestion of therapeutic efficiency that
+went with them. When this suggestion failed because the physician who
+administered the remedy lacked confidence, the real place of the
+supposed specific as merely another mind cure was recognized.
+
+Indeed, many of the remedies that have been introduced have not been
+merely harmless drugs, but not a few of them have probably had rather
+a detrimental physical effect than a beneficial influence. In spite of
+this, the influence on the patient's mind has been sufficient to
+neutralize whatever of harmfulness there might have been and to arouse
+new courage and new energy. The consequence of this has always been
+that the patient was tempted to live more in the open air and to eat
+more. _These_ are the two efficient remedies for tuberculosis. With
+the additional life in the open air and increase of food his appetite
+grew, for nothing so adds to appetite as the exercise of it, and with
+the gain in weight there was a cessation of cough, a reduction of
+fever, a disappearance of night sweats and a definite increase in
+resistive vitality which gradually helped to overcome the disease.
+Manifestly, then, the use of mental influence in tuberculosis is very
+significant.
+
+
+PROGNOSIS AND SUGGESTION
+
+The most important element in any treatment of tuberculosis must be
+the neutralization of unfavorable suggestions which are weighing upon
+the patient and preventing him from using even the vital forces that
+he has for resistance against the disease. The popular impression of
+tuberculosis, happily waning, is that it is an intensely fatal
+disease.
+
+Though this is true in general, tuberculosis is by no means a
+necessarily mortal disease in individual cases, and, indeed, a great
+many more patients recover from tuberculosis than die from it. Papers
+read at the International Congress on Tuberculosis, in Washington, in
+1908, showed from careful autopsy records that practically all adults
+either actually had had at the moment of death, or had suffered
+previously from tuberculosis. If there are not active lesions then
+there are always healed lesions of tuberculosis in the body of almost
+every human being who has passed the age of thirty. Most people have
+quite enough resistive vitality to enable them to recover from the
+disease. It is only those who are placed in very unfavorable
+circumstances during the initial stage of the disease, or who have
+some serious drawback against them, who succumb to it. The fact that
+the bacillus finds a lodgment in so many individual tissues shows that
+it is not insusceptibility that makes the difference {352} between
+people, since we are all susceptible, but it is the lack of resistive
+vitality, and that most of us have, under ordinary circumstances, and
+all of us can have under favorable conditions, quite sufficient
+immunizing power to prevent serious developments.
+
+Even in advanced cases it is perfectly possible for the progress of
+the disease to be stopped and for many years of useful life to be
+gained. Probably patients who have gone beyond the incipient stage, in
+whom there has once been a breaking down of pulmonary tissue never are
+entirely cured, but they may be so much improved that all their
+symptoms disappear and they are able to follow an ordinary occupation
+for many years. There is no disease in which the unfavorable prognoses
+of physicians have been more frequently disappointed than in
+tuberculosis. In any city hospital dispensary one finds many cases of
+tuberculosis turning up as relapses of previous conditions, with the
+story that when they were seriously ill before, some prominent
+physician, since dead, said they had only a few months to live. The
+fact that the physician who made the unfavorable prognosis has since
+died himself adds greatly to the zest with which patients tell their
+story. Neither the severity of the symptoms nor the amount of lung
+tissue attacked is quite sufficient to justify an absolutely
+unfavorable prognosis in the majority of cases of pulmonary
+tuberculosis.
+
+
+No Incurable Cases.--Above all, it cannot be insisted on too
+emphatically that there is never a time in the course of the
+tuberculosis when a physician is justified in saying to a patient
+suffering from any form of tuberculosis that his case is hopeless. One
+is never justified in saying "You are incurable." Practically every
+town of any size in this country has a number of cases in which
+patients were told by physicians that there was no hope, and yet they
+have recovered to chronicle as often as they get the chance the fact
+that they have outlived their physician. To say that no case of
+tuberculosis can be confidently declared incurable will seem to many
+an exaggeration. There are patients in whom the prognosis is so
+unfavorable as to be almost hopeless. There are never cases of which
+it should be said there is no hope. When patients are told, as they so
+often are, that they are incurable, absolutely no good is done and
+harm is inevitable.
+
+
+Heredity of Resistance.--When the disease has developed very rapidly
+in patients in whom there is no previous history of tuberculosis, and
+in whom there is no history of previous cases in the family, the
+outlook is always serious. These cases come as near being incurable as
+any the physician sees. But the most apparently hopeless of these will
+sometimes recover, contrary to all anticipation. In spite of the
+opposite impression so commonly accepted, the most helpful element in
+these cases is the presence of a trace of tuberculosis in the family
+history. This always means the existence of some immunity against the
+disease and there may be a turn for the better even when the case
+looks absolutely hopeless and when it seems to just be verging on its
+fatal termination. Probably the most discouraging are the cases in
+which miliary tuberculosis is at work and conditions are about as
+unfavorable as possible. There are cases of this kind on record,
+however, with the most startling contradiction of anticipation, in
+which undoubted miliary tuberculosis produced high fever for weeks and
+even months, then gave rise to pleurisy, to peritonitis, to various
+cutaneous abscesses and to abscesses of bone, in which patients lost
+one-third of {353} their weight or even more, and yet after the
+external lesions began to discharge freely, recovery occurred.
+
+
+Slow Cases.--As for slow-running cases in which there is a distinct
+history of tuberculosis in the family, not even the most experienced
+physician can state with any certainty that a fatal termination is
+inevitable and that recovery cannot occur. Some of the most expert
+diagnosticians have been deceived in these cases. After half a dozen
+physicians have given a man up, some gleam of hope has buoyed his
+feelings and a turn for the better has come. Men with cavities in
+three lobes, even in four lobes and occasionally it is said in all
+five lobes, have survived acute stages, have recuperated to a
+considerable degree and have been able to return to work or at least
+to take up some useful occupation for a time. Where the lung lesion
+progresses slowly it is surprising how small an amount of healthy lung
+tissue is needed to support life. Only those familiar with many
+autopsies on the tuberculous can appreciate this. Ordinarily we are
+apt to think that when more than half the pulmonary tissue is involved
+so as to be of little or no use for respiratory purposes, death must
+be inevitable. On the contrary, one-fourth the ordinary lung capacity
+will serve and all of one lung may be quite out of commission and only
+a portion of a single lower lobe be available, yet the patient may
+survive for a prolonged period.
+
+
+The Specter of Heredity.--The most serious contrary suggestion that
+patients suffering from tuberculosis are likely to have is that their
+affection is hereditary and that, therefore, there is little hope of
+its cure. It is in the family strain and cannot be obliterated. This
+idea, fortunately, does not carry the weight it used to. It should,
+however, have no unfavorable influence at all and this needs to be
+emphasized. We discuss the subject more fully in the chapter on
+Heredity. We know very definitely now that the hereditary element in
+tuberculosis is so small that it is quite negligible. There are good
+authorities who do not hesitate to say that heredity plays no role in
+the causation of tuberculosis and does not even produce a
+predisposition. Some remnant of the old superstition (for
+superstition, from the Latin, superstare, means a survival from a
+previous state of thinking, the reasons for which have disappeared)
+always remains, and predisposition is the last rule of outworn
+opinion.
+
+We know now that contagion is the important element. The possibilities
+for contagion vitiate all proofs of the predisposition idea.
+Especially is this true when we recall that thirty years ago
+practically no one took proper precautions to prevent the
+dissemination of tuberculosis, and very few took them even fifteen
+years ago. Even at the present time many tuberculosis patients cough
+around the house with open mouth, spreading tubercle bacilli all
+around them. We are caring for the sputum, but many other avenues for
+the diffusion of the disease are open. Children acquire the infection,
+overcome it, but retain the seeds of it in them and then in some
+crisis in life, as after puberty, or when they are over-working and
+over-worrying, or during the first pregnancy, an opportunity is given
+to still living tubercle bacilli to find their way out of sclerotic
+confinement. Other forms of contagion count in the absence of a case
+in the immediate family. We can trace the contagion only too easily,
+even if there is no consumptive member of the home circle.
+Scrub-women, laundresses, those who are careless in their attendance
+upon the tuberculous, workers in dusty places or in factories, where
+there are others who cough, all {354} these get the disease.
+Predisposition counts for so little that it is a vanishing factor.
+
+Patients can be assured at once then that they need not worry that the
+hereditary factor will make their affection less curable. On the
+contrary, our recent careful studies in tuberculosis show just the
+opposite of the old false impressions. The children of parents who had
+tuberculosis are much more likely to possess resistive vitality to the
+disease than those whose parents never had it. As we emphasize in the
+chapter on Heredity, the nations that have had the disease the longest
+among them are the most resistant to it. When the affection is newly
+introduced into a tribe or race it carries off a great many victims.
+This immunity, however, is not a function of heredity or of the
+increase of resistive vitality by the inheritance of an acquired
+character from the preceding generation, but tuberculosis takes the
+non-resistant, weeds out all those who have not some immunity against
+it, and consequently those that are left possess some immunizing
+power. Tubercular heredity, then, instead of being a source of
+discouragement should rather be a source of hope. It is surprising to
+note what a relief to many patients' minds is the explanation of this
+newer view of heredity in tuberculosis; it lifts a burden from many
+and makes them eat and sleep better for days.
+
+
+ANNOUNCING THE DIAGNOSIS
+
+Friends and especially near relatives sometimes come to a physician
+when there is suspicion that a young person is suffering from
+tuberculosis and ask that, if there is a ground for a positive
+diagnosis, it shall not be communicated to the patient. They usually
+urge that they fear the discouragement will kill the patient. The
+young are not so easily killed and the reaction on being told the
+truth and the facing of it bravely is such a magnificent help in
+therapeutics that the physician should always refuse for the patient's
+sake alone, quite apart from any ethical obligations in the matter, to
+enter into any such arrangement. The assurance may be given that the
+patient's condition will be so stated that, far from the patient being
+discouraged after due consideration, he or she will look forward with
+confidence to overcoming the affection.
+
+
+EARLY DIAGNOSIS
+
+Mental treatment is most valuable in the very early stage of incipient
+cases of tuberculosis. The time is past when the diagnosis of
+tuberculosis was made only after the recognition of definite physical
+signs in the lungs and a considerable loss in weight.
+
+In the _Medical News_ for April 9, 1904, I called attention to the
+question of "Early Diagnosis of Tuberculosis" from the pulse and the
+temperature in these cases, and pointed out that a disturbance of
+temperature need not necessarily be a febrile temperature of over 100
+degrees, but that any increase of the normal daily variation of
+temperature, usually considered to be about a degree and a half,
+should suffice to arouse serious suspicion at least. If the morning
+and evening temperatures differ by two degrees, this would indicate
+the presence of some pathological condition, usually tuberculosis. If
+in addition to this and the pulse disturbance there is any localized
+area of prolongation of {355} expiration, then tuberculosis is almost
+certainly present, even though there may be no other physical signs,
+no cough, no tubercle bacilli in the sputum, nor any other signs of an
+active process.
+
+It is in these cases particularly that patients can be benefited. Very
+often they have a slight hacking cough, frequently repeated, with some
+disturbance of appetite and of digestion and sometimes some loss in
+weight. Indigestion is recognized now as one of the early stages of
+tuberculosis. The cough in these cases, as has been said, is often
+spoken of as a stomach cough and is supposed to be due to the nervous
+reflex from the pneumogastric nerve carrying irritative impulses from
+the stomach to the lungs. It is much more likely to be due directly to
+irritation of the terminal filaments of this same nerve in the lungs
+themselves.
+
+
+FAVORABLE MENTAL ATTITUDE
+
+The most important element in any cure or successful treatment of the
+disease is a favorable attitude of the patient's mind. He must be told
+at once that consumption takes away only the "quitters." People who
+give up the battle or who, though still hoping, do not hope
+actively--that is, do not make the exertion necessary to get out into
+the open air and to eat heartily--inevitably succumb to the disease.
+
+
+Eating.--Eating is often more a question of exertion than appetite or
+anything else for consumptive patients. They have no active appetite
+and they simply must force themselves to chew and swallow. Their
+fatigue from chewing is, indeed, likely to be so disturbing that it is
+advisable to furnish patients as far as possible with such food as
+requires no chewing. Milk and eggs and the thin cereal foods, like
+gruel, and rather thin puddings are the best for this purpose.
+Patients must be persuaded that they must take these whether they care
+for them or not. Occasionally they may cough after a meal and vomit it
+up. The rule in the German sanatoria for consumptives is that whenever
+this happens they must, after a short interval, repeat the whole meal.
+Only rarely does it happen that a tuberculous patient vomits without
+some such mechanical cause as coughing. They must be made to
+understand that any food that stays down does them good no matter how
+they may feel toward it.
+
+The actual state of affairs as regards their future must be put before
+them. It is a question of eating or of death. They face these two
+alternatives. Eating is objectionable but, as a rule, death is more
+so. The kinds of food they do not care for, if they are good for them,
+must be insisted on. Most people who think that they cannot take milk
+can do so, if it is only presented to them insistently, with at first
+such slight modifications of taste as may be produced by a little
+coffee, or tea, or vanilla, or by some other flavoring extract, which
+modifies its taste. Butter and the meat fats will be taken quite
+readily if it is only once made perfectly clear to patients that they
+must take these or else lose in the conflict with the disease.
+
+It deserves to be repeated here that in many of these cases the
+disinclination to eat is due to the fact that patients find it almost
+intolerably wearying to make the effort necessary for mastication.
+This is particularly true if they are asked to eat meat frequently,
+and especially if asked to eat underdone beef, {356} which usually
+requires vigorous chewing. Such meat is excellent for them once a day,
+but it may be made much easier to take by chopping or scraping so that
+practically no exertion is required. Besides, it is by no means
+necessary that these patients should eat much meat nor that they
+should have to chew laboriously at their food. Raw eggs may be the
+basis of the diet, especially eggs beaten up, and these will be found
+not only to be very tasty, but eminently digestible. Their vegetables
+may be taken in purees, so that they require very little chewing
+effort, though patients must be warned to mix starchy substances well
+with saliva so as to facilitate their digestion. Their bread may be
+taken in the shape of milk toast, or in some other soft form--bread
+pudding for instance. All this helps, without demanding too much
+effort, to prevent loss of weight and to regain it when it has been
+lost.
+
+
+Air and Comfort.--Next to food, the most important adjuvant is fresh
+air. Often patients find many objections to this. It is too cold for
+them; they are shivery and become depressed. Most patients need to be
+dressed much more warmly than is the custom at present, and hands and
+feet should be covered with woolen gloves and socks and even a woolen
+hood worn around the head if necessary. There is usually too much
+covering worn on the chest and too little on the extremities. With
+fleecy wool garments next the body and sufficient clothing, properly
+distributed, many a patient who complains of the cold will at once be
+more comfortable. They must be made to understand that fresh air is
+absolutely essential. Every extra hour they spend in the air is that
+much gained; every hour they spend inside is just that much lost in
+the curative process. If they are uncomfortable, however, they become
+discouraged, and a discouraged tuberculous patient never resists the
+progress of his affection. Not only does he not improve, but he
+inevitably retrogresses. It must not be forgotten, however, that the
+thin anemic patients who complain bitterly of the cold, when they
+first take up the habit of living outside, will grow used to it after
+a time and then will from habit and the accumulation of a ten-pound
+blanket of fat be able to stand the cold much better than many healthy
+persons.
+
+
+Stimulating Examples.--Tuberculous patients need to have their courage
+kept up. It is true that the toxin of the tubercle bacillus has the
+definite effect of stimulating its victims so that they are likely to
+be hopeful, but very often this hopefulness is vague and does not
+tempt them to eat and to live in the open air, the two things that
+make their continued resistance to the disease possible. I find that
+the knowledge of how bravely and how successfully other sufferers from
+the disease resisted its invasion and succeeded in doing a good life's
+work is the very best tonic that sufferers from tuberculosis can have.
+Needless to say, there are any number of examples of heroes of
+tuberculosis who put to shame perfectly healthy people in the amount
+of work they succeeded in accomplishing in spite of the drawbacks of
+their disease. The unfavorable suggestion of the number of deaths from
+the disease must be overcome by the contrary suggestion of the brave,
+busy lives lived by those who suffered even the very severe form of
+the disease and often accomplished the full term of existence in spite
+of their handicaps from tuberculosis.
+
+
+_Robert Louis Stevenson_.--The best example in recent years is
+undoubtedly Robert Louis Stevenson. In spite of tuberculosis in severe
+form which prevented his living in the ordinary climates for the last
+twenty years of his life, he succeeded in doing an amount of work that
+is simply marvelous and in {357} influencing his generation more
+widely than most of the perfectly healthy writers who lived in his
+time. There are over, 2,000,000 published words to the credit of
+Stevenson, and, when we recall that most of this, owing to his
+critical care, had been written over and over many times, some idea of
+the vast amount of work he accomplished will be realized. Perhaps the
+climax of his cheerful nature, the utter lack of discouragement in the
+face of what is usually the most depressing possible incident, is to
+be found in his famous letter to a friend telling him, as he lies in
+bed, that he cannot write at any great length now but that he will
+write a long letter next week if "bluidy Jock," his playful name for
+hemorrhage from the lungs, would only let him.
+
+One of the most striking illustrations of his insatiable appetite for
+work and his complete refusal to admit that he was being conquered by
+the disease has been recently told with regard to his unfinished
+novel, "St. Ives." He had been suffering from certain severe symptoms
+and had been forbidden to do anything at all, even to dictate brief
+notes, or anything else that would make any extra work for his
+respiratory organs. The ideas for chapters of "St. Ives" were in his
+head and would work themselves out in spite of the doctor's
+prohibitions. He would not let the thought of his disease overcome
+him, and so he dictated these chapters to a secretary in the sign
+language, which he had learned so as to be able to communicate under
+such conditions. I know nothing that is more likely to make people
+realize how a brave spirit can overcome every discouragement of body,
+and how much such a spirit is its own reward, since it secures for its
+possessor a prolongation of the life of the body that would surely be
+worn out by depression, by discouragement, and by worry. Undoubtedly
+Stevenson's interest in his work literally gave him new life. It did
+use up some nervous energy, but if his mind had been occupied by
+thoughts of his disease, and its probably fatal consequences, much
+more of his precious store of nervous energy would have been exhausted
+in anxiety and worry.
+
+
+_J. Addington Symonds_.--After Stevenson probably the most striking
+example among modern literary men is John Addington Symonds.
+Comparatively early in life he found that he could not live in England
+owing to the inevitable advance of tuberculosis when he tried to do
+so. He took up his residence then at St. Moritz and other places of
+rather high altitude in Italy and continued his literary work. When we
+see the row of books that we owe to Symonds' literary activity it is
+surprising to think that he, too, like Stevenson, had to watch his
+temperature, that every now and then there were discouraging
+developments and incidents in his tuberculosis, and that a return to
+the ordinary habitations of men away from the friendly altitudes of
+the Italian Alps was always followed by a recrudescence of his
+symptoms. Symonds' work was not merely literary, but his books are
+valuable historical monographs on many subjects requiring much reading
+and diligent study and consultation of authorities. There are few men
+in perfect health and with abundant leisure who have succeeded in
+accomplishing as much as did this hero of tuberculosis.
+
+
+_Thoreau_.--There are other distinguished literary men of the
+nineteenth and twentieth centuries the stories of whose tuberculosis
+has a special interest and tonic quality. One of these is our own
+Thoreau, another is Francis Thompson, the English poet, whose recent
+death has brought him even more publicity than did his great poems
+while he was alive. Both of them are typical examples of another phase
+of tuberculosis that is interesting to realize. {358} It is probable
+that if Thoreau had lived the ordinary, practical, everyday life,
+which those who lived around him thought he should, he would have died
+of tuberculosis before he was thirty. He had no use for money beyond
+his present needs and when he had made enough to keep himself very
+simply he refused to earn any more. He had not time, as he said, to
+make money. He wanted to live his life for itself and for the
+interests higher than the material that there can be in it.
+Accordingly, he set himself to learn all about the birds and beasts
+and the trees and plants and the waters and their inhabitants around
+his country home. He introduced the modern taste for nature study in
+its most beautiful way. He spent most of his time out of doors.
+
+Undoubtedly this out-of-doors life prolonged existence for many years
+beyond what would have been his term. His biographers say that
+probably his being out of doors in all sorts of weather laid the
+foundations of "the cold which settled on his lungs" and eventually
+carried him off. Those of us who know anything about tuberculosis, as
+it has been studied in recent years in the tuberculosis sanatoria, are
+not likely to agree with such an opinion. Our patients in the
+Adirondacks live outside ten or twelve hours a day and then sleep with
+their windows open with the temperature sometimes down to zero during
+the severest winter weather. Rain and dampness are not allowed to
+interfere with the open air program. Colds that "settle on the chest"
+so that people die from consumption are not due to exposure to cold
+but to the bacillus of tuberculosis. Where this once gains a foothold
+the one hope of prolongation of life is out-door air and the more cold
+and stimulating that out-door air is, provided he can stand it without
+discouragement, the better for the patient. Thoreau is an example of a
+man whose life was prolonged by his out-door habits and by his refusal
+to live the humdrum, practical existence of other men, just to be like
+those other men and measure his supposed success by their standards.
+
+
+CHARACTER AS A THERAPEUTIC ASSET
+
+Recent interest in tuberculosis has taught us that the best possible
+asset for a tuberculous patient is character. Resistive vitality in
+the physical order and character in the moral order seem to be
+co-ordinate factors. If a man will not give in in the fight, if he
+insists on struggling on in spite of difficulties, discouragement and
+an outlook that seems hopeless, then he will almost without exception
+get over his tuberculosis, if there is any favorable factor in his
+environment. We talk much of immunity inborn and acquired to the
+disease, but it seems to go hand in hand with a certain capacity to
+stand the debilitating symptoms of the disease without allowing one's
+mind to become depressed or one's disposition rendered despondent by
+them.
+
+
+Courage and Constancy.--The career of Dr. Trudeau to whom we owe so
+much of our knowledge of tuberculosis is a striking example of the
+power of character to enable even an apparently delicate organization
+to withstand the ravages of the disease. This is all the more striking
+because he was an advanced case when he finally reached an environment
+in which he could make head against the disease. The story of his own
+personal struggle for life at Saranac, in which he both learned
+himself and taught others what the modern {359} treatment of
+tuberculosis should be, is one of the best therapeutic documents of
+modern times. Under circumstances that were quite apt to be
+discouraging to anyone of less character than he, with the bitter cold
+of the Adirondacks around him and quite inadequate heating facilities,
+so that even old-fashioned lamps were in requisition for heating
+purposes, he yet succeeded in winning back his own way to health and
+showing others how it could be done. The struggle had to be kept up
+for long, it had to be renewed again and again, our greatest American
+authority on tuberculosis had to learn in his own person all the
+clinical details of the disease, but in the midst of it all he
+succeeded in accomplishing a life work that will stand beside that of
+any man of his generation and will probably mean more in the history
+of American medicine than that of any of his supposedly more
+distinguished colleagues in our large cities and large teaching
+institutions.
+
+This is the sort of man whom tuberculosis does not take in spite of
+every advantage that the disease may seem to have. Two others of our
+American authorities on tuberculosis had almost the same experience.
+
+
+Persistence.--Recently I have been in correspondence with a young man
+who illustrates the same power quite as strikingly. He went to Florida
+and soon found that the unfortunate fear of tuberculosis that has so
+unwarrantably come into many minds in recent years made it extremely
+difficult--indeed, almost impossible--for him to live under such
+circumstances as he hoped for when he went there. In any
+boarding-house he went to just as soon as there was question of his
+having tuberculosis the landlady would either insist on his leaving at
+once or else plead with him to take his departure, lest her other
+boarders should desert her. He was coughing, he had some fever, his
+disease was advancing in the midst of all this disturbance, physical
+and mental, and the outlook seemed hopeless. His picture of this
+selfishness of humanity, scared about nothing (for there is
+practically no danger if tuberculous patients take reasonable
+precautions, as even nurses in sanatoria do not acquire the disease,
+though living in the midst of it), constitutes one of the most
+poignant indictments of human nature in its worst aspect that I have
+ever had presented to me.
+
+Finally he made up his mind that there was nothing for him to do but
+to tent out and live by himself. Fortunately he was able to do that
+and just as soon as he was settled under circumstances where human
+nature did not bother him, nature began to do him good. He feared that
+he would die during the first month in the tent, for he was having
+fever up to 102-1/2 and sometimes more every afternoon; but he laid in
+a store of provisions which with the milk and eggs delivered to him
+every day enabled him to stay in bed for a week, opening up the flap
+of the tent in the middle of the day. Then he went out and got another
+stock of provisions and stayed in bed for another week. His thoughts
+were gloomy enough, he had only some old illustrated newspapers to
+give him a few fresh thoughts every day, he had no one to visit him,
+but he hung on and kept up his habit of rest and forced feeding in
+spite of disinclination. At the end of two weeks he had no temperature
+in the afternoon. At the end of the third week he made for himself a
+reclining chair and sat in the sun outside of his tent wrapped in a
+blanket. At the end of four weeks he had gained five pounds in weight.
+From that on all was plain sailing. It was his character that
+conquered his tuberculosis.
+
+{360}
+
+
+SUGGESTION AS TO SYMPTOMS
+
+Besides the value of suggestion for the general condition in
+tuberculosis many of its symptoms can be treated best by changing the
+mental attitude of the patient towards them and giving him a proper
+appreciation of their significance. Most symptoms are likely to
+produce exaggerated reactions, especially in patients who are
+over-solicitous about themselves. Not a few of the symptoms are really
+nature's attempts at compensation, or the result of conditions which
+show a natural disposition to bring about a cure. Fever, for instance,
+produces lassitude and great fatigue on exertion, and patients are
+prone to think that this means weakness or exhaustion. It is really
+only an indication of the necessity for rest, and is brought about by
+nature's refusal to supply all the demands of the muscles for
+nutrition, at a time when the febrile condition is burning up a lot of
+extra material. Far from being a disadvantage, weakness is a decided
+advantage in this condition.
+
+
+Hemorrhage.--Probably no symptom that occurs in connection with
+tuberculosis is more influenced by the mental attitude than
+hemorrhage. It is a most disturbing incident. Even in quite small
+amounts it upsets the patient seriously and, of course, in large
+amounts it is a source of profound disturbance even to the most placid
+of patients. Excitement always adds to it. Probably no physical means
+that we have at command can be depended on to control it. Ergot used
+to be popular, but such physiological action as it exerts, so far as
+we know the drug, would seem to be likely to do as much harm as good.
+
+Other remedies have gradually lost favor in the hands of those who
+have had most experience with the symptom and gallic acid and
+supra-renal extract, the older and newer remedy, are now little
+depended on. Two things are important--to secure lower blood pressure
+and lessened pulmonary activity. For these opium in some form is
+undoubtedly the best drug; and then a placid state of mind on the part
+of the patient must be secured as far as possible. The scare in these
+cases, in so far as it is relaxing, is rather favorable than
+unfavorable for the patient. In addition, it is necessary to insist on
+absolute quiet and silence and then to allay all reactionary
+excitement. It is important to make patients realize that while
+hemorrhage is a serious complication, it is by no means so serious as
+is usually thought.
+
+Many cases of tuberculosis that eventually run a slow course are
+ushered in by hemorrhage, or have it as a very early manifestation. It
+is surprising how many people have had hemorrhage as a symptom and
+live to tell of it thirty or forty years later. This was not due to
+any mistake of diagnosis, for a generation ago tuberculosis was more
+likely to be missed when actually present than to be diagnosed when
+absent. Indeed, this tendency for the cases in which hemorrhage
+occurred to run not so fatal a course as others was a fact that seemed
+to an older generation of physicians to require explanation. They
+suggested that possibly the hemorrhage swept out with it some of the
+virulent elements from the lungs and so lessoned the infection. From
+what we now know this is a doubtful explanation, but it seems not
+unlikely that a frank hemorrhage might reduce the amount of toxins in
+the circulation and so in an early stage of the disease give nature a
+fresh start in resistive vitality.
+
+{361}
+
+What is much more likely, however, is that the occurrence of early
+hemorrhage made it easier for the patients to appreciate the
+seriousness of the affection and brought them to accept advice as to
+proper precautions. Under ordinary circumstances it is difficult and
+used to be even more so in the past to make the patient understand at
+the beginning of the affection the necessity for giving up indoor
+occupations and living the outdoor life with the care for nutrition
+that is so important if the case is to be improved. Hemorrhage scared
+them into submission. In the old days it was the first positive
+symptom of consumption. Now we have many others, and instead of
+following the advice of over-solicitous relatives that we should not
+tell patients what is the matter with them, we tell them frankly and
+secure such care of the health as will bring about improvement.
+Probably nothing illustrates so well the necessity for thus
+influencing the patients' minds into caring for themselves as the fact
+that the hemorrhagic cases, as a rule, do better than the others. All
+of this can be used to make the minds of patients much less disturbed
+than they would otherwise be by this alarming symptom.
+
+
+Cough.--In the chapter on Coughs and Colds we have outlined how much
+coughing may depend on suggestion, or habit, or on the tendency to
+yield to slight bronchial irritation when there is no real necessity
+for it. Most tuberculous patients cough much more than is necessary.
+This is always somewhat dangerous for them since it disturbs their
+lungs, has a tendency to distribute tubercle bacilli in their lungs,
+or in the air around them, and may by efforts at expulsion lacerate
+affected blood vessels and produce hemorrhage. Whenever cough is
+productive it should be indulged in, for it removes material that
+should not be allowed to accumulate. Unproductive coughing, however,
+can usually be controlled by training.
+
+It is particularly at the beginning of phthisis that the control of
+coughing by suggestion is important. There are many little coughs,
+"hacks" as they are sometimes called, frequently repeated by those in
+a very early stage of pulmonary tuberculosis and which are consequent
+upon irritation either of pulmonary nerves or of pulmonary tissues,
+but that are quite unnecessary, as a rule, if a little attention is
+paid to suppressing them. As a warning sign they are excellent, but
+the patient should be taught not to indulge in them. Coughing tends to
+prevent nature's curative reaction and the contraction of pulmonary
+tissues which may take place around a lesion. In beginning
+consumption, even where there is but slight infiltration, we know from
+the observation of the movements of the diaphragm either by the X-ray
+or directly by Litton's method that its excursions on the affected
+side are shortened. Coughing is in direct opposition to this setting
+of the lung at rest and therefore should be controlled; however, as
+our drug remedies are likely to disturb the stomach, whose healthy
+function is so important in these cases, the use of the mind in the
+control of the cough is of the greatest value.
+
+
+Thoracic Discomfort.--Complaints are often made by the tuberculous of
+pains in the thorax. Ordinarily the discomfort is supposed to be due
+to the lung condition, and it is assumed that it is either actually in
+the lung itself or in the pleura, or communicated from them by reflex
+to the muscles. In most cases, however, patients complain of pain on
+the side that is either not affected at all or least affected. If they
+have been told that the other side is suffering most from
+tuberculosis, they are prone either to think that now the {362} well
+side is being invaded or else that their physician is making a
+mistake, and both thoughts are seriously discouraging. The reason for
+the pains on the well or the better side, however, are easy to
+understand. As far as possible, as can be readily demonstrated by the
+X-rays or seen in the observation of the so-called Litten's
+phenomenon--the excursions of the diaphragm--nature puts the ailing
+lung at rest and the diaphragm moves much less on that side than on
+any other. In order to make up for the lack of breathing in this side
+the other lung does compensatory work. This over-stretches the muscles
+of the thorax on the well side and causes some over-work in them. The
+consequence is a tiredness which may become fatigue; in damp weather
+this may be even painful. Just why damp weather has this particular
+effect on muscles is not surely known. Muscular action is probably
+accomplished with more difficulty in damp weather because of the
+relaxing effect of moisture on tissues and circulation. Reassurances
+may be given them, then, that will keep them from thinking seriously
+of the significance of these pains except as an index of nature's
+compensatory efforts. The painful conditions instead of causing
+discouragement will, then, be a source of encouragement. It must not
+be forgotten that rubbing with some gentle stimulant, soap, liniment,
+or the like, will greatly improve the thoracic muscles in these cases,
+but the rubbing must be done gently and by someone else beside the
+patient, for it is only beneficial if done from before, backwards, in
+order to help the return venous circulation which runs in that
+direction in the external respiratory muscles.
+
+
+Altitude.--There is a marked difference between the amount of water
+which finds its way out through the lungs at varying altitudes. At sea
+level an ordinary patient will lose during the night about 300 cc,
+that is, something more than half a pint of water, through his
+respiratory tract. At an altitude of 5,000 feet, however, this amount
+is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet
+it is half as much again as it is at sea level. This copious giving
+off of water has a marked effect on the lungs. It constitutes one of
+the reasons why altitude is a favorable element in the treatment of
+tuberculosis. Only beginning cases of tuberculosis, however, are able
+to stand the additional work thus put on them, though a slight
+elevation, up to 2,000 or even 3,000 feet, rather seems to be of
+benefit to all cases. How far-reaching the effect of this extra loss
+of fluid is, is appreciated from the concentration of blood which
+takes place and which produces a blood count of 8,000,000 red cells at
+a mile of altitude in patients who, at the sea level, have no more
+than 4,500,000. Such patients, of course, need much more water and
+fluids generally to be comfortable than when living lower down.
+
+
+Suggestion and Treatment.--There are many accessory suggestions with
+regard to food that serve to confirm the patient in the idea that
+abundance and variety of food must be taken if the battle with the
+disease is to be won. To patients who find milk difficult to take, it
+must be explained that a copious amount of fluid in the system is
+needed in order to make coughing easier. So milk serves a therapeutic
+as well as a nutritional purpose. In the same way it may be explained
+that fats, such as bacon and cream, help to keep the bowels from
+becoming constipated and constipation inevitably disturbs the
+appetite.
+
+Explanations as to the advisability of being out of the city and in a
+portion of country not very thickly populated, in order to avoid the
+possibilities of secondary infection with other respiratory diseases
+and bacteria of various {363} kinds, will make a patient understand
+the necessity for leaving town. It may be helpful, also, to insist on
+the value of living at some elevation above sea level as an aid to
+expectoration.
+
+Cough is the symptom that many of these patients fear most, and a
+promise of any amelioration of it by a simple change of location helps
+them to make the sacrifice of city life for a while. Some patients who
+have been benefited by a stay in a sanatorium come back with a relapse
+of their symptoms. They dread to return to the sanatorium and think
+they can care for themselves as well at home, since they know what the
+regulations are, though it may be evident to the physician that they
+are losing ground in their city environment. It is well worth while to
+give them a careful explanation of what we know of the effect of
+altitude upon consumptives who have sufficient reactionary power to
+stand it.
+
+
+_Negative Suggestions_.--Some suggestions are valuable for the
+prophylaxis of complications. For instance, tuberculous patients must
+be warned not to indulge in breathing exercises without the express
+consent of the physician. So much is said in popular literature as to
+the value of breathing exercises that many a patient suffering from
+tuberculosis thinks that, not only may they be indulged in with
+impunity, but that they will surely do good and can do no possible
+harm. Nothing could be more erroneous. Many localized lesions have
+been diffused in this way and there is always danger that the strain
+will cause hemorrhage. Patients must be warned also to avoid any
+possible condition in which they might have to over-exert themselves.
+Because of the dust inevitably breathed during automobile riding, this
+pleasure must be denied to tuberculous patients as a rule, but even
+when they have recovered sufficiently so that this may be permitted
+they must be warned not to take long rides into the country lest the
+breaking down of the machine should place them under the necessity of
+walking a long distance. This idea should also be emphasized for
+rowing excursions, or trips by motor boat, for occasionally they lead
+to serious and exhausting exposure.
+
+One negative suggestion should be given at the very initial stage to
+every patient in whom the presence of pulmonary tuberculosis has been
+recognized. This should be a warning to exercise the greatest care
+against permitting the development of constipation. Tuberculous
+patients must never strain at stool. Almost necessarily a certain
+number of tubercle bacilli are swallowed every day whenever pulmonary
+tuberculosis is at all active and they are constantly present in the
+digestive tract. If tuberculous patients then strain at stool, little
+abrasions of the mucous membrane of the rectum are caused in which
+tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are
+common among the tuberculous and rectal fistulas often give much
+bother. When a tuberculous patient develops such a condition, a period
+of depression and discouragement will follow, for there is a curious
+tendency to depression associated with all lesions of the rectum. A
+pulmonary patient who has been doing well will often fail to make
+progress for months after the development of even a small
+ischio-rectal abscess.
+
+{364}
+
+
+CHAPTER III
+
+NEUROTIC ASTHMA AND COGNATE CONDITIONS
+
+
+For the consideration of its psychotherapy asthma may be divided into
+two forms--symptomatic and essential, or neurotic, asthma. Symptomatic
+asthma is a difficulty of breathing, the result of some interference
+with the circulation, as by heart disease, or with the oxidizing power
+of the blood, as by kidney disease, or various blood conditions, or
+from direct interference with respiration from some pulmonary
+affection. Essential asthma is not dependent on any organic condition,
+but is an interference with breathing without any distinct
+pathological condition in the lungs themselves or in the general
+circulation. There may be some emphysema, but not enough to account
+for the respiratory difficulty. It is spoken of as neurotic asthma,
+and the most careful investigations made of individuals who have died
+during a seizure has failed to give any sure pathological basis for
+the affection. Certain accompanying phenomena are worthy of note. The
+most interesting of these are Curschmann's spirals, which usually
+occur in the form of translucent pellets very characteristically
+described by Laennec as pearls. They are evidently formed in the finer
+bronchioles and show that the affection extends to the terminal
+portions of the bronchial system. In connection with these the
+so-called asthma crystals first described by Charcot and Von Leyden
+and sometimes called by their combined names are often found. Besides,
+there are a large number of eosinophiles in the sputum itself
+entangled within the filaments of the spirals and an eosinophila of
+the blood.
+
+
+Etiology.--Not only are we ignorant of the reasons for these phenomena
+but there is even some doubt as regards the mechanism of the
+respiratory spasm itself. There is a general impression that the
+paroxysm is due to incapacity to inspire because of a paroxysmal spasm
+of the respiratory muscles. Gee in his "Medical Lectures and
+Aphorisms" [Footnote 30] rather leans towards the explanation that
+suffering is due not to any inability to fill the lungs but to
+incapacity to empty them when they have become over-distended with
+air. He tells the story related by Dean Swift of the old man whose
+barrel-shaped chest was fixed in spasm so full of air that the patient
+could not find room for the slightest additional breath. "If I ever
+get this air that is in me out," the patient declared to the Dean, "I
+will never take another breath."
+
+  [Footnote 30: Frowde, Oxford Univ. Press. 1908.]
+
+It is important to differentiate symptomatic from neurotic or
+essential asthma. In symptomatic asthma the only assured treatment of
+the condition must come through amelioration of the organic condition
+causing the symptoms. Cardiac and renal asthma respond promptly to
+remedies which relieve critical conditions that may be present in the
+heart or kidneys. It must not be forgotten, however, that respiration
+is readily disturbed by mental influences. Where cardiac or renal
+disease causes interference with respiration this is much emphasized
+by the patient's unfavorable mental attitude toward it, or much
+relieved by keeping him from worrying over his condition. Even
+symptomatic asthma, then, has a definite place in psychotherapeutics,
+though {365} it would be serious not to recognize the underlying
+conditions and treat them. If the patient's attitude of mind is one of
+discouragement, the respiratory difficulties will continue to be a
+marked symptom of the case, even though the proper remedies for the
+relief of cardiac or renal conditions are administered.
+
+
+Symptomatic Picture.--What is likely to be one of the most disturbing
+experiences of the young physician early in practice, especially if he
+has not before seen a typical case, is to be called to a patient
+suffering from a severe attack of asthma. Often the sufferer is
+sitting up in bed so as to get all the air possible, and, though the
+windows are wide open, he is gasping for breath, usually pleading for
+more air with a tense, anxious expression, starting eyes, and the
+sweat pouring from his forehead, while the accessory muscles of
+respiration, deeply engaged in moving his thorax to move air enough to
+keep him from stifling, emphasize his dyspnea. Occasionally a degree
+of cyanosis develops that is quite startling for the untrained
+observer. Most of those who see the symptomatic picture for the first
+time think that death is impending, and the patient himself, if he has
+not had a series of attacks, will fear a fatal termination. It appears
+impossible to believe that the next morning, within six or seven hours
+of this, the patient will, as a rule, be quite well and walking round
+in the enjoyment of apparent good health.
+
+As a rule, the worse these cases seem in their intensity and the more
+the patient is anxious, the more surely are they merely of functional
+nervous origin; above all, the more complaints of lack of air and of
+fear of impending death that are made, the more likely is the patient
+to be all right within a few hours. Asthma looks as though it must be
+due to some serious organic condition. Of course, in many cases of
+difficult breathing, even with asthma-like attacks, there are
+underlying serious conditions of heart and kidneys that are extremely
+dangerous. As a rule, however, these do not produce the woeful
+pictures of purely neurotic asthma. Even when the basis of the asthma
+is an emphysema, which of itself is not dangerous and is quite
+compatible with long life, the attacks, though frequent and severe,
+are usually not so serious looking as those in which absolutely no
+pathological condition of the lungs, or heart, or kidneys can be
+found, and, indeed, in which there is absolutely no organic change to
+account for the extremely uncomfortable and even terrifying symptoms.
+
+
+Mental Influence.--In the medical literature of asthma there are
+abundant proofs that the attitude of mind of the patient towards his
+affection means very much. There is the story, thoroughly vouched for,
+of the two friends stopping at a little country hotel late at night.
+One of them was a neurotic subject, who, whenever he remained for some
+time in a stuffy atmosphere, was likely to have a severe asthmatic
+attack. The quarters assigned to them proved to be one of the cramped
+little rooms with a single small window that occasionally are found in
+the attics of country inns in England. During the night the patient of
+asthmatic tendencies had one of his attacks and begged his friend to
+open the window. The friend, suddenly roused from sleep, did not
+remember the position of the window and, the night being very dark, he
+felt for it and finally found it. He could not raise the sash and he
+could not move it either inward or outward and there seemed no way of
+getting it open. His friend was insistently clamoring for air with
+that tone of despair and {366} dread of impending death so
+characteristic of the young, inexperienced asthma sufferer. Unable to
+get the window open, the sympathetic companion finally took his shoe
+and smashed the glass. The relief was immediate. Scarcely had the
+crash of the broken glass been heard before the patient gave an
+audible sigh of relief. When his friend went over to him he felt so
+much better that it was rather easy for the sufferer to persuade him
+that nothing more would be needed and that he should go back to bed.
+In the morning, when the friend awoke, his first glance, directed by
+the sunlight that came streaming into the window, was toward the
+broken panes of the night before. To his surprise it was not broken.
+Wondering what had happened, he looked round the room to find that he
+had smashed two panes in an old bookcase set into the wall, and that
+it was the breaking of the glass with the suggestion of free ingress
+of air that it involved and not any real provision of fresh air that
+had cured his friend's asthma so promptly.
+
+
+_Suggestion_.--When much-vaunted cures for asthma are analyzed, many
+of them are found to depend more on suggestion than on any other
+element. Various forms of cigarettes are used, comparatively innocuous
+in themselves, and certainly of no strong therapeutic action, yet they
+work marvels in loosening the spasm that comes over the lungs in
+asthmatic attacks. Any sort of a cigarette will do at the beginning. I
+have seen dried grape-vine stems work very well in the country,
+especially in young women to whom the idea of smoking anything was
+strongly suggestive. Cubebs cigarettes have the same effect on older
+people. Doubtless there is some relaxing action in the smoke. This is
+not enough, however, to account for the effect produced without mental
+influence. After cubebs have been tried for a period and begin to lose
+their efficacy, then other materials that produce a pungent smoke or
+have a certain sensory action, as stramonium leaves, may be used, and
+will also have the marvelous power of cubebs. After a time, however,
+they, too, lose their efficacy, and, as a rule, each successive
+cigarette that is tried has less power than the first to control the
+difficulty of breathing.
+
+The more one hears of cures for asthma, and the longer one has
+experience with these cases, the clearer does it become that there is
+a large suggestive element in every successful treatment. If a piece
+of ordinary blotting paper be dipped in a strong solution of saltpeter
+and allowed to dry, it will, if touched by a lighted match, burn
+slowly without flame, but with the production of heavy, thick smoke.
+The therapeutic elements in this are not very strong, but the
+suggestive element, when a room gets full of it, is intense and is
+cumulative. Very probably the thick smoke, rich in nitrites, has some
+tendency to relax the spasm in the lungs which causes the asthmatic
+seizure, but after a time the remedy fails and something else has to
+be tried. In many cases, when first used, it almost works a miracle.
+This is the simplest type of suggestive treatment for asthma.
+
+
+_Mental Shock_.--Any strong mental influence, especially if
+accompanied by the suggestion of assured relief, is likely to do much
+for asthma of essentially neurotic character, and indeed is more
+powerful in dispelling the symptoms of the seizure than almost any
+other means that we have. Sometimes even things absolutely indifferent
+which produce a profound mental impression, prove curative. There are
+many stories of men in the midst of a severe asthmatic seizure being
+suddenly roused by the cry of fire, or an alarm of some {367} kind
+near them, having the spasmodic conditions disappear as if by magic.
+Occasionally where attacks of asthma recurred regularly on successive
+nights for a considerable period, travel on a railroad train or
+anything else which occupied the attention much, prolonged the
+interval between seizures and sometimes put an end to the series of
+attacks. The more one knows of asthma the more one realizes how much
+its occurrence depends on mental influences of many kinds in
+association with various reflex irritations, some of them very distant
+from the respiratory tract and comparatively trivial in their effects
+on other people.
+
+
+_Loss of Control_.--Occasionally in elderly neurotic people
+over-fatigue induces an attack of asthma about the time that sleep
+becomes deep. This usually occurs after the first hour or two of
+sleep. The inhibitory power of the nervous system over spasmodic
+contraction of the lung tissues seems lost in deep sleep and then the
+asthmatic condition develops. The greater the effort to breathe the
+more intense does the contraction become, until the antispasmodic
+effect of the presence of a lessened amount of oxygen and an abnormal
+quantity of carbon dioxide in the blood makes itself felt. In many
+cases these patients will be relieved of the tendency to such spasm by
+taking a cup of coffee. This stimulates the general circulation and
+minimizes the reflex tendency which centers in their respiratory
+tracts. Such patients after taking an amount of coffee that would keep
+ordinary people awake all night, sink in the course of half an hour
+into a quiet, restful sleep and awake quite refreshed. This is not
+entirely suggestive, but suggestion plays an added role in the relief
+of all the symptoms.
+
+
+Treatment.--_Varied Cures_.--We do not mean to say that asthma is
+entirely amenable to suggestive treatment, but we emphasize the mental
+influences in its production and its cure. A new and almost infallible
+cure is announced nearly every year for asthma, as for tuberculosis.
+Sometimes this is some new treatment for the nose, occasionally it is
+a novel method of treating the throat, but reflexes from a great many
+other organs not at all in touch with the respiratory system have also
+been supposed to be productive of asthma, and their treatment has been
+followed by relief from this trying condition. Washing out the
+stomach, for instance, has been followed by prolonged cessation of
+asthmatic attacks. In children it is claimed that occasionally the
+correction of eye-strain by the proper glasses has cured neurotic
+asthma. There are those who have had cases where the relief of
+long-continued constipation had a like therapeutic result and there
+are other and even more curious claims for curative effect in this
+affection.
+
+
+_Negative and Positive Suggestion_.--Any condition in the human body
+that sets nerves in tension and requires constant inhibition may lead
+to such a cumulative effect of repression that reaction follows and
+explosion takes place. In particularly susceptible individuals,
+irritable respiratory centers may be affected with consequent
+asthmatic seizures. The direct treatment of the respiratory tract to
+secure ease of respiration often does away with the liability to
+asthma by direct prevention. If patients, especially young patients,
+are mouth-breathers the clearing out of the throat and nose so as to
+insure normal breathing can naturally be expected to lessen any
+tendency to asthma. In the same way treatment of irritative or
+degenerative conditions in the throat and larynx, as well as in the
+nose, may be considered directly curative. On {368} the other hand,
+there is no doubt that many of the slight ameliorations of intranasal
+conditions suggested by enthusiastic specialists as curing asthma do
+not have any direct therapeutic influence but owe their efficacy to
+the strong suggestion of the operator's assurance on the patient's
+mind that this treatment has cured asthma in many cases and will
+surely cure him.
+
+
+_Drugs and Suggestion_.--The medicines that are especially effective
+in asthma of neurotic origin are those which also have a large
+suggestive influence because of their taste or their effects upon the
+system. Hoffman's anodyne is an efficient antispasmodic and is
+wonderfully effective in relieving the tendency to asthma. I have
+always felt, however, though I have given it freely, that a large
+element in its effectiveness was its particularly disagreeable taste
+and odor and then its excretion through the lungs with a certain sense
+of well-being allied somewhat to the intoxication that comes from the
+inhalation of ether. I have seen asthmatic tendencies in young women
+greatly relieved by the use of valerian. Undoubtedly this remedy, like
+the compound spirits of ether, is antispasmodic in action, yet to a
+much less degree than Hoffman's mixture, and over and over again I
+have noted that in pill form, though given in large doses, it was not
+as effective as if given in liquid form when its nauseating smell
+added distinctly to its suggestive influence. The drug itself does
+good but it is distinctly helped by the influence upon the patient's
+mind of its taste and, above all, of its aroma. The elixir of ammonium
+valerianate being particularly unpleasant is likely to be more
+beneficial to these patients.
+
+
+_Climatotherapy and Suggestion_.--The climatic treatment of asthma has
+received much attention. Change of scene and environment nearly always
+does good. Different patients, however, require very different
+conditions. Of two cases of neurotic asthma in which no diagnostic
+differences can be found, one will improve at the seashore or on a sea
+voyage, while the other will be made worse by such a change though
+probably the asthma will be improved in the mountains or in some dry
+climate. Even moving from one part of a city to another has brought
+great improvement in asthma. Sometimes there were good reasons for
+this, as, for instance, when an investigation showed that the patient
+had previously been living above a bakery from which there came a good
+deal of hot air and flour dust. Some people are actually improved by
+close contact with human beings in rather crowded quarters. I have
+known a settlement worker to experience great relief from asthma when
+living in the slums. Where there is intense occupation of mind,
+especially if combined with the suggestion that now the asthma ought
+to be better, seizures will be less frequent and less severe. All
+sorts of places in the mountains and by the seashore have acquired
+reputations as relieving asthma which were justified by many cured
+cases and yet they have lost this reputation. Whenever there are many
+sufferers together, the expectancy of relief seems to do great good.
+
+
+
+CHAPTER IV
+
+DUST ASTHMA, SEASONAL CATARRH, HAY FEVER
+
+
+Grouped under the term "hay fever" there are probably as many
+different affections as there are under the term "chronic rheumatism."
+There are {369} people who, in the springtime, as soon as the weather
+gets warm, suffer from what is popularly called hay fever. This is
+often called "spring catarrh" or "rose cold" and seems often to be
+associated with the pollen of flowers. Then there are people whose hay
+fever, as it is called, develops about the first of June and continues
+to be bothersome until the middle of July, when there is a remission
+of symptoms, though in dry prolonged hot periods after that the
+affection may recur. It seems as if, at the beginning of the heated
+term, the warm, dry dusty air irritates their nostrils very much,
+while after some weeks they gradually become used to this and the
+reaction is not so violent. Then there are the regular hay-fever
+patients whose affection occurs principally in haying time, during
+August and September, though most of them have not been near hay
+pollen, and the disease is an affection of dwellers in cities rather
+than in the country, of indoor livers more than of farming people, who
+might be expected to suffer most from the supposed cause, hay pollen.
+Even where pollen is directly concerned in its causation it is
+probably oftener the pollen of the rag weed rather than that of hay
+that is responsible for it.
+
+There are two elements in the disease apparently of equal importance.
+One of these is a strictly local condition interfering with
+respiration in some way, or with the circulation to the mucous
+membrane of the nose and the lachrymal ducts. The other is an
+individual over-sensitiveness so that there is an exaggerated reaction
+to irritation. Some of this is mental, that is, is due to expectancy,
+or to the persuasion that this reaction is sure to occur under certain
+circumstances. As a consequence, attacks of hay fever are reported
+even after a distant view of a hayfield, or of rose cold due to the
+sight of an artificial rose, and of other recurrences that show the
+power of the mind to bring about at least a beginning of symptoms.
+
+While the first or physical element in the etiology of dust catarrh
+can be treated successfully by various means, it is important to get
+the mind of the individual in a favorable state so as to enable him to
+obtain better control over his vaso-motor system which is so much
+influenced by emotions and thoughts. It is this latter element in the
+causation of the disease that has been successfully treated by the
+many remedies that for a time have had reported success in the cure of
+hay fever yet afterwards proved to be of no benefit because they had
+lost their influence over the patients' minds.
+
+In a review of Morell MacKenzie's book "Hay Fever, with an Appendix on
+Rose Cold," Dr. J. N. MacKenzie   [Footnote 31] has some paragraphs on
+hay fever which, though written twenty-five years ago, are worth
+recalling for a proper understanding of the disease. He preferred to
+call the disease rhinitis sympathetica or coryza vaso-motoria
+periodica, names which are much better descriptive terms and have no
+unsubstantiated suggestions of etiology in them.
+
+    [Footnote 31: _American Journal of Medical Sciences_, 1886.]
+
+  According to our conception, the so-called nasal reflex neuroses,
+  whether taken singly or collectively, as the cause of the _ensemble_
+  of phenomena known as "hay fever," may be regarded as the protean
+  manifestation of a morbid condition to which we have given the name
+  rhinitis sympathetica, and which is characterized by a hyperesthetic
+  condition of the vaso-motor nerve centers linked to a peculiar
+  excitability of the nasal cavernous tissue. For, if we inquire what
+  condition or conditions is common to them all, and what morbid
+  process is capable of producing them, either singly or in
+  combination; how phenomena apparently {370} so widely different in
+  character and anatomical sphere of operation may be traced to a
+  solitary source, we find the answer in certain more or less clearly
+  defined changes in the nasal apparatus and in a certain exalted
+  state of the sympathetic nervous system, to which latter we
+  instinctively turn as the organ most conspicuously concerned in the
+  evolution of purely reflex acts. In whatever relation the local
+  nasal affection and the condition of the sympathetic stand to each
+  other in the matter of cause and effect, they must both be regarded
+  as inseparable factors in the production of the phenomena under
+  consideration. It matters not to what hypothesis the path of
+  speculation may lead. Of this we can be reasonably sure, that in the
+  production of the characteristic symptoms of this disease, a certain
+  excitability of the nasal passages is necessary, plus an exalted
+  state of the central nervous system.
+
+Dr. MacKenzie calls attention particularly to the erectile character
+of the tissues mainly involved in all these forms of dust catarrh and
+dwells on the rôle that mental influence always plays in the phenomena
+noted in such tissues. This with the vaso-motor elements in the
+affection which are so largely also under the control of the emotional
+nature make it clear that the pathology of the affection must be
+considered from this standpoint and, therefore, its therapy also.
+
+Dr. MacKenzie continues:
+
+  From our present knowledge of the disease, it seems difficult to
+  escape the conclusion that its pathology is intimately interwoven
+  with a morbid condition of the vaso-motor sympathetic, and probably
+  a hypersensitive state of the nerve centers themselves. When we
+  recall the fact that in the famous section of the sympathetic in the
+  neck by Claude Bernard, symptoms similar to, or closely allied to,
+  the phenomena of hay fever were produced; when we reflect upon the
+  results reached by Prevost in his experiments on the spheno-palatine
+  ganglion, is there not a clue to lead us through the labyrinth of
+  our difficulties to a rational solution of the question? . . .
+
+  . . .In the human body, wherever erectile tissue is found, it is
+  intimately related to reflex or sympathetic acts; there seems to be
+  connected with it a certain receptivity to reflex producing
+  impressions, a certain power of reflex excitability dependent upon
+  its structure and functions. It is thus peculiarly a tissue of
+  sympathy in which we may most satisfactorily study the mechanism of
+  purely reflex or sympathetic acts. Now it seems to us that, as the
+  nasal corpora cavernosa belong to this class of sympathetic tissues,
+  there will be little difficulty in explaining the rôle which they
+  play in the paroxysms of an affection which is probably connected
+  with, if not dependent upon, an excitation of the sympathetic nerve
+  centers, and in more clearly defining the intimate relation which
+  its erection bears to the reflex manifestations of the disease under
+  review.
+
+These considerations explain the heredity of the affection in many
+cases, since it is dependent on defects that may be family traits, yet
+they also enable us to understand how slight lesions of the nasal
+mucous membrane may be the center from which radiate the underlying
+pathological conditions of the disease.
+
+
+Railroad Asthma.--There is a form of dust asthma which deserves
+special attention here because it is due to modern conditions and
+helps to an understanding of the etiology. It occurs in sensitive
+persons when they travel on railroad trains in warm weather,
+particularly if it has been dry for several days and dust is abundant.
+It has been called railroad asthma or railroad catarrh by the English
+and the Germans, but the condition has no necessary connection with
+the railroad. It occurs as a consequence of the infiltration into
+railroad cars of fine dust during the passage of the train. {371} I
+have seen it in those who had made long trips over dusty roads in
+automobiles, though the dust of the railroad seems finer and more
+penetrating. It develops just as much at the end of a long train as if
+the passenger spent most of the journey in the car next the engine and
+apparently it makes no difference whether the engine burns hard or
+soft coal. They use soft coal almost exclusively in England and
+Germany, but one sees cases of it here after travel on roads that burn
+hard coal and are especially cleanly in this respect. Soft coal adds
+somewhat to the amount of dust and therefore this increases the
+irritation, but there is nothing specific about coal dust. It is
+surprising how severe the symptoms may be. I have seen a patient who
+had traveled continuously for four days across the continent who had
+so much photophobia when he alighted from the train, that he was
+almost unable to open his eyes, and it was not until twelve hours had
+passed that he could open his eyes with any comfort, yet at the end of
+two days practically all the symptoms had passed off.
+
+Prof. Fraenkel, professor of laryngology and rhinology at the
+University of Berlin, who was one of the first to classify the
+condition among the affections related to "hay fever," described
+certain features of it very well in a clinical lecture reported in
+_International Clinics_, Vol. II, Ninth Series, 1899. As a rhinologist
+he insists on the nasal conditions that underlie the affection yet
+suggests that the nasal hyperemia may be due to reflexes of one kind
+or another. The basis of these is undoubtedly very often an emotional
+condition of the patient, a dread of dust, an expectancy of symptoms
+and a consequent exaggerated reaction. Unorganized dust produces
+asthma, but organic materials bring more severe and lasting effects,
+partly because of the mental effect of odors and other sensory
+conditions in connection with them.
+
+
+The Personal Element and Power of Suggestion.--The history of these
+asthmas and other symptoms produced by odors and dust make it clear
+that the more that is known about the disease the surer it becomes
+that there is a large personal element, usually dependent on a certain
+frame of mind, in the cases. Some people are affected by one form of
+irritant, some by another, some by pollen, others by animal
+emanations, and not a few by a persuasion of the likelihood of
+suffering from these things, since occasionally the sight of an
+artificial product produces a like result. Certain classes suffer much
+more than others. Those who are much confined to the house and who are
+especially prone to reflection upon themselves and their feelings form
+the great majority of the patients. In old days the monks were
+favorite victims, in modern times literary folk, students, and those
+who have the time and the inclination for reading and introspection
+are particularly likely to suffer. How much the mental element may
+account for in these cases is not clear, but it stands for much more
+than has been thought and there seems no doubt that more relief of
+symptoms is afforded by diversion of mind and change of dwelling quite
+apart from external conditions than in any other way. It is important
+to remember that no specific dust but almost any kind of dust produces
+these conditions in sensitive persons.
+
+Dr. MacKenzie describes an interesting case in which all the symptoms
+were produced by the presence of an artificial rose. The story is so
+striking and he has told it so well that I prefer to tell it in his
+own words. I may say, however, that the clinical history of the case
+was typical. About the end of {372} May or the beginning of June every
+year the patient suffered from a coryza preceded for a few days by an
+indefinite sense of general depression with a disagreeable feeling of
+heaviness in the head. Sometimes there were chilly feelings and
+general malaise. The catarrhal stage commenced with profuse watery
+discharge from the nostrils, copious flow of tears with redness of the
+conjunctiva, itching of the puncta lacrymalia and photophobia. The
+exterior of the nose, especially at the tip, became intensely red and
+toward the close of the attack the cuticle desquamated. There was a
+short, dry, hacking cough relieved by sneezing, an intense tickling
+sensation in the throat, the voice became husky, the pharynx dry, the
+ears stopped up and tinnitus occurred. Her attacks continued most of
+the summer and were always brought on by the pollen of any plant and
+above all by the smell of a rose. It was, indeed, an example and of
+the most aggravated form. She was brought to Dr. MacKenzie in
+consultation and I leave him to tell the rest of the story.
+
+  Decidedly skeptical as to the power of pollen to produce a paroxysm
+  in her particular case, I practiced the following deception upon
+  her, which still further confirmed me in that belief. For the
+  purpose of the experiment I obtained an artificial rose of such
+  exquisite workmanship that it presented a perfect counterfeit of the
+  original. To exclude every possible error, each leaf was carefully
+  wiped, so that not a single particle of foreign matter was secreted
+  within the convolutions of the artificial flower. When the patient
+  entered my consultation room, she expressed herself as feeling
+  unusually well. The evening before she attempted to wear some roses,
+  but had been obliged to remove them from her dress, as they had
+  produced a great deal of discomfort. Apart from this incident she
+  had been perfectly comfortable for several days and nights. Her
+  conjunctivae were normal, the nasal passages free, and there was
+  nothing to indicate the presence of her trouble. She conversed with
+  me for some time about her case and on general topics, speaking in
+  the most encouraging manner concerning the progress she was
+  apparently making toward recovery. I proceeded to remove the slight
+  slough from the cautery operation, which lay loose in the nostril,
+  and made an application to the mucous membrane, and all without
+  exciting the slightest tendency to reflex movements. After I felt
+  sure that such tendency was absent, I produced the artificial rose
+  from behind a screen, where it had been secreted, and, sitting
+  before her, held it in my hand, at the same time continuing the
+  conversation. In the course of a minute she said she must sneeze.
+  This sensation was followed almost immediately by a tickling and
+  intense itching in the back of the throat and at the end of the
+  nose. The nasal passages at the same time became suddenly
+  obstructed, and the voice assumed a hoarse nasal tone. In less than
+  two minutes the puncta lacrymalia began to itch violently, the right
+  and afterward the left conjunctiva became intensely hyperemic and
+  photophobia and increased lacrymation supervened. To these symptoms
+  were added, almost immediately, itching in the auditory meatuses and
+  the secretion of a thin fluid in the previously dry nasal passages.
+  In a few minutes the feeling of oppression in the chest began with
+  slight embarrassment of respiration. In other words, in the space of
+  five minutes she was suffering from a severe coryza, the counterpart
+  of that which the presence of natural roses invariably produced in
+  her case. An examination of the throat and nasal passages was then
+  made. The right nostril was completely obstructed by the swollen,
+  reddened, irritable, turbinated structures; the left was only
+  slightly pervious to the air current; both were filled with a
+  serous-looking fluid. The mucous membrane of the throat was also
+  injected, but did not exhibit the same amount of redness and
+  irritability found in the nasal passages. As the discomfort was
+  rapidly increasing, and as I considered the result of the experiment
+  sufficiently satisfactory. I removed the rose and placed it in a
+  distant part of the room. When told that the rose was an artificial
+  one, her amazement was great, and her incredulity on the subject was
+  only removed upon personal examination of the counterfeit {373}
+  flower. She left my office with a severe coryza, but also with the
+  assurance that her disease was not altogether irremediable. A few
+  days later she called to see me again, and on that occasion she
+  buried her nostrils in a large, fragrant specimen of the genuine
+  article and inhaled its pollen without the slightest tendency to the
+  production of reflex acts.
+
+There is but one conclusion that can be drawn from this: that
+suggestion plays a large rôle in the relief of the symptoms of the
+disease. If patients once become persuaded that something will do them
+good, then it surely does. It is true that this good effect will
+usually not persist, but that is because after a time conditions
+conspire to make the suggestion fail of its purpose. This does not at
+all imply that hay fever, or just catarrh as I prefer to call it, is
+imaginary. The relief of our most serious and fatal diseases with
+profound pathological lesions, such as tuberculosis, may well be
+brought about by suggestion. After all, just the same story is told
+about consumption and its many remedies as of hay fever and its many
+"cures." However, the most important therapeutic element so far
+discovered for the treatment of hay fever is evidently suggestion. If
+the patient's mind can only be brought to a favorable attitude in
+which the discouragement incident to imperfect oxidation can be
+greatly lessened, then relief of many of the symptoms will be afforded
+and under favorable conditions the patient will deem himself cured.
+Undoubtedly the large amount of attention given to hay fever, the
+gathering of these patients in particular localities, the repetition
+of the story of their symptoms to each other, the body of literature
+that has gathered around hay fever and is read with such avidity by
+those who are pleased to call themselves its victims, adds to the
+unfavorable suggestions and inveterates the symptoms, exaggerates the
+nasal hyperemia and makes the general condition worse.
+
+I am the more positive about the influence of suggestion, favorable
+and unfavorable, in the affection after having carefully noted the
+conditions in certain patients from year to year for a number of
+years. I became interested in it because it is a family affection and
+several sisters as well as myself are sufferers from it. At the
+beginning, when the real nature of the trouble is not recognized,
+there is a year or two of considerable general discomfort, though not
+much local disturbance. Then comes the realization of what the
+recurrent affection is and a period of distinct depression during its
+continuance. Eventually it begins to be appreciated that a number of
+local applications will lessen the symptoms from day to day and that
+there need be no apprehension of serious sleep disturbance, or of any
+lasting effect upon the general health, the affection becomes quite
+bearable and, while still annoying, is no longer the object of
+particular solicitude.
+
+
+
+CHAPTER V
+
+DYSPNEA--CAT AND HORSE ASTHMA
+
+
+There is a class of cases of difficulty of breathing allied to asthma
+and often called by that name, the study of which throws light on the
+origin and the relief of neurotic asthma. These cases are usually
+accompanied by such a sense of oppression on the chest that breathing
+becomes labored and, to some {374} extent at least, the accessory
+muscles of respiration have to be called into play. The most typical
+cases are connected with the mental influence produced by the presence
+of some particular animal, the cat being the most frequent and the
+horse not rare, or with emanations from these animals, when there
+seems to be some physical nexus between the animal and the symptoms.
+
+
+Cat Asthma.--The symptoms associated with cats are rather common, and
+they occur at the sight or touch of the animal, but may be the result
+only of its presence which in some way the patient is able to
+recognize without sight of him. Shakespeare's expressions in a number
+of places, such as "I could endure anything before but a cat" and
+"some that are mad if they behold but a cat," shows that the affection
+was commonly recognized at that time and that the reason for it was
+considered unknowable, for Shakespeare says, "There is no firm reason
+to be rendered why he cannot abide ... a harmless necessary cat."
+
+Dr. Byron Bramwell in his "Clinical Studies," Vol. I, page 107, has an
+interesting paragraph with regard to these curious asthmatic
+conditions which develop in the presence of animals of various kinds.
+He sums up many of the curious features of this affection as reported
+by various good observers. Many more people than we would be apt to
+think are affected by it. He says:
+
+  In some persons the smell of a horse or of a cat produces an attack
+  of asthma. Some years ago I repeatedly saw a young gentleman who
+  invariably had an attack of asthma if he went near a stable or a
+  horse. He was so susceptible that he was unable to drive in a cab or
+  a carriage; when traveling from place to place, while sending his
+  traps from the station to the hotel in a cab, he himself was obliged
+  to walk.
+
+Dr. Goodhart mentions a similar instance which occurred in the
+practice of Prof. Clifford Allbutt. Dr. Goodhart also mentions a
+remarkable case of "cat asthma":
+
+  I have known of two cases of cat asthma. In one of them the
+  existence of cats is the bane of life, for before accepting an
+  invitation she is obliged first to ask, "Is there a cat?"
+  [Footnote 32] An attack of urticaria and coryza followed by asthma
+  has been noticed to come on within ten minutes of having stroked a
+  cat. At other times, sitting in a room in which there was a cat,
+  without any actual contact with it, was sufficient to produce a bad
+  attack, beginning within ten minutes of entering the room.
+
+    [Footnote 32: A case of this kind came under observation as this
+    book was nearly ready for the press. The patient, a young woman in
+    an office, had to refuse a vacation with a wealthy friend in
+    Florida, because she knew that friend could not be separated from
+    her pet cats, five in number, and the patient would have been
+    intensely miserable were she near them, so that even the joys of
+    Florida in the winter did not make up for the constant,
+    intolerable discomfort they would have caused her.]
+
+There are two forms of this intolerance of a cat. One of them takes on
+the character of a dread and is discussed in the chapter on Dreads.
+The other is accompanied by dyspnea or asthma with a sense of
+discomfort and tightness of the chest that cannot be overcome. It is
+not merely an imagination, for sometimes even when they cannot see the
+cat, or at times when friends have been careful to exclude cats from
+the room, these people become impressed with the idea that a cat is
+near and a search usually shows that their impression is true, though
+just what was the means through which they came to know it is
+difficult to understand.
+
+{375}
+
+Dr. Weir Mitchell's review of the subject of "Cat Asthma and Allied
+Conditions" in a paper read before the Association of American
+Physicians brought out many curious details. There is no doubt about
+the power to recognize the presence of the unseen cat. Besides the
+respiratory oppression, some patients develop urticarial lesions and
+occasionally even conjunctivitis and a catarrhal condition of the
+nasal mucous membrane. These seem to be due to the direct irritant
+effect of animal emanations. As the symptoms of rose cold or hay fever
+have sometimes developed after the sight of an artificial rose, or
+even, it it said, the picture of a hay field, so, in some of these
+cases, the sight of a picture of a cat has produced at least some of
+these symptoms. Probably the most interesting feature of the affection
+is that the large cats, the tiger and the lion, do not have any effect
+on the patient. There seems to be no doubt, then, that the mind plays
+an important role in the matter and that relief must be secured
+through mental influence.
+
+In some of these cases a careful searching of the past of the patient
+will show that there has been some terrifying incident connected with
+the cat. In one case in my own experience the patient's earliest
+recollection, and the first time that death was brought home to her,
+was when a favorite bird was killed by a cat. Ever after that she had
+a horror of the animals, the family cat had to be disposed of, and her
+family never had another. She used to suffer from a severe dyspnea at
+the sight of a cat and was sure that she could recognize its presence
+without having seen it. She mentioned a number of occasions on which
+that had been true. The very idea of living where a cat could come
+near her was appalling. She was sure that she was even waked by the
+mere propinquity of a cat if by any chance one got into her room at
+night, though without any noise.
+
+A change in her material circumstances compelled her to teach in
+private families. Under these circumstances her cat detestation made
+difficulties for her. I suggested, since she had had no feeling toward
+cats before the bird incident, that probably her symptoms were due to
+suggestion and an acquired habit of mind and that she might by
+discipline overcome them. She was sure that would be impossible. With
+determined effort, however, and practice in withstanding her feelings
+in the presence of cats she finally learned to overcome practically
+all of her feelings so that though it still requires an effort she can
+even pick up a cat and stroke it. I have had several other patients
+with less marked forms of the affection who have by self-discipline
+overcome their feelings to a great degree. It is always well to search
+the past of these patients in order to find out whether there may not
+be a dominant idea derived from some unfortunate experience, which
+acts as an auto-suggestion in the production of their symptoms of
+constriction of the chest and sometimes even the recurrence of the
+swelling of the mucous membrane of the nose that produces difficulty
+of breathing. Whenever this can be found, contrary suggestion can be
+given and the patients can be persuaded to try, by frequently repeated
+auto-suggestion, to relieve themselves of the trouble.
+
+Occasionally these curious manifestations of a catarrhal or asthmatic
+character in the presence of cats occur in people who like cats. Dr.
+Taylor in his "Types of Habit Neuro-Psychoses" published in the
+_Proceedings of the Massachusetts Medical Society_, 1896-98, tells the
+story of a young woman in whom he saw conjunctivitis developing while
+she was fondling a cat. In many cases {376} besides the hyperemia of
+the nose and of the respiratory mucous membrane generally there is
+marked injections of the ocular conjunctiva. It is rather difficult to
+understand the phenomena of asthmatic attacks in connection with cats
+and other animals in terms of a habit formed, because at some time
+asthmatic or hyperemic manifestations occurred in association with the
+handling of these animals and that then, somehow, suggestion works to
+reproduce the same symptoms in the presence of the animals later; but
+this is undoubtedly the only rational explanation that we have for
+many of these cases. It represents the most helpful explanation, so
+far as treatment is concerned, for by means of suggestion either in
+the waking state or in the first stage of hypnosis, in many cases
+relief can be brought to these patients. Repeated profound hypnotism
+is a vaunted remedy for these conditions in the hands of professional
+hypnotists, but serious physicians who have tried hypnotism do not
+recommend it. It helps for a time but relapse follows. Only continued
+suggestion and a carefully cultivated habit of self-discipline and
+control succeed.
+
+
+Horse Asthma.--The cases of dyspnea in connection with horses are not
+less interesting. Occasionally, even when all aversion is absent,
+emanations from horses are capable of producing a curious effect on
+certain individuals. How much of this is psychic is not clear. I was
+once consulted with regard to a patient who suffered from asthma
+whenever she went to a dance. It mattered not how careful she was in
+not exposing herself to night air, or in wrapping herself up warmly;
+invariably a few hours after her return home, she was wakened from
+sound sleep by an attack of difficult breathing that required the
+opening of windows and the use of the accessory muscles of respiration
+in order to satisfy her air hunger, and even then her symptoms were
+quite alarming to herself and her friends. At first, her asthma was
+thought to be due to sudden changes of temperature in going out into
+the air after the dancing, and various devices were tried to lessen
+the shock of the cold to the respiratory mucous membrane. None of them
+had any effect. Then it was thought that the dust of the ball-room
+made the difference and so she was forbidden to dance. After a time it
+was found, however, that if she went out in the evenings to social
+functions, whether she danced or not, or though she avoided completely
+being in dusty rooms or where many people were moving, she still had
+the attacks a few hours after she returned home.
+
+Finally it was noted that these attacks of asthma also occurred on
+several occasions after she had been out riding during the day in a
+carriage. Then one evening after a rather long intermission free from
+attacks, in spite of directions and her fears, she went to a ball, but
+owing to circumstances went and returned by trolley instead of, as
+usual, in the family carriage. That night she had no attack of asthma.
+Experiments were made then and it was found that whenever she rode
+behind horses she suffered from an attack of asthma during the
+following night. The attack was evidently not due to suggestion. The
+story illustrates the necessity for carefully analyzing all the
+circumstances of an asthma patient and making sure that some one of
+these curious and unusual conditions are not at work, for if they are,
+the only possible curative treatment is by influencing the patient's
+mind, first by demonstrating the cause of the affection and then by
+training in self-control to reduce the reaction.
+
+{377}
+
+Recently I have been consulted with regard to a physician who has
+developed in a rather curious manner a sensitiveness to the presence
+of horses. As an interne at a hospital during an epidemic of
+diphtheria he took a dose of diphtheria antitoxin for immunizing
+purposes. The amount injected was 750 units, the remainder of the dose
+of 1,500 units contained in the phial being given to the nurse who had
+charge of the cases. She suffered absolutely no ill effects, so that
+the manifestations in his case were entirely due to idiosyncrasy and
+not to anything in the serum itself. Within fifteen minutes after
+taking the injection the mucous membrane of his nose became so
+congested as to make it impossible for him to breathe through his
+nostrils and the mucous membrane of his soft palate was seriously
+disturbed in the same way. His face became much swollen, the edema
+affecting particularly his eyelids and his lips and hundreds of wheals
+appeared all over the body. Fortunately the edema did not affect the
+larynx, or the issue might have been fatal, or would surely have
+required intubation. His pulse became extremely rapid and weak, there
+was marked dyspnea, and whenever the patient sat up there was fainting
+or a distinct tendency to it.
+
+Under active stimulation and elimination the symptoms rapidly passed
+off so that the only noticeable edema the next morning was in the
+eyelids and lips, which, however, also disappeared within twenty-four
+hours. Up to this time the physician had never been bothered by any
+tendency to hay fever or to asthma and there is no history of either
+of these affections in his family. Thereafter, however, though quite
+without his anticipating it, and, indeed, the first symptoms were
+incomprehensible, he became extremely sensitive to emanations from
+horses. When he rides behind a horse for some distance his
+conjunctivae become injected, the nostrils become congested and
+difficulty of breathing sets in with a sense of constriction of the
+chest. These subside as soon as he gets away from the presence of the
+horse and has washed himself thoroughly. He suggests that he has
+become sensitized to horse serum and, as it did not exist before his
+experience with diphtheria serum, he, of course, connects that
+incident with the present tendency. It is easy for such a case to have
+its real significance entirely missed and, of course, treatment by
+prophylaxis, the most efficient form, would then be out of the
+question.
+
+
+Other Forms.--Apparently at times human emanations or some peculiarity
+of odor seems to influence asthmatic conditions. I have been told by a
+good observer--a physician--of two brothers who had an attack of
+asthma whenever they visited each other. At first this was attributed
+to something in the air or some other condition of the visit. After a
+time it was found to occur under varying circumstances, but that the
+one essential was the association with each other.
+
+
+Treatment.--The more one knows about asthmatic conditions the more
+does it become clear that special study of individual cases is
+extremely important for any definite knowledge of the causation in a
+particular case. Without a knowledge of the cause the treatment is
+very unsatisfactory and in the meantime the unfavorable suggestion of
+the recurrence of the attacks acting upon the patient sometimes
+disturbs the general health. To remove this unfavorable influence must
+be the first care of the physician and then if the real cause can be
+found, favorable suggestion and modifications of the mode of life,
+with self-discipline and control of the mental attitude and of the
+{378} nervous system, may greatly aid in the reduction not only of the
+number of attacks and of the severity of the symptoms, but finally
+lead to complete eradication of the affection.
+
+Mental control to some degree can be obtained and it has even been
+suggested that if the emanations from an animal cause physical
+symptoms, gradually increased dosage of them, beginning with very
+small amounts, that is, short periods of association with the animals
+in question, may gradually lead to the production of an immunity to
+them as it does even to the much more serious results of snake poison.
+Certainly some patients seem to have succeeded in bringing relief to
+themselves by this means and it is worth while remembering in the
+therapy of the affection, if for no other reason than the strong
+suggestion that goes with it.
+
+{379}
+
+SECTION IX
+
+_PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM_
+
+
+CHAPTER I
+
+PAINFUL JOINT CONDITIONS--PSEUDO-RHEUMATISM.   [Footnote 33]
+
+  [Footnote 33: The position here taken, that acute articular
+  rheumatism never leaves a mark after it, is entirely due to the
+  observation that whenever cases were seen in which sequelae were
+  noted, there always seems to the writer to be question of something
+  else besides simple acute articular rheumatism--a complication.
+  Subsequent pathological investigation may show that occasionally
+  acute articular rheumatism does to some extent disorganize joint
+  tissues. Personally, however, I have the feeling that there are a
+  number of different kinds of acute arthritis, probably three or
+  four, and that most of them leave no pathological condition in the
+  tissues. Perhaps we shall be able to differentiate the severer forms
+  and recognize them from the beginning, as we have already done with
+  regard to scarlatinal, gonorrheal, influenzal and other so-called
+  rheumatisms. For practical purposes it certainly seems better to
+  emphasize the fact that chronic rheumatism following an attack of
+  simple acute arthritis is so rare as to be negligible.]
+
+Many painful conditions in connection with joints give rise to more or
+less continuous or frequently repeated discomfort, which often leads
+patients to think that there are serious pathological factors at work,
+or that some progressive disease condition has obtained a hold of
+them. Many of these painful conditions are due entirely to local
+causes: to over-exertion, to the wrong use of muscles, to the exercise
+of joints under unfortunate mechanical conditions and the like. Just
+so long as people are assured that an ailment is local, is not likely
+to be followed by serious impairment of function, that the discomfort
+of it is only temporary, and, above all, just as soon as they get rid
+of the notion of a progressive constitutional malady, they are content
+to bear even annoying pain without much complaint, and, what is more
+important, without such discouragement and worry as may impair the
+general health. Unfortunately, it is the custom to call most of these
+vague painful conditions "rheumatism," unless there is some other
+patent cause for them. Especially is this done if the symptoms happen
+to be worse in rainy weather, or in damp seasons. Rheumatism is always
+thought of as a progressive constitutional disease, and the very idea
+of it produces an unfortunate sense of depression.
+
+
+Exaggeration of Significance.--Toothache, for instance, unless it is
+allowed to nag for a long time, awakens no dreads and consequently
+fails to produce the corresponding depression and discouragement, seen
+so often in connections with conditions much less painful, but
+associated with the thought of the possibility of serious
+developments. _"Omne ignotum pro magnifico,"_ what is not well
+understood is always exaggerated, was Cicero's summing up of the
+tendency of the human mind to make the significance of misunderstood
+things greater than they really are. It is particularly true of
+painful {380} conditions of the body, and the tendency must be
+combated if patients are to be relieved. This must be done not alone
+because along this way lies relief of suffering, since not a little of
+the discomfort is due to the mental concentration consequent upon the
+dread, but because, also, the discouraged state of mind interferes
+with the trophic influences that go down from the central nervous
+system to the periphery to keep it in good health and to restore
+function when there is anything out of order. In a word, the
+exaggeration of significance so likely to influence such patients for
+ill must, as far as possible, be removed for their immediate relief as
+well as ultimate cure.
+
+
+Rheumatism, Gout, Catarrh.--There are three words in popular medical
+language which can be made to include more diseases and explain more
+symptoms than any others. Their meaning has become so indefinite that
+they now convey very little information, though they are much
+used--and abused. They are: rheumatism, gout and catarrh. Curiously
+enough all three of them when their etymology is studied mean the same
+thing as far as their derivation goes. Catarrh from [Greek text] the
+Greek word to flow down and rheumatism from [Greek text] the Greek
+verb to flow are terms that correspond exactly in etymology to gout,
+which is probably derived from _gutta_, the Latin word for
+drop--referring to the excess of secretion that is supposed to occur
+in the disease. All of these have for their basic idea, in etymology
+at least, an increase of secretion. A generation or two ago, the word
+rheumatism included a host of disparate painful affections, and was
+even more sadly abused than now, though its abuse has not ceased. The
+word catarrh is now at its acme of abuse. Gout has been pushed
+somewhat into the background by the other two. Any one of these three
+terms carries with it, in the popular mind, a connotation of
+progressive constitutional involvement which is not justified by
+anything that physicians know with regard to these diseases.
+
+
+The Uric Acid Diathesis.--The usual supposedly scientific explanation
+of a decade ago for many of these vague pains and aches classed as
+chronic rheumatism was that they developed on the basis of an excess
+of uric acid in the system. Advance in chemistry has completely
+obliterated the significance of the observation on which the theory of
+a uric acid diathesis, as it was so learnedly called, as an
+explanation for these conditions was founded. After uric acid there
+came for a time the theory of an excess of lithic acid, the so-called
+lithemia or American disease of a few years ago. These are, however,
+merely pseudo-scientific hypotheses and the more physicians know of
+chemistry the less they talk about them. Many practitioners, however,
+continue to accept this universal explanation which makes diagnosis so
+easy and which is supposed to be so suggestive for treatment. There
+are various remedies that are claimed to reduce the uric acid content
+of the blood or the system, and then there are various changes of diet
+that are supposed to do the same thing. These two systems of treatment
+and the combination of them have constituted the main therapeutic
+resource of many physicians for these so-called rheumatic cases,
+though their success has been anything but what they hoped for.
+
+
+Diet Tinkering.--Tinkering with diet has been particularly harmful in
+these cases. Over and over again I have seen patients who had lost
+considerably in weight because they had had all the supposed
+acid-forming elements removed from their diet. In many physicians'
+minds this seems to include most of the starches, as well as the
+fruits and many meats. Without any {381} potatoes, with only a limited
+amount of bread, with a warning as to red meats, and occasionally even
+some distrustful remarks with regard to butter, it is not surprising
+that the patients lost weight, that muscles became weaker, that
+painful conditions became severer, and that, above all, the patients'
+minds became less capable of bearing whatever discomfort is present.
+Besides, constipation intervenes with its train of consequences and
+patients become miserable, lose sleep often because of insufficient
+nutrition and actual clamoring on the part of their gastrointestinal
+tract for food. I have seen a man who was not much over normal weight
+to begin with lose twenty-five pounds, nearly one-sixth of his weight,
+while being dieted for vague pains (worse on rainy days) that were
+really due to his occupation, but that had been diagnosed as
+"rheumatic," consequent upon the uric acid diathesis, for which coal
+tar products were prescribed over a long period and his diet
+strenuously regulated. This has become as much of an abuse as the
+old-time purgings and bleedings.
+
+
+Irregular Treatment.--As we have said, this group of cases constitutes
+the most frequent and abundant source of profit for quacks and
+charlatans and irregular practitioners generally. The naturapath, the
+osteopath, whom we have already mentioned, for to these cases he owes
+most of his success in appealing to legislatures for recognition, the
+irregular electropath, many supposed diet specialists, and even the
+special shoemaker, have reaped a rich harvest from these patients. The
+reason why they have done so is that, as a rule, they have at once
+reassured the patients that their condition was not seriously
+progressive and have promised them certain relief from their ailment.
+Usually various local measures, such as St. John Long's liniment of
+one hundred years ago and many of its successors, or the
+mechanotherapy and the massage and the manipulation of the osteopaths
+of the present day, have been employed with consequent restoration of
+circulatory disturbances to normal conditions and, in general, the
+setting up of better mechanical employment of muscles than was
+possible before. If so-called chronic rheumatism is to be treated
+successfully and this opprobrium of medicine, as it has been called,
+is to be removed, it can only be done by a careful analysis of the
+ills of each individual patient and a definite determination as to
+just what local pathological condition is at work and not by a
+slip-shod diagnosis of rheumatism with immediate recourse to a
+supposed or assumed theoretic diathesis for the explanation of its
+etiology.
+
+
+Differentiation of Joint Conditions.--The local conditions that give
+rise to painful conditions of joints are most diverse in character.
+There was a time when all of the infectious joint affections had the
+term rheumatism applied to them. Even at present it is not unusual to
+hear of scarlatinal or gonorrheal or influenzal rheumatism. What is
+meant, of course, is that the microbes of these specific diseases have
+for some reason found a lowered resistive vitality in one of the
+joints, or perhaps several of them, and have set up an inflammatory
+disturbance. These specific arthritises are now definitely separated
+from the rheumatism group and it seems clear that in the near future
+we shall have rheumatism itself divided up into a series of diseases.
+By this I mean that even where there is the redness, the swelling and
+the fever of true inflammation of joints, it is not always due to one
+microbe, but to various microbic agents, and so we shall have various
+forms of rheumatism. At present we are prone to speak of many of the
+neuritises as rheumatic, but it is probable that {382} here a series
+of varying microbic infections will be found, some of them much more
+serious than others, most of them capable of complete cure, though
+some of them will tend to leave pathological conditions in nerves that
+are more or less crippling.
+
+
+Painful Joint Affections.--These pains and aches occur particularly in
+the old and those who have been hard muscle workers, in those who have
+been exposed much to the elements and especially in the subjects of
+old injuries. All of these conditions, one way or another, have left
+their mark upon tissues so that the nerves do not receive proper
+nutrition, especially when there is considerable exertion or in rainy
+weather.
+
+There are a number of reasons why rainy weather produces this effect.
+The humidity of the atmosphere lessens evaporation. This disturbs heat
+conditions in the tissues, for evaporation is the most important
+element in heat dissipation. This leads to the accumulation of heat in
+the parts and conduces to congestion. Any tissue of lowered vitality
+will be affected by this and nerves become oversensitive. Besides, it
+seems probable that the fall in the barometer with the lessened
+pressure from without makes a difference in the circulation. There is
+a general feeling of depression in wet weather and apparently the
+circulation is not so active. It is particularly slow at the surface
+of the body and in the terminal portions, so that the hands and feet
+are likely to be cold. Just as soon as the barometer goes up somewhat
+these conditions cease to be active and there is restoration of the
+circulation to its previous condition. Besides, it seems not unlikely
+that dampness produces some relaxation of muscles, so that it is more
+difficult to make them contract, and consequently they are used at a
+greater mechanical disadvantage and painful tiredness more readily
+ensues. All sensitive tissues become more sensitive in rainy weather,
+though in the case of toothache or neuralgia, for instance, we do not
+think of connecting this with the word rheumatism.
+
+
+_Classes of Sufferers_.--In persons who are over-thin or over-stout
+complaints of joint discomfort are not uncommon. In the first case
+they are due to the fact that muscles working around joints are not
+strong enough to accomplish their normal purposes. In the other cases,
+owing to the weight of the body, the muscles are overstrained. In a
+number of stout people the muscles do not increase proportionately to
+the size of the frame, much of the extra weight being in the shape of
+adipose tissue that constitutes a grievous burden. In people who run
+rapidly to either of these conditions of disturbed nutrition--thinness
+or stoutness--complaints are particularly likely to be heard. Familiar
+examples are often seen in the tuberculous who have lost weight
+rapidly or in convalescents from typhoid fever who are much thinner
+than they were before they took to their beds. On the other hand,
+those who gain in weight rapidly after typhoid fever or some other
+such pathological incident, or who, as the result of careful
+sanatorium treatment, put on twenty pounds in the initial stage of
+tuberculosis, may have similar discomforts to complain of in and
+around their joints.
+
+
+Heredity of Rheumatism.--The strongest unfavorable suggestion which
+most patients have is that their ailment, whatever it is, is
+hereditary and therefore not amenable to treatment. Nothing is more
+amusing to one who knows the present-day status of opinion in biology
+with regard to heredity than the frequent declaration that rheumatism
+is hereditary. Probably {383} nothing is commoner than to have a
+patient who is suffering from some vague, painful condition in muscles
+or joints, especially if that condition is worse on rainy days,
+declare that it must be rheumatism because father or mother suffered
+from rheumatism. I took the trouble to analyze in more than a dozen
+cases the rheumatism that was supposed to exist in the preceding
+generation, and found that it consisted of everything from pains due
+to old injuries and especially dislocations or fractures, through the
+various deformities connected with flatfoot, up to and including the
+worst manifestations of arthritis deformans. The condition in the
+parents supposed to be hereditary is never genuinely rheumatic.
+
+There is just as much sense in talking of hereditary pneumonia as of
+hereditary rheumatism. Perhaps there is an hereditary lack of
+resistance in the pulmonary tissues of some people that predisposes
+them to pneumonia. It must not be forgotten that a century ago, or
+even less, it was not uncommon to hear that certain people had
+hereditary tendencies to lung fever. We know now that these were
+tendencies to tuberculosis and not to true pneumonia. We know,
+besides, that tuberculosis itself is not hereditary and that probably
+even the predisposition to it is not specifically hereditary.
+
+As can be readily understood, the question of heredity in rheumatism
+is extremely important for psychotherapy, since the persuasion that
+their affection is inherited always produces an unfavorable effect
+upon patients' minds. In the old days, when tuberculosis was
+universally considered to be hereditary, a patient was likely to think
+himself the victim of an hereditary condition which could not be cured
+and which inevitably led to a fatal termination. Something of the same
+idea, though the immediate outlook is not so gloomy, is likely to
+follow the persuasion that rheumatism is hereditary. The question of
+heredity, of course, is bound up with that of rheumatism being a
+constitutional disease dependent on hyperacidity or some other
+pathological condition of the blood. Acute rheumatism, that is, acute
+arthritis, is an acute, infectious disease due to a microbe. This
+ought to dispose of any question of heredity in it. Chronic rheumatism
+is supposed to be related to acute rheumatism and to represent, as it
+were, a low-grade enduring condition such as in sudden accessions
+gives rise to acute rheumatism.
+
+
+So-called Chronic Rheumatism.--In these cases it is always a question
+whether the condition which causes the pain and discomfort is genuine
+chronic rheumatism or not. I am one of those who doubt whether we have
+any genuine, definite symptom-complex that should be termed chronic
+rheumatism. I have seen many ailments called chronic rheumatism. Any
+painful condition in the neighborhood of the joint that is worse on
+rainy days is likely to be labeled rheumatism and, because the
+salicylates are supposed to be a specific for rheumatism, treated with
+large doses of these drugs. These relieve the pain, as do any other
+coal tar products, but it is hard to understand how they are ever
+supposed to do any good for the underlying pathological conditions.
+The most noteworthy characteristic of acute rheumatic arthritis is
+that it leaves no mark upon the joints that were affected by it. These
+get completely better and the patient has no disability, no deformity,
+and there usually remains not even the slightest sign of there having
+been a serious inflammatory condition within the joints.
+
+In this it resembles pneumonia rather strikingly. True lobar pneumonia
+{384} clears up completely and the man has no symptoms once he has
+come through the convalescence. There are certain diseases affecting
+the joints, especially the arthritises in connection with various
+infectious diseases and the arthritis which accompanies acute
+arthritis deformans, in which there are serious sequelae and sometimes
+even complete disorganization of the joint. It is by these
+after-effects alone that we are sometimes able to differentiate
+genuine rheumatic arthritis from these other very different affections
+which resemble it so closely. Just the same thing is true of
+pneumonia. There are pneumonias that run a course at the beginning
+strikingly like true lobar pneumonia but which do not have a frank
+crisis and in which the lungs are seriously affected afterwards. We
+know now that in these cases it is not an uncomplicated pneumococcus
+pneumonia that has been at work, but either some other infection or
+else true pneumonia with a complication. Very often a dormant
+tuberculosis causes true pneumonia to run a different course from that
+which it ordinarily follows, and this, as a complication, leaves its
+serious mark upon the lungs.
+
+_Recurrence_.--In some cases there seems to be a tendency for the
+"rheumatic" disease to recur. This also is true of pneumonia. This
+does not so much indicate, however, any loss of special tissue
+vitality as a certain loss of vital resistance to a particular
+microbe. Certainly this tendency is not sufficient to make us think of
+chronic rheumatism or use that term any more than we would, under
+similar conditions, talk of chronic pneumonia or of chronic
+diphtheria, though both of these affections have a tendency to leave a
+lack of resistive vitality. In a number of cases, subacute rheumatism
+runs a course that is very bothersome and annoying and that is quite
+intractable, with relapses and sequelae, but even this is entirely
+different from the ordinary idea of chronic rheumatism. It is probable
+that these cases, like the pneumonias that do not end by crises, are
+complicated by some other condition in the joint that leads to
+reinfection.
+
+
+Unclassified Forms.--It is possible that in a certain number of cases
+for which as yet we have no name but rheumatism, there is a virulence
+of the microbic factor that brings about some joint disorganization.
+This, however--and the cases are very rare--is probably an affection
+to which the name of rheumatic arthritis will not be given when we
+know more of the disease and its cause. There are probably many forms
+of acute rheumatic arthritis due to varying microbes which will
+eventually be divided into groups, as we have made groups in the
+typhoid series of diseases and in the scarlet fever group and hope to
+do with other diseases.
+
+
+The Individual Case and Reassurance.--The main role of psychotherapy
+in these affections is to set patients' minds at rest as far as
+possible, by pointing out exactly what is the matter with them and
+keeping them from worry, discomfort, and even interference with their
+physical condition by over-solicitude. It is important to know every
+detail of the patient's occupation, of his habits, of his environment,
+of his exercise, and, above all, of his individual peculiarities of
+structure in the neighborhood of joints, so as to decide exactly what
+is the matter with him, and not be satisfied with the easy but
+unscientific diagnosis of rheumatism, which may mean much but usually
+means nothing.
+
+Unless such reassurance is given, and especially if the ordinary drug
+treatment for so-called chronic rheumatism is persisted in, after a
+time these {385} patients, unimproved by salicylate treatment, wander
+off to all sorts of irregular practitioners and form the greater part
+of the lucrative clientele of quacks and advertising specialists in
+the cure of chronic diseases. More probably than any other class of
+cases do they support the irregulars. Osteopathy has particularly
+appealed to a great many of these patients. It has done it in two
+ways. The first and most important probably by its effect upon the
+mind of the patients. Osteopaths immediately proceed to reassure the
+sufferers that their affection is not rheumatism, but some local
+condition dependent upon either a subluxation of the vertebra which,
+according to the founder of osteopathy, constitutes the basis of
+ninety-five per cent. of all the ills to which human nature is heir or
+upon some joint or muscle condition which can be corrected by
+manipulation or massage. These patients have, as a rule, been
+suffering a good deal before this from the thought that they were
+afflicted with a progressive constitutional condition which would
+almost inevitably cripple them. Often they have seen patients who were
+suffering from arthritis deformans in its worst forms and advanced
+stages; they have heard this called rheumatism and they have concluded
+that it was only a question of time when they would be in the same
+condition. There is no good reason to speak of such conditions as
+rheumatic. They are entirely local, the hope of relief between attacks
+is by properly applied massage and passive movements which facilitate
+the blood supply in the neighborhood, and the best applications at the
+time of discomfort are the various rubefacients which stimulate the
+circulation in the parts, call the blood to the surface, and prevent
+that congestion in the neighborhood of small nerves which is the cause
+of the aches or pains. These affections take on a much more serious
+character in the minds of patients as soon as the word rheumatism is
+mentioned. To tell them that the condition is entirely local, has no
+tendency to spread, has nothing to do with any constitutional
+condition, and can be relieved by local measures and the improvement
+of the general health, will often bring the patient a good measure of
+relief.
+
+
+SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS
+
+How much the treatment of these so-called chronic rheumatisms depends
+on suggestion, in spite of the apparent improbability of anything so
+materially discomforting being under the influence of the mind, is
+best appreciated from a consideration of the many inert materials that
+have been used for the cure of rheumatism. There is, of course, no
+more virtue in red flannel than in any other colored flannel, but many
+people suffer from rheumatism or rheumatic discomfort whenever they do
+not wear red flannel and are sure that it means much for them. Then
+there are all sorts of supposed electrical contrivances that do not
+generate an ion of electricity. They are effective only through the
+appeal they make to the mind. Some men wear electric belts and
+attribute their freedom from rheumatic pains to them. Others wear
+so-called electric medals or electric shields or electric insoles. Any
+number of people in this country wear electric rings on the little
+finger of one hand and get marvelous relief from it for their chronic
+rheumatism. Some have noted good results from even less likely
+objects. There are thousands in this country who carry horsechestnuts
+as a preventive against rheumatism, and some of {386} them,
+intelligent men and women, are persuaded it lessens their pains and
+aches.
+
+In another place I have told the story of the woman who was a sufferer
+from rheumatism and who found great relief from carrying a
+horsechestnut. As her husband was also a sufferer, she wanted him to
+carry one, too, and when he would not, she carried one for him. It is
+to be hoped that her conjugal tenderness in this matter had as good an
+effect on him as she was sure the propinquity of the horsechestnut had
+on her.
+
+The patients' occupations must be regulated by proper advice and
+detailed directions, and distractions of various kinds must be
+provided to keep their minds from becoming concentrated on certain
+portions of their body, emphasizing whatever discomfort is present and
+preventing nature's curative processes. Finally, local treatment of
+various kinds must be employed suitable to each individual case, that
+will remove all mechanical difficulties, disperse congestions, relieve
+fatigue and over-tiredness, and make conditions favorable for the
+healthy, normal use of joints and muscles.
+
+Many painful affections of joints, sometimes complicated by
+immovability, are really psycho-neuroses. Sir Benjamin Brodie once
+said that four-fifths of the joint troubles that he saw among the
+better classes were hysterical. Sir James Paget thought this an
+exaggeration, but confessed that he saw many of them and among all
+classes of people. One-fifth of those that he saw in hospital and in
+private practice were entirely neurotic. He emphasized the fact that
+they must be looked for not only among women but that they are often
+found in men and that they are by no means confined to those who are
+nervously inclined, the silly young women or the foolish old women,
+but that they may be found in special circumstances among the most
+sensible people. They are often initiated by an injury which makes it
+quite difficult to differentiate them from real joint affections.
+Usually, however, there is no redness, nor swelling nor heat with
+them, though sometimes one of these symptoms at least may occur with
+the redness. The connection between the trivial accident and the large
+reaction is usually hard to find and causes a suspicion as to the real
+process at work. Often, too, there is a delay of several days or
+sometimes weeks after the accident before the neurosis declares
+itself. In the meantime it has been getting on the patient's mind.
+
+In general, it must be remembered the patient's attitude of mind in
+these cases of pain around joints and in muscles is extremely
+important. They have furnished a goodly proportion of the patients on
+which quacks and charlatans have fattened. Greatrakes in the
+seventeenth century, Mesmer and Perkins, St. John Long, the early
+electrotherapeutists, the blue glass faddists, all the various
+liniment makers, many of the manufacturers of blood purifiers, and
+Eddyism and mental healing besides osteopathy in our day have all
+benefited these sufferers for a time and the patients have often been
+men and women of education and influence in their communities and have
+exerted their influence for the benefit of their supposed benefactors.
+The methods of treatment come and go. The promise of the physician or
+the healer and the confidence of the patient are the only factors that
+are common to all the supposed "cures." If people stay at home without
+the air and exercise they should have, if they nurse their ills and
+consider that they are sure to get worse, because they labor under
+hereditary or constitutional ailments, nothing will benefit them.
+{387} If they are convinced that their disease is only local and begin
+to go out to see their friends once more, a change comes over the
+whole aspect of their disease.
+
+
+
+CHAPTER II
+
+OLD INJURIES AND SO-CALLED RHEUMATISM
+
+
+As people advance in years, it is a common experience that tissues
+injured years before are the source of no little discomfort and are
+particularly prone to be bothersome during changeable seasons and in
+rainy weather. A bone broken when the patient was young may twenty or
+thirty years later continue to give warnings of the approach of change
+in the weather and be a source of annoyance. A dislocation, especially
+if complicated in any way by considerable laceration of the tissues in
+the neighborhood of the luxated joint, is sure to be a source of
+discomfort of this kind. These painful conditions are generally more
+noticeable when patients are run down, or when they have been recently
+affected by exhausting disease of any kind, during convalescence from
+severe ailments or injuries, or when they are undergoing a special
+mental strain. These conditions, like nearly all others worse in damp
+weather, are sometimes grouped under the term rheumatism and have been
+treated by internal medication. Almost needless to say, such treatment
+is sure to fail or to be of only temporary anodyne benefit. As
+rheumatic remedies are usually coal-tar products they may even be
+distinctly harmful, especially for old patients. It has been shown
+that the salicylates, for instance, are much less rapidly eliminated
+in the elderly than in the young, in those with defective circulation
+or kidney insufficiency than in the well. Their accumulation in the
+system causes anemic tendencies and disturbs nervous control.
+
+Just what is the underlying pathological condition in these cases is
+not easy to say. In the case of luxations with laceration of tissues
+there has undoubtedly been such a disturbance of venous and lymphatic
+circulation by the break in continuity of tissues and the resultant
+scar tissue, that lymphatic if not also venous congestion occurs
+whenever there is any circulatory disturbance. For the maintenance of
+normal nutrition of nerve endings a constant flow of blood past them
+and a proper action of the lymphatic channels to carry off waste
+products is essential. It is easy to understand how much these may be
+disturbed in the injuries under consideration. When a bone is broken
+there is usually laceration of the surrounding tissues. Owing to the
+fixation required to procure proper bony union, the circulation to the
+part is much more defective than usual and so the repair of torn lymph
+and venous vessels is not as complete as would otherwise be the case.
+
+This seems to explain why such injuries are especially called to the
+attention of the patients in damp weather. It is not so much during a
+rain storm as some hours before it, about the time when the barometer
+begins to drop, that these old injuries become sensitive. Indeed, it
+is often said that old persons who have suffered one of these injuries
+earlier in life carry a barometer around with them.
+
+Not a few of the lesions called sprains, especially those of the
+ankles and {388} wrists, though also of other joints, are often really
+breaks of small bones, or at least laceration of ligaments and other
+structures. These may long afterward prove a source of pain and
+discomfort, worse always in unsettled weather, or after the feet have
+been wet, and may seem to be due to some constitutional condition,
+though they are merely local. These occur more commonly in women than
+in men and the condition needs careful investigation and must not be
+put under the vague diagnosis of rheumatism, or the patient will
+probably not be improved by the treatment suggested. In all these
+cases the general condition must be looked to, and it must not be
+forgotten that fat may not mean health, and that increased weight may
+be a prominent factor in the production of symptoms in these cases,
+especially when individuals live a sedentary life.
+
+There is an important therapeutic method for the prophylaxis of these
+conditions that has been attracting attention and yet probably not all
+the attention it deserves in recent years. Prof. Lucas-Championnière
+of the University of Paris has pointed out that when fractures and
+dislocations are treated by the open method with easily removable
+apparatus and the employment of massage within a few days after the
+fracture, the subsequent discomfort of these lesions is much lessened.
+
+It seems worth while to emphasize this treatment by manipulations and
+massage, because it represents a psychotherapeutic factor in the
+treatment of these injuries. The hiding away of a limb or a joint for
+days and perhaps weeks, while they wonder whether it is getting better
+or not is most discouraging to patients. To have the physician see it,
+to have him declare that it is getting on well, to have the evidence
+of their own senses that conditions are gradually improving, is of
+itself a valuable factor for that satisfaction of mind which conduces
+to the regular functioning of tissues. Repair undoubtedly goes on
+better under such circumstances. Besides, the lack of constriction or
+at least its rather frequent periodic relaxation, the airing of the
+skin, the regulation of the circulation by massage and manipulation,
+all react upon the mind and prevent it from inhibiting trophic
+impulses and encourage it to stimulate them in every way.
+
+As to the after-effects of fractures and dislocations as with regard
+to all this series of vague pains and aches, the patient's attitude of
+mind is of great importance. As they get older their aches and pains
+grow worse, partly because circulation is more defective and partly
+because they are prone to be much more in the house and the nerves of
+patients who are much within doors are always more sensitive than
+those of people who are much in the open. If their attention becomes
+concentrated on their pains and aches, because of lack of diversion of
+mind, then the condition may become a source of serious annoyance.
+When these painful conditions develop patients are almost sure to keep
+much to themselves and to nurse their ills, and consequently to
+increase their discomfort. The circulation to the affected parts must
+be stimulated by local treatment, by rubbings, by the milder
+liniments, by massage and manipulations, and by local hydrotherapy.
+Douches, as hot as can be borne, on the limb followed by cold,
+especially if patients are otherwise in good health, will do much to
+relieve the stagnant circulation.
+
+Active and vigorous movement while the affected part is supported at
+_skin pressure_ (there must be no constriction) is even more valuable
+than {389} massage, liniments or douches in the treatment of all these
+painful conditions of joints in which there is any scar-tissue.
+Wonderful results may be obtained in an old sprain of the wrist, knee
+and ankle by covering in the part completely (taking care to surround
+the limb) with strips of adhesive strapping simply laid on at skin
+pressure, but following exactly every fold or angle of the part, and
+then with the part completely covered in this way to urge immediate
+and constant exercise. The maintained pressure prevents any tendency
+to venous congestion or exudation and favors absorption of fibrous
+tissue, and exercise, which should be immediate, is now possible
+through the support furnished by the strapping. The re-assumption of
+normal active movement molds the old scars, strengthens the muscles
+and ligaments and improves the patient's general condition. The relief
+afforded _is immediate_, and the cause of relief, a simple mechanical
+device, is apparent. Rheumatism is forgotten as the old crutch is
+discarded and the patient is able to use the limb with confidence.
+
+Recent sprains or bruises treated in this way recover perfectly and do
+not leave old scar tissue to be a future seat of pain.
+
+
+
+CHAPTER III
+
+MUSCULAR PAINS AND ACHES
+
+
+Whenever exposure to cold causes a period of discomfort in almost any
+organ, except the teeth and certain definite nerves (for neuralgia has
+been taken out of the rheumatism group in recent years) we are sure to
+hear the word rheumatism employed in connection with it. To add to the
+confusion, the various "specialists" have taken to assuring their
+patients that local manifestations in the eyes, in the ears, and in
+the nose, for which they can find no good reason, especially if they
+are worse in damp weather, are signs of the rheumatic diathesis.
+
+Unfortunately, our supposed knowledge of the uric acid diathesis
+became widely diffused, and it is not surprising in the light of the
+widespread acceptance of this theory, that muscular pains of all kinds
+should have the word rheumatic attached to them, and that patients are
+sure that the discomfort is only one manifestation of a severe
+constitutional disease, which they cannot but infer will probably make
+still more serious trouble for them in years to come, since it seems
+to be dependent on conditions beyond their control, such as heredity
+and general constitutional traits and their special mode of nutrition,
+rather than on local or passing conditions.
+
+
+Local and Constitutional Conditions.--It cannot be repeated too often
+that it is this persuasion as to the constitutional character of the
+disease that has in recent years proved a very unfavorable suggestive
+element in these cases. Patients think themselves the victims of a
+serious diathesis, a deep-seated pathological condition, and attribute
+a host of feelings to it that are sometimes rather seriously
+disturbing but are really only sensory manifestations of various kinds
+in the organs and in the skin and muscles, which would be attributed
+to simple local causes--fatigue, faulty mechanical conditions,
+etc.--but for the concentration of attention on them.
+
+{390}
+
+_Individual Cases_.--The careful study of these cases is thus
+extremely important. They are eminently individual and not to be
+grouped together. The exact diagnosis of the various conditions from
+which each patient is suffering is of itself a precious factor in
+psychotherapeutics. The precise recognition of the condition present
+is of immediate avail in helping him to dismiss many of his symptoms,
+or at least to keep him from thinking as much of them as he did before
+or inevitably will if the older ideas as to the constitutional nature
+of his affection are allowed to remain.
+
+Nearly every large group of muscles in the body may be the subject of
+these painful conditions. In recent years, perhaps, the muscles most
+affected in this way are those that pass around the ankle and give so
+much discomfort in cases of flatfoot, or beginning flatfoot
+(euphemistically called weak foot), when the plantar arch is yielding.
+The manifestations are not only in and around the ankle, but occur in
+the calf muscles and even above the knee. These painful conditions
+always develop unless the arch is supported. Until recent years it was
+rare to discover a bad case of flatfoot in which the patient had not
+taken many rheumatic remedies and had not come to the conclusion that
+he was the subject of an incurable and probably hereditary
+constitutional disease. Flatfoot is likely to cause considerable
+deformity in the old, the toes becoming bent and twisted up, and the
+subjects of it complain very much of their feet. Flatfoot runs in
+families. When the father and mother have complained of what they
+called rheumatism in their feet which got worse every year, then the
+son and daughter, when they have their first manifestation, conclude
+that they are inevitably bound by the stern laws of heredity.
+
+
+Occupation Aches.--Flatfoot is taken, however, only as an extreme and
+therefore striking illustration. Whenever a particular group of
+muscles has to do an excessive amount of work, practically always
+there is a development of an uncomfortable condition worse on rainy
+days and therefore likely to be called rheumatic. Over-use of the arm
+at any occupation, in writing, in the use of a file, at an
+ironing-board, in sewing, or at anything requiring repeated movements,
+will produce it almost inevitably. Especially is this true if the
+occupation is carried on without such careful attention to muscular
+action as enables the muscles to do their work to the best advantage.
+These painful conditions are much more likely to occur in run-down
+individuals of nervous temperament, above all if they have been or are
+subject to worry. Men who have lost money and now have to do hard
+physical work, after previously having lived sedentary lives, and
+women whose previous source of support has been withdrawn and who have
+to work for a daily wage after former gentle conditions of living, are
+especially likely to suffer in this way. The conditions develop on a
+neurotic basis or an exhausted nervous system.
+
+Other groups of muscles may also be the subject of these painful
+conditions. The large group in the loins, called the lumbar muscles,
+which are so important for stooping, for the erect posture and for
+lifting, are so commonly the subject of discomfort that a special name
+has been applied to their affection--lumbago. In the leg the large
+group of muscles supplied by the sciatic nerve are likely to be
+affected, and this affection is so common in men who have to bend the
+knee and flex the hip at their work that it, too, has received a
+special name--sciatica. Besides the arm muscles the groups of muscles
+around the shoulder girdle are often unfavorably affected and though
+we have not invented {391} a name to cover their conditions, it is so
+common that we think of it as a separate entity almost in the same
+manner as we think of lumbago and sciatica. In the neck the group of
+muscles that rule the movements of the head, especially those at the
+side may be affected and the special name of torticollis has been
+given. Practically all of these affections are thought of at times as
+rheumatic and the ordinary rheumatic treatment is given for them.
+There is no doubt that the salicylates will relieve the pain almost at
+once, but so will any other coal-tar product and phenacetin,
+acetanilid or even antipyrin may be used with good effect. There is no
+evidence, however, that these drugs make the underlying condition
+better and, indeed, after patients have tried them for a while, unless
+the affection is merely passing, they try some other physician and
+perhaps are treated the same way with a different form of the drug.
+These are the cases that make their way around to a number of regular
+practitioners of medicine and then eventually go to some irregular or
+quack and sometimes obtain relief where the regulars have failed.
+
+When the irregular succeeds it is always because he has done three
+things. First he has persuaded the patient that it is not rheumatism,
+with all the unfavorable suggestion that goes with that word, that is,
+the matter with him; secondly, he has treated the local condition;
+and, thirdly, he has diverted the patient's mind. Local treatment is
+often the real secret of his success, though the psychotherapeutic
+element is not without distinct benefit.
+
+
+Mode of Occurrence.--These muscular conditions present themselves
+under two forms, acute and chronic. The acute condition occurs almost
+suddenly and is accompanied by spasmodic pain and acute discomfort.
+Muscles go into spasm to avoid the movement that would necessarily
+bring pain with it. A typical example is found in torticollis in which
+the patient wakes up some morning to find a stiffness in the muscles
+of his neck with limitation of movement much more pronounced on one
+side, and this usually gets worse as movements are attempted during
+the day. This spasmodic painful condition usually lasts for some days
+and suggests all sorts of topical applications and often requires
+anodyne drugs. A similar acute condition may be observed in some cases
+of lumbago. In this the pain in the loins comes on suddenly, usually
+during movement, often in the midst of lifting something that one has
+been able to lift without difficulty before. This pain is so sudden,
+so unexpected, usually comes entirely without warning and seems so
+mysterious in its origin, that it is no wonder the Germans speak of it
+as _Hexenschuss_--"witches' shot"--a remnant of the superstition that
+a witch, by means of the evil eye or some other maleficent power, or
+by sticking pins in a wax image of a victim that had previously been
+devoted to the devil, might produce effects upon the person at the
+part where the thought was directed or the pin inserted.
+
+These painful conditions, especially when acute, are, as a rule the
+consequence of exposure to dampness, or to a draft blowing directly on
+the part, usually in damp and changeable weather, and often when the
+patient has been sweating just before. The train of events that brings
+about the painful condition is not difficult to understand. There is a
+disturbance of the normal smooth-running, indeed almost frictionless,
+mechanism by which muscles glide over one another. There are
+practically a series of joints in all muscular groups so as to permit
+just as free a play as possible of muscles over one another. Each
+muscle is covered with a glistening membrane so familiar {392} from
+our dissecting room days, which secretes a substance resembling a
+synovial fluid, to enable muscles to move upon each other without
+friction. When, because of exposure to drafts or the evaporation of
+moisture on the surface, there is a disturbance of the circulation in
+these intermuscular planes, the secretion which prevents the friction
+of muscle movements is disturbed. The blood is driven from the surface
+and some congestion and consequent heat accumulation occurs in the
+muscles, affecting particularly their contiguous layers. As a result,
+the muscle surfaces are no longer smooth and the muscles now have not
+as free play over one another as before. It is not surprising that,
+owing to this, sensitiveness occurs and some spasm develops. This,
+however, is thoroughly conservative in character since nature's idea
+is to set the part at rest so as to allow the normal condition to be
+restored.
+
+This is the pathological condition that underlies these so-called
+muscular rheumatisms which develop suddenly. It is important to note,
+however, that these conditions develop nearly always in people who
+have been over-using or wrongly using the groups of muscles which
+become thus affected. The history of a torticollis patient will
+usually show that there is some contortion of the muscles of the neck
+familiarly practiced by him. Sometimes it will be found that the
+patient has the habit of sitting on a particular easy chair in a
+special relation to the light and that in order to accommodate himself
+to his chair and the light in his reading, the head has to be placed
+in such position that the neck muscles are constrained. It is this
+that predisposes the patient to the development of the condition which
+seems to be so acute and yet is really only an exacerbation of a
+chronic condition. Lumbago will develop in men who have been stooping
+much, especially for heavy lifting, or in women who scrub or have to
+stoop much while cleaning, dusting and the like.
+
+Some interesting muscle pains occur as a consequence of the jostling
+movements of various modes of transit. They are particularly
+noticeable if an uncomfortable position has been maintained for a
+number of hours. People who travel on railroad trains often come with
+the story that they _must_ have caught cold on the trip for they have
+been sore and achy in many of their muscles since. I have known people
+who went on a crowded excursion and had to stand for several hours
+confident that, standing in the drafty aisle of the car on their way
+home, they had acquired rheumatism. All that had happened was
+over-tiredness of muscles on the jolting train which required constant
+balancing and unaccustomed muscular exertion. On board sea-going
+vessels people often suffer from pains in the loins and in various
+trunk muscles, due to the roll of the vessel, especially while they
+are asleep. These, too, are likely to be attributed to drafts, or to
+some form of rheumatism, or at least to the catching of cold. I have
+even seen people sure, because of pains in their loins, that they must
+be developing some kidney trouble. After a time they get used to the
+swinging motion of the vessel and then their achy muscle tiredness is
+relieved.
+
+One now sees affections of the same kind in connection with the
+automobile. People who ride for many hours, especially if the riding
+is rapid and over a rough road and they are not used to it, are likely
+to develop pains and aches which they may attribute to the catching of
+cold or to rheumatism or to something of that kind. The muscles of the
+trunk are especially likely to {393} suffer. The abdominal muscles may
+be quite sore and then later the lumbar muscles develop aches. The
+arms suffer if they are held in unusual positions because of the
+jolting. The discomfort may be relieved by any of the coal-tar
+products, though gentle rubbing with a stimulant such as soap
+liniment, always in the direction of the return circulation in the
+muscle, will help to relieve the painful condition. The salicylates
+are often given for these conditions and relieve the discomfort but
+because of their value as anodynes, which they share with the coal-tar
+products, and not because of any genuine antirheumatic effect.
+
+
+Treatment.--Counter-irritation of various kinds, especially the milder
+forms, always seems to do good. The underlying therapeutic principle
+seems to be that the attraction of blood to the surface lessens the
+hyperemia or at least diverts the circulation and permits the
+restoration of function and encourages the reintegration of normal
+conditions. Rubbings are especially helpful if accompanied by rather
+deep pressure from the periphery of the circulation towards the
+center. The leg muscles must be rubbed upward, the arm muscles upward,
+the neck muscles downward, the trunk muscles generally in the
+direction of their return circulation. This would seem to indicate, as
+might be expected, that it is the venous circulation especially that
+is disturbed in the tired condition of the muscles, that a venous
+congestion with interference with the nutrition of nerves accounts for
+the aches; hence, a mechanical helping of the circulation is of
+benefit. There are some whose opinion is not to be put aside lightly,
+who think that the rubbing alone is the most important part of these
+external treatments and that the liniments and counter-irritants are
+only of secondary importance. Indeed, some consider that the tingling
+of the surface is mainly beneficial in making the patient feel that
+now that part of the body at least _ought_ to be better.
+
+Liniments for these conditions, however, though introduced on merely
+empirical grounds, are very old and have the testimony of many
+generations as to their therapeutic efficiency. Whenever that is the
+case, it is a serious question to doubt the conclusions that have been
+arrived at. The experience of a single generation, and, above all, of
+a small group or school of men, no matter how learned or how
+scientific they may be, is often fallacious. The experience of many
+generations, however, even though no good reason for the benefit
+derived from the treatment they suggest can be found, is almost
+inevitably correct. After all, though it is usually forgotten, the use
+of mercury, of iron, of quinin and of most of the tonics depends on
+nothing better than empiricism. In our day the liniments have been
+neglected, more perhaps than was proper, considering how many
+generations of physicians found them beneficial.
+
+Where it is a neurosis rather than a real disturbance of the
+circulation, however, that is involved, the use of a counter-irritant,
+by attracting attention more and more to the part, may really do more
+harm than good. In nervous people it must be remembered that local
+neurosis may occur almost anywhere in the body and that subjective
+discomfort alone in these cases must not be taken to signify a
+pathological condition, unless the localization is such as to indicate
+that a particular group of muscles is affected. The differential
+distinction between a pure neurosis and a discomfort due to a true
+pathological condition in the intermuscular planes is, that in the one
+case a group of muscles is affected, while in the other a locality is
+complained of, and {394} while local tenderness is likely to be a
+marked source of complaint in the neurosis it is comparatively slight
+as a rule in the muscular condition.
+
+For the more chronic soreness and discomfort of muscle groups,
+manipulations with massage are of great importance. Undoubtedly the
+discomfort and soreness is due in most cases to a disturbance of the
+venous or lymphatic circulation of the parts. This interferes with the
+nutrition of nerves and leads to nerve sensitiveness from lack of
+nutrition, or actual nerve irritation from pressure upon sensitive
+nerve endings while in a state of congestion. These conditions may be
+relieved by gentle manipulation and by massage, provided always these
+measures are not painful. These encourage the circulation and very
+soon tend to restore functions. Just as soon as the pain of these
+remedial measures or of any mechano-therapy becomes noticeable, it is
+not likely that they are doing any good. Pain, of course, must be
+judged from conditions and not from the patient's complaints, which
+may be due to fear lest pain should be inflicted.
+
+The main point is that local treatment, gentle, simple, yet directed
+with the proper therapeutic purpose so as to create a favorable
+expectancy in the patient's mind, will do much for these conditions,
+which have in many ways been the opprobrium of modern medicine. The
+rule has almost been to call them rheumatism, because they were worse
+in rainy weather. The word rheumatic instinctively calls up in most
+physicians' minds some cut-and-dried formula of internal medication.
+So these patients go the rounds of the regular practitioners in
+medicine taking a series of these formulae in succession and, as a
+rule, not getting any better. Then they go to an osteopath or to a
+naturapath, or some other kind of path, have some local massage and
+manipulations performed, which restores the circulation of the part,
+to some degree at least, and as a consequence they are encouraged to
+look for further relief. Not a few of them find the relief they look
+for, and it is these cured patients that in many parts of the country
+have insisted on securing for the osteopaths legislative recognition
+and actually obtained it for them in many cases, just because the
+regular physicians have neglected methods of cure ready to hand, but
+not made use of, because drugs are allowed to occupy their attention
+too exclusively.
+
+
+Disuse, Atrophy and Pain.--I have seen a striking example of atrophy
+and pain due entirely to disuse in the upper part of the leg as the
+consequence of a fall. No bone was broken, the man was laid up for
+nearly a month from the wrench, and then continued to be somewhat halt
+for many years. After nearly twenty years his attention became
+concentrated on this limb and then he spared it more and more in his
+walking, tilting his pelvis and merely swinging that leg, until there
+was a difference of nearly two inches between the size of the thighs.
+Of course, under these circumstances any use of the limb brought
+fatigue and pain with it. To walk was painful, and he had some
+twitchings at night. There was no disturbance of sensation, however,
+anywhere and no reaction of degeneration. His knee jerk was slighter
+than on the other side, but it was present and the weakness was due to
+the loss of power in the muscles. It was only weak in proportion to
+the atrophy of the muscles. This atrophy was not trophic in the sense
+of any failure of nerve impulses from the central nervous system, but
+was due to disuse, that is, it did not come from any nervous lesion,
+central or peripheral, nor from any disturbance of circulation, but
+from the dwindling of muscles that inevitably {395} comes when they
+are not employed for their proper purpose. Power to use depends on
+continuance of function.
+
+All sorts of remedies had been employed in his case, but he did not
+improve until he was made to understand that there was no bone lesion,
+no lesion of nerves or muscles, and that what he needed to do was to
+re-exercise his muscles gently but persistently and confidently back
+to their normal strength. This was accomplished by exercise and
+resisted motion, with care never to fatigue the muscles, but at the
+first sign of tiredness to stop, taking up the exercises at first
+twice, and then three and four times a day.
+
+As can be readily understood, these curious atrophic muscular
+conditions from disuse occur more frequently in the legs than in the
+arms. They may, however, occur in the upper extremities and are noted
+sometimes in the trunk. After all, certain of the stooping postures of
+men as they get old are due to lack of use of the large muscles at the
+back with consequent atrophy of them to the extent that makes standing
+up straight an effort very fatiguing and even painful. To attempt to
+straighten an old man by means of braces will lead to the development
+of painful conditions of tiredness if the correction is emphasized. In
+the arms the atrophic conditions are not so noticeable because the
+arms may be used without having to do the hard work required of the
+trunk and leg muscles in holding the man erect. It is the fear of the
+strain put upon them by this weight that makes the disuse continue,
+since there has come into the mind the thought that the muscles cannot
+be used to bear the weight and the burden is thrown on other muscles
+with unfortunate results.
+
+Many of these atrophies from disuse are cured by mental influence of
+one kind or another. They are the best sources of profit and
+reputation of the "healers." Once the patients become persuaded that
+they can use a group of muscles if they will, they begin to improve,
+and it is only a question of six or eight weeks until they are so much
+better that they persuade themselves that they are as well as ever. It
+is easy to understand that if a person who has been lame for five to
+fifteen years, vainly going to physicians of all kinds, is cured by
+some new form of treatment, all the non-medical world is perfectly
+sure that there must be much in the new method of treatment.
+
+
+
+CHAPTER IV
+
+OCCUPATION MUSCLE AND JOINT PAINS
+
+
+There is one variety of painful conditions of muscles and joints,
+often spoken of as muscular rheumatism or as chronic rheumatism and
+frequently the source of so much discomfort that patients feel that
+occupations must be given up, even at a great sacrifice. These deserve
+a special chapter. They occur in persons who have some occupation
+which requires them to use a particular group of muscles a great
+number of times during the day. They are most frequent in the arms,
+but they may be seen in the muscles of the neck, they occur very often
+in the legs and are not at all infrequent in the muscles of the trunk.
+Whenever a patient comes complaining of a painful condition in a
+particular group of muscles, careful inquiry must be made as to his
+{396} occupation, with details of the movements required. These pains
+are, of course, as are all human discomforts, worse on rainy days and
+in damp seasons, so that this has come to be known as rheumatic
+weather. It is easy to assume without further inquiry that they are
+rheumatic and this has been done frequently in the past.
+
+There is scarcely any occupation involving frequent and habitual use
+of muscles which may not be the source of discomfort if the actions
+necessary for it are done in such a way as not to use the muscles to
+the best mechanical advantage. In other words, there are a whole group
+of occupation fatigues which may take on a character of painful
+discomfort if the individual has not been properly trained in the use
+of his muscles. This refers not only to the use of muscles in the
+accomplishment of rather difficult tasks, but especially for those
+that require nice co-ordination for their accomplishment, though they
+may not demand the exertion of much muscular energy. In other words,
+what we have to deal with are rather painful occupation-neuroses than
+muscular fatigue in its proper sense.
+
+
+Writers' Ache.--Perhaps the most typical example of these is the
+painful conditions that may develop in connection with writing.
+Writers' cramp is well known and consists in a contraction of muscles
+which makes it increasingly difficult to hold the pen properly for
+writing and may eventually make it impossible to do so. This is
+accompanied by a certain amount of distress, but the writer's
+discomfort that is much more common than writers' cramp does not occur
+in the fingers, but in the large group of muscles just below the elbow
+and may extend even to the shoulder. The pain is of a vague achy
+character and as it is worse on rainy days and in damp weather, the
+temptation to think of it as rheumatism is very great. It occurs in
+people who write very much and rapidly, but especially those who write
+in a bad position. Now that the typewriter has come in much less is
+heard of it than before among reporters, but it used to be common with
+them. There is very little hint that it is due to writing, unless one
+makes careful inquiries.
+
+
+_Gowers' Rule_.--Its occurrence can be lessened to a great extent by
+following Sir Wm. Gowers' directions as to writing. Gowers was a
+parliamentary reporter before becoming a physician and he learned the
+difficulties of much writing and studied out the causes of the
+discomfort as well as of the cramp and of the best methods to avoid
+it. His rule is to sit on a rather high chair before a rather low
+table so that the elbow swings free of the table and the writing is
+what is called free-hand. The extent to which Gowers demands this
+freedom of the elbow carried may be best appreciated from his
+direction that the writing must be done in such a way that if a second
+pen were fastened to the elbow, it would write exactly the same thing
+that is written by the pen held in the hand. There must not be any
+movements of the fingers nor of the muscles of the forearm. All the
+movements required from writing must be accomplished from the
+shoulder. Just as soon as sufferers from vague aches and discomforts
+from much writing learn this method of writing, their aches disappear
+to a great extent. My own experience in the matter, when, as a medical
+reporter, I often wrote ten thousand words a day, taught me the value
+of the suggestion. During one winter I suffered so much from
+discomfort in the shoulder that I was sure that I had a progressive
+rheumatic affection. Just as soon as I learned to write properly the
+trouble was minimized to such {397} a degree that I realized that it
+was merely a question of faulty writing. I have noted over and over
+again, as is true in my own case, that if there has previously been
+any injury in the arm, this discomfort is much more likely to develop
+than otherwise.
+
+
+Occupation Pains and Habitual Muscle Movements.--What is true for
+writing is true for any habitual movement of groups of muscles
+requiring careful co-ordination. I have seen it in marked form in the
+makers of cigars and the strippers of tobacco. I have seen it in men
+who do much filing and whose working bench is so high, that pressure
+direct from their shoulders cannot be brought into play to supply any
+force that is needed in carrying on the filing process. If such a
+series of movements as filing is to be accomplished with comfort, then
+the arms must be held straight, the force being applied from the
+shoulders and not by the exertion of the muscles of the forearm, which
+are meant only to guide and not to supply the needed pressure. The
+Sloyd methods of working at benches are particularly important for
+workmen if they are not to develop these curious painful conditions
+which are due to habitual wrong use of muscles, and not to any
+diathesis. Any and every form of work must be looked at from this
+standpoint. Women often iron at a table or ironing board placed too
+high for them, and as a result apply the pressure necessary through
+their forearm muscles. If they are at all of nervous constitution they
+will suffer rather serious discomfort from this after a time and this
+will always be worse in damp weather. I have known women ready to give
+up because of the discomfort thus occasioned, who found that they
+could work without muscle discomfort for much longer periods, if the
+ironing board was placed low enough.
+
+
+_Arm and Shoulder_.--The occupation aches and discomforts in the arm
+and shoulder are very frequent and their variety presents an
+interesting study in the individual and his history. I remember once
+having three cases present themselves at a dispensary service of the
+Polyclinic Hospital on the same day, all presumably suffering from
+rheumatism. One of them was a motorman suffering from the occupation
+pains that so often come to those who use their arms overmuch, and the
+pains seen so frequently, for instance, in baseball pitchers. These
+pains are always worse on rainy days and in damp weather. There is of
+course a large individual element as the basis of these. Why can one
+man pitch nearly every day all season and not suffer with his arm
+while another man cannot? We can no more tell the reason for this
+difference than we can tell why one man is right-handed and another
+left-handed. One individual has a store of nervous energy that serves
+him very well. Another has a store of nervous energy that serves him
+well enough for his left hand but not for his right hand. The mystery
+would seem to be the original endowment of nerve force according to
+the individual's constitution. The motorman who suffers severely from
+putting on the brake of a heavy car will probably never be able to
+continue his occupation with comfort to himself unless his sore arm is
+due to some temporary condition, easily recognizable.
+
+A second of my patients with rheumatism complained of his shoulder. He
+had been first easily fatigued, then it was painful when he moved
+much, most so on rainy days, and finally he had practically lost power
+in it entirely. His occupation was that of finisher in a molding
+works. He lifted a heavy hammer many hundreds of times a day with his
+right arm, striking quick short {398} blows and using mainly his
+deltoid muscle in the lifting process. It was just his deltoid that
+was affected and the nerve supply had evidently given out. The third
+man complained not of his right hand, but of his left and of his
+forearm, not his shoulder, having lost power especially on the ulnar
+side of his hand. He was a stonecutter, who held a chisel firmly in
+his left hand, grasping it mainly with the under or ulnar side of his
+hand, and consequently overusing the group of muscles supplied by his
+ulnar nerve, leaving that structure open to pathological conditions.
+
+There was just one feature in the history of all three that was the
+same. They did not drink alcohol to excess often, but they did take
+some whiskey straight every day. The easiest explanation seemed to be
+that there was a neuritis set up in the nerves, which their
+occupations caused them to use so much, and that, as a consequence,
+the low grade neuritis finally developed to such a condition as to
+make further use of the muscle supplied by the affected nerves
+practically impossible. Just why alcohol will select certain nerves
+and not others upon which to exercise its deteriorating influence and
+why lead usually affects an entirely different set we do not know. In
+the ordinary man of sedentary occupation who walks occasionally, as
+his only exercise, his most used nerve is his anterior peroneal. Those
+of us who are not used to walking much, know how soon this nerve
+complains of fatigue when we take some forced ambulatory effort. It is
+this nerve then that with most people is affected by alcohol. But any
+nerve that is overused will apparently be affected the same way, and
+as many outdoor workers take some whiskey straight pretty regularly,
+it is not surprising to find that some of them have an idiosyncrasy
+and develop a low grade alcoholic neuritis.
+
+Alcohol, however, is not the only substance that acts thus
+insidiously. I was once asked to treat a painter who was suffering
+from intense tired feelings in his right forearm. They were always
+worse on rainy days, and he had been treated for rheumatism without
+avail. He had no signs at all of wrist-drop, there were no suspicious
+signs on his gums and he had never suffered from constipation or
+anything like lead colic. It seemed far-fetched, then, to say that his
+muscles were fatigued mainly because of the irritating presence of
+lead in the nerves supplying his right forearm. He slipped on the ice,
+however, and sprained his wrist, and the next day turned up with a
+typical lead wrist-drop. This fact of having lead poison develop
+shortly after an accident is not unusual, just as a sprained ankle may
+sometimes be the signal for an outbreak of alcoholic neuritis in the
+lower leg which has been preparing for some time, the accident itself
+being at least partially accounted for in many cases by the
+awkwardness of muscles with disturbed nerve supply.
+
+
+_Leg Occupation Pains_.--What is true of the arm is also true of the
+leg. If a man uses his leg muscles very much and especially at any
+mechanical disadvantage, he usually suffers painful discomfort that is
+always worse on rainy days. Before the invention of the electric
+dental engine, dentists used to suffer from this and the profession
+talked about the "dentist's limp." This was also more painful in damp
+weather and many of them were treated for rheumatic conditions, though
+it was really only over-fatigue.
+
+
+Neurosis and Neuritis.--There are many cases of painful conditions in
+the limbs where it becomes difficult to diagnose between a neurosis
+and a neuritis. The usual differential characteristic of tender points
+along the course of the {399} nerve cannot be used in many patients
+with confidence, because they are prone constantly to respond to the
+question "is that tender" in the affirmative. Besides in a neurosis
+there always seems to be a hypersensitiveness of the nerves involved
+that may simulate the tenderness of neuritis. In a number of obscure
+cases I have felt that the condition was a real neuritis when the
+development of a corresponding condition on the other side, or relief
+on one side followed by development on the other, has led to the
+diagnosis of neurosis. Of course, a double neuritis may well occur in
+the same nerve on both sides of the body under certain toxic
+conditions. Double sciatica nearly always indicates glycosuria.
+Diabetes may cause double neuritis in any other much used pair of
+nerves. Alcoholic neuritis may manifest itself on both sides.
+Ordinarily, however, the transference of symptoms or their spread to
+the other side of the body means a neurotic condition.
+
+In some of these cases where it has been difficult to distinguish
+between neuritis and neurosis, a change of occupation or some strong
+diversion of mind for a considerable period or a change of residence
+has proved the beginning of a cure. I have seen what was considered by
+experienced physicians to be a chronic low-grade neuritis of quite
+intractable form clear up completely as the result of the young woman
+being compelled to take up a wage-earning occupation, when it had
+always seemed before as though life was going to be smooth and there
+was no necessity for her to labor. I know of cases of so-called
+neuritis that had been very obstinate to treatment that were cured by
+Eddyite treatment. What really happened in these cases was that a
+group of muscles used considerably more than usual had produced a
+painful tired condition referred to a particular nerve. Just as soon
+as the mind's inhibitory action was taken off them by the persuasion
+that there was nothing the matter with them the patient proceeded to
+get well, gradually progressive use bringing back the normal trophic
+condition.
+
+
+Discomforts of Bursae.--In any consideration of painful conditions in
+and around joints, especially in connection with occupations, the
+question of the formation and of the inflammation of bursae must be
+insisted upon because many of these inflammatory incidents are
+confused with joint affections and not infrequently treated as if they
+were due to constitutional disturbance. Practically everybody is
+familiar with housemaid's knee. Most people know that bunions are
+inflammations of the bursae which form over the metacarpo-phalangeal
+joint of the big toe whenever there is pressure and irritation of it.
+Very few realize, however, that frequently repeated irritations, when
+pressure is exerted over other joints and bony projections, will
+produce a bursa, and then, if the irritation continues and an
+opportunity for infection occurs, there is bursitis. Some of these are
+mistaken for other conditions and often have been thought by the
+patient to be serious developments of one kind or another with regard
+to which there has been much solicitude. An interesting case of this
+kind in my experience was that of an Italian organ-grinder who
+suffered from the occupation bursa which so often forms over the
+anterior superior spine of the ilium because of the frequently
+repeated rubbing of the hand and arm as it passes this region while
+turning the handle of his instrument. It had finally become inflamed,
+and the Italian was much disturbed and he feared that it was
+appendicitis.
+
+Other bursae are not commonly seen in America. I have seen bursae over
+{400} the elbows of miners, and in one case saw one of these inflamed
+so that miner's elbow became a concrete entity. This case had been
+taken for an acute inflammatory arthritis with the suspicion of
+tuberculosis.
+
+
+
+CHAPTER V
+
+PAINFUL ARM AND TRUNK CONDITIONS
+
+
+Cervical Ribs.--Some interesting cases with painful conditions of the
+arms develop as a consequence of the presence of cervical ribs. It
+would be more or less naturally expected that trouble of this kind
+would occur early in life, but, as a matter of fact, many of the
+patients are well on toward thirty or even beyond middle life when the
+painful symptoms develop. Cases are practically always at the
+beginning diagnosed as rheumatism because the first symptom is likely
+to be pain followed by weakness. Even when this quite fruitless
+diagnosis is not made, the affection is often declared to be rheumatic
+neuritis, though it is really a traumatic neuritis and entirely a
+local condition, as are so many of the painful conditions spoken of as
+rheumatism. Usually the pain is referred to the inside of the arm and
+is described as resembling slight toothache at first and even severe
+toothache after a time. It will often be many months or even several
+years after the first symptoms before wasting of muscles occurs, but
+this practically always follows after a time and even at this stage
+some physicians still talk of rheumatic neuritis as affecting the
+trophic nerve fibers and causing the muscles to waste. Almost a
+differential diagnostic sign in the case of cervical ribs is that
+raising the arms above the head nearly always relieves the pain.
+Patients usually learn this for themselves because they have been
+tempted to place their arms in many positions in order to get relief.
+The reason for it is easy to understand as the elevation of the arms
+changes the relative position of tissues in the neck and so relieves
+pressure.
+
+The direct reason for the late development of the disease is probably
+the ossification of the cervical rib and the pressure of this hard,
+bony substance upon the roots of the brachial plexus. When the disease
+occurs as early as the age of 30 there is likely, for some reason, to
+have been a preceding loss of weight. Patients are run down and then,
+either because there is a precocious calcification as a consequence of
+deterioration of tissue, or because the loss of substance in the
+muscles in the neighborhood makes the nerves more likely to be pressed
+upon, the first symptoms develop. There is only one way definitely to
+decide the diagnosis. That is to have a careful skiagraph, or, in case
+of negative results, several of them taken, in order to determine the
+presence or absence of cervical ribs. Not all the cases of cervical
+ribs give symptoms and in one recently published series of 26 cases
+just one-half presented symptoms and the other half did not, but all
+these vague cases of pain in the arm, especially if any tendency to
+atrophy manifests itself, should be examined from this standpoint.
+
+
+_Local Conditions_.--The subjective symptoms in these cases often
+include {401} much more than pain. There may be numbness and the hands
+often feel cold, though they do not become blue. As a rule, indeed,
+the arms are more affected than the hands, though not infrequently one
+of the hands becomes more sensitive to injuries than the other and, as
+a rule, both hands do not heal well after injury. Even scratches take
+a long time to heal and slight abrasions cause skin lesions that are
+more or less indolent for some time before healing. Any fresh injury,
+even of slight degree, puts back healing much more than would
+ordinarily be the case. In fact, most of the so-called tendency not to
+heal is local rather than constitutional. When a patient complains
+that though his or her tissues used to heal rapidly now they are very
+slow to heal, it is well to think of nephritis or diabetes but it is
+especially important to know the local conditions.
+
+
+Pleural Adhesions.--Another interesting cause of pains in the arms is
+the possible contraction of adhesions of the pleura and surrounding
+tissues at the apices of the lungs and the spreading by continuity of
+a low-grade inflammation even to the lower roots of the brachial
+plexus. A certain number of cases of this kind have been reported in
+which there seems to be no doubt of the diagnosis. In these, the early
+symptoms were pains or aches in the arm followed by some weakness of
+muscles and even some trophic disturbances. Ordinarily the condition
+has been very acute as, for instance, a pneumonia when the first
+symptoms were noticed. In the course of the exudation and the
+contraction of the inflammatory exudate the brachial plexus is
+interfered with. This, like the cases referred to the presence of a
+cervical rib, emphasizes the necessity for thoroughly studying local
+conditions in order to understand the meaning of painful conditions in
+the arms. It is easy to say the word rheumatism, while it requires
+time and careful investigation to find the real pathological factor at
+work; but the difference in the value of the two diagnoses for both
+patient and physician can be readily understood.
+
+
+Other Conditions.--Besides these, there are the various conditions
+discussed in other chapters of this section--old injuries, breaks and
+dislocations, so-called sprains with laceration of tissues, and any
+serious pathological condition that has affected the tissues deeply.
+An old periostitis, for instance, will leave an arm rather easily
+liable to the development of various painful conditions. Of course, a
+tuberculous process anywhere in the arm will produce a like effect. An
+arm that has had a lead neuritis will often be uncomfortable in rainy
+weather for long after and a crutch palsy may, in the same way, leave
+the arm sensitive. The musculo-spiral palsies that occur from lying on
+the arm when drunk, or that are seen sometimes in coachmen who wrap
+the reins around their arms--a Russian custom--or the nerve conditions
+seen in patients who have suffered from an anesthetic nerve-pressure
+disturbance, may all be at the bottom of subsequent painful
+conditions, worse in rainy weather. The only sure rule is to
+individualize the cases and make an exact diagnosis. The etiology will
+probably suggest itself if the history is carefully taken.
+
+In these cases the most important treatment is to disabuse the
+patient's mind of the idea that there is rheumatism, or any other
+constitutional ailment present, and to make him realize that the
+trouble is entirely local. After this, the strengthening of the
+affected muscles must, as far as possible, be secured by local
+measures and exercises.
+
+{402}
+
+
+CHAPTER VI
+
+LUMBAGO AND SCIATICA
+
+
+Any affection involving discomfort, pain, ache, or disability of the
+large muscles in the lumbar regions is likely to be called lumbago,
+not only by patients but by physicians. Any condition that makes it
+painful to use the upper part of the lower limb and especially the
+group of large posterior leg muscles just below the nates is called
+sciatica. These are commonly supposed to be typical "chronic
+rheumatisms." Anything in this region that is the source of discomfort
+on rainy days and comes especially to the working man who has been
+exposed to the elements, or that follows a wetting or the wearing of
+damp clothes, is confidently classified as a chronic rheumatic
+condition. Almost needless to say any such conclusion as to the
+heterogeneous groups of symptoms that occur in these regions, far from
+adding to our knowledge, rather confuses the situation. There is an
+assumption that we know something about them when we call these
+conditions either lumbago or sciatica, but unless each individual case
+is carefully investigated and its conditions studied so as to get at
+their true etiology, it is almost impossible to treat them
+successfully. While the general practitioner of medicine of the
+regular school often fails in his treatment of them, these affections
+are among the most fruitful sources of revenue for the irregular
+practitioners.
+
+It was particularly for pains and aches in the back that St. John
+Long's liniment proved so efficacious about a century ago. So-called
+lumbago and sciatica patients were among the most frequent callers on
+Perkins in the days of the famous tractors and many of them received
+great relief. In our own time these constitute a class of patients who
+go from physician to physician and who finally are cured or relieved
+by some irregular practice which we know contains nothing especially
+remedial, but the advocates of which somehow succeed in persuading
+these patients that they must be better than before. Most old people
+have some aches and pains in either the lumbar muscles or the large
+muscles at the back of the thigh. Many of them are relieved by
+massage, but still more of them find relief in the rubbings and
+manipulations of the osteopaths, and they are great advertisers of the
+relief that has been afforded them and they have helped much in
+securing such state recognition as has come to the systems they
+thought curative in their cases. Eddyism has been helpful to a certain
+number of them. Fads of various kinds catch still others. Evidently
+these intractable cases deserve to be studied from the standpoint of
+what mental influence can do for them.
+
+
+Conditions Mistaken for Sciatica or Lumbago.--Needless to say, a large
+number of conditions occur which may be called sciatica or lumbago,
+but which are due to the most varied causes. An affection of any of
+the joints in this neighborhood will produce pain to which is often
+added tenderness and occasionally swelling, and nearly always
+disability. Disease of the lower part of the lumbar spine due to
+tuberculosis is often in its earlier stages called lumbago. Indeed,
+without careful investigation showing that there is a special point of
+tenderness, some irregular fever and that the muscles are in spasm
+{403} to protect the underlying joints from use, it is difficult to
+decide just what is the affection in a particular case. I have seen
+three physicians diagnose a one-sided tenderness and pain in muscles
+with disability as lumbago, when the course of the disease proved that
+it was tuberculosis of the sacro-iliac joint. Any of the bones or
+joints in this neighborhood may give rise to pain, tenderness and
+spasm of muscles and it is important not to make the facile diagnosis
+of lumbago, unless careful investigation has eliminated all underlying
+organic conditions.
+
+There are other conditions not infrequently mistaken for lumbago or
+sciatica which are interesting. Needless to say unless they are
+definitely recognized there will be no relief afforded for any
+discomfort of a permanent character, though the coal-tar products will
+give temporary surcease of pain. Occasionally internal hemorrhoids
+produce an achy discomfort in the lower part of the back that is
+described as lumbago, and unless the physician is careful to
+investigate he may tentatively accept that diagnosis. Proper
+regulation of the bowels and the use of gluten suppositories will
+often practically cure the condition, though there will be relapses
+whenever constipation returns. Chronic posterior urethritis sometimes
+simulates painful conditions very low down in the back or in one hip
+or the other. Usually in that case there is a chronic inflammatory
+condition in the seminal vesicle on the side to which the symptoms are
+referred. Occasionally over-distention of the seminal vesicles, as
+seen in widowers who have been accustomed for many years to regular
+evacuation of them, may cause so much pain and disability in the
+region of the hip on one side as to be mistaken first for lumbago and
+then even for tuberculous hip joint disease. Artificial emptying of
+the seminal vesicle by milking through the rectum will usually afford
+relief. In all of these cases as soon as the exact diagnosis is made,
+the patient's mind is relieved of a serious burden of anxiety and it
+is usually not difficult to bring a great measure of relief.
+
+
+_Old Injuries and Discomfort_.--Many of the painful conditions
+described as lumbago are due to old injuries, to wrenches and sprains
+in this region due especially to heavy lifting and to the laceration
+of ligaments from over-exertion.
+
+
+_Typhoid Spine_.--Protracted cases of typhoid are sometimes followed
+by pain in the lumbar or sacral regions, developing usually after a
+slight jar or shock, sometimes after a fall or even following a severe
+injury, which are really the result of the physical condition of the
+patient. Stiffness, aching discomfort on movement and sometimes
+tenderness on pressure are present. Often there are associated
+neurotic symptoms of various kinds. This used very commonly to be
+considered rheumatism and occasionally one still sees cases so
+labeled. On the other hand, much more serious conditions, as Pott's
+disease, abscess of the liver, or some form of spondylitis, may be
+suspected. Absence of temperature is almost the rule and usually is
+the pathognomic differential against these. The whole condition is
+usually a neurosis though there may be some perispondylitis. The
+treatment is to increase the patient's nutrition, which has usually
+suffered to a marked degree, and get the mind off the condition in the
+back. Concentration of attention on it will make it very
+uncomfortable, so that even heavy doses of opiates will scarcely
+relieve the discomfort, and this emphasis of attention will further
+disturb the mind and develop neurotic {404} symptoms. Diversion of
+attention, gentle movements, plenty of air, and regulation of the
+functions of the body will bring about a cure.
+
+
+Stooping Occupations.--Occupations are especially important in lumbago
+and people who have to stoop much, above all those who do hard work in
+a stooping position--lifting, pushing, sawing, planing, and the
+like--are particularly prone to suffer. Miners working where the
+height of the vein does not permit them to stand up are commonly
+subject to it. Any one who has to assume, or has the habit of
+assuming, a stooping posture for long hours may suffer from lumbago.
+Constrained position predisposes more than hard work. Tailors, though
+in a sedentary occupation, often suffer from it.
+
+
+SCIATICA
+
+
+Etiology.--What has been said of lumbago applies to a great extent
+also to sciatica. There are a number of different affections which
+have come to be grouped under the term sciatica. Here, much more
+frequently than in the lumbar region, the cause of the pain is a true
+neuritis. This may be of many forms. Occasionally it is syphilitic in
+origin; whenever the sciatica is double it commonly develops on a
+basis of diabetes, while in many cases it is of an infectious nature.
+There is no special reason to think that there is a rheumatic
+infection of the nerve, though inasmuch as rheumatic arthritis is
+probably due to infections by many different kinds of microbes, it may
+well be that some of these play a role in sciatica. There is no good
+reason, however, why the word rheumatism or the term chronic
+rheumatism should be applied either to lumbago or to sciatica.
+Certainly there is no reason in any definitely known etiology of the
+affections. Each individual case must be studied carefully. Always
+these are local and not constitutional conditions, and usually
+something in the patient's occupation, or in his habits of life, helps
+us to understand the development of sciatica or lumbago and gives the
+most valuable hints for treatment.
+
+Men who shovel much and who bend one knee as they stoop in shoveling
+will often suffer, though more frequently in the leg which they do not
+bend than in the other. The same thing is true for men who use one
+foot to run a lathe or a small printing press, or anything of that
+kind. They must be taught to alternate in the use of their limbs.
+
+
+_Pressure_.--Occasionally direct pressure upon the nerve is the cause
+of the disturbance. I once was asked to see in consultation an elderly
+lady who had complained very much, first of discomfort and then
+numbness in her legs, until finally she lost all power in them below
+the knees. The affection was considered to be some sort of creeping
+paralysis. I found that her favorite chair, an old-fashioned cushioned
+easy chair, allowed her to sink down so that the edge of the wood seat
+frame pressed upon her just where the sciatic nerve comes closest to
+the surface. As soon as the habit of sitting on this chair was changed
+her numbness and inability to use her limbs began to disappear.
+
+
+_Alcoholic Neuritis_.--In both lumbago and sciatica one underlying
+factor is often present. This is the consumption of undiluted whiskey
+in considerable quantities. Outdoor workers are prone to take an
+occasional glass of whiskey, especially in the winter time, and a
+copious quantity of malt liquors in the summer. Both of these
+predispose to the development of a low-grade {405} neuritis in
+susceptible individuals. Alcohol is said to have an idiosyncrasy for
+the anterior tibial nerves. That only means, as a rule, however, that
+these nerves are more frequently affected by alcoholic neuritis than
+others in the body. The reason for this special location of the
+affection is that in people who stand and walk much, this constituting
+their main form of exercise, these nerves are much used. They are
+probably in such people (that is, if the intensity of impulses that
+pass through them be taken into account) the most used nerves in the
+body. It is this that makes them most susceptible to alcohol. In
+people who stoop much or who have to work hard in stooping postures,
+the nerves in the lumbar region and those that make up the sciatic
+trunk are over-used. This makes them more susceptible to pathological
+influences than others, hence the tendency for neuritis to develop in
+them.
+
+
+_Intrapelvic Causes_.--Sciatica may be due to various pathological
+conditions within the pelvis. Women with fibroid tumors are
+particularly likely to suffer from it. Their removal by operation does
+not always assure against the occurrence of sciatic troubles. I once
+saw an obstinate case of sciatica in which there was a story of a
+fibroid having been removed years before and, though there were no
+signs of any recurrence of the growth of another, there were some
+adhesions in the region, and there was an obstinate constipation
+particularly likely to have as one symptom an accumulation of fecal
+material in the rectum until it was very hard. The keeping of the
+bowels open meant more than anything else for the relief of the
+sciatica. This patient subsequently died from what was diagnosed by a
+well-known French surgeon as rupture of the bowels. This was probably
+due to the adhesions that occurred after the old operation, done
+without any regard to the possible development of such a sequela, some
+twenty years ago. The sciatica was undoubtedly connected with the
+group of disturbed conditions within the pelvis.
+
+
+_Position at Work_.--In this case, as in others that I have seen, the
+position assumed while at work seemed to have been an appreciable
+factor in the production of the pain in the limb. The lady made her
+living by writing and often wrote on a board resting on her knee--a
+feminine, not a masculine habit. This brought pressure to bear upon
+the right limb a little more than the other and then, when she crossed
+her knees in order to put the writing board on top of the knee, this
+side seemed to be used more than the other.
+
+This question of the position in occupation, even though sedentary, is
+very important. I have seen a strikingly typical case of the so-called
+_neuralgia paresthetica_, the achy condition of the outside of the
+thigh with some anesthesia and paresthesia, occur in an old lady who
+still retained the girlish habit of sitting on her foot while she did
+crocheting. I have often seen achiness of muscles of the trunk develop
+in persons who read much in a cramped position because of the reading
+light being too low or otherwise wrongly placed for group reading.
+Whenever a patient has to stand much on one foot while doing
+something, it is important to remember that there should be
+alternation in the use of the limbs; otherwise sciatica and lumbar
+pains will often develop, usually on the side corresponding to the
+limb that is kept rigid.
+
+
+Treatment.--_Mental Persuasion_.--The patient must be made to realize
+that his affection is not rheumatism, but is due to local conditions.
+Just as soon as a patient's mind is relieved by being made to
+appreciate that certain habits in his occupation, or certain local
+conditions that can be corrected, {406} are responsible for much of
+his discomfort, then that discomfort is much easier to bear. Even in
+cases where actual neuritis has developed, or where there have been
+changes in the intermuscular planes bringing considerable disability,
+the aches caused by these will be much more bearable if the patient's
+mind is set at rest as to the real significance of the condition. No
+condition should be called rheumatic unless at some time in the
+history of it there was an acute inflammatory condition with Galen's
+classical symptoms--_tumor, color, rubor_ and _dolor_. Pain alone is
+never sufficient to justify the diagnosis. Painful disability is
+usually due to local causes.
+
+
+_Treatment of Acute Symptoms_.--For acute symptoms, the coal tar
+products may be used and usually afford distinct relief. They include
+all the old-fashioned salicylates as well as certain more recent
+compounds, such as aspirin. Phenacetin, however, though usually not
+thought of in this connection, is an excellent remedy for the
+discomfort. These drugs should be used freely so as to give relief
+from the painful condition. The fact that they afford relief, however,
+should not be taken as an argument that the condition is rheumatic.
+Rheumatism, as we know it, is an acute infectious disease and there is
+no reason in the world for saying that the salicylates or cognate
+drugs are specifics in this affection. They relieve the pain, but just
+in the same way they would relieve the pain of toothache or of any
+other painful condition. After the acute symptoms are removed, the
+condition that remains may be treated in various ways, by massage, by
+local applications, and by such manipulations as will restore the
+normal circulation of the part. Care must be taken, however, to
+distract the patient's mind from the local condition after a time, or
+mental influence, by interfering with the capillary circulation, may
+inveterate the symptoms. It is not good to keep patients at rest,
+though rest, of course, is always indicated if there is much
+discomfort. Sometimes, however, the discomfort is really due to the
+fact that muscles have not been used for some time and so are easily
+fatigued and may ache even under ordinary use. In this case, a gradual
+restoration of the muscles to normal strength by progressively
+increased exercise is important.
+
+
+_Counter-Irritation and Its Suggestive Value_.--Personally, I have
+found the use of turpentine particularly efficacious in connection
+with suggestion. The old-fashioned system of ironing seems to do more
+good than any ordinary application of turpentine. For this a piece of
+flannel wrung out in warm water has some turpentine scattered over it
+and then is placed on the affected loins or back of the thigh and
+covered by another piece of flannel, and a hot flat-iron is rubbed
+over it. The physical effect is a considerable hyperemia, but the
+effect upon the patient's mind is especially interesting, the
+unusualness of the mode of application adding decidedly to the effect.
+It must not be forgotten, however, that there are some people who are
+over-susceptible to the influence of turpentine, and its use is
+followed by a rash.
+
+
+_Lumbar and Sciatic Psychoneuroses_.--Many cases of lumbago and
+sciatica are really psychoneuroses. They develop exactly as
+psychoneurotic conditions do in the abdomen or in joints. Not
+infrequently there is some accident or injury, some sprain or strain,
+or exposure to dampness or draft, that serves as the occasion. The
+Germans group all these occasions together under the word "insult."
+The "insult" produces little physical effect but after some days or
+sometimes weeks, the slight discomfort present secures the center of
+{407} attention and then the patient suffers from what seems to be
+severe pain and often inability to move or use muscles. Even when
+there is true sciatica or lumbago, that is, a genuine low-grade
+neuritis of the lumbar or sciatic nerves, most of the symptoms may
+come from the associated psychoneurosis. This is proved to be so by
+the fact that such patients are often cured, for the time being at
+least, by some shock or fright or sudden excitement, that makes them
+move, forgetful of the pain and inability from which they suffered
+just before. Besides, such cases are often cured by inert remedies of
+many kinds, by local applications that have no specific effect, and by
+various methods of treatment which cannot be responsible for the
+recovery. The amelioration of the condition is due to the mental
+influence accompanying the methods of treatment and the reassurance of
+the patient's mind.
+
+
+_Diversion of Attention_.--Almost anything that produces a continuous
+succession of sensations on the surface of the affected area that
+attract and hold the attention of the patient may prove a valuable
+therapeutic suggestion and even eventual relief from symptoms that
+have proved obstinate to more rational treatment. Liebault, the
+well-known founder of the Nancy school of hypnotic therapeutics, tells
+in his "Thérapeutique Suggestive," that he has frequently cured
+lumbago by the simple recommendation of a rather stiff piece of paper
+to be applied over the patient's loins. The rationale of this
+treatment seems to be that the patient's attention is attracted to the
+skin surface by the sensations constantly produced by it and attention
+is distracted from other feelings deeper in the muscles. It often
+happens that after an acute lumbago has run its course, there is left
+a chronic achiness only partly physical and largely psychoneurotic.
+Some of it is undoubtedly due to the habit, formed during the acute
+period, of keeping the muscles quiet, in order to avoid the spasmodic
+pain that occurs on movement. Patients cannot, as it were, let go of
+their muscles, and their discomfort is largely due to holding them in
+a cramped position. The sensation produced by the paper on the
+cutaneous nerves distracts the attention and brings about relaxation
+of the muscles with decrease of discomfort and gradual relief of all
+symptoms.
+
+The paper acts as a constant source of suggestion for the cure of the
+psychoneuroses when the affection is purely psychoneurotic. The mind
+has become concentrated on the idea of pain and discomfort in this
+region and needs another thought to occupy itself with so as to
+neutralize this. Wearing the paper with the assurance, for instance,
+that because of its impermeability to air it keeps the part more
+thoroughly protected from variations of temperature and from such
+possibilities of transudation as have before been possible, serves to
+lift patients out of themselves and affords relief. Whenever the
+sensation produced by the paper is noted, there is a renewal of the
+suggestion and its curative effects. There are many plasters that have
+obtained the reputation for curing lumbago. It is doubtful whether any
+of these have sufficient medicaments on them to be of any serious
+pharmaceutic significance. They are mostly rubber plaster. The
+presence of this and the consciousness of the sensation produced by it
+acts as favorably as does Liebault's sheet of paper.
+
+
+_Mechanical Agents_.--It must not be forgotten, however, that a large
+sheet of adhesive plaster firmly applied may act as a mechanical
+therapeutic agent, somewhat in the same way that strips of adhesive
+plaster relieve the pain of pleurisy, or are helpful in a sprained
+ankle or a knee. The muscles may be {408} held rather firmly together
+and so there is no necessity for constant attention to prevent
+spasmodic pain. Undoubtedly some of the newer large-sized adhesive
+plasters produce an excellent effect in this way. If, besides, the
+patient has the feeling that they must be doing him good because of
+materials in their composition, the psychoneurotic elements are more
+readily relieved. The old idea was that such plasters drew out the
+pathological elements to the surface whence they were dissipated.
+There is no truth underlying this thought.
+
+In the old days blisters were applied rather freely to these regions
+and the actual cautery was often employed. Both of these therapeutic
+processes are likely to do good in chronic cases, but much more from
+their psychic than their physical effects. The actual cautery is not
+used nearly so much as it ought to be in chronic muscular and neurotic
+conditions, for the mental effect of its application and the
+distraction of attention to the skin surface while the cauterized
+areas are healing are excellent remedies.
+
+There are other counter-irritant procedures of the same kind that have
+been used with reported successes in many cases. Hot needles, for
+instance, if pushed deeply into the muscles, often have an excellent
+effect. Some years ago a distinguished surgeon insisted that both
+lumbago and sciatica might be cured in many cases by the insertion of
+needles deeply into the muscles. He argued that what happened was that
+these needles brought about an equilibrium of electricity in the
+muscular structures which had somehow been disturbed. Deep injections
+of water into the muscles also do good. Stretching of nerves has been
+applied with reported success. After a time all of these measures
+fail, however, because somehow after the novelty of the treatment
+wears off for the physician, the patient's mind is not sufficiently
+impressed and then the former results are not secured. Where there are
+actual neuritic processes present they will almost surely fail. So
+many of these cases are almost pure psychoneuroses, however, that it
+is little wonder that anything which produces a strong impression on
+the mind and leaves after it some condition that attracts attention
+and so furnishes favorable suggestion will almost surely cure even
+chronic conditions for which all sorts of physical remedies, employed
+on rational grounds, have failed.
+
+Anything that modifies the circulation, even to a slight degree, or by
+causing a reaction in the local vaso-motor state, alters previous
+conditions, tends to enable the patient to control the affected part.
+These psychoneurotic conditions in large muscles help us to understand
+what happens in organic diseases. There is a physical element that
+must be modified, but unless a strong influence is brought to bear
+upon the mind so as to arouse all its capacity for control, the cure
+will not come. Anyone of a dozen things, however, may be used in this
+way and often when one fails another will succeed. In obstinate cases
+of lumbago and sciatica if necessary a number of these forms of
+treatment should be used successively.
+
+
+_Hypnotism_.--How much pure psychotherapy may mean for many of these
+obstinate cases of lumbago and sciatica can be appreciated from the
+many reports of cures by hypnotism or by suggestion in a light
+hypnoidal state, or occasionally, under favorable circumstances, even
+in the waking state. One of these cases, indeed, is responsible to
+some extent for the French interest in hypnotism which attracted so
+much attention in the last quarter of the {409} nineteenth century.
+Prof. Bernheim of the University of Nancy had seen a case of sciatica
+in which every therapeutic means at his command had failed. As the
+result of disuse the leg was emaciated and possessed little muscular
+power. It looked as though the man would never be able to regain the
+use of it properly. Dr. Liebault succeeded in curing the patient by
+light hypnotic sleep, in which the suggestion that he would be better
+was given while the physician stroked the limb. After the first seance
+the patient was able to use the leg better and the discomfort was
+greatly decreased. Further seances with Dr. Liebault brought further
+improvement until finally the condition was cured. Prof. Bernheim, who
+knew how intractable these cases are, had the case called particularly
+to his attention and naturally wanted to learn more about the method
+by which it had been brought about. Liebault's methods had been quite
+contemned by the regular faculty before. After a series of experiences
+under Dr. Liebault's direction Prof. Bernheim became enthusiastic over
+the use of hypnotism as a curative agent and this led to the
+publication of his well-known work "De la Suggestion et ses
+Applications dans la Thérapeutique."   [Footnote 34] It was the
+interest aroused at Nancy that led Charcot to take up hypnotism, and
+while he came to very different conclusions, there is no doubt that
+the work at Nancy meant much for our knowledge of suggestion in both
+waking and hypnotic state in therapeutics.
+
+  [Footnote 34: On Suggestion and its Applications in Therapeutics.]
+
+
+
+CHAPTER VII
+
+PAINFUL KNEE CONDITIONS
+
+
+Most of the painful knee conditions of which patients complain are not
+directly due to true pathological conditions either of the knee joint
+itself or of its neighboring structures, but rather to affections of
+other portions of the leg that set a special strain upon the knee and,
+above all, to various kinds of foot disturbances. The erect position
+is maintained principally by a nice balance of nervous and muscular
+energy in the knee joint and its surrounding structures. Any irregular
+sensory or motor impulses to the knee-joint or to the muscles of the
+thigh will disturb the absolute equilibrium of the flexors and
+extensors and will make standing painful or even impossible. Whenever
+a morbid condition requires a different use of the muscles and tendons
+around the knee from that to which they are accustomed, fatigue
+readily ensues, and aches and even tenderness in muscles and tendons
+develop as the result of the over-exertion. These collateral
+conditions must not be overlooked in the diagnosis and treatment of
+painful knee conditions.
+
+
+Etiological Factors.--Even a slight sore on one foot will give rise to
+considerable achy fatigue of the knee of the opposite leg, because,
+consciously or unconsciously, we stand much more on that leg, use it
+more in walking, and spare the other because of the pain induced by
+use of the foot. Above all, throwing more weight on the other leg
+causes us to use muscles a little abnormally with consequent soreness.
+This painful fatigue is most likely to be felt around the knee, though
+it may extend to the hip and even the lumbar {410} region of the well
+side if the foot continues to be spared for a number of days.
+Particularly will this be true if there is anything the matter with
+the big toe, on which so much of the use of the foot depends. An
+ingrowing toenail will not infrequently give so much discomfort to the
+well knee and hip as to make the patient sure that there must be some
+rheumatic or other condition at work in these joints. The serious
+affection of the joint which the patient apprehends is found to be no
+more than a sympathetic fatigue induced by having to use his feet, or
+one of them, a little differently from usual, perhaps because of some
+condition that leads him to spare them. To call the patient's
+attention to this is of itself therapeutic.
+
+
+_Inequality of Legs_.--The effort required for standing and the
+accurate balance of the muscles involved in it is such that any
+mechanical disturbance of the feet or legs or even a trivial
+pathological condition causes painful fatigue. It must not be
+forgotten, for instance, that the presumption that human limbs are of
+exactly the same length is not confirmed by accurate measurements.
+There is an average difference of probably half an inch in length
+between the limbs of normal persons, and there may be even a
+difference of more than an inch before deformity is said to be
+present. The longer limbs are likely to do more work and are,
+therefore, more subject to fatigue and consequent complaint. One of
+the reasons why we can distinguish persons by their gait even at a
+distance is that the difference in the length of their limbs makes
+noteworthy characteristics in their walk.
+
+
+_High Heels_.--People who are used to walking in a natural manner and
+who don a pair of high-heeled shoes for the first time are sure to
+complain of pain in the calf and knee, because the high heels require
+them to hold the knee more rigid and in a somewhat different position
+from that required when the persons stand under ordinary
+circumstances. It is the unusual in muscular effort that gives rise to
+the extreme fatigue which becomes positive pain if it is allowed to
+continue. It is curious how small a raising of the heel will cause
+discomfort. Over and over again I have known the careless putting on
+of rubber heels to be responsible for pains around the knee, which in
+damp weather were the source of so much discomfort that it was hard to
+persuade the patient that he was not suffering from rheumatism or some
+serious incipient pathological condition.
+
+
+_Unusual Occupations_.--Joint pains often develop after the patient
+has been doing something quite unusual and putting an unaccustomed
+strain upon his muscles. I have often seen dispensary patients whose
+knee pains began after there had been a family moving. In the course
+of the removal of household goods, both men and women are likely to
+help in hanging pictures, in taking them down, in moving heavy
+furniture and other occupations of this kind which make them extremely
+tired. If there is any tendency to relaxation of joint structures the
+tiredness may manifest itself as a sense of painful discomfort. The
+knees are particularly likely to suffer if there is a relaxed
+condition anywhere in the leg. It must be remembered that the laxity
+of tissue which predisposes a patient to weak or flat feet will have a
+tendency to produce some looseness of fiber, at least, also in the
+tissues around the knee. The patient may not have a wabbling knee, nor
+may he be able to overextend the limb, but still there will usually be
+some noticeable relaxation of the tissues which will help in the
+production of the painful condition by {411} making exaggerated calls
+upon the muscles in order to keep the joint in proper position in
+spite of the over motion in it.
+
+The disturbance is most frequent in waiters, store clerks, tailors'
+cutters and fitters, bench men in the trades, and in all those who
+have to spend much time on their feet. I have seen many such ready to
+give up their occupations, though they had no other resource and the
+future looked very blank, indeed, away from their work. It was
+difficult at first to persuade them that a slight yielding of the arch
+had so changed mechanical conditions in the use of the muscles of the
+leg as to produce such pains. But as soon as they were put in a
+condition where their arch was not allowed to sink, they were at once
+relieved of their discomfort to a great extent. The question of
+treatment is discussed more fully in the chapter which follows on Foot
+Troubles.
+
+An interesting set of painful conditions around the knee develops in a
+class of people in whom it might least be suspected of being due to
+over-exertion connected with their occupations. These are lecturers,
+clergymen, teachers, and others who, for several hours each day, are
+on their feet in a position from which, as a rule, they do not move,
+but stand almost perfectly quiet. A distinguished laryngologist has
+pointed out that not infrequently men who come to be treated for the
+chronic laryngitis, which is known as clergymen's sore throat, but
+which is seen so frequently in those who have to talk in the open air,
+auctioneers, cart-tail orators about election time, and in lecturers
+to large audiences who do not know how to use the voice, also complain
+of grievous discomfort from painful knee conditions which often makes
+the ascent or descent of stairs a painful task. He attributes the
+simultaneous occurrence of these conditions to some blood dyscrasia,
+uric acid, or the like, affecting the two most used sets of muscles
+and organs, the legs and the vocal cords. Whenever I have seen this
+condition--and circumstances have brought me into intimate personal
+relations with many clergymen and lecturers--the trouble at the knee
+has been due to some yielding of the plantar arch, while the laryngeal
+condition, if present, was due to an erroneous mode of using the voice
+consequent upon lack of proper training.
+
+Sufferers of this kind must be warned not to stand absolutely
+immovable while addressing an audience. Some men stand without moving
+during a whole hour's lecture. This is unfortunate, for it obstructs
+the return circulation through the tense muscles, for the venous
+circulation was intended to be helped by muscular contraction. Many a
+man finds, as he comes down from pulpit or platform, that his knees
+are stiff and sore, though a moment before he knew nothing about it.
+The failure to notice any discomfort before is of itself an example of
+the influence of the mind over the body for the relief of pain.
+
+
+Associated Lumbar Discomfort.--The painful condition around the knee
+which develops when high heels are worn is almost sure to be
+accompanied by pains, or at least a tired feeling, in the back. If we
+convince the patient that the trouble is due merely to a derangement
+of the mechanism involved in maintaining the erect posture we shall
+have scant need of medicine or even of local treatment. But as the
+pain is much worse on rainy days, owing to the relaxation of the
+muscles, we must be careful to remove the patient's suspicion that the
+pain must have a rheumatic origin. The restoration of normal
+mechanical conditions with the removal of the cause will prevent the
+{412} recurrence of the affection, and if some discomfort remains, the
+patient will not worry, and the muscles will gradually grow accustomed
+to the strain upon them. Of course, these conditions of discomfort are
+more common in those who are not naturally strong, who are run down,
+who are under-weight, or whose neurotic tendency will make any
+irritation seem worse than it is.
+
+
+Heavy and Light Patients.--Two classes are likely to suffer more than
+others from these conditions. They are the people who are overweight
+and the people who are underweight. Those who are overweight exert
+much more effort to maintain the erect posture than ordinary people,
+and, besides, in most adipose persons the distribution of weight is
+such that a disproportionate amount of it is carried forward of the
+normal center of gravity. High heels cause a further tilting forward
+that has to be counter-balanced, and that, at least at the beginning,
+gives rise to muscular discomfort. In people who are underweight the
+nutrition of the muscles has suffered, and, as a consequence, they are
+not able to support the frame as well as before. In them the
+additional effort necessitated by the tilting tendency of high heels
+is particularly felt because such people are nearly always among the
+neurotically inclined.
+
+
+Muscle Disuse.--Sometimes treatment of these conditions seems to lead
+up to the disuse of certain muscles and the over-use of others. I
+followed for several years an interesting case of this kind in which
+the course of the affection was so typical as to deserve to be
+recalled. A fuller account of the case occurs in my paper on
+"Rheumatism versus Muscular and Joint Pains" in _The American Journal
+of the Medical Sciences,_ August, 1903.
+
+In that case the joint symptoms caused by the pinching of a loose
+cartilage within the joint occurred suddenly on two or three
+occasions, so that a surgeon deemed it wise to put the knee in
+plaster. As a consequence, some atrophy of the muscles of the leg
+occurred, and a halt became habitual in the gait. Through this halting
+gait, the muscles of the back on the same side were also spared and
+thus became somewhat atrophied. Painful conditions developed in the
+muscles of the other side of the back from the over-use necessary to
+compensate for the condition on the less-used side. All of the muscles
+on the affected side became painful, apparently because of the
+atrophic condition to which they were reduced.
+
+The young man, though with the best of good will, was utterly unable
+to conquer the tendency to halt in his gait, and so the muscles
+remained under-exercised and were used at a mechanical disadvantage,
+with the usual painful result. He went to at least two prominent
+orthopedic surgeons, who assured him that all he needed was confidence
+in himself to walk straight, and that then the normal condition of the
+muscles and absence of pain would result. But their directions were
+absolutely without result. He went through the hands of masseurs, of
+osteopaths, of rubbing quacks of all kinds, and suffered at least two
+attacks of artificial eczema as a consequence of the use of turpentine
+liniments, but he remained after it all in what he considered to be an
+intensely miserable condition. These cases are practically always
+cured by definite exercise of the muscles of the affected limb so as
+to bring them back to their normal tone. It requires special attention
+for this purpose, however, and the patient's mind must be brought to
+understand that at first the unaccustomed use of muscles will cause
+discomfort, but that this will disappear after a time. These patients
+are persuaded that they must be "cured" to get well.
+
+{413}
+
+
+CHAPTER VIII
+
+FOOT TROUBLES
+
+
+The more physicians see of affections of the feet and of painful
+conditions of the legs due to foot troubles the more they realize that
+the human faculty of the erect position becomes the source of many
+discomforts unless care is taken of the muscular apparatus of the
+legs. There are few people engaged in standing occupations who do not
+suffer from their feet. These achy sensations are especially
+bothersome if the patient is run down in health, or is in the midst of
+worry or irritation from physical or mental stress. Even under
+favorable conditions there are few who reach old age without serious
+foot troubles or without, at least, some deformity of the feet, which,
+by preventing or limiting exercise, have an important influence upon
+the general health. Careful analysis of the conditions that develop
+will convince an observer that yielding of the joints of the foot has
+much to do with the deformities and that the wearing of unsuitable
+shoes rather than any internal pathological condition is responsible
+for the foot troubles that are so common.
+
+
+Foot Deformities in All Classes.--An Englishman who visited this
+country, and who had ample opportunity to observe our people, declared
+after seeing the bathers at Newport, that there were two interesting
+peculiarities of American masculine anatomy--the deformity in their
+feet and the appearance of having swallowed a watermelon whole and
+retained it within them. The latter condition has doubtless much to do
+with the causation of the former. Inactive lives, overeating, and the
+overweighting of flaccid limbs that are not capable of bearing even
+their normal burden, complicated by tight and ill-fitting shoes, give
+rise to the deformities of the toes that are so common--hammer toes,
+over-riding toes, bunched toes, twisted toes, bent toes. Examples of
+most of these are sure to be seen wherever we observe our men and
+women bathing. The Englishman's observation was of our so-called
+better class--at least, our leisure class. Ordinarily, it is assumed
+that clerks, waiters, and others, who have to stand upon their feet
+are the principal sufferers from foot deformities. They are, but they
+are not alone, and a goodly proportion of the population suffers in
+this way.
+
+
+Mechanical Factors.--The most important deformity in these cases is a
+yielding of the arch of the foot with consequent flattening of the
+instep and lengthening of the foot. This overstretches especially the
+flexer tendons which run underneath the arch, produces bunions, and
+gives occasion for the development of corns. The pull upon the flexor
+longus hallucis which runs along the inside border of the foot, gives
+rise to the bunion by pulling the big toe outward--in the direction of
+least resistance. The pressure upon the tendons of the flexor longus
+digitorum pedis causes the smaller toes to bend somewhat, and this
+gives rise to projecting angular points on which corns readily form.
+Besides, the imperfect action of the muscles of the foot consequent
+upon the fall of the arch gives rise to plantar corns and callouses
+that are often painful. The living cushion of muscle which is the best
+protection against injury, while walking or running, has its vitality
+interfered with by {414} the fall of the arch and the consequent
+blocking of the return circulation through the thin walled veins. This
+gives rise to cold feet and, in those who stand much, to the tender
+feet that are now so much complained of and for which so many foot
+powders and appliances are advertised.
+
+
+Confusion of Rheumatism and Foot Troubles.--Most foot troubles are
+reflected up the leg because muscles have to be overused or used at a
+serious mechanical disadvantage. This combined discomfort of foot and
+leg is readily referred to rheumatism. Some of the pains produced by
+yielding of the arch are in the ankle, some are in the calf, some in
+the tissues around the knee, and some even in the muscles and tendons
+above the knee. It is much easier to say "rheumatism" than to
+investigate carefully and differentiate the conditions that may be
+present. Out of forty successive patients who came to the dispensary
+of the Polyclinic Hospital of New York complaining of rheumatism,
+eighteen were suffering from flatfoot. Out of twenty-four who thought
+they had rheumatism in the feet or legs eighteen proved to be cases of
+flatfoot. Of the others, one was suffering from that rare disease
+meralgia paresthetica, two were suffering from sciatic neuritis, one
+was suffering with sub-acute joint trouble consequent upon pinching of
+a cartilage within the knee joint, and one had a painful condition
+consequent upon an old dislocation of the ankle due to a fall,
+accompanied by considerable laceration of the soft tissues. Analyses
+of the cases left no room for the so-called chronic rheumatism which
+had so easily covered all the cases at the beginning.
+
+It was not unusual to see patients who had consulted many physicians
+and taken all sorts of internal and external remedies for the
+rheumatism that they supposed was causing their discomfort, yet who
+had nothing more than flatfoot. Their condition had become so bad that
+some of them had actually given up occupations that required them to
+stand. Merely following the advice to wear flatfoot braces in their
+shoes relieved these patients almost as if by magic. There was no need
+to measure them particularly; all they needed was an ordinary set of
+flatfoot braces. Some of them needed only a pair of good shoes, but
+the metal braces were advised to make sure that there would be a firm
+support for the arch of the foot. No wonder the "magic shoe-maker" had
+such success in New York a few years ago.
+
+Nearly always the shoes worn by dispensary patients are of the worst
+kind, considering the condition. The patients' feet are often cold,
+and they think this is nature's demand for heavy shoes, so they buy
+heavy shoes and large sizes so as to be sure they will not hurt their
+feet. This clumsy footgear allows the arch to drop still further
+because no proper support is furnished, and the foot-trouble becomes
+more poignant. Then working people nearly always wear older shoes on
+rainy days, and this makes two elements for discomfort instead of one.
+The yielding arch is already a source of discomfort which is more
+noticeable in rainy weather because any affection around a joint is
+more bothersome at such times. The support that a new pair of shoes
+affords to the arch is lacking when what are so aptly termed "sloppy
+weather shoes" are worn, and the consequence is that the patient is
+particularly miserable in damp weather.
+
+
+Unfavorable Disease Suggestions.--Of the cases in my experience of
+so-called rheumatism in the legs, over one-half are due either to
+flatfoot or to the incipient yielding of the arch which is called weak
+foot. Rheumatism is {415} most commonly held accountable for the
+condition, though gout comes in for its share of blame with quite as
+little justification. Occasionally some even more serious pathological
+condition is appealed to. I have seen the tendency to passive
+congestion in the feet with slight swelling around the ankle
+consequent upon the yielding of the arch called kidney trouble in
+spite of the fact that there was nothing in the urine to justify any
+such diagnosis. I have even known the coldness of the feet, which is
+likely to be a symptom of the disturbed circulation consequent upon
+the yielding of the arch, attributed to heart disease. As we shall
+see, most of the curious deformities of the old that make locomotion
+so difficult and so painful are due to a breaking down of the arch
+just after middle life and then to a progressive deformity of the
+foot. The mechanics of the support of the body are sadly interfered
+with when the arch yields, for bones are pushed out of place and
+ligaments and tendons are lengthened in order that the foot may
+accommodate itself to the new conditions. In nearly all these cases
+the patients are prone to say that they are sufferers from rheumatism.
+This diffuses and inveterates the notion which is a source of many
+unfavorable suggestions, that rheumatism is a curious progressive
+crippling disease which begins insidiously but advances remorselessly
+and eventually leaves its victim a prey to deformity.
+
+
+Gout and Flatfoot.--Bunions consist originally of an enlargement of a
+bursa over the proximal end and the inner side of the big toe in order
+to protect the bone and joint from friction. If the irritation is
+continued, the proximal end of the first phalanx may enlarge, though
+usually this is preceded by a series of attacks of more or less acute
+inflammation of the bursa, when the bunion is said to "become
+sensitive." I have seen these attacks called gout so often that I feel
+sure that much of the gout reported in this country is nothing more
+than bunions. There is true gout, and it is probably almost as
+frequent with us as it is in England, but many of the so-called cases
+are really flatfoot associated with development of the bunion that so
+commonly occurs as the arch yields.
+
+I was once asked to see a physician's wife who was thought to be a
+sufferer from gout. Long ago Oliver Wendell Holmes said that, as the
+shoemaker's children are likely to wear the worst shoes of the
+village, so the doctor's family is likely to take the least medicine,
+that is, be subjected to the least formal medication. The physician
+had seen the more or less acutely swollen and red enlargement of the
+base of the big toe, and heard his wife complain of the severe pain
+associated with it, and had suggested the possibility of gout. After
+rest in bed and the administration of salicylates and colchicum, the
+pain subsided and the redness and much of the swelling disappeared.
+This was a typical illustration of one event following another without
+causal relation. The succession of events was taken as a therapeutic
+test of the diagnosis of gout, and the patient was advised to regulate
+her diet so as to prevent the further accumulation of urates or uric
+acid in her blood. She was warned about eating red meat, about taking
+acid fruits, and about the acid fermentation of starchy vegetables.
+The main result of eating only white meat is apt to be simply a
+limitation in the amount of meat eaten, because white meat is less
+savory and after a time palls on the appetite. In the same way fruit
+was largely eliminated and sweets were taken out of the diet and
+vegetables were limited.
+
+{416}
+
+As she did not escape recurrent attacks of soreness in her bunion,
+while at the same time there were achy feelings in her foot, she took
+up the careful study of the dietary for gouty patients which she found
+in the books in her husband's library. So many things have seemed
+possibly deleterious for gouty people that it is not surprising that
+after a time nearly everything worth eating except a few cereals and
+milk and eggs had to be eliminated and she began to suffer from
+inanition. Then, after a time, came constipation, due to the
+insufficient amount of residue in her intestines, and this, partly by
+physical action but largely by mental suggestion, still further
+diminished the appetite for food, and a loss of over twenty pounds in
+weight was the result. The weakening of the general muscular system
+consequent upon this loss emphasized the trouble with the foot and the
+painful condition at the base of the big toe became more marked.
+
+The supposed necessity for more exercise in the open air led her to
+walk long distances and in order to prevent her feet from hurting her,
+as she thought, she wore roomy shoes, distinctly too large. This is
+one of the common mistakes of people whose feet bother them, and it is
+just the wrong thing to do, since a snug, well-fitting shoe provides
+both support and protection. It is not surprising that the attacks of
+sub-acute bursitis became more frequent and more painful.
+
+It was then that I saw her, and, as I feared to disturb the family
+harmony by suggesting that the whole trouble was a bunion and
+flatfoot, I compromised by saying that, while there might be some
+gout, there was undoubtedly flatfoot, and if she would wear the proper
+sort of shoe and stop limiting her diet so strenuously, and cease
+suggesting to herself that she had a progressive gouty affection that
+would lead to deformity and decrepitude, she would soon be much
+better.
+
+It required tact to make her look favorably on this advice, after all
+that she had gone through during months of limited diet and enforced
+exercise. Though not quite convinced, she was ready to try the new
+method. She began to be better as soon as she was fitted with a pair
+of shoes that supported her arch and as soon as her increased
+nutrition began to make itself felt. At the end of two weeks she was
+able to give up the remedies for constipation that she had been using
+for nearly a year, while at the end of four weeks she had regained ten
+pounds of weight and felt much better.
+
+Several years have passed since I saw her professionally and
+occasionally I hear from her only to be told what a great measure of
+relief it afforded her and how much better she has been as a
+consequence of a few simple directions with regard to her feet. I have
+seen at least a dozen of cases of so-called gout in educated people
+which followed almost exactly the same course and yielded promptly to
+the same treatment. The hardest symptom about these cases to cure is
+the cherished mental conviction that they are the victims of
+constitutional disease, either gout or rheumatism, to which all their
+symptoms are attributed. They are cases for psychotherapy more than
+any other form of therapeutics and need for a considerable period to
+have repeated assurances of the entirely local character of their
+affection.
+
+
+Bunions and Flatfoot.--The etiology and preventive treatment of a
+bunion has always seemed to me to bear a closer relation to a flat
+foot than to anything else. The flatfooted man has nearly always a
+tendency to bunions. The {417} explanation of this is not difficult if
+one traces the relation between the tendons that run around the arch
+to the big toe. The usual etiological explanation, however, is that in
+youth short shoes were worn which initiated a tendency to divert the
+big toe inward toward the other toes. But there are many reasons
+against this explanation. Anyone who tries will find that it is
+practically impossible to wear shoes that are so short that the big
+toe is crowded back. Women are more apt to shorten their shoes than
+men, yet women suffer both from flat feet and from bunions much less
+than men. The reason for this seems to be that the forward position
+with the elevation of the heel of the shoe supports the arch and gives
+the shoe a shape more fitted to the normal foot than is found in the
+masculine flat-heeled shoe. Besides, this form of shoe maintains its
+shape better, and then, too, women are not so prone to wear old
+so-called comfortable shoes as are men.
+
+The mechanism of the formation of the bunion in many cases seems to
+be, that the large toe, instead of lying straight along the inner edge
+of the foot, is pushed or pulled toward the other toes. If this
+process began from the wearing of pointed shoes, especially if such
+shoes did not have a straight line on the inside, conditions within
+the foot would soon tend to emphasize it. If the adductor hallicis
+once gets the habit of contracting rather strongly, as it is likely to
+do through the irritation set up by the yielding of the arch, it will
+be hard for its opposing muscles to counteract it. More important than
+this, however, is the fact that the tendon of the flexor longus
+hallucis runs along the inner border of the foot and is particularly
+affected by the yielding of the arch. For it works at a decided
+mechanical disadvantage under the new conditions and is stretched in
+such a way as to pull forcibly and constantly upon the big toe,
+necessarily turning it more and more outward as the arch continues to
+yield. The dropping of the arch makes the distance from the heel to
+the toe longer than before and the tendon pulls the toe as far outward
+as possible to compensate for this, as the distance to its insertion
+is thus made somewhat shorter.
+
+The yielding of the arch lengthens the foot and puts the tendons of
+all the flexors on the stretch. All of them have a tendency to bend
+the toes, and as this action is constant, gradually the tendons of the
+extensors become over-stretched and these muscles are not capable of
+exerting their full force in overcoming the action of the flexors. The
+flexor longus digitorum has a tendency to cause a bending of the small
+toes, and as it also runs across the foot it pulls the toes somewhat
+inward, that is, toward the big toe. This crowding leads to hammer
+toes and over-riding. The big toe, however, is maintained in a state
+of extension by its firm, full contact with the sole of the shoe and
+with the floor when walking barefoot. The one direction in which it
+can yield rather readily is outward toward the other toes because this
+shortens the distance between the end of the toe and the heel. The
+pressure put upon the flexor longus hallucis will have a tendency to
+cause this, for it is over-stretched by the yielding of the arch and
+keeps constantly pulling on the big toe until that member has a
+distinct flexion outwards.
+
+This makes the metacarpo-phalangeal joint prominent and then nature
+proceeds to protect it by a water cushion, a special bursa due to the
+formation between layers of connective tissue of a pocket in which
+some serum is constantly present. One can scarcely admire enough this
+provision of nature by {418} which she protects prominent bony points
+whenever they are subject to much irritation or to such use as would
+cause injury to important structures below. If continued pressure
+continues to be irritating, however, the water cushion proves
+unavailing and an inflammation of the overlying skin occurs with
+occasionally a spreading of infectious agents from the surface into
+the serum pocket below. This serum is such a good culture medium that
+an acute abscess is likely to form--the acute bursitis of the
+surgeons.
+
+
+Rarer Foot Troubles.--Besides bunions, a number of other deformities
+of the feet occur as a consequence of the yielding of the arch. All
+the toes are likely to bend rather acutely, and the points of them are
+pressed against the shoe, while the knuckles, so to speak, are made
+prominent and are more likely to be subject to corns than would
+otherwise be the case. Besides, the displacement of the big toe toward
+the little toes leads to a crowding of the toes together, and this
+gives rise to soft interdigital corns and to a lowered resistive
+vitality which may be the predisposing factor to slight infections of
+various kinds that will make the patients miserable. Such affections
+may appear negligible, a matter for the chiropodist, and not deserving
+the physician's attention; but they mean so much for the comfort of
+the patient and the prevention of exercise through sore feet reacts so
+deleteriously on the general health that these minor ailments become
+important and merit careful attention. Dr. Emmet tells the story of
+the old family servant, always grumpy and complaining, who, when he
+had the many blessings of life pointed out to him, confessed that the
+Lord had been very good to him, but said, "The Lord knows He takes it
+out of me in soft corns."
+
+
+_Hammer Toes--Clam Toes_.--Nature has provided a wonderful mechanism
+in the arch of the foot and the anatomical relations of the toes to
+support the weight of the body firmly, gracefully, and comfortably;
+yet any yielding of any part of it leads to a disturbance of its
+delicate mechanical relations and, consequently, to ever-increasing
+deformity. Hammer toes are typical examples of what such a disturbance
+may lead to. One of the toes becomes pressed downward between two
+others. This over-stretches the extensor muscles and tempts the
+unbalanced flexors to contract. As the extensor muscles become, after
+a time, unable to work in the constantly bent toes, they atrophy to
+some extent and then the flexor muscles pull the toe farther and
+farther down until there is no possibility of its being straightened
+at all. Now, if the flexor tendons are cut and the toe straightened
+the atrophic extensor muscles will not hold it in that position, and
+when the flexors grow together the old condition will reassert itself.
+In the meantime, muscle changes in the neighboring toes have also
+taken place. With no resistance on one side of them, they become bent
+sidewise over the hammer toe, and so their muscles on one side are
+overstretched and on the other side become contracted. After a time it
+is impossible to correct this series of deformities which are being
+constantly increased and emphasized by the weight of the body above.
+
+
+Present-day Shoes.--In recent years we have heard much more than
+heretofore about foot troubles. As the old-fashioned shoes were
+carefully made by skilled shoemakers to fit the feet of one individual
+and not to conform to some supposed ideal pedal extremity, they
+supported the feet much better than do the modern cheap machine-made
+shoes. These custom shoes lasted a long time, and, after they were
+once molded to the foot, the wearer was not {419} disturbed for many
+months by the process of having to become accustomed to another shoe.
+The many advertisements in quite recent times of foot powders and
+other artificial relief for the foot show that people are suffering
+much more than before, or, at least, are less able to bear the
+discomfort. These powders, however, are not likely to do good in the
+long run, since they tempt the wearers to stand the discomfort against
+which they do furnish a certain amount of soothing. It is much better,
+however, for the sufferer to find the cause of the discomfort and to
+remove it if possible, for otherwise it will lead to constantly
+growing displacement of bones and muscles and may eventually even
+bring on actual and ever-increasing deformity.   [Footnote 35]
+
+  [Footnote 35: How much deterioration of the tissues of the foot may
+  be brought about by improper footwear and, above all, by sedentary
+  life and the substitution of the trolley car for the exercise of
+  walking, is well illustrated by the functions that are lost. The
+  child can use its adductor and abductor muscles for the toes quite
+  as well as for the fingers. Those who go barefooted retain those
+  muscular powers. Some time we will be able to influence young folks'
+  minds enough to keep them from sacrificing all the more delicate
+  muscular powers of their feet to the fashion of small or curiously
+  shaped shoes. Armless men learn to use their feet almost as hands,
+  they write, pick up small articles, oven play musical instruments.
+
+  Some people have special muscular faculties, as, for instance, the
+  power to displace certain tendons and bring them back with a snap
+  which makes a distinct sound. The Fox sisters, to whom we owe the
+  origin of modern spiritism, confessed that this was the way they
+  produced their spirit rapping. Some mediums can, it is said,
+  dislocate the tendon of the flexor longus hallucis onto the edge of
+  its grove and then bring it back with a snap. Others can produce
+  partial toe dislocations which by muscular power are suddenly
+  reduced with a dull noise like the sound of a gloved hand rapping
+  beneath the table.]
+
+
+Prophylaxis.--The most important means of prophylaxis in these cases
+is to have patients who must assume the standing position for some
+hours each day, exercise their legs rather vigorously. If teachers,
+lecturers, and the like, have to stand for a long time, it is
+important that on the way to and from their occupations they should
+not have to stand up in cars nor assume cramped and uncomfortable
+positions. It would be better for them to walk rapidly for several
+miles rather than ride in a standing or a constrained position. If
+they are convinced of the necessity for exercise, there is much less
+likelihood of the development of the severer discomfort that is
+sometimes very discouraging. It is particularly difficult to make
+women understand this; yet, once they have found how much relief is
+afforded by vigorous exercise, they are likely to overdo it and thus
+run the risk of incurring ills quite as serious as those consequent
+upon not taking enough. In nervous people the nagging discomfort of a
+yielding arch will sometimes (just as eye strain does) produce reflex
+headaches, constipation, lack of appetite, and apparently predispose
+to the frequent recurrence of migrainous headaches. I have, in not a
+few cases, seen these conditions relieved by rational treatment of the
+foot condition.
+
+
+Circulatory Disturbances Due to Flatfoot.--An interesting direct
+consequence of flatfoot is the disturbance of the venous circulation,
+which is likely to bring about some swelling of the feet and nearly
+always considerable coldness and numbness, particularly in the winter
+and, above all, on damp days during cold weather. The swelling of the
+feet makes the patient think--sometimes at the suggestion of his
+physician--of kidney trouble or heart trouble, and sometimes it is
+hard to persuade him that there is nothing serious the matter with
+these important organs. The disturbance of the circulation further
+leads to numbness, to some anesthesia, and to paresthesia. Corns and
+especially callouses grow more readily between the toes, and patients
+who are prone to read about such ailments may conclude that they are
+suffering from hypesthesia {420} and hyperesthesia due to some serious
+progressive organic nervous disease. I once had a woman patient
+discourse learnedly to me about these things who was sure that she had
+the beginning of some incurable spinal disease. Locomotor ataxia was
+the least she might expect from her description of her feelings. What
+I found was flatfoot. Raising her arch cured her.
+
+The cold feet and the numbness, to call them by simple Saxon names
+which will not disturb patients, may sometimes keep them awake. In the
+chapter on Insomnia we suggest that the best thing for this is to
+secure a return of the circulation either by exercises, or by wearing
+a flatfoot brace during the day, or by putting the feet in water as
+hot as can be comfortably borne and keeping them there for a quarter
+of an hour. Of these means exercise is the best. Raising up on the
+toes after the shoes are off and coming down on the outside of the
+foot strengthens the muscles, pulls the bones of the arch firmly
+together and encourages the circulation. For beginning flatfoot this
+is a curative measure and it is the natural mode of treatment for the
+coldness and numbness of the feet. Rubbing, also, is good for the feet
+in order to restore the circulation, but patients are inclined to rub
+downwards while they should rub upwards in order to help the hampered
+venous circulation. The thin-walled veins are more likely to be
+compressed by any disturbance of tissues than are the firm-walled
+arteries, and it is to help the veins that our remedial measures must
+be directed.
+
+
+Secondary Consequences.--The secondary consequences of flatfoot are
+interesting. It is surprising how many people who frequently suffer
+from sprains of the ankle have some yielding of the arch as a
+predisposing factor to that condition. Two classes seem to suffer
+frequently from sprained ankle--those with yielding arches and those
+with high insteps. Apparently there is weakness in the excess in both
+directions. Very flatfooted people apparently do not suffer so
+frequently from sprained ankles as those in whom there is only an
+incipient yielding of the arch. They seem to have learned to walk more
+circumspectly. Perhaps, too, their well-known tendency to toe outward
+lessens their liability to turning on their ankle. The effects of
+sprains of the ankle in people with weak foot last, as a rule, longer
+and leave more weakness after them than they do in ordinary cases.
+This, of course, might be expected, but it is surprising how often the
+significance of beginning flatfoot fails to be noticed even by the
+physician. I have seen rather frequently cases of so-called chronic
+rheumatism in which there is a series of stories of sprained ankle
+because of the assumed weakness of the ankle from supposed rheumatism,
+when the whole case can be summed up in a yielding arch.
+
+
+Exercises.--If the arch has not yielded much, it is often unnecessary
+to prescribe flatfoot braces or arch supports of any kind, unless
+perhaps at first. After the first soreness has passed off, exercises
+may be employed to strengthen the muscles. As we have said, the
+patient should rise on his toes and then come down slowly on the
+outside of his feet. He may be instructed to sit with his feet--not
+his legs--crossed, the feet resting on their outer edges. He may be
+shown how even various slight movements of his toes, almost without
+moving his shoes at all, will strengthen the muscles that pass around
+the arch, which, thus strengthened, will hold the bones of the arch
+firmly together and prevent further yielding. There is, at the present
+day, a tendency to recommend too freely the wearing of flatfoot braces
+or arches. After all, these are {421} only crutches and should not be
+worn unless absolutely necessary. If the arch can be strengthened--as
+it can be in many cases--so as to bear the body weight without
+discomfort, then this is much the better treatment. If the arch is
+restored the feet are in a more natural condition, while artificial
+support leaves the muscles without that exercise which will preserve
+their functions. Flatfoot braces may be necessary, but only if
+absolutely necessary should they be advised, and palliative measures,
+such as exercise, manipulations, and rubbings, should be given a fair
+trial after the unfavorable suggestions as to his foot condition have
+been removed from the patient's mind.
+
+
+Significance of Foot Troubles.--We have devoted much space to foot
+troubles--more, perhaps, than will seem justified to the minds of many
+physicians. We have done so, however, because of the firm conviction
+that the feet are the source of more discouragement and depression of
+mind than any other part of the body. Life very often takes on another
+aspect when foot troubles are relieved. In the old, progressive
+deformities of the feet consequent upon mechanical disturbance are
+probably the source of more discomfort, and by their interference with
+exercise and outing, the cause of more ill-feeling and even
+disturbance of health than any other single factor. Even life may be
+shortened by the confinement or limitation of movement consequent upon
+bad feet. Above all, the idea that any constitutional trouble, or
+hereditary disease, is at the bottom of their affliction must be
+removed, and then these patients are encouraged to live their lives
+more fully and with more happiness for themselves and others. Hence
+this long chapter.
+
+
+
+CHAPTER IX
+
+ARTHRITIS DEFORMANS
+
+
+Arthritis deformans has unfortunately been called by several names
+besides the descriptive term which, in the present state of our
+knowledge, is the most suitable for it. We do not know its cause. We
+do not well understand even the predisposing factors in its causation.
+Hence, the term arthritis deformans, which declares simply that it is
+an inflammatory condition of the joints producing deformities, exactly
+fits it. It has often been spoken of by such names as "rheumatic
+arthritis," or "rheumatoid arthritis," and, above all, by the
+unfortunate term "rheumatic gout." Many of the worst suggestions that
+attach to the word rheumatism are founded on these ill-chosen
+designations. Arthritis deformans was supposed to be connected with
+rheumatism or with gout, or perhaps to be due to a combination of the
+two. In a majority of the cases there is no history of either true
+gout or rheumatism to be obtained from the patient, and where a
+rheumatic or gouty history does occur, it is either quite indefinite
+or it is clear that arthritis deformans developed in a gouty or
+rheumatic subject, that is, following genuine gout or rheumatism, just
+as it might develop in any other individual without any causal
+connection between it and the other affections.
+
+Supposed under the old theory to be a constitutional, probably a
+blood disease, patients who saw the ugly, crippling deformities
+produced by it and {422} then heard the word rheumatism used in
+connection with it were prone to think of this as the terminal stage
+of all the severe rheumatic conditions. As a matter of fact no
+evidence that we have shows that the disease has any connection with
+chemical modifications of nutrition or metabolism; nor, above all, has
+the so-called uric acid diathesis or any other superacidity of the
+blood any etiological connection with it. It has always seemed to me
+to be clearly a nervous arthropathy, as the lesions are almost without
+exception more or less symmetrically distributed. The joints that
+suffer are commonly the smaller ones in corresponding positions on
+opposite sides of the body, and they run a definite atrophic course
+sometimes with the preceding phase of hypertrophy that is so
+characteristic of the trophic lesions of an affection produced by a
+disease or defect of the nervous system. This symmetrical distribution
+constitutes the best possible evidence that arthritis deformans is not
+a nutritional disease and, above all, is not due to chemical changes
+in the blood.
+
+The affection exists in at least three forms and there is a growing
+persuasion that there are even more varieties of it that will have to
+be separated by clinical observation.
+
+There is a good study of the three types of the disease in _Guy's
+Hospital Reports_, Vols. 56-57, London, 1902. The article is entitled
+"Acute Rheumatoid Arthritis," but there seems no reason for applying
+the word rheumatoid to the group, especially since there is no proved
+connection with rheumatism and no similarity, except in the case of
+acute deforming arthritis in which at the beginning it may be
+difficult to differentiate the two affections.
+
+
+
+HEBERDEN'S NODES
+
+The most familiar form is named Heberden's nodes, from the great
+English physician who first made a special study of it. The affection
+is characterized by an enlargement of the sides of the distal
+phalanges with small, hard nodules, "little hard knobs", as Heberden
+called them, developing at these points. They are more frequent in
+women than in men. Evidently neither hard work nor exposure nor
+excesses in eating or drinking occasions them. They occur in all
+classes, the poor and rich, manual workers as well as professionals.
+It is rare to find them on one hand alone, though it is not at all
+rare to find them affecting solely the little fingers of each hand. I
+have seen several cases where surgical intervention had been attempted
+on one little finger because of the deformity produced when the node
+originally appeared. When I asked if there was not some trace of a
+similar condition on the other hand I was told there was not, yet I
+have been able to show that the first signs, at least, of a
+corresponding growth already existed on the little finger of the other
+hand. In the two cases in which my attention was called to a slight
+enlargement on one side before anything developed on the other, my
+tentative prophecy that corresponding nodosities would grow on the
+other side was fulfilled during the following years.
+
+While this form of the disease is a true arthritis deformans it seems
+to be entirely separate from the progressive forms which we shall
+speak of later. The nodes increase in size and occasionally develop on
+all of the fingers, but usually never spread beyond the phalangeal
+joints. There is a tradition in the {423} medical profession of
+England, where this affection has been observed with care for some two
+hundred years, that sufferers from these nodes commonly live to long
+life. This is not founded on any theory, but is an actual observation.
+There is also a tradition, though I cannot vouch for its truth, that
+the people who are thus affected have some sort of immunity to
+tuberculosis, or at least good resistive vitality against a rapidly
+running tuberculous process.
+
+I have had at least a score of Heberden's nodes cases under
+observation for more than ten years and some of them for nearly twenty
+years, and have been surprised at the slowness with which the process
+develops. A year often makes no change in the size of the nodes, and I
+have seen cases where after five years the photograph showed no
+difference. The lesions are often exquisitely symmetrical so that the
+question of the origin of the affection in the spinal cord constantly
+crops up, for that is the symmetrical influence in the body. There
+are, however, no other symptoms that point to involvement of the cord
+in any way. Most of these patients have suffered more from worry about
+it than from their affection. It is another case of "having many
+troubles most of which never happen."
+
+Some of my patients are physicians, and all of them have consulted
+other, some many other, physicians. As a consequence, many of them
+have taken to various diets, especially eliminating certain foods and
+liquids with the idea that this might stop the progress of the
+disease. I have never known any change of diet or any abstinence from
+liquids or solids that seemed to make the slightest difference, though
+I have seen a number of cases that were considerably worse than they
+would have been if the diet had not been tinkered with to such an
+extent as seriously to disturb nutrition.
+
+The main disturbing feature of the affection is the dread of the
+development of serious crippling conditions in the hands or in the
+large joints.
+
+As a rule, after a time the nodes cease to grow, and then a period of
+remission sets in that lasts for many years and there may be no
+recrudescence of the affection. This remission is delayed if the
+patients allow themselves to run down in general health. It is
+apparently hastened by getting the patients up to normal weight and
+removing any factors that disturb their general health. If the
+patients' minds are properly disposed, the neurotic symptoms that
+sometimes develop as the result of over-solicitude about their
+condition are done away with, the patients are more comfortable, and
+even the progress of the disease is inhibited.
+
+
+ACUTE PROGRESSIVE ARTHRITIS
+
+The second variety of the affection is a general progressive arthritis
+which usually begins with fever, redness, and swelling, involving
+especially the smaller joints. The diagnosis of the disease can almost
+be made on the fact that its favorite locations are the jaw and the
+joints of the spine. It is a much more serious affection than
+Heberden's nodes. In its beginning it often simulates acute
+rheumatism. It occurs particularly in people who are run down for any
+reason, in young women who have recently come to the country and are
+working as domestics, in young men who have recently changed their
+occupation from indoors to outdoors and are not used to the
+inclemencies of the weather. On the other hand, it occurs rather often
+in young persons of {424} both sexes used to living and working out of
+doors who take up an occupation in a damp interior.
+
+The fever usually runs a lower course than that of genuine acute
+articular rheumatism, the pain is not favorably affected by
+salicylates, and the duration of the disease is generally longer. This
+affection always leaves its marks on the joints and there are always
+recurrences. It is, indeed, the confusion of this quite distinct
+disease with acute articular rheumatism that has given the latter
+affection the bad name it has in many minds as a producer of
+deformities. Arthritis deformans or general progressive arthritis is
+always a crippling disease; acute articular rheumatism has for its
+surest diagnostic sign, when the complete history of the case is
+known, the fact that it leaves no mark after it except, unfortunately,
+that so often seen in the heart.
+
+
+CHRONIC ARTHRITIS DEFORMANS
+
+The third type of arthritis deformans is the chronic slow running type
+which involves many joints before the process is complete. One form of
+this, commonly seen in old men, called osteoarthritis, is often
+confined to the hip joint, and often produces considerable deformity.
+Another form is more common in women. It begins in middle life by
+deformities in the terminal joints of the fingers and the
+carpo-metacarpal joints of the thumbs. Bony outgrowth takes place
+until the joints become almost or quite useless. It spreads from the
+joints primarily affected to the elbows, the knees and occasionally
+involves other joints. The disease has no favorable course, but is
+progressive, and there is great discomfort, marked disability, aches
+and pains particularly in rainy weather and, finally, the patient may
+become quite helpless.
+
+
+Preliminary Stage.--An early symptom associated with arthritis
+deformans of chronic character is likely to be a distinct loss of
+muscle power, which may be the first symptom in cases that have no
+acute beginning. The patient notices that he is unable to hold a
+satchel as he did before, or that quite unaccountably it drops from
+him. There may be a loss of control over muscles and especially small
+muscles that attracts the patient's attention. He finds that he cannot
+hold a book as he used to, or that it is difficult to pick up small
+objects. He finds it hard to turn a door handle or to pull a cork,
+although the pulling action may be perfect, but the ability to insert
+the corkscrew is lacking. These symptoms are prone to be intermittent.
+They are most noticeable when the patient is tired, or after a damp
+day, or a succession of damp days, when he is not feeling well. It
+will usually be found that a joint, the affection of which is missed
+unless it is carefully looked for, that between the radius and ulna
+has become affected, and as a consequence there is a difficulty in
+supination. The lesions are different from those which occur in lead
+poisoning but at the beginning the symptom complexes may easily be
+confused.
+
+This form of arthritis deformans, in its earlier and its later stages,
+is a source of unfavorable suggestion as regards other affections. Its
+first symptoms may be thought neurasthenic, and if it is so called,
+those who hear the diagnosis and see the later developments will
+conclude that neurotic symptoms {425} can lead to serious sequelae. On
+the other hand, the painful tiredness that is always worse in damp
+weather may be termed rheumatism and be a correspondingly unfavorable
+suggestion. Patients who develop aches and pains as a consequence of
+occupations, or through the relaxation of joint tissues, are most
+uneasy because of the confusion of the later stages of this disease
+with rheumatism. This must be recalled by the physician if he would be
+successful in treating such pains and aches; for not a little of the
+discomfort is due to an exaggerated mental impression of their
+significance. This of itself often proves sufficient to keep the
+patients from the exercise that would relieve many of their secondary
+symptoms, at least, and serve to make their discomfort more bearable.
+
+
+Course of Chronic Arthritis.--The course of chronic arthritis
+deformans is always interesting. It is never as serious as the
+prognosis at the beginning seems to indicate, and it always has
+intermissions which, in most cases, become favorable remissions with
+such improvement that the patients feel encouraged, though they never
+get entirely well. Six rather typical cases have been under my eyes
+for from five to fifteen years. In all of them the course was slow and
+the progress of the disease vague at the beginning; and it was
+difficult to say how the affection began, or what was its cause, and
+apparently nothing would stop its advance. After a time all of them
+became discouraged and began to go the rounds. Almost without
+exception the physicians told them that they were incurable, and
+nearly all of them received unfavorable prognoses either directly from
+the physician or from hints sometimes dropped to friends, or from the
+attitude of the physician toward them. Much of this discouragement
+proved unjustified by the actual progress of the disease for many
+years. While they got but scant encouragement from regular physicians,
+nearly all of them received hopeful suggestions from irregulars and
+were, as a rule, for the time being, somewhat bettered by the
+treatments suggested by these, no matter what they were.
+
+Every one of these six cases, as was to be expected under the
+circumstances, went through a period of intense discouragement, with
+loss of appetite, partly from confinement to the house, partly from
+thinking so much about themselves, partly from lack of exercise and,
+in general, from their morbid mental condition. As a consequence of
+the loss of appetite, or, at least, of failure to eat in the midst of
+discouragement, severe constipation developed in five of the six cases
+and this further complicated the situation. They ran down very much in
+weight, and this emphasized the apparent size of the hypertrophic
+nodosities in their joints and weakened their muscles to such an
+extent that even under good conditions they found it difficult to
+move. After a time, usually many months, sometimes a couple of years,
+something happened to make them realize that while they were crippled
+and were going to be deformed, they still might find much in life that
+was not to be despised. Then they began to pick up in weight, their
+muscles got firmer, their nodosities seemed to disappear because the
+soft tissues around them filled out, though in most cases some of the
+material previously laid down actually was or seemed to be reabsorbed,
+perhaps as a consequence of the patient's better metabolism.
+
+
+Neurotic Additions.--All of these patients are now in much better
+physical and, above all, in much better dispositional states than they
+were during the first year or two at the beginning of their disease.
+While they allowed {426} themselves to run down in weight they were
+supremely miserable, with many neurotic pains and aches that were
+extremely hard to relieve, they had tendernesses and sorenesses on
+rainy days, usually attributed to their rheumatic conditions but
+really due to intense depression of the nervous system, with a
+constant tendency to exaggerate slight pains and aches into torments,
+and in general were invalids, a burden to themselves and others. They
+have improved to a noteworthy extent so as to become cheerful,
+reasonably happy in their power to help others, interested in many
+things and, in at least two of the cases, accomplishing more actual
+good for those around them than they probably would if their lives had
+continued to be the conventional existences that they had been before
+their arthritis came to them. This reminds one of Dean Stanley's
+famous expression that life looks different when viewed from a
+horizontal position. He used the expression with reference to fatal
+illness, but it might well be applied to any ailment that makes people
+think seriously and keeps them from occupations only with frivolous
+things. One of these patients is a source of consolation to many
+friends, who are much better in health than she is, who bring their
+troubles to her, and who marvel at her power to make the best of
+things.
+
+The prognosis for cure is extremely unfavorable, but the prognosis for
+a reasonable amount of happiness and a large amount of usefulness is,
+in my experience, excellent and though, of course, new habits will
+have to be formed and new ways of looking at life assumed, if this can
+be quietly and persuasively made clear to the patient early in the
+case, much of the more or less inevitable suffering that the patient
+will have to endure may be lessened.
+
+The older the patient, as a rule, the better the prognosis in these
+cases. As with regard to diabetes, tuberculosis and many another
+affection, every year after fifty adds to the prospect that the
+patient's ordinary span of life will not be much shortened and that
+the symptoms will not be severe. Occasionally the disease develops in
+patients who have been extremely healthy until they were well past
+sixty. I have in mind particularly a patient who did not begin
+seriously to suffer from the disease until she was sixty-eight. Then
+for two or three years she was very miserable, mainly because she had
+been very active and she feared that the disease would cripple her. It
+did bring about a considerable limitation of her activity. Ten years
+have passed, however, and she is still able to be about, and, though
+now well on the way to eighty, in good weather she still attends to
+various duties that take her outside of her home and occupies herself
+with many interests.
+
+I was never able to tell her that she would be better. I assured her
+from the beginning, however, that she would never be so much worse as
+she imagined, and that she would never be actually crippled. During
+the early stages of the disease, her discouragement and, above all,
+the diminution of activity, the lack of exercise and occupation of
+mind and the over-occupation with herself, made her not only mentally
+miserable but seriously interfered with many bodily functions.
+
+
+TREATMENT
+
+In the treatment of arthritis deformans the most important object is
+the general health of the patient. Owing to the confinement, the
+pains, which {427} are often worse at night, cause disturbance of
+sleep which reacts upon the general health. As a result of depression
+and discouragement, patients are prone to loss of appetite. This is
+sometimes looked upon as a symptom of the disease, but it is not a
+direct symptom except during the acute stage when there is fever, and
+is due rather to the changed conditions in which the patients live and
+the mental influences that surround them. If the patient loses in
+weight, as is so often the case, the effects are likely to be more
+serious, for the remission is delayed and is less complete in its
+consequences. Above all, it is important not to disturb the diet of
+the patient in such a way as to interfere with nutrition. Owing to the
+supposed rheumatic element, meat, or at least red meat, is
+occasionally taken out of the diet by the recommendation of the
+physician. Whenever this is done, harm results. There is a definite
+tendency to anemia, which will be emphasized by an exclusively
+vegetable diet, especially in those accustomed to eat meat freely. As
+a rule, there is much more need to encourage the patient to eat than
+to limit the diet in any way. Patients must rather be advised to take
+a generous mixed diet and to consume about as much meat and the same
+varieties as before. Tinkering with the diet has never been known to
+do any good for arthritis deformans and often does harm. The drinking
+of large quantities of water seems to do more than almost anything
+else to help these patients into a better frame of body and mind.
+Their neurotic symptoms are, as a rule, even more important than their
+joint symptoms, and if the neurotic symptoms can be cured, as they
+usually can without much difficulty, the patients feel much better.
+
+
+Systematic Exercises.--As soon as the acute stage has passed patients
+should be encouraged to take some systematic exercise in spite of the
+discomfort that is associated with it. Unless muscles are moved
+regularly deformities in bad position will result and there will be
+crippling which can be avoided in most cases. It is sometimes
+difficult to secure exercises for the small muscles that are involved
+and definite occupations are better than artificial exercises. For the
+fingers, for instance, I find that the best thing is knitting. By this
+I mean using the old-fashioned knitting needles for the making of
+stockings, wristlets, jackets, and the like. Crocheting is also of
+some use, but it does not give employment to as many of the small
+muscles as knitting. If the knitting is done with old-fashioned yarn
+from which the lanolin has not all been extracted, some of this
+substance comes off on the fingers during the movements associated
+with knitting. This seems to do good by rendering the joints more
+supple and the muscles more easy of movement. At least the suggestion
+is very helpful to the patients.
+
+
+Electricity and Mechano-therapy.--Electricity has been much praised,
+but whatever good it accomplished has always seemed to me to be
+confined to the exercise afforded the muscles. Its use, however,
+serves to keep up the patient's hope.
+
+Mechano-therapy often does good and some of the Zander machines are
+likely to be useful. Pulleys and weights for the shoulders and arms
+have their place and resisted movements serve to restore muscles to
+function which they had lost during the time when the joints were
+worst. Their use helps to bring the joint into the most available
+conditions.
+
+Something that has distinct hope in it must always be done for these
+patients. For this local treatment means more than anything else.
+Unfavorable {428} suggestions keep flowing in upon him from the
+failure of medicine, and serve to concentrate his attention on his
+condition and make him think that nothing can benefit him. Often the
+physician finds that his patient has been to someone else, who did
+some simple thing that brought relief of symptoms, at least for a
+time, and restored his confidence to such a degree that he felt much
+better for a time at least. These ailments are emphasized by advancing
+years and, though we cannot prevent decay of tissue, we can keep the
+patient's mind from inhibiting still further the functions of the
+impaired tissue.
+
+
+General Condition.--The patient's general condition must be made as
+good as possible. For this outdoor air is the most important factor.
+It increases impaired appetite, makes sleep more restful and easy, and
+gives one of the best occupations of mind that can be obtained. Of
+course, changes in the weather will bring discomfort. Where it is
+possible, such patients must be sent to climates as equable as
+possible. Such a change of climate during December, January and
+February will often make them very comfortable, and the distraction of
+mind, with the possibility of getting out in the mild climate, will
+diminish their sensitiveness and be more powerful factors in the
+dissipation of their aches and pains than the climate itself. Where
+people cannot be sent away from home, the securing of corresponding
+distractions means a great deal. The one thing necessary for the
+physician is to keep the patient from brooding upon himself and his
+ills and to find other occupations of mind for him.
+
+
+
+CHAPTER X
+
+COCCYGODYNIA
+
+Coccygodynia, or, as it is sometimes called, coccydynia, is a painful
+affection of the coccyx or bony end of the spinal column. It usually
+results from trauma, as a fall on the buttocks on an icy pavement, or
+particularly a fall in coming down stairs in which the main portion of
+the impact is on the seat. Occasionally it follows horseback riding.
+It is said to be on the increase among women who ride astride.
+Occasionally it is reported after severe labor, particularly when the
+head of the child was very large, or after first labor when the coccyx
+has been beforehand bent inward somewhat abnormally and is pushed out
+by the oncoming head. It seems to develop with special frequency in
+nervous people who have to sit much, particularly if they sit on
+unsuitable chairs. The chair seat with the ridge in the center which
+has been introduced in recent years is sometimes blamed. Occasionally,
+on the other hand, it is said to come from sitting on heavily
+cushioned chairs, particularly leather chairs which do not allow of
+much transpiration and cause a feeling of uncomfortable heat.
+
+There are, indeed, so many different causes suggested, sometimes of
+quite opposite or even contradictory effects, that it seems evident
+that the main element in the disease is some predisposition to
+sensitiveness in this region which is exaggerated and emphasized by
+the cause that is blamed. It occurs particularly in women, though it
+is occasionally seen in delicate or neurotic men. Sufferers from it
+sometimes find it impossible to sit for any length of time. {429} Even
+lying down, especially if they lie on their backs, becomes a source of
+pain. Various operations, such as the reposition in place of the bent
+coccyx, or even the removal of the tip of the coccyx, have been
+suggested. Some reported cures are to be found in the literature.
+These are mainly surgical cures, however, that is to say, the patient
+recovered from the operation, was seen for a month or two afterwards,
+and was then on a fair way to complete recovery. Some of us who have
+had to treat these cases afterwards for painful conditions apparently
+due to the scar of the operation, or to a neurotic condition closely
+corresponding to the old coccygodynia, are not so confident of the
+value of an operation, though probably in purely traumatic cases
+surgical intervention is of value.
+
+In most cases the sufferers are women who have little to do, who have
+much time on their hands to think about themselves, and who usually
+receive abundant sympathy from friends and relatives. In one case
+under my observation the death of a husband and the discovery that his
+estate was much less than had been anticipated, so that his widow had
+to take up a wage-earning occupation, did more in a short time than
+all the treatment that had been employed before to relieve her
+discomfort. She had been quite unable to move around at times,
+especially in rainy weather, and was something of an invalid during
+all the winter, but now she was able to go out to work every day and
+had very little trouble. Her affection originally dated from a fall on
+an icy sidewalk and her fear to go out in the winter seemed to be
+dependent on the dread of another fall. She realizes now that
+practically all her former trouble was due to over-attention to a
+discomfort which is still present, but which she is now able to
+forget, except at times when she is alone after there have been
+worries and troubles that have reduced her power to control her
+nerves. In young girls an injury to the coccyx by a fall on the
+buttocks will often leave tenderness for months or even years, but if
+attention is distracted from this and the patient is not allowed to
+concentrate her mind on it and does not hear of the awful
+possibilities of coccygodynia--a mouth-filling Greek name in which we
+map out our ignorance, and which seems to carry with it such a weight
+of pathology--she will probably recover completely.
+
+Coccygodynia often resembles hysterical coxalgia or the hysterical
+arthritises, and seems sometimes to be due to the fact that there is a
+natural or traumatic abnormal mobility of the coccygeal vertebrae
+which, owing to concentration of attention, has developed into a
+neurosis analogous to the corresponding condition in a joint. There
+are undoubtedly cases in which a real pathological lesion exists, but
+these are comparatively few. In this, as in other joint and bone
+affections with vague pains likely to be worse on rainy days, the word
+rheumatism is often mentioned, but it has no proper place. Treatment
+that will put the patients into good general condition--never local
+unless there is objective indication--outdoor air and exercise with
+reassurance of mind and distraction of the attention are the important
+therapeutic agents. Patients with much time on their hands do not
+readily get well, while those who are busily occupied seldom suffer
+for long.
+
+
+{430}
+
+SECTION X
+
+_GYNECOLOGICAL PSYCHOTHERAPY_
+
+
+CHAPTER I
+
+MENTAL HEALING IN GYNECOLOGY
+
+
+All physicians are convinced of the good that has been done by the
+extension of the application of surgery to women's diseases during the
+pest generation. On the other hand, there are probably very few,
+except the ultra-specialists, who are not quite sure that there has
+been too much surgery in gynecology, and that many a woman has been
+operated on without sufficient reason and without definite
+indications. In suitable cases surgery is sometimes life-saving and is
+often the only means of relief for suffering that is seriously
+disturbing the general conditions and is making life unbearable. Its
+very possibilities of good, however, have led to abuses. From the
+abuse of a thing, the old Latins used to say, no argument against its
+proper use can be derived, and this is eminently true of gynecological
+surgery. It will not belittle the great benefit that operative work
+has been to state how much of auxiliary good may be accomplished by
+the use of psychotherapy in gynecology.
+
+Many a woman who is operated on is benefited only for the time being,
+and her old symptoms return after a time. Dr. Goodell, one of our
+first great gynecologists, used to warn his students insistently that
+women had many organs outside of the pelvis. The individuality in
+gynecology is extremely important. Some women suffer what they
+describe as excruciating pain or unbearable torture from pathological
+conditions that other women do not notice at all. Very often these
+women either have no real interest in life and are so self-centered
+that they emphasize their feelings by dwelling on them, or else their
+attention has been attracted to some sensation not necessarily
+pathologic and then by concentration of mind on it they so disturb
+vasomotor conditions and the nutrition of nerves that the condition
+does become a veritable torture and apparently demands surgical
+intervention. It is possible to cause a hyperemia in the skin by
+thinking about certain portions of it, and the genital organs are
+particularly prone to be influenced by mental states. If for any
+reason a woman gets her mind on her genital tract and becomes
+persuaded that there is a pathological condition in it, symptoms will
+develop until an operation seems inevitable. But the operation will
+bring relief only for a while, and then her mind will find something
+else to dwell on and produce similar symptoms.
+
+{431}
+
+Place of Psychotherapy.--To fail to try to sway the mind by all the
+methods and auxiliaries outlined in the earlier chapters of this work
+before suggesting an operation to a woman is to neglect a most
+important means for relief in many gynecological cases. There is
+scarcely any pathological condition from which women may suffer that
+does not become worse as the result of the depressing influence of
+much thinking about it, and that is not made better by a change in
+their mind that makes them realize the possibility of being well
+again. The most important preliminary to operation is the promise of
+complete relief through surgery. The acme of suggestion is reached in
+the preparation for operation with its constant encouragement and then
+the congratulations after the operation. Then come the weeks of
+convalescence during which the same strong suggestion is constantly at
+work making the patient sure that she must be better. All this serves
+to add tone to the system, invigorates the appetite and puts patients
+in the best possible mental attitude to bring about a favorable
+result. Indeed, the ten or fifteen pounds in weight that such patients
+gain during their convalescence, especially when they have been under
+weight before, is often the most beneficial result of their hospital
+experience.
+
+If the same patients had been given the same promise that they would
+surely be cured, and then had been removed from depressing home
+influences and bothersome trials and labors, and been told that what
+they needed for complete recovery was to gain in weight; if they had
+then been visited by friends who congratulated them on the fact that
+now at least they were going to be better and their symptoms were
+going to disappear, and if they had gained the fifteen pounds that
+came in convalescence after their operation, most of them would have
+recovered quite as completely as by the operation from many of their
+vague gynecological difficulties. This is, of course, true only of
+cases where there are not very definite indications for surgical
+intervention. But in a certain number the symptoms are so vague that
+operation is decided upon rather with the hope than the assurance of
+benefit; and it is particularly in these that psychotherapy is useful
+and must be given a thorough trial.
+
+
+_Pain Relief_ .--It is often set down as a maxim of gynecologic
+practice, that pain which cannot be relieved except by recourse to
+dangerous or habit-forming drugs is an indication for operation. Pain,
+however, is a relative matter and, as we have shown in the chapter on
+Pain, its intensity depends not a little on the patient's attitude of
+mind towards it. When there is discouragement and depression, pain
+becomes insufferable, and what was borne quite well at the beginning
+may now prove intolerable. Whenever occupation of mind can be secured,
+however, pain is diminished in intensity.
+
+
+Reputed Remedies and Suggestion.--Probably the most striking indirect
+testimony to the value of mental influence and especially of
+frequently repeated suggestion in gynecology is found in the recent
+history of various much-advertised remedies that have been sold in
+enormous quantities for all the ills of women. The composition of
+these remedies is not, as is popularly supposed, a great mystery. They
+have all been analyzed and their ingredients are well known. As a
+rule, they contain only simple tonic drugs that have absolutely no
+specific effect on the genital organs, but that are stimulating to the
+general system. There has been much surprise at the definite evidence
+{432} furnished by expert investigators, that the principal ingredient
+in most of them--certainly their most active element--is the alcohol
+they contain, which, until the passage of the pure food and drug law,
+was in such considerable quantities that practically each
+tablespoonful of these favorite remedies for women was equal to half
+an ounce of whisky. No wonder that this gave an immediate sense of
+well-being which rose in most of those unused to alcohol to a feeling
+of exaltation. The patient was sure beyond contradiction that she
+could feel the effects of the medicine! Of the after effects, the less
+said the better, but there is no doubt that many women acquired the
+alcohol habit through indulgence in these nostrums.
+
+Illusory as was this sense of well-being, it sufficed in many cases to
+relieve women of discomfort that had become so serious, to their minds
+at least, that they feared an operation would be necessary.
+Undoubtedly many of the testimonials given to such remedies are
+founded on actual experiences of this kind in which patients were sure
+that they were cured of serious ills. Where alcohol is not the chief
+ingredient of these remedies, some other tonic stimulant is employed,
+and it has proved sufficient to make the patients feel, or at least
+suggest to themselves, that they must be better. This has given them
+courage to take more exercise and get more out into the air, and
+consequently relieves them of many physical symptoms that had
+developed because they thought they were the subjects of some serious
+ailment and must be solicitously careful of their health. The idea of
+care for the health in many persons' minds seems to be to do as little
+as possible of external, useful work and to occupy themselves
+principally with their internal concerns. They stay in the house too
+much and in so doing disturb nearly every physical function. Perfectly
+well people, if confined with nothing to interest them, become
+short-circuited on themselves and develop all sorts of symptoms,
+physical and mental.
+
+
+The Mind as a Factor in Gynecological Affections.--A gynecologic
+incident of any kind may become to many women such a center of
+attention that it is impossible for them to distract their minds from
+it, and every symptom or feeling that can by any stretch of thought be
+connected with the genital system becomes greatly exaggerated. Young
+women, whose menstruation has been perfectly regular, may have it
+disturbed by fright, grief, a change of environment, getting the feet
+wet, or something of that kind. At immediately succeeding periods
+their fear of bad effects will of itself influence unfavorably the
+conditions in their genital system. They have always had more or less
+discomfort, but now this discomfort becomes difficult to bear because
+of the fear that there may be further serious consequences of the
+disturbing incident in their menstrual life. It occupies all their
+attention; instead of deliberately trying to disregard it, they fear
+that, if they should do so, they would be allowing some progressive
+condition to gain a hold on them which would lead to serious results.
+
+One is apt to see this condition in young married women who have had a
+miscarriage in their first pregnancy and who fear that there will be
+serious results from it. If they have been much disturbed by the
+miscarriage, they may lose in weight, and then a number of subjective
+symptoms in their genital life will appear. Though their menstruation
+appears regularly, lasts the usual time, and is neither more scanty
+nor more profuse than before, and {433} though their physical
+conditions are normal as ever, they suffer from bearing down pains and
+feelings and backache just before menstruation begins; their ovarian
+regions become sensitive and, if they are constipated, their right
+ovarian region is likely to become tender, and they develop a set of
+symptoms that seems to call for surgical interference. If, however,
+they are put in conditions where they have some other occupation
+besides themselves and their ills, it is surprising how the case will
+clear up. They gain in weight, their subjective symptoms disappear and
+especially they lose the persuasion, so common among them, that any
+betterment of their symptoms is due to their getting used to the
+pathological condition present and not to any real improvement of it.
+
+
+Treatment.--In the treatment of gynecological conditions such as are
+not necessarily indications for operation, the most important
+consideration is to reassure the patient's mind and secure the
+discipline of self-control. If patients are under weight this
+condition must be corrected. If they are in an unfortunate environment
+it must be modified, as far as possible. If they are without
+occupation this must be provided for them. Dominant ideas and morbid
+auto-suggestion must be overcome--not always an easy task, yet always
+possible if patience, tact, and skill are exercised. They must be made
+to realize that the women of the past, before the development of
+modern gynecology, not only lived useful lives without any of the
+modern gynecological operations, but that most of them were quite
+happy in so doing. Even though many of them had physical symptoms, the
+lack of unfavorable suggestion as to the significance of these
+prevented mental exaggeration, and morbid dwelling on them was not
+allowed to produce such a deterioration of the physical condition as
+to emphasize the pathological conditions. This does not mean that
+women may not have to be operated on, and, when that is necessary, the
+operation should be determined on and performed with no more delay
+than is proper to put the patients into suitable physical condition.
+But many operations that are undertaken without definite indications
+merely because the women complain, and it is hoped that an operation
+will somehow prove of relief, would be replaced with much more final
+satisfaction and relief by properly directed psychotherapy.
+
+There are many minor pathological conditions such as slight cystic
+enlargements, hyperemias with tenderness, slight displacements of the
+ovary, slight dislocations of the uterus or twistings of it that can
+often be successfully treated the same way. After all, what is
+considered the normal condition of the feminine internal organs is
+only an average reached from observation and many deviations from this
+average cannot be considered abnormal. Many a woman living practically
+without symptoms, or certainly without such symptoms as to justify an
+operation, has pathological conditions of her internal organs worse
+than those for which operations are sometimes suggested because
+over-sensitive women complain of their symptoms. The rule must be
+first to relieve the over-sensitiveness and then to determine whether
+an operation is necessary or not. Pain alone, unless it is of a
+disabling character or reacts upon the physical health, is not a
+sufficient indication for operation.
+
+
+{434}
+
+
+CHAPTER II
+
+PSYCHIC STATES IN MENSTRUATION
+
+
+One does not need to be a physician to be familiar with the curious
+psychic states which develop or are accentuated during the menstrual
+period. Practically all the peculiarities of the individual are
+emphasized at this time and if there are any special neurotic
+conditions or psychic anomalies these become quite marked. All the
+dreads, for instance, are more noticeable at this time. Women who at
+all times feel uncomfortable on looking down from a height are likely
+at this time to be quite overcome by fear and be unable to approach
+any position from which they might look down for a distance. Women who
+are afraid of horses, yet conquer their dread sufficiently to ride
+behind them, cannot do so, or only with great difficulty, during the
+menstrual period, and the same is true of the dread of cats or other
+animals. Misophobia, the dread of dirt, may be particularly emphasized
+at this time and servants are puzzled as to what has come over a woman
+who was not so punctilious in the matter a short time before.
+
+
+Irritability.--Dr. Charcot, the famous French nerve specialist, used
+to say that for a day or two before menstruation and during the first
+day or two of their period many women were not quite responsible. This
+is not merely an exaggeration of French contempt for women, for
+Möbius, the distinguished German neurologist, insisted that there is a
+certain physiological mental disturbance with distinct hampering of
+the faculty of judgment (Schwachsinn) normally associated with
+menstruation.
+
+Few physiologists or gynecologists agree with these extreme views, but
+there is no doubt that many of the troubles which business men
+experience with women in their employ begin with hasty words spoken at
+these periods when the real reason for the irritability is not known.
+The consciousness of this on the part of some women saves them from
+much undesirable friction by making them more careful at these
+periods. Many a domestic misunderstanding begins at these times and is
+unfortunately allowed to continue because the real reason for it--the
+instability of disposition due to menstruation--is not recognized.
+
+
+Lack of Inhibition.--There is no doubt that, except in women of the
+most stable physical and psychic character, a notable lack of
+inhibition characterizes all their actions at this time. To think that
+this is universal, however, would be a mistake. Healthy women deeply
+occupied with something they like often pass through menstruation
+absolutely undisturbed, and this is particularly true of the mothers
+of families. In spite of its exaggeration, it is well to keep the
+great French specialist's expression in mind, for it helps to explain
+many things that produce much suffering in the world. This is
+particularly true now that women are working more and more out of
+their homes at occupations which often make strenuous calls on them
+just at periods of the month when they should have more rest than
+usual. The consequence often is the development of a highly neurotic
+condition in which psychic {435} symptoms are likely to be prominent
+as well as a tendency to exaggerate the significance of their feelings
+which is disturbing to the patient and may even disturb the physician.
+
+
+Exaggeration of Sensitiveness.--The most striking feature of this is
+the tendency to exaggerate the meaning of physical symptoms which they
+have often borne with for a good while without much inconvenience, but
+which now appeal to them as of serious significance. Any uncomfortable
+feeling is likely to be dwelt on to such an extent as to be called an
+unbearable ache or even an excruciating pain, and the patient is prone
+to connect it with some serious pathological process in the region in
+which it is felt. If a woman has been reading about some special
+ailment, or, above all, has been listening to the tale, usually
+neither plain nor unvarnished, of a friend's medical woes, she is
+almost sure to think that there must be something seriously wrong with
+herself. Many a supposed chronic indigestion had its origin in nothing
+more than the uncomfortable feelings in the stomach region during
+menstruation, which call attention to that organ and then, by morbid
+introspection, lead to the exaggeration of various sensations that
+have always been present but have hitherto been disregarded.
+
+It is a good rule to neglect symptoms that develop during the
+menstrual period and not to treat them directly until it is plainly
+seen that they persist afterwards; for symptomatic treatment at this
+time will cause an over-attention to the condition. And we should be
+careful not to suggest to a woman at this time that her symptoms may
+be due to some pathological condition in an important organ. Such a
+suggestion will almost surely be accepted seriously and dwelt on so
+much as to become an auto-suggestion that may lead to the disturbance
+of the function of the organ in question because of the surveillance
+over it. The diagnosis must be put off until menstruation is over in
+order that the exaggeration of this period may be eliminated. If this
+were more commonly done and if women were advised to counteract their
+feelings at this time as far as possible by occupations of interest to
+them, there would be much less need of medication. As between rest and
+strenuous work during the menstrual period, work is probably always
+the better. Rest with nothing to do emphasizes morbid introspection to
+such a degree as to make even ordinary feelings unbearable.
+
+
+_Symptomatic Conditions_.--It is interesting to note how often
+affections that are always present give symptoms only during the
+menstrual period or just before it. Many women, however, suffer
+considerably about the time of the menstrual period from an extremely
+tired, painful condition of the leg below the knee which is really due
+to flatfoot. At other times it gives them little annoyance. Old
+dislocations and sprains are particularly likely to give bother at
+this time. All the occupation pains and aches are emphasized.
+Tiredness becomes a torment. This extreme over-sensitiveness extends
+to physical ills of all kinds, even those that are trivial. For
+instance, corns and bunions become almost unbearable, especially if
+there is any change of the weather with moisture in the air about the
+time of menstruation. Teeth become sensitive and often will ache when
+there is little that the dentist can find the matter with them. Women
+are often suffering from teeth that are supposed to be quite
+intractable because of over-sensitiveness, while in reality it is only
+at these certain times that the over-sensitiveness is present.
+
+{436}
+
+Over-reactions.--Even habitual actions which are accomplished without
+much difficulty at other times are likely to be a source of annoyance
+about this period. If a young woman has to call out figures or read
+off lists of names, she soon becomes hoarse, her voice becomes husky
+and it requires more effort to accomplish her work than at other
+times. Complaint of sore throat is common about this time, and if
+there have been any recent changes in the weather this is almost sure
+to be a premonitory symptom of menstruation. Singers and elocutionists
+are likely to find their occupations particularly trying at this time
+and actresses are seldom without considerable physical discomfort that
+makes playing difficult and unsatisfactory. This happens in all
+occupations requiring frequently repeated use of particular muscles.
+Piano-players and typewriters find that their fingers become sensitive
+at this time. This sensitiveness of the ends of the fingers may become
+so marked as to prevent these usual occupations, or at least may
+require their limitation.
+
+
+Physical Basis of Psychic States.--The physical basis of these
+troubles is probably more responsible for them than has been thought,
+though the mental state renders the individual more susceptible to
+annoyances of any and every kind. Careful weighing seems to show that
+there is a gain in weight amounting sometimes to three to five pounds
+toward the end of the menstrual month. This is accompanied by a sense
+of fullness that is perhaps an actual plethora, as if nature were
+manufacturing a superabundance of blood in anticipation of the loss.
+This produces a systemic hyperemia. It is well known that hyperemic
+areas are more sensitive than tissues in ordinary condition and this
+seems to be the case in menstrual life. This renders the nervous
+system more active and irritable and the nerve endings more sensitive.
+With the menstrual loss this physical condition is relieved and then
+there is a return to normal with a loss of weight only partly due to
+the actual blood loss and somewhat to increased excretion in
+perspiration, in transpiration through the lungs and through all the
+emunctories.
+
+
+Treatment--To know that these psychic disturbances are likely to occur
+at the time of menstruation is to be prepared for them so as to lessen
+their effect upon one's self and others. They are much relieved by
+this frank recognition and the patient understands that with the
+betterment of the psychic condition by such reassurance the physical
+symptoms are lessened. Many a woman gives up her occupation at such
+times who would be much better if she bravely clung to it and resisted
+the temptation to be moodily occupied with her condition. Above all,
+she needs to be in the air. Oxidizing processes within the body are
+slower and while much exercise is not beneficial and may be often
+harmful, riding in the air, sitting in the air, above all, sleeping
+where there is an abundance of fresh air is all-important. Every form
+of exertion will be reflected in increased irritability. Shopping,
+balls and parties will disturb the woman's mental equilibrium and make
+it more difficult for her to stand whatever physical discomforts she
+may have, and also make it hard for her to pursue her ordinary
+occupation if this is somewhat exacting. Even these, however, must not
+be given up if the sacrifice involves the throwing of the patient back
+on self and increases introspection. Diversion of mind and
+temporizing with symptoms are the basis of therapy at the menstrual period.
+
+{437}
+
+
+CHAPTER III
+
+AMENORRHEA
+
+
+No feature of menstrual difficulty shows so clearly the influence of
+the mind over bodily function, and especially over those genital
+functions that are supposed to be involuntary and spontaneous, as
+amenorrhea. Almost any kind of mental trouble may produce a cessation
+of the menstrual functions. Profound grief or a severe fright nearly
+always does. Every physician of large experience has seen cases of
+women who have missed their period because they were disturbed by a
+fire, or a runaway, or an automobile or railroad accident within a
+short time before their menstruation should normally occur. Even
+slighter shocks may have a similar effect, and a profound shock of any
+kind will seriously disturb menstruation. The most frequent effect is
+to inhibit it, but it may be anticipated or delayed, and where there
+is a tendency to too profuse a flow, it may produce menorrhagia.
+
+Every physician knows that much less serious mental influences than a
+profound shock or fright may somewhat disturb menstruation and, in
+young women at least, this disturbance is nearly always in the
+direction of lessened flow and amenorrhea. Home-sickness, for
+instance, will often have this effect. Many of the foreign-born
+domestics who come to this country have serious disturbances of their
+menstrual flow, usually a diminution, during the first three or four
+months after they arrive in America. This may, of course, be due in
+part to change of climate, change of food and change of habits of
+life. These girls while in their European homes have often been
+accustomed to be much more out of doors and to have more exercise in
+the open air than they have here.
+
+That the mental state has much to do with menstruation may be
+appreciated from the fact that serious changes of her state of life
+may be accompanied by amenorrheal symptoms even when the patient stays
+in the same climate and under conditions not different physically from
+those under which she has lived. Country girls who come to the city
+often suffer from such symptoms. Young women who enter convents
+sometimes have these symptoms for some months, and this is so well
+recognized as to be expected in a certain number of cases. Indeed,
+there is danger that it should be attributed too much to the change of
+mental state, and that other factors, such as incipient tuberculosis,
+or disease of the ductless glands, or anemic states, which are
+responsible for it, may fail to be appreciated because of the ready
+explanation afforded by the mental factor. General experience shows
+that the attitude of mind of a patient toward menstruation, the
+expectancy of it at a particular time, and a good general physical
+condition that predisposes to it, are quite as important for its
+regularity as the specific physiological conditions which naturally
+bring it about.
+
+
+Fright and Amenorrhea.--Fright particularly may disturb menstruation
+in many ways. Occasionally the disturbance of menstruation consequent
+upon shock lasts for months or even years. At times when a woman
+between thirty-five and forty is seriously frightened, especially by
+terror that endures {438} intensely for some hours, the sort that is
+said to blanch the hair in a single night--and there are
+well-authenticated instances--menstruation never recurs or if it does
+recur it is vicariously from some other portion of the body than the
+genital tract. Among my notes is a case of a woman frightened by a
+revolver which a maniac had flourished for hours at her while she
+dared not make a move nor a sign. Her menstruation stopped completely
+for a time and then came back irregularly and usually from the ear.
+The bleeding was from the pierce in the lobule which had been made for
+earrings, and before it started a large swelling of this would come on
+in the course of an hour, often not subsiding for days. In another
+case a woman who was frightened during menstruation by an insane
+person flourishing a knife near her had for several years after an
+extremely irregular menstruation, and usually only the molimina in the
+genital tract, while the bleeding was from the nose. Deep emotion can
+very seriously affect menstruation.
+
+
+Pseudocyesis.--The mind may bring about a cessation of menstruation in
+another way without any other factor interfering and in spite of the
+fact that physiological conditions would all seem to be favorable to
+its regular occurrence. We have many cases in medical literature in
+which married women anxious to have children have concluded that they
+were pregnant, and have had complete cessation of their menstruation
+for months with all the symptoms of beginning pregnancy, so as to
+deceive even careful physicians. The best known historical instance is
+that of Queen Mary, the eldest daughter of Henry VIII of England, who,
+nearly forty when she married Philip II of Spain, was very anxious to
+have children. Not long after her marriage menstruation stopped and
+all the ordinary symptoms of beginning pregnancy developed. Her
+condition was widely heralded throughout the kingdom; then, after a
+time, to the intense disappointment of the Queen and her friends, it
+proved that she was not pregnant but that her mental attitude had
+produced the series of symptoms that proved so deceptive. These cases
+of pseudocyesis are so likely to occur that a physician in dealing
+with a woman, who being rather well on in years when she marries is
+anxious to have children, must be on his guard and he must always take
+into account the possibility of a pseudo-pregnancy and must be careful
+not to be deceived by symptoms that would ordinarily indicate beyond
+doubt the beginning of pregnancy. Even experts have been deceived in
+such cases, and it is in them that accurate rules for the certain
+detection of pregnancy are most needed.
+
+These symptoms have reference not only to the uterus, but also at
+times to other organs. They are not merely subjective, but sometimes
+become so objective as almost to demonstrate the diagnosis of
+pregnancy, and yet a mental condition is the only source of the
+changes. For instance, cases of false pregnancy have been reported in
+which, besides the gradual enlarging of the abdomen with many of the
+signs of pregnancy accompanying that phenomenon, there has been an
+enlargement of the breasts and even the secretion of milk. In a few
+cases the enlargement of the abdomen has been accompanied by
+pigmentation and the areola of the nipple has also become pigmented.
+This is not surprising, since corresponding changes take place in
+connection with fibroid tumors, and the deposit of pigment is not a
+symptom of pregnancy, but only a result of the congestion which takes
+place in these structures during their enlargement.
+
+{439}
+
+Amenorrhea from Dread.--In some cases all the symptoms of pregnancy
+develop, or at least there is complete cessation of menstruation, as a
+consequence of nervousness and dread of the occurrence of pregnancy.
+Unmarried women who fear that they may have become pregnant by
+indiscretion, sometimes become so worried over their condition that,
+without any physiological reason, they miss one or more periods and
+thus add to their nervous state and further inhibit menstruation,
+though usually two months is the limit of such amenorrhea and the
+menstrual flow commonly makes its reappearance shortly before or after
+the time of the third period. Occasionally, however, in the case of
+anxiously expectant married women further symptoms of pregnancy may
+appear and the case becomes more complicated. Every physician of
+considerable experience has seen such patients, and doubtless much of
+the harvest which advertisers reap from drugs that are supposed to
+produce abortion comes from nervous young women who are not really
+pregnant, but have inhibited their menstruation by worry, and who take
+these medicines with confidence and have the menstrual flow restored
+by trust in their efficacy.
+
+
+Ductless Gland Disease.--Of course, in many cases of amenorrhea there
+are serious underlying constitutional conditions which may or may not
+be amenable to treatment, but the possibilities of which must always
+be thought of. One case of amenorrhea I saw in recent years proved to
+be due to a beginning acromegaly. There was no sign of enlargement of
+the hands, though there had been a coarsening of the face which was
+attributed to growth and to the fact that the girl was taking much
+horseback exercise in all weathers. She had a headache for which no
+remedy seemed to be of any avail, and when the amenorrhea developed it
+was naturally thought that the headache must be due to gynecologic
+conditions. Nothing was found on investigation, however, and
+eventually the gradual development of the symptoms of acromegaly
+showed what was really the basic cause. Occasionally diseases of other
+ductless glands, as the thyroid, may have amenorrhea as one of the
+first symptoms. It is seldom that any serious thyroid condition
+develops without disturbance of menstruation, but this is less
+frequently in the direction of diminution than toward profusion and
+prolongation. In some cases, however, one or more periods is missed in
+the early development of the disease. In this, however, others of the
+characteristic tripod of symptoms--rapid heart, tremor,
+exophthalmes--are sure to be present even though the enlargement of
+the thyroid is not noticeable.
+
+
+Tuberculosis.--But more important than these causes of amenorrhea is
+the early development of tuberculosis. In some cases, even before
+there is any cough that calls attention to the condition, or when the
+cough has been considered to be one of those myths now fortunately
+passing, "a cold that hangs on," the cessation of menstruation may
+depend entirely on the weakness and anemia due to the growth of
+tubercle bacilli in the lungs.
+
+
+Inanition Amenorrhea.--Sometimes indigestion, or what is supposed to
+be indigestion, may be at the root of the amenorrhea. In many cases it
+really is not true indigestion that is present, but a disinclination
+for food which has increased to such a degree as to bring about a
+lowered state of nutrition. In nervous young women and, above all, in
+nervous spinsters beyond forty, disturbances of menstruation
+consequent upon lack of nutrition are not infrequent. Often their
+indigestion is considered to be a reflex from their genital {440}
+organs, when, on the contrary, whatever disturbance of their genital
+organs is present is due to the inanition which has developed because
+they have not been eating enough. Many of these women literally starve
+themselves, and they, must be persuaded to eat once more and taught
+what to eat, and their weight must be watched until it gets up to what
+is normal for their height.
+
+
+Psychotherapy and Treatment.--The treatment of amenorrhea on
+psychotherapeutic principles will be readily understood from the fact
+that there is a distinct psychic element in practically all the cases
+touched on in this chapter. This psychic element is generally
+appreciated and admitted. If a woman is accustomed to connect certain
+physical incidents with disturbances of menstruation, then those
+disturbances are almost sure to recur. As a rule, many an incident
+said to be disturbing to the function would probably have no influence
+upon it but for the dread connected with it and the anticipation of
+some interference. In all cases of amenorrhea, then, the patient's
+mind must be put into a favorable state and suggestions must be made
+that will lead to the expectancy of menstruation at the next regular
+period. If the mind can cause menstruation to cease, as is clear from
+experience, any inhibition from this source must be removed and its
+power set to bring relief to these patients. Drugs should not be
+neglected, and general physical conditions must be improved, but if
+the patient's mind continues to be unfavorably affected towards her
+menstruation, its satisfactory return will be delayed until somehow
+mind as well as body are co-ordinates for the resumption of the
+function.
+
+The best testimony to the value of psychotherapy in amenorrhea is
+found in the success of many of the remedies used for the condition,
+which, in the successive phases of medical development, have included
+all sorts of home treatments, many types of quack medicines, and
+innumerable proprietary combinations. Many of these have acquired a
+reputation for efficacy not justified by any direct pharmaceutic
+effects which we now know them to possess. From the familiar gin and
+hot water, through the various combinations of aloes and the tonic
+remedies of a later time, only the most general and obvious effects
+could have been produced by the medicines, yet apparently specific
+reactions have followed them in the menstrual cycle. But this was
+because the mind of the patient was prepared by the taking of the
+remedies and unfavorable suggestions as to menstruation were removed.
+Above all, with amelioration of the general health, constipation being
+relieved, the appetite restored and the whole tone of the system
+improved, nature became capable of taking up once more the menstrual
+function. What was accomplished by indirect psychotherapy in the past
+can now be done much better by direct mental suggestion, when at the
+same time various remedial measures in other therapeutic departments
+are employed as auxiliaries. But the physician must be sure that the
+mind of the patient is properly disposed or remedies may fail and
+symptoms continue.
+
+
+
+CHAPTER IV
+
+DYSMENORRHEA
+
+
+Practically every woman of menstrual age has more or less discomfort
+during menstruation. In most cases this does not rise beyond a heavy
+depressed {441} feeling shortly before menstruation begins, followed
+by a sense of weight and discomfort in the back and then some
+sensations more or less acutely uncomfortable due to congestion in the
+pelvis, which begin to be relieved with the commencement of the flow
+and then gradually disappear. Even in otherwise healthy women, various
+achy feelings of distention are often felt in the neighborhood of the
+ovaries, but these would scarcely be described as pain, unless the
+patient is over-sensitive. The effect upon the disposition is more
+marked and more universal. Some women are inclined to be irritable and
+hard to get along with for a few days before their menstruation and
+sometimes during the whole of its course. The frank recognition of
+this fact by them and a consultation of the calendar when they find
+that everything seems to be going against them and that everybody is
+lacking in sympathy, usually leads to an appreciation of the fact that
+the trouble is in themselves rather than in those around them, and
+their condition becomes more bearable. It is curious, however, to note
+how often this is forgotten, with consequent give-and-take of
+irritation in their environment that makes the nervous and mental
+condition worse and emphasizes the physical symptoms.
+
+The term dysmenorrhea, from the Greek, means difficult menstruation
+and is usually associated with painful conditions in connection with
+the menstrual flow. It may be applied, however, to various
+uncomfortable feelings, to superirritability, to fatigue, to lack of
+energy, or even to more vague discomforts at this period. The
+discomforts are usually spoken of as pains, especially after the
+patient has been dwelling on them for some time and has been reading
+patent medicine advertisements that tell of how women suffer in
+silence, but analysis often shows that they are sensations of
+pressure, of compression, of achy distress at most, and sometimes only
+of unusual feelings--paresthesiae--that having got over the threshold
+of consciousness, through concentration of attention upon them, are
+occupying the center of the stage of mental activity to the exclusion
+of all serious interests.
+
+The serious difficulties of menstruation are due to definite
+pathological conditions such as displacements of the uterus,
+affections of the uterine mucosa and of the ovaries. There are,
+however, many cases where the trouble is merely functional, dependent
+on conditions that can be easily corrected without serious surgical or
+even lengthy medical treatment, and where the patient's attitude of
+mind towards the trouble is the most important factor in the medical
+aspect of the case. As a matter of fact, many of the discomforts and
+even serious pains complained of in connection with menstruation are
+due rather to the patient's incapacity to bear even slight discomfort
+with reasonable patience and without exaggerated reaction than to the
+actual pain inflicted by whatever disturbance of function and tissue
+may be present. People differ very much in their power to stand
+discomfort and what seems quite trivial to one becomes unbearable
+torture to another. With this in mind it is possible to relieve many
+women who suffer from dysmenorrhea from their discomforts so that they
+shall only have to bear what is every woman's heritage in the matter.
+Successful management of these cases will save them from the supposed
+necessity of being operated on, which is likely to be constantly
+suggested to them in an age when women so often talk of their
+operations.
+
+The amount of pain suffered from any cause is dependent on two
+factors, the pathological condition and the power of the individual to
+withstand {442} discomfort. When we are irritated, when we are very
+tired, when we have fever, when we suffer from want of food or lack of
+sleep or any other condition that exhausts vitality, even slight pains
+become hard to bear. In relieving pain it is as important to remember
+this lessened capacity to stand discomfort as it is to get at the
+cause of the discomfort itself. This habit of standing discomfort with
+reasonable patience is one of the best remedies for lessening
+suffering, especially when it is known that the discomfort is only
+temporary and the end of it is in sight.
+
+
+Physical Condition.--In the treatment of suffering incident to the
+menstrual period, then, the correction of all conditions that may
+increase nervous irritability and make patients less capable of
+standing pain should be the first care. Young women who are thin and
+anemic, especially if they are more than ten per cent. under weight,
+are likely to suffer much at their menstrual periods for two
+reasons--through their lack of power to withstand discomfort and owing
+to the fact that their ovaries and the uterus itself are especially
+sensitive, probably through lack of nutrition consequent upon their
+general condition. In these cases local treatment is not as necessary
+as improvement of the patient's general condition and the raising of
+her general bodily tone.
+
+The bowels must, of course, be regulated, partly for the sake of the
+general condition and the fact that it is very hard to have a regular
+appetite unless there is a daily evacuation, and partly also because
+the presence of an accumulation of fecal material in the lower bowel
+is likely to produce congestion in the pelvic region. This added to
+the normal congestion due to the menstrual function may cause undue
+pressure upon sensitive nerves in the ovaries and uterus. Indeed a
+regulation of the function of the bowels is immediately followed by a
+lessening of the menstrual discomfort as well as by a general
+improvement. Many women find that the taking of a gentle purge a day
+or two before the menstrual period serves to make that period a source
+of less discomfort than it would otherwise be, and undoubtedly the
+suggestive value of such a remedy persuades many women that their
+discomfort should be lessened.
+
+Professor Goodell's reminder that women have many organs outside of
+their pelvis is important in dysmenorrhea. Almost any ailment that
+drains a woman's strength and brings a series of irritations to bear
+upon her nervous system will be reflected in her genito-urinary system
+and will cause discomfort during the menstrual period. Over and over
+again the physician finds that the true source of the menstrual
+discomfort is not in the essentially feminine organs, but in the
+digestive organs or occasionally even in such distant organs as the
+lungs, and that proper attention to these brings relief during the
+menstrual period. Just as soon as they realize that this is not a new
+affection but only a reflex from their other ailment, whatever it may
+be, they stand it with much better spirit and their complaints
+diminish.
+
+Anyone who has seen the difference between the reaction to menstrual
+moliminia when patients are in good condition and when they are
+otherwise run down will realize how much a matter of over-reaction to
+symptoms dysmenorrhea may be. Teachers who begin the school year,
+invigorated by their vacations, scarcely notice their periods, but at
+the end of the course, when run down by months of hard teaching work
+and especially by the confinement of the winter, they find the strain
+extremely hard to bear. In many of these cases an examination by a
+specialist seems to reveal something that might be {443} benefited by
+operation. There may be various uterine displacements, sensitive
+ovaries, perhaps slightly enlarged yet often not distinctly
+pathological, but just as soon as the physical condition is made
+normal, the symptoms given by these conditions completely disappear.
+Women who have nothing particular to do, who talk much about
+themselves and their ills, who have had friends operated on and heard
+much talk about the subject, are soon convinced that only an operation
+will do them good. Once _that_ suggestion is implanted in their minds,
+the hypnotic dread of the operation and the morbid attraction of being
+a center of interest and commiseration will make them exaggerate their
+symptoms to such a degree that operation becomes almost inevitable.
+
+
+Moral Fiber.--It is often said that modern women, as the result of
+civilization, refinement, and city life, are of laxer physical fiber
+and therefore cannot stand the ills that their grandmothers bore with
+equanimity and considered as nothing more than what was to be expected
+in this imperfect existence. Most physicians must feel, however, that
+the increased laxity is not so much of the physical as of the moral
+fiber. We have not weaker bodies than our forefathers, but weaker
+wills. This is especially so with those who have much time to think
+about themselves, and, therefore, is more true, of women than of men,
+though in our generation men also have become very introspective. I
+have seen--and I am sure that my experience is a common one among
+physicians--delicate women who seemed unable to stand any trial or
+hardship successfully, placed by unfortunate conditions--such as the
+sudden death of a husband, or his failure in business--in
+circumstances that were extremely hard to stand up bravely against.
+Not only did they stand it, but they had better health, they had less
+complaint of pains of all kinds, particularly in this matter of
+dysmenorrhea, than they had before.
+
+
+Pain and Occupation of Mind.--The more claims a woman has on her
+attention the less likely is she to be bothered at her monthly
+periods. If she does not _have_ to get up in the morning because there
+are no insistent obligations upon her, she is likely to lie in bed and
+worry about herself and by concentrating her attention on her ills
+will make them worse than they are. But if she has to be up and doing,
+if household cares cannot be put off, if she has to earn her living by
+working every day, she not only succeeds in doing it, but often also
+forgets her ills to a great extent in her occupation. Of course, there
+are pathological conditions that cannot be put off in this way, and if
+there are serious uterine changes, or if an infection has spread along
+the tubes to the ovaries, there will be symptoms that cannot be
+distracted away. Even where there are minor pathological conditions,
+however, occupation of mind will make pain less annoying and even make
+it quite negligible. We know our own experience with toothache. This
+is a real pain and with a real pathological condition of the most
+material kind. The congestion of the sensitive dentine or the
+irritation of an exposed nerve filament causes about as severe pain as
+it is given to mortals to bear. Even with toothache, however, we can
+by occupying ourselves with friends, or with a pleasant book, or a
+game of cards, or the theater, so diminish the annoyance consequent
+upon the pain as to be comparatively comfortable. If anything
+completely occupies our attention as, for instance, a fire or an
+accident, or bad news from a friend, then it may be hours afterwards
+before we realize that we were suffering from a toothache. Since this
+will happen with a dental nerve, why should it not {444} happen to
+branches of the genital nerve? There is no reason why one should be
+more sensitive than the other, and whatever reason there is is rather
+in favor of the dental nerve giving more bother, since it is nearer
+the center of the nervous system and these nerves are usually said to
+be more sensitive.
+
+
+Working Women.--With regard to painful menstruation, the habits of
+many country people, and of the European peasantry generally, furnish
+valuable indications of the power of work to dissipate discomfort.
+During my medical student days in Vienna I had the opportunity to know
+rather well a group of women who were engaged in working on a
+building. They carried up the bricks and mortar for the men and worked
+the windlasses by which heavy materials were carried to the different
+stories, and they mixed the mortar and prepared the building materials
+generally. These women, living constantly in the air and working very
+hard, had almost no symptoms of menstrual difficulty. They never laid
+off at this time except in a few cases in which subinvolution after
+pregnancies and genital infections had left conditions that made it
+hard to understand how they worked at all.
+
+I learned in addition from them, for most of them came from the
+country, that the women who work so commonly in the fields in central
+Europe have little difficulty with menstruation and practically do not
+know that it is coming on them until the show indicates its presence.
+I had known before how true this was for the Irish peasant women. This
+seems to be the normal healthy condition, and the state of mind of
+these women aids this satisfactory state of affairs. They rather look
+down upon women who complain at this time as being of such inferior
+health as to be despised. Doubtless if they were persuaded, as so many
+seem to be, that a woman must expect to have a serious time, or at
+least a great deal of discomfort about this period, they would have
+it, too. Of course, they have some difference of feeling at this time.
+They feel more tired in the evenings, and they awake in the morning
+less rested, but that is no more than the changes in the weather bring
+to men.
+
+On the coast of Brittany and Normandy many of the women rake for
+shellfish. Their custom is to wade into the water and, standing with
+the water often above the knee and waves sometimes washing as high as
+the waist, to rake all day for the shellfish that they are seeking.
+They do not lay off from this occupation, as a rule, when their
+menstruation is on them, but continue as if nothing were the matter,
+and there are very few complaints of menstrual troubles among them.
+Such occupation would seem to be positively counter-indicated, but
+long years of experience have shown them that there is no need of
+interruptions in their work and as they need every centime that they
+can obtain in this way for the support of their families, they
+continue even in very cold weather, when it would seem inevitable that
+this must produce serious results.
+
+It is not uncommon for a young woman, who, while her family was in
+good circumstances, was a severe trial to everyone for a week more or
+less, every month, to become quite free from trouble for herself and
+others when, owing to a change in the family circumstances, she has
+had to take up some occupation for a living. I have notes of cases of
+this kind in which the pain was so severe that, after several years of
+medication and external applications, it was decided to dilate the
+cervix uteri in the hope of affording relief. The relief thus
+afforded, however, was only temporary. A little later in life, {445}
+however, the necessity of earning a living has in some cases quite
+freed these young women from the torments that sent them so frequently
+to their physicians.
+
+
+We need the report of many more of such gynecological conditions which
+get better as a consequence of occupation of mind without any other
+treatment. We have any number of reports of benefits derived from
+operation, but not infrequently these reports refer only to a few
+months after the operation, when the strong mental suggestion of the
+performance of the operation and the general betterment of health
+consequent upon care during convalescence are still acting upon the
+patient, and she has the benefit of the gain in weight and strength
+that usually follows because of hope, appetite, exercise in the air,
+etc. Not infrequently in these cases there are, later on, sad relapses
+into painful conditions quite as severe as before, while, on the other
+hand, some change in the circumstances of the individual, or some
+intense preoccupation of mind a few years after, brings lasting cure,
+thus showing that it was the mental state which was at the root of the
+condition rather than any bodily affection.
+
+
+Spasmodic Dysmenorrhea.--There are two forms of dysmenorrhea that have
+been the subject of much study. One of them consists of cramp-like
+pains which occur some time before menstruation, are relieved if the
+flow is copious, but continue if it is scanty. This affection has
+often been attributed to mechanical obstruction. Nearly twenty years
+ago Dr. Champneys in his Harveian Lectures on Painful Menstruation
+discussed this subject, and showed that the mechanical explanation
+while very simple and popular was probably not correct. His conclusion
+was that the dysmenorrhea was more frequently due to conditions
+outside of the uterus than in that organ. He recommended plenty of
+healthy exercise between the periods and especially riding if the
+patient were not a working woman, regular activity of the bowels with
+epsom salts as probably the most valuable single remedy, and then a
+number of drugs such as guiacum and sulphur that are not specifics but
+have a general effect. In his experience castoreum, a strongly
+suggestive remedy, gave more relief than anything else. He advised
+against local treatment unless there was a very definite reason for it
+and frankly expressed the opinion that the complaints were often due
+more to an incapacity to stand the slight discomfort that is more or
+less inevitably associated with the congestive state that precedes
+menstruation than to any pathological lesion.
+
+
+Membranous Dysmenorrhea.--This affection like membranous colitis
+remains one of the mysteries of pathology and etiology. There is no
+doubt, however, that there are large nervous elements in its
+production and that it is worse at times of worry, while mental
+factors of many kinds influence its occurrence and also its relief. In
+his Harveian Lectures Dr. Champneys discussed the questions connected
+with it very well and his monograph is a classic on the subject. Many
+drugs have seemed successful and then have failed. Castoreum has done
+good in this as in spasmodic dysmenorrhea. A number of gynecological
+methods of treatment have been successful when first applied, when
+physician and patient were both confident of their value, and then
+later has failed. Probably nothing does more good than getting the
+patient's mind off her condition, securing such occupation as will not
+permit of introspection to any extent, though of course treating
+surgically whatever requires operation. It must not be forgotten that
+while many of those suffering from the disease {446} complain of pain,
+not a few sufferers from it have no symptoms of this kind and their
+condition is discovered more or less by accident. After this there is
+likely to be much more discomfort from it. All this must be borne in
+mind in its treatment.
+
+
+Minor Ovarian Lesions.--In many cases there is vague discomfort in the
+ovarian region about the time of menstruation, and the ovary is found
+to be somewhat enlarged or perhaps dislocated. In these cases if there
+is continued complaint of pain, operation will almost surely be
+advised and frequently cysts are found. This is considered to be
+justification enough for the removal of the ovaries or at least for
+their resection. It is doubtful, however, whether ovarian cysts in the
+majority of cases are really a pathological condition. Those who are
+engaged in spaying cattle think it almost if not quite normal for
+cysts to exist in the ovaries. Whether this is not also true of women
+we have not the data to determine. In a number of the patients who are
+operated upon for this condition there is a relapse of symptoms, and
+there seems to be no doubt but that whatever good is accomplished
+comes from the expectation of relief followed by the weeks of rest and
+quiet in bed and very often the gain in weight which succeeds the
+operation. Whether something of this kind would not follow from the
+simpler procedure of improving the general health is an open question.
+
+It is sometimes insisted that the general health will not improve in
+gynecological cases unless the offending pathological condition is
+removed. This is true if the patient is persuaded that there is some
+pathological condition present which must be corrected or else she
+will not be better, and if favorable suggestion cannot be used to
+advantage. If, however, these patients understand from the beginning
+that probably the local condition, which gives the symptoms, is due
+rather to their general health than to a definite lesion, there is
+more probability of improvement. It is surprising how many of these
+cases are relieved by an improvement of the general health, by the
+relief of constipation, by the decrease of congestion by laxatives,
+and by the persuasion that there is nothing which will go on to
+serious developments (this is the most disturbing of dreads) but only
+a condition that will probably get no worse and the symptoms from
+which may yield to general treatment.
+
+The popularity of many so-called remedies for women's diseases is due
+to their success in lifting the veil of discouragement and, by
+alcoholic and other tonic stimulation, helping the women into a better
+general condition and a more favorable frame of mind.
+
+
+The Individual.--In all cases of dysmenorrhea, then, it is important
+not to be influenced too much by the complaints (for here, as
+Broadbent insists with regard to angina pectoris, the more complaint
+we have the less serious the condition will often be), but to
+investigate the patient's condition and, where there is not some
+definite and serious pathological lesion, to analyze the beginning and
+the development of the individual case and eliminate the neurotic
+elements. Often the menstrual difficulty is due to suggestion, as the
+patient has been in contact with others who were sufferers and caught
+her complaint from them by psychic contagion. Special investigation is
+needed as to her occupation of mind. This must be provided for her.
+Nothing else will save her from herself. Travel may do it, exercise
+may be helpful, but an occupation in which she is deeply interested,
+especially if it involves {447} association with other people, is the
+best basis of psychic treatment. Improvement of the general health and
+the relief of various symptoms are auxiliaries.
+
+
+Unfavorable Suggestion.--After consulting with many women physicians,
+with many women who have lived active lives, with many superiors of
+religious orders in consultation about their religious women, I cannot
+but conclude that painful menstruation is ever so much oftener a
+result of mental and nervous states than of organic disturbances.
+Unfortunately a tradition has now been established that women suffer
+much at this time, so many of them give in to their feelings,
+exaggerate their discomfort, dwell on their sensations, affect the
+blood supply to the genital organs through the sympathetic nervous
+system, actually produce functionally pathological hyperemia where
+only physiological was present (the simile of the blush makes this
+easy to understand), and finally set up a condition that is actually
+painful, though there was only some discomforting sense of compression
+and congestion before. We have been educating young girls in disease,
+not in health. Plato pleaded for the opposite. After these 2,400 years
+we might take it up seriously.
+
+
+
+CHAPTER V
+
+MENORRHAGIA
+
+
+While the influence of the mind in producing painful menstruation and
+a much diminished menstrual flow is well recognized, the connection
+between the mind and an increased menstrual flow is not so generally
+appreciated. Usually profuse menstruation (especially when it reaches
+a height where it would properly be called menorrhagia) is considered
+to be due to some serious pathological condition. Its most frequent
+cause is undoubtedly subinvolution of the uterus after pregnancy, or
+an overgrowth of the uterine mucosa because of some pathological
+condition--usually an infection. While menorrhagia is often attributed
+to colds or to getting the feet wet (and undoubtedly the disturbance
+of the circulation consequent upon wet feet is an active factor in the
+production of an increased menstrual flow) there is no doubt that in
+most cases there is some more distinctly local cause at work. Another
+important cause of profuse menstruation is the presence of a fibroid
+tumor or other neoplasm which brings an increased blood supply to the
+uterus and a consequent greater elimination at the menstrual epoch.
+
+In most cases of subinvolution a curettage, at least, will have to be
+done. Often the use of extremely hot douches, that is, just as hot as
+can be borne, may accomplish much. Such quantities as a quart or two
+are useless; several gallons should be taken, and that not in the
+awkward cramped postures in which douching is sometimes done and in
+which it cannot be expected to accomplish its purpose, but in the
+reclining position and to be followed by an hour or two of rest with
+the hips elevated. This treatment will be more effective if women do
+not get the idea that an operation will surely have to be done on
+them. Operations are now so much spoken about that some women
+apparently do not feel that they have had quite all the experience
+that is coming to them in life unless they have at least one to their
+credit. If they can be made to realize that, in the past before the
+days of operative gynecology, most such cases recovered of themselves
+and that now if courage is {448} resumed, appetite strengthened
+through the will, constipation relieved, an abundance of outdoor air
+secured (exercise is not so necessary), recovery will probably be more
+complete than after an operation, there would be much less need of
+operations than at present.
+
+The material conditions based upon pathological changes which usually
+produce menorrhagia hardly seem amenable to influence by the patient's
+state of mind, yet experience demonstrates that much can be done for
+these patients by setting their minds at rest, by improving their
+general condition, by soothing their worry as to what the profuse flow
+means. Many nervous patients have quite normal menstruation, as
+regards the length and quantity of flow, until some serious
+disturbance occurs in their mental state. I have had patients who for
+months would have a perfectly normal menstrual flow of three to five
+days to whom a serious mental disturbance always brings a profuse
+menstruation. The arrest of a woman by mistake just before or at the
+beginning of her menstrual period will often cause a greatly increased
+flow and great weakness will follow. Women approaching the menopause
+already have a tendency to an increased flow though not beyond the
+bounds of what might be considered normal, and at this time almost any
+shock will produce profuse menstruation and lead to prostration. If
+the secondary anemia from this is not overcome during the interval
+profuse menstruations may succeed each other for many months.
+
+The necessity for reassuring these women, therefore, becomes evident.
+Most of us have seen women who were worried at having a slightly
+increased menstruation, and who had been told that they had a fibroid
+tumor which was producing the increased menstruation, and which would
+have to be removed if it continued to bring on this serious condition.
+Such a suggestion inevitably leads to a series of more profuse
+menstruations during the following months. Such women worry over their
+state and dread an operation. They do not eat well and, even though
+they do not lose much in weight, they often become distinctly anemic.
+This anemia adds to the tendency to a freer flow and as a consequence
+the menstrual period is lengthened in time and increased in amount.
+This soon brings them to operation, though very often there has been
+no increase in size of the fibroid tumor and there is no more reason
+for operation than there was when they were first examined.
+
+I have had under observation during the last two years a patient in
+whom the diagnosis of a fibroid brought this unfortunate result. Her
+menstruation had been profuse and prolonged before but now it became
+still longer and lasted nearly fifteen days each month. As she lost
+much in weight, was run down in strength, became self-centered, stayed
+more at home, and took less exercise, the resultant depression in her
+general condition emphasized the menorrhagia. As soon as it was made
+clear to her that her case had but one indication for operation--the
+loss of blood and that the fibroid was so small that it might well be
+allowed to remain until after her menopause, when involution would
+probably prevent further unfavorable action, she took heart, began to
+exercise, ate more heartily, her marked constipation was relieved, she
+slept better and in three months her menstruation was almost normal.
+For many months she had no menorrhagia.
+
+I have seen other cases in which amelioration of symptoms came just as
+soon as the patient learned that, by improvement in the general
+health, there {449} was a possibility of lessening the tendency to
+hemorrhage and thus of putting off the necessity for operation for a
+time at least, if not until such natural changes occurred in the
+system as to lessen the danger from the growing tumor. I have in mind
+the wife of a physician whose menopause was delayed for some ten years
+as a consequence of a good-sized fibroid growth. She had it when she
+first came to me, and I watched the case for some seven years, and she
+absolutely refused to entertain the idea of operation. I set her mind
+at rest as to the seriousness of the growth provided the bleeding was
+not injurious and no infective conditions occurred through the
+intestinal walls to complicate the condition and cause adhesions.
+Whenever she worked hard, or whenever she was much worried, she would
+have alarming flooding. Under ordinary circumstances, however, when
+things did not go awry, she had a menstruation somewhat more profuse
+than normal and of five or six days in length. This continued from her
+fiftieth to her fifty-fifth year, and then gradually subsided. She is
+still alive at the age of sixty and, though she has had many trials
+and hardships at the end of her life, she is healthy and considers
+herself much better off than if she had had an operation. I doubt
+whether this is true, that is, if the operation had been done twenty
+years ago. But, after watching such a case and realizing that
+operations on fibroids are more often fatal than any other of the
+gynecologic operations that do not involve serious conditions, a
+physician is justified in tiding women over the time to their
+menopause and then letting nature dispose. Infective incidents
+pointing to the formation of adhesions are a contraindication to this
+policy, however.
+
+The sufferer in this case was one of the most patient of women. She
+had had to suffer much in mind and in body as the result of being left
+almost destitute after a life of luxury, yet she seldom complained.
+One might almost think her indifferent to hardship if one did not know
+her well. She was not at all a stoic but she never allowed her
+imagination to run away with her, she bore the ills of the day without
+thinking of what was going to come next week and she worried as little
+as possible under the circumstances. The ordinary woman, nervous and
+excitable, would have broken down under the strain that was placed
+upon her but she promises to live to a good age and her trials have
+not hurt her vitality nor spoiled her disposition and she looks the
+world in the face with surprising cheerfulness. This state of mind
+modifies even fibroid menorrhagia favorably.
+
+Fibroids have been reported "cured" by so many different
+remedies--local applications, acupuncture, hot needles, electricity in
+various forms, even internal treatment, which afterwards proved quite
+unavailing--that it is manifest that the mind plays a large rôle in
+controlling the symptoms.
+
+Before operation it is important to put the minds of these patients
+into an attitude of confidence, for operators who make it a point to
+secure the confidence of their patients, or who for some reason have
+their full faith, have better results in these cases than others of
+equal surgical skill.
+
+In unmarried women the development of a small fibroid with its reflex
+disturbances is sure to be followed by excessive reaction in many
+ways. Nervous symptoms are likely to be marked and the increase in
+menstruation is usually much more profuse as a consequence of the
+solicitude than because of the fibroid. Some of these tumors which,
+though of small size, are so situated with regard to the nervous and
+circulatory systems of the uterus as to produce {450} profuse
+menstruation even in women of phlegmatic disposition. In these
+patients operations will be necessary whenever the loss of blood makes
+it clear that the drain on the system is producing serious effects.
+There are cases, however, in which the menorrhagia is not due directly
+to the fibroid, but rather to its effect upon the general system and
+this may be lessened very much by reassurance, by regulation of the
+general health, by resumption of exercise and toning up of appetite
+and, above all, by relief of the constipation which so often
+complicates these cases. Fibroids may or may not continue to grow. The
+removal of one is no guarantee that others will not form, nor that
+others are not present in very small form which will develop later. As
+a rule, there can be no question of the removal of the uterus unless
+conditions are serious.
+
+If in spite of general treatment and the calming of the patient as far
+as possible profuse menstruation continues, it is an indication for
+surgical intervention. Psychotherapy may readily be abused in these
+cases, but it has a distinct use, and its application is more
+frequently successful than has been thought; but it must be
+deliberately employed. When, however, menorrhagia is a symptom of some
+serious progressive condition, psychotherapy will do harm rather than
+good. I have known women whose menstruation was stopped and then
+recurred and even became profuse reassured that this was only a
+symptom of the menopause when it was the first symptom of a cancer. In
+such cases there must be no temporizing or reassurance, but a careful
+determination of the actual condition must be made and immediate
+operation done if it seems necessary. Psychotherapy may have a place
+in incurable cancer, but in other cases it has none at all except to
+calm the patient for operation where surgery may be of service.
+
+
+
+CHAPTER VI
+
+THE MENOPAUSE
+
+
+While the phase of feminine sexual life which involves the cessation
+of menstruation is physiological and not morbid, it is so commonly
+associated with physical and mental symptoms difficult to bear that,
+practically always, it sends the woman to a physician. This is as true
+of the artificial menopause induced by removal of ovaries as it is of
+the normal process by which, in the course of time, ovarian function
+comes to an end and changes are brought about in the system consequent
+upon the absence of ovarian secretion. The ovaries, like many other
+organs, have two functions. One, that of ovulation, is so prominent
+that the other, the internal secretion, has been too much neglected.
+How important this is, however, may be judged from the change that
+comes over feminine nature after its cessation. Much of the
+emotionality of woman disappears, not a few of her special sex
+qualities are modified and even masculine physical peculiarities may
+assert themselves. The physical effects of the ovarian internal
+secretion may be inferred from the definite tendency to grow stout
+which results from its suppression by the menopause. Certain changes
+in the organism are inevitable then, and the only hope of therapy is
+to keep them from disturbing life processes.
+
+
+Neutralizing Unfavorable Mental Attitude.--Psychotherapy can do more
+{451} for the troubles of the menopause than any other treatment. The
+symptoms of the change of life in the long ago, if we can trust
+traditions, were not so troublesome as they are now. Only rarely did
+women suffer from it as they are supposed to suffer at the present
+time. Women are so persuaded that there is to be much suffering, or at
+least prolonged physical discomfort, as to make it difficult for them
+to be quite themselves. They are prone to think that their physical
+symptoms are noted, and that their condition is a subject of remark.
+This adds to the difficulty of bearing in patience whatever symptoms
+are present. The introspective attitude of our time has reacted upon
+such affections as occur in the menopause, and, by creating an
+abnormal susceptibility of mind, has added much not only to its
+possibility but also to its actuality of suffering. Drugs or other
+remedial measures will modify the conditions only partially and
+temporarily. The mental prophylaxis of suggestion must alter the state
+of mind both before and during the progress of the condition.
+
+
+Favorable Suggestion.--After the menopause women are less disturbed by
+emotional strains and troubles of any kind than before. They settle
+down into more placid, easy-going lives. They are not subjected to the
+monthly interruption of their routine of work or amusement, everything
+comes a little easier to them, and they are not, to use the word in
+its physiological sense, so irritable--that is, so responsive in
+reaction. They are not so likely to respond to slight irritations, and
+are often physically and mentally more content with life. This must be
+insisted upon, for, at the present time, unfavorable suggestion with
+regard to the menopause is the universal rule. Women look for the
+worst from it, and their expectation makes conditions less tolerable
+than they really are. Most women dread it as if it were the beginning
+of the end of life, the first descent into old age, while it is often
+the dawn of a larger and broader life free from sexual and other
+irritations, and with better possibilities of accomplishment.
+
+
+Definite Prescriptions.--These patients are best reassured by being
+told that every woman who has lived to the age of fifty has gone
+through a similar experience and that they have all, with rare
+exceptions, revived with health of both body and mind. It is more
+important to insist on the patients cultivating a certain gaiety of
+disposition, to plan for regular diversions two or three times a week,
+to see that they are not too much alone and that they find abundant
+occupation of mind and body, than to try to combat their manifold
+symptoms by drugs or local measures. Of course, their physical
+functions must be kept normal. It is surprising, however, how much
+improvement can be brought about in the menopause symptoms by definite
+prescriptions as to the time to be spent in the open air--at least two
+or three hours a day--with regard to having a definite diversion of
+some kind in mind two or three days ahead to which they look forward
+with pleasure, and by convincing them that whenever they allow
+themselves to dwell much on their condition, their symptoms of
+discomfort will become so severe as to be intolerable, while when they
+are occupied with other things they will find them quite easy to bear.
+
+As a rule, mothers of families with many cares and diversions of mind,
+with little time to think of themselves, do not suffer much at this
+period, or at least not nearly so much as do those who are without
+these diversions. The more time a woman has to think about herself at
+this period, the worse for {452} her. Her irritability of mind will be
+reflected upon her physical condition and make it worse. In the olden
+time mothers of families went through it and no one knew about it, or
+even noticed that there was anything the matter with them except
+possibly a little increased irritability at certain periods. Neither
+menstruation nor the menopause is necessarily connected with more than
+passing discomfort, if the patient is in good health. This is
+perfectly true if symptoms are not brooded over, if there is not too
+much expectancy of evils, and the feelings and manifestations which do
+not deserve the name of symptoms are taken as a matter of course. Best
+of all, let the woman keep her mind well occupied with many
+duties--with care for others, the helpless, the ailing, around her,
+instead of with herself and her passing ills.
+
+
+Dread of Insanity.--There are few women who go through this period
+without the hideous thought that possibly they may go crazy. This is
+especially likely if, as a consequence of the exaggerated desire for
+seclusion that many women have at this time, they do not get out into
+the air nor exercise as much as they should. As a consequence, they
+suffer from constipation, from lack of appetite, and capriciousness of
+taste for food, and they may have a series of symptoms that, when
+dwelt on during the hours of solitude, very seriously disturb the good
+feeling that is so important for the normal accomplishment of
+physiological functions.
+
+
+Diversion of Mind.--This tendency to withdraw from social relations
+with their friends and from the occupations that take them out of
+doors and which are often a helpful diversion of mind is one of the
+worst symptoms of this time and must be strenuously combated. It
+superinduces a series of physical symptoms which are attributed to the
+menopause but are really due to lack of air, to inactivity, to absence
+of interest and the consequent opportunity provided for unfortunate
+auto-suggestion and introspection. These superadded physical symptoms
+can be readily relieved by directions for rational living and then the
+genuine menopause symptoms may be so diminished as to be scarcely
+noticeable. It is impossible for the ordinary human being to stay much
+in the house, to lie down a large part of the time, eat irregularly
+and let the bowels become sluggish without having many symptoms of
+depression.
+
+
+Summary of Treatment.--The treatment, not of the menopause but of the
+patients passing through the menopause, then, must consist, first, in
+putting them in as good physical condition as possible and keeping
+them in it; second, in maintaining such normal natural habits of life
+as will enable them to keep up this physical condition without
+disturbance; thirdly, in putting off solicitude with regard to the
+menopause and realizing that it is a normal natural process with a
+definite place in human life and not at all representing a terminal
+stage of human existence. Nature meant that the mature woman, formed
+by precious experience, with sympathies broadened by years, should be
+able to devote herself without sexual irritation to the many things
+that naturally come to her at this period. There is a place in life
+for the grandmother and even for the grandaunt, though a French
+visitor recently declared that he thought there must be no
+grandmothers in America since all the women seemed to dress in the
+fashion of the young girl. If this submission to natural conditions is
+recognized and accepted there are long years of happiness and
+helpfulness in store for the woman of middle age and the menopause may
+be welcomed as an important step towards a larger development of life.
+
+
+{453}
+
+SECTION XI
+
+_PSYCHOTHERAPY IN OBSTETRICS_
+
+
+CHAPTER I
+
+SUGGESTION IN OBSTETRICS
+
+
+In no department of medicine is favorable or unfavorable mental
+influence more important than in obstetrics. Unfortunately,
+unfavorable suggestion has here played a serious rôle and must be
+controlled, modified, neutralized. Suggestion is valuable in its every
+phase, during the course of pregnancy, in labor itself, in
+_post-partum_ convalescence, and with regard to nursing. Many women in
+our time are prone to persuade themselves that labor is a more serious
+incident than it usually proves to be and the consequence is an
+unfortunate suggestion of pain to come that so exaggerates
+sensitiveness as to make the actual suffering seem more than it really
+is. Sympathy expressed for women in pregnancy and in anticipation of
+their labor is sure to do more harm than good. Pain instead of being
+lessened by sympathy is increased and capacity to bear it is
+diminished. Anything that calls attention more particularly to the
+pain removes distracting conditions that might modify it favorably.
+Animals have the admirable instinct of withdrawing to some quiet
+corner when they are in pain, preferring to be alone. In this they
+follow nature and imitation of them is worthy of consideration, at
+least so far as the avoidance of opportunities for the expression of
+sympathy is concerned.
+
+
+PREGNANCY
+
+
+Maintenance of Health.--Women must keep up their normal health and
+strength during pregnancy. By not taking sufficient exercise and by
+being too much indoors, many women develop a morbid mental state in
+which every discomfort is less bearable than it was before. Lack of
+air and of exercise, furthermore, makes them prone to constipation,
+makes their sleep less restful, and reduces the appetite. For the sake
+of the being within them, they force themselves to eat, but this often
+serves only to make them obese, without improving their general
+health. If a woman in her ordinary condition, who was accustomed to
+going out-of-doors several hours every day and having reasonable
+diversion of mind and exercise of body, were to adopt the habits of
+life that many pregnant women form, she, too, would become morbidly
+introspective, fearful of the future, irritable over little things,
+restless at night, and even have certain physical symptoms, such as
+constipation, tired feelings, loss of {454} appetite, etc. Many of the
+discomforts and symptoms of which women complain during pregnancy are
+really due to unfortunate habits and to their mental attitude toward
+their conditions, rather than to any specific influence of pregnancy
+on the general health. As a rule, women who live naturally are in
+somewhat better physical health during pregnancy that at other times.
+
+
+Obesity and Pregnancy.--It is important that women should not become
+obese during pregnancy. The woman who is taking too much fat in her
+diet and accumulating fat is likely to have a fat baby, and with these
+there is more difficulty in labor itself, and the infants have less
+resistive vitality than if they were unencumbered with useless adipose
+tissue. Her will must overcome the tendency to lassitude and the
+proneness to inactivity that comes over her, and she must feel that
+labor and her condition after it are dependent on normal, healthy life
+at this time.
+
+
+Delayed Labor and Suggestion.--One phase of maternal impressions or of
+suggestion for the mother's mind that I have always been interested in
+has been that of the possibility of preventing delay in parturition by
+frequent suggestion of the time that delivery should be expected.
+There seems to be no doubt that expectation has some influence on the
+time of delivery. We do not know just why, after the uterus has
+tolerated the presence of the fetus for nine calendar months, it
+should then refuse to do so any longer and contract and expel it. Any
+number of theories have been suggested and even now our best
+obstetricians are not agreed as to the reason for this action on the
+part of the uterus. In some cases this contraction does not take place
+normally. The due term of labor is past and as a consequence fetuses
+grow too large within the uterus, greatly increasing the difficulties
+of parturition and adding to the risk of both mother and child. It is
+the custom to announce with pride the birth of twelve- and
+fifteen-pound babies, but it is doubtful whether nature intended that
+growth to this extent should take place before birth. There is in
+this, as in other phases of pride with regard to children, a curiously
+perverted feeling.
+
+Many obstetricians feel that the babies who weigh much more than the
+average of seven pounds have probably been delayed in the uterus for a
+lunar month beyond the time when they should, or at least could have
+been normally born. It is a question whether this delay would have
+occurred if the mother's expectation of the birth had been directed to
+a date a month ahead of that on which her mind became fixed as the
+time of labor. Parturition usually takes place about the period of the
+recurrence of the menstrual molimina, or at least of that monthly
+cyclic feeling which many women experience, though there is no flow.
+It is not always easy to say at which of two monthly periods the birth
+should be expected. While physicians have warned patients of the
+possibility of the child being born at the first of the two possible
+periods, they have been inclined to dwell on the fact that it will
+probably be delayed until the later term. Women themselves are more
+prone to take the later than the earlier termination of their
+pregnancy. Both physician and patient are timorous of the ridicule
+that may follow if they make premature announcements. Whether we have
+not in this way created a tradition tending to delay parturition by a
+lunar month in many cases, is a problem that requires careful study.
+
+The suggestion of as early a period as is compatible with the data
+provided, so as to create a definite expectancy in the mother's mind,
+seems well worth {455} deliberate attention. This is a role that
+psychotherapy has to play in lessening the dangers and the
+difficulties of parturition. With most healthy women, as indeed with
+most sensible normal women in life as regards all things, no
+suggestion is needed and nature will take her course promptly and
+properly. It is the nervous women, over-anxious about themselves,
+often of lax physical fiber because of their nervous condition, that
+need this phase of psychotherapy. It is in them that the unfavorable
+or mistaken suggestion may be emphasized to such a degree as to delay
+labor for a lunar month or even more.
+
+
+Vomiting of Pregnancy.--One of the dreaded complications of pregnancy
+is serious prolonged vomiting. We know now that this is of two kinds,
+toxic and neurotic. The toxic variety may be associated with kidney
+changes, but is more commonly the consequence of certain rare forms of
+degeneration of the liver. The pathological picture after death is not
+unlike that of phosphorus poisoning. These cases are due to some
+serious disturbance of metabolism or to the absorption of some little
+understood poison. They are probably always fatal. The cases of
+neurotic vomiting are rather common. They are exaggerations, of the
+ordinary familiar vomiting of pregnancy which is exhibited by nearly
+all women at the recurrence of the menstrual times in the early
+portion of pregnancy. In some of these cases, however, the vomiting is
+so persistent and so prolonged that the patient's nutrition suffers
+severely, and there seems to be danger of a fatal termination.  The
+condition has received the unfortunate name of "pernicious vomiting."
+In these cases there is sometimes question of the advisability of
+terminating the pregnancy lest the woman should die. Unfortunately
+this question has been so commonly discussed that most prospective
+mothers are likely to know something about it, so that when vomiting
+begins they are fearful lest they should have to lose their child.
+This becomes an obsession in some minds and an unfavorable suggestion
+that helps to maintain the vomiting.
+
+A number of remedies have been highly recommended for this at various
+times. Nearly every alterative drug has had its period of popularity.
+In the older time nitrate of silver was said to be efficacious. Small
+doses of ipecac were highly recommended at one time. Small doses of
+cocain were suggested, and the painting of the back of the throat with
+cocain. Small doses of morphin had a vogue; codein had its turn after
+its introduction, and heroin also had a time of popularity. Oxalate of
+cerium was highly recommended. Any obstetrician of experience will
+remember many other remedies that have been supposed to be
+efficacious. Various gynecological procedures have been suggested: the
+touching of the _cervix uteri_ with a mild caustic, with iodin or with
+nitrate of silver, slight dilatation of the cervix, sometimes the
+application of a tampon with just enough glycerin to produce a
+reaction, but not enough to terminate the pregnancy. Occasionally
+local applications over the stomach region, a mustard leaf, or certain
+plasters, or finally even a piece of sized paper bound on over this
+region have been known to be followed by the cessation of the
+vomiting. When as many different remedies are recommended and seem for
+a time to be successful and then later prove to be inefficacious, it
+is reasonably clear that it is not the remedies but the effect
+produced by these on the mind that is the important therapeutic
+factor.
+
+Many obstetricians of wide experience now teach that most of these
+cases of vomiting in pregnancy are merely neurotic and are to be
+treated entirely {456} as if they were hysterical. The patient's mind
+is to be distracted from her condition; she is to be assured that even
+severe vomiting is quite common in pregnancy, that it is annoying, but
+never serious in its consequences, that it always ends without
+unfortunate incident for mother or child, and that there need be no
+solicitude. Above all, no hint of the possibility of the necessity for
+the termination of the pregnancy, if vomiting continues, should be
+given. Some physicians are entirely too solicitous in the matter and
+have by their anxiety made the neurotic condition of their patients
+worse. Some men see what they call a "pernicious vomiting" in every
+hundred labors. A well-known obstetrician in New York has had 3,000
+births without seeing a single case. He is known for his placidity and
+lack of over-anxiety. In the great obstetrical clinics in Europe
+vomiting to the extent that will put mother or child in danger is
+extremely rare. The greatest obstetrician of the later nineteenth
+century reports 100,000 obstetrical cases with only one artificial
+labor.
+
+In foreign obstetrical clinics these cases in recent years have been
+treated expectantly, without any active interference, especially with
+pregnancy, and the results have been much more satisfactory than any
+other method of treatment. There are a number of cases on record now
+in which pregnant women have lost from twenty to forty pounds as the
+result of vomiting for weeks, yet after a time the attack has passed
+and they have carried the child to full term. Where vomiting has
+occurred and relief has once been afforded by the termination of
+pregnancy, it is very unlikely that succeeding pregnancies will pass
+without corresponding conditions in which no remedy will prove
+effective, except the dreaded obstetrical intervention for the
+termination of the pregnancy. It is extremely important then that
+these cases should be treated conservatively and that from the very
+beginning there should be nothing to arouse the patient's solicitude
+with regard to herself or above all to give her any hint of the
+possibility of obstetrical intervention being necessary in her case.
+For some women the knowledge that a consultation has been held to
+discuss such a possibility will of itself prove a persistent
+unfavorable suggestion, that will surely prolong the vomiting.
+
+This may seem a rather strong opinion from one who is not in practical
+touch with obstetrics. It has been the growing opinion, however, among
+the great German obstetricians for the last generation. Ahlfeld, in
+the _Archiv für Gynaekologie_ (Band 18 Heft 2 page 310) said that he
+had seen [in a very large obstetrical practice] three cases of
+so-called pernicious vomiting (_unstillbaren Erbrechen_) in all of
+which the patients wanted an abortion because they had previously
+learned the success of this method of treatment, but all of them
+recovered without incident and carried their children to term. Kronig,
+ten years ago, in his monograph on "The Significance of Functional
+Nervous Diseases for Diagnosis and Treatment in Gynaecology"
+[Footnote 36] said: "The excessive vomiting of pregnant patients has
+for a long time seemed to be a genital reflex neurosis. We thought
+that the growing uterus irritates certain nerve tracts which are
+connected with the mucous membrane of the stomach. We owe it to
+Kaltenbach that this opinion was overturned and _hyperemesis
+gravidarum_ set down as the result of a functional neurosis,
+hysterical in character. A large number of gynaecologists have
+accepted this opinion in recent {457} years (men of all nations) among
+others Calderini, Charpentier, Schaeffer, Klein, and Graefe."
+
+  [Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten
+  für die Diagnostik und Therapie in der Gynakologie von Dr. B.
+  Kronig. Leipzig, 1902.]
+
+
+Winkel and the leading obstetricians of Germany, especially the
+directors of obstetrical clinics in the large cities, must be quoted
+as of the same opinion, since Winkel has collected the statistics of
+100,000 pregnancies in the large German clinics in which 6,555
+obstetrical operations were performed and in only one case was
+artificial abortion produced. German opinion is rather strong in the
+assertion that a number of cases of abortion in the practice of an
+obstetrician indicates over-hastiness in coming to conclusions as to
+danger, or leaves him open to the suspicion of yielding too readily to
+the wishes of mothers who would prefer not to carry their children to
+term. The suggestion of the possible necessity for abortion has done
+much to make the hysterical vomiting of these patients continue until
+this remedy is employed. Insistence from the very beginning that
+vomiting, though it may injure both mother and child, never
+necessitates abortion--one out of 100,000 cases is practically
+never--would be the best possible contrasuggestion.
+
+Kronig thinks that the vomiting of pregnancy is an especially
+favorable subject for suggestive treatment. He inclines to the opinion
+that the remedies that have been reported to do good and so many of
+which have subsequently proved unavailing have really owed whatever
+success they have had to the suggestion that went with them. Bumm, in
+his text-book of obstetrics (Grundriss zum Studium der Geburtshülfe
+von Dr. Ernst Bumm, Wiesbaden, 1902), accepts Kaltenbach's and
+Ahfeld's conclusions and thinks that the consideration of
+_hyperemesis_ as an hysterical neurosis is well supported by the
+success and failure of our therapeutics. All sorts of remedies, any
+number of drugs, all manner of gynecological procedures short of
+abortion, though also including abortion, have been reported as doing
+good. All of them even including abortion have failed in a certain
+number of cases. Evidently suggestion plays a large role. Hypnosis
+often proves an excellent remedy.
+
+
+Excessive Salivary Secretion.--Bumm considers that the excess of
+secretion of saliva which is so often noticed in pregnancy is of the
+same nature and should be treated rather by suggestion than by any
+particular remedy, though remedies should be tried because of certain
+helpful physical effects, and then the psychic element that goes with
+them. The less importance given to the symptom, the less attention it
+attracts, the more its passing trivial character is emphasized, the
+sooner it will subside. Solicitude causes it to persist and even
+increase.
+
+
+
+LABOR
+
+
+Suggestion in Labor.--When the subjects are normal, expectancy has
+much to do with the severity of labor pains. In recent years so much
+fuss has been made and so much said and written about woman's burden
+and travail in the pains of childbirth, that preliminary dread and
+anxious attention have wrought young women up to such a poignancy of
+expectation as to make these pains worse than they really are. In the
+old days child-bearing was as much a matter of course as the husband
+going out to his daily work, and the taking of the dangers and
+fatigues of it was a simple matter of duty. Labor was then {458}
+comparatively easy and, while never pleasant, was also never an
+over-uncomfortable process. The effect of unfortunate suggestion has
+been to make it seem ever so much worse than it really is. Multiparae
+furnish the best proof of this. A healthy woman who has already had
+more than one child does not dread labor pains very much, or only to a
+slight degree, because the previous maternities have lessened the
+physical pain to be experienced, though a healthy woman's tissues are
+so thoroughly resilient that nature is able to bring about a return to
+normal conditions so complete that it is not always easy to decide
+whether a woman has given birth to a child or not. Of course, there
+are many cases in which tears reveal the former labor, but there are
+others in which it is not so, and the renewal of the birth process
+must, therefore, be nearly if not quite as painful as before,
+especially if it is recalled that succeeding children are usually
+larger. In spite of this in multiparae, labor has lost most of its
+terrors because real knowledge of its comparative ease has replaced
+the previous unfavorable suggestion, and instead there has come a
+proper appreciation of what will have to be borne, and of the positive
+pleasure of the relief when it has been borne successfully.
+
+Healthy women of the lower classes have so little difficulty in labor
+that they are quite frank to confess that it means scarcely more than
+a few severe muscular pains during an hour or so. Some of them mind it
+so little that up to within half an hour of the birth of the baby they
+occupy themselves with other things and succeed effectually in
+distracting their pains away.
+
+In their article on "Hypnotism and Suggestion in Obstetrics" Drs.
+Auvard and Secheron   [Footnote 37] suggest that hypnotism can be
+employed with advantage during labor, but it is more difficult to
+produce it then than in the normal condition. Its only advantage is
+anesthesia, and this can be obtained during the preliminary pains in
+many cases. It is frequently impossible to produce complete
+anesthesia, however. To replace hypnotism they advise that suggestion
+in the waking state be used and they even suggest the employment of
+pseudo-choloroform or other like means. This method they consider more
+advisable than hypnotism, for there are no inconveniences and many
+real advantages. The nervous condition of the patient after hypnotism
+during labor is sometimes far from satisfactory.
+
+  [Footnote 37: "L'Hypnotisme et la Suggestion en Obstétrique,"
+  Paris, 1888.]
+
+
+Nature's Methods.--In obstetrics and labor we have been finding in
+recent years that we have not trusted nature enough, have not looked
+sufficiently to the woman herself for assistance in its difficulties,
+and have made her too much a passive rather than an active factor.
+Practically all of the dangers that have accrued to the woman in
+childbirth, certainly many times more than have come from any other
+factor, have been due to well-meant but unfortunate attempts to help
+her while preventing her from helping herself. Before the middle of
+the nineteenth century most of the puerperal fever was due to
+infection from over-zealous but unclean attendants. Now men are
+proudly reporting hundreds of cases of delivery without even a vaginal
+examination. Above all, we have failed to take advantage of the
+occupation of mind that could be used to save women much of the
+anxiety and suffering of labor. If the parturient woman were allowed
+to change her position, as she does so naturally and frequently in a
+state of unsophistication, and to help actively, as she can {459} in
+many postures, in the delivery of her child, it would mean much in
+diverting her mind from pain which is emphasized by inactivity. The
+rule of having the woman lie on her back has been unfortunate in many
+ways and has required much more external interference than if other
+positions were adopted, while the pains have been more unbearable
+because that is actually the position in which the woman suffers most
+and in which she can do least to lessen them.
+
+I was once told by an Irish grandmother the story of nearly one
+hundred deliveries without accident of any kind, in which the only
+rule had been not to touch the woman, but to allow her to change her
+position and, above all, to facilitate her in getting on her knees in
+a stooping bent-over posture so as to help herself. The upper mattress
+was doubled over completely and the woman was encouraged to kneel on
+the lower straw mattress, which was so arranged that it could be
+changed completely, or destroyed immediately after labor. This seemed
+old-fashioned and unscientific twenty years ago, when I heard the
+story, but I have been interested recently in reading Professor King's
+address on "The Significance of Posture in Obstetrics."   [Footnote
+38]
+
+  [Footnote 38: _Bulletin of the Lying-in Hospital_, Vol. V, No. IV.]
+
+
+Professor King is sure that there are many advantages in following
+certain natural inclinations of the mother to change her position and
+that this helps her in many ways. Above all, as the psychotherapist
+sees at once, it will occupy her mind, keep down anxiety and lessen
+pain in many natural ways, besides encouraging concentration of
+attention on muscular effort instead of on painful sensation. The
+whole article is well worth reading, for in it he suggests that
+certain obstetrical operations, even version, would not be so often
+necessary, if the woman were sometimes allowed to assume the squatting
+position in the course of birth. His illustrations make very clear the
+help that changes of position are in the mechanics of many
+difficulties of labor. The pressure of the patient's thigh on the
+abdomen, when she was allowed to assume a squatting position, enabled
+him, in a case in which the woman had been in labor twenty-eight
+hours, in which ergot had been given by the midwife, in which the
+waters had been discharged and the uterus was tetanically contracted
+around its contents, to deliver the child without instrumentation and
+without further delay. In five minutes the arm (for it was an arm
+presentation) began to recede, and in twenty minutes the child was
+delivered, head first, and mother and infant both did well. Other
+cases with similar results have been reported by obstetricians quite
+as distinguished as Professor King. Many other experienced obstetrical
+teachers have expressed themselves to the same purpose in recent
+years.
+
+
+Postures after Labor.--Allowing changes of position after labor also
+has its advantages. There is often retention of urine and this can be
+relieved by allowing the woman to assume the usual position. It may be
+impossible owing to the swelling and hyperemia in the neighborhood of
+her urethra for the woman to pass water, and yet if she is allowed to
+sit in the usual position upon a commode, she will in most cases pass
+her water in a few minutes without difficulty and the risks attending
+catheterization will be obviated. The power to urinate is due in these
+cases partly to the pressure of the thighs upon the abdomen which
+helps the bladder to contract and undoubtedly also to the suggestive
+influence that the position has.
+
+{460}
+
+
+NURSING
+
+The attitude of mind of a woman toward her milk supply is important,
+as the flow of milk is closely subject to mental influence. The
+presence of the child and the consequent exercise of maternal instinct
+does more to bring about the prompt, healthy flow of milk than
+anything else. Sometimes women in the later months of their first
+pregnancy upon seeing a mother nursing her child have felt the flow of
+milk to their breasts not rarely with such painful overdistention of
+the milk ducts as to require artificial relief. On the other hand, a
+fright may stop the flow of milk or make it scanty and a mother's
+aversion to a child may prevent her being able to nurse it. The sight
+of the father of the child in a state of intoxication may have a
+similar result.
+
+How much milk supply may be dependent on the state of mind, or at
+least the state of the nervous system, can be realized from the
+animals from which we obtain milk. Any serious disturbance is likely
+to interfere with the milk supply. When a cow's calf is taken away the
+animal will often refuse for a time to give milk. If a cow is scared,
+as by the attack of a wild animal, or by being hit though only
+slightly injured by an engine, it will often not have milk for several
+days or even longer. There is an impression prevalent among farmers
+that if a cow takes a dislike to a particular person they are not
+likely to "give down" as much milk as would otherwise be the case.
+This may be only a curious farmer tradition, that has no basis in
+fact, although it is supported by so many observations reported from
+many different countries that it is apparently to be taken as of
+scientific value.
+
+In modern times many fashionable women do not nurse their children
+because they have not the proper supply of milk. It is easy to see how
+this can be brought about through suggestion from many sources and the
+sight of others neglecting their duty in this matter. Most fashionable
+women would rather not nurse their children, and yet many of them feel
+a bounden duty in the matter. Some of these, however, having heard
+that many mothers of the better class are not capable of nursing their
+children, easily persuade themselves that they come in this category,
+and so their whole attitude of mind toward nursing is one of extreme
+doubt. Knowing as we do how the mental state influences nursing we are
+not surprised when these women prove not to have sufficient milk in
+the early days of the nursing. If they are to have it they must look
+forward with confidence to nursing their children and they must be
+ready and willing to take such food and secure such fresh air as will
+put them in the best possible condition for this function, always with
+the thought that nothing can be better for a child than to be nursed
+by its own mother. Nature has made exactly the form of food suited for
+the particular child, and it matters not how healthy a wet nurse may
+be, her milk is not likely to be so suitable. Much depends on the
+nutrition of the child during this early susceptible period of its
+life and there is more that passes over with the milk than merely the
+food elements. It is well recognized now that the reason why nurslings
+are protected from most of the so-called children's diseases and the
+contagious diseases generally, is that, as a rule, their mothers {461}
+have had these diseases, have acquired an immunity to them and this
+immunity is transferred to the child so long as the nursing process is
+continued. This has been shown to be true over and over again in
+animals and holds good for human beings.
+
+Professor Von Leyden, the distinguished professor of medicine at the
+University of Berlin, points out that we are not quite sure as yet
+just what may happen to the human race from the very general refusal
+of mothers to nurse their children and the almost universal
+substitution of the bovine mother; whether in times to come certain
+bovine traits, at least as regards susceptibility to disease, may not
+be stamped upon the human race, cannot be determined until this
+experiment in ethnology, now being conducted on so large a scale, has
+been carried to some definite conclusion.
+
+Perhaps this view is groundless, but there is no doubt that milk is
+more than merely a food and that during the period after birth when
+the child's nervous system is being formed, the perfectly adapted
+mother's milk is more likely to be the proper food than anything that
+human ingenuity can elaborate. We have heard much in recent years of
+the tendency of education and civilization to lower the birth-rate and
+to make women less fitted for maternity and for such maternal duties
+as nursing, but stronger than any deterioration of the physical
+constitution by the mental development is the unfortunate unfavorable
+effect of mental suggestion upon such functions, by which the
+preparation of the organism for their fulfillment is greatly
+influenced. It is in this respect that the women of to-day differ from
+the woman of the past much more than in mere physical development.
+
+
+
+CHAPTER II
+
+MATERNAL IMPRESSIONS
+
+
+"Maternal impression" is accepted as a specific designation to signify
+the real or supposed influence of emotion and especially serious
+trouble, which may affect the mother's mind during pregnancy and be
+transferred to the child _in utero_, with the production of
+deformities or mother's marks. There used to be an almost
+superstitious belief in the power of the maternal impressions to
+influence unfavorably the child _in utero_. With the newer
+developments as to the influence of the subconscious and subliminal
+there might well occur in some minds an exaggeration of these ideas
+with the production of much mental suffering at least, if not of more
+serious results.
+
+
+Maternal Impressions in Old Literature.--The belief in the influence
+of maternal impression on the child _in utero_ is so strongly fixed
+that to most people it will seem paradoxical to question the whole
+subject. The evidence for it, however, is quite trivial, and none of
+it rises above the grade of what may be explained by coincidence. But
+there are many apparently insuperable difficulties, from the
+standpoint of our modern scientific knowledge, with regard to the
+whole subject. If we take up the medical books and the popular
+science, or rather pseudo-science, and the folk stories of a century
+ago we find overwhelming evidence for the belief in maternal
+impressions. More recent {462} literature has but few examples, and
+the more the details are studied the less is the evidence of any kind
+that the mother's mind influences her unborn child. There is really no
+more reason why a child should he marked within its mother's womb than
+that it should be marked while nursing at the breast if something
+should happen to the mother at that time. This latter effect strikes
+one at once as absurd; the former, as we shall see, is exactly of the
+same nature.
+
+Many of the older stories of maternal impressions are reported on no
+better grounds than the vomiting of snakes and the like, even live
+mice, which used to be found in old-time medical literature. It is
+true that there was usually no such morbidity about the stories of
+maternal impressions, but men wanted to find some explanation for the
+problem of the occurrence of deformities and markings and the maternal
+impression idea seemed satisfactory and inviting by its very mystery.
+The belief that animals could live for some time in human stomachs is
+now relegated to the limbo of old-time credulous traditions. Maternal
+impressions are on the same path and in twenty-five years they will be
+as great curiosities in serious medical literature as the gastric
+fauna of two generations ago. Under these circumstances prospective
+mothers who are anxious over possibilities and who have dreads of all
+kinds about their unborn children should be reassured and informed as
+to the scientific status of this important question.
+
+
+Mother and Child Distinct Beings.--There is no direct connection
+between the mother and her unborn babe. No nerves run in the cord and
+none pass from the uterine tissues to the placenta. It is easy to
+understand the influence of mind on body under ordinary circumstances,
+at least the mystery has a rational explanation. The central nervous
+system rules the nutrition of the body. To cut off the nerve supply
+has as serious an effect as to cut off the blood supply. Owing to the
+existence of a chain of neurons, that is, a succession of nervous
+elements, instead of one continuous nerve fiber from center to
+periphery, it is possible for one of the neurons of the chain to be so
+disturbed that the conducting apparatus is interrupted and impulses do
+not flow. Hence, if a strong impression is produced on the mind with
+regard to a particular part of the body the neurons leading to it may
+be so disturbed that trophic nerve impulses do not flow down, the
+blood supply of the part may be disturbed through the vaso-motor
+system and consequent changes may take place.
+
+
+_Absence of Circulatory Connection_.--Since no nerves pass, as we have
+said, from mother to babe, disturbances acting on the mother's mind
+can at most only influence the blood supply to the baby. Most people
+think that there is a direct blood supply from mother to child and
+that the mother's blood literally flows in the baby's veins. This is
+not true. The baby's blood is an entirely independent structure,
+originating in the child's own body, and always maintaining a distinct
+and quite different composition from that of the mother. The baby's
+blood has a higher specific gravity, and it has, in normal condition,
+nearly double as many red corpuscles to the cubic millimeter as the
+mother's blood. If the blood supply is disturbed by mental influences,
+then it is not the baby's blood nor its circulation that is disturbed,
+but only the circulation through the maternal part of the placenta
+where an exchange of gases and nutrient elements between mother's and
+baby's blood takes place. It is {463} impossible to conceive that
+during this passage through a membrane of nutrient elements, soluble
+proteids, gases, etc., mental influences should also pass over.
+
+
+Supposed Examples of Maternal Impression.--The stories that are told
+would lead us to believe that somehow definite changes in the mother
+are reproduced in the babe. One case, which in a circle of friends
+that I knew very well made many a convert to the idea of maternal
+impressions, was that of a young woman at whom, during an early stage
+of her first pregnancy, her husband playfully threw a tiny frog. He
+did not know that she had a mortal dread of frogs. She was seriously
+frightened and put up her hand to ward off the animal, and as the
+clammy thing struck her palm she felt a shiver go through her. When
+her baby was born a curious growth that had some pigment in it and
+that, by a stretch of the imagination, might be considered to resemble
+a frog was in the baby's hand--the same hand, by the way, as that
+which the mother used to ward off the animal. The lack of any nervous
+connection and of any direct blood connection between mother and child
+makes the story simply absurd as an illustration of maternal
+impression.
+
+In recent years such stories have come from more and more distant
+parts of the country. Kansas was the principal source of them until a
+generation of great editors arose there. Texas was then their favorite
+location, but Texas has in recent years become so progressive and so
+closely connected with the rest of the world that, in spite of its
+size, it does not produce so many of these wonders. A generation ago
+the announcement of the birth of six children at once in Austria, or
+somewhere else in Central Europe, would usually be followed by a
+report from Texas announcing seven at a birth. Maternal impression
+stories grew luxuriantly for the benefit of the news-gatherer in dull
+seasons. A standing type of them is that of the farmer cutting hay on
+his farm who puts his fingers too far into the hay cutter and has them
+taken off. His wife binds up the bleeding stump. She is pregnant at
+the time. When her baby is born--usually two or three months
+later--just the same fingers are missing on the same hand of the
+child. Now the mechanism by which such maternal impression could be
+transferred to the child is incomprehensible. There is no connection
+between the two, and the old metaphysical axiom (_actio in distans
+repugnat_) that all action between bodies at a distance from one
+another, that is without some connecting link between them, is absurd,
+holds as good in modern times as it did in the Middle Ages. Surely a
+tendency-to-amputation is not carried over from mother's blood to
+baby's blood through the membrane in the placenta just as are the
+gases for respiration and the nutrient elements for food. If it is, we
+have a greater mystery than ever to solve.
+
+
+Period of Occurrence.--The infant in the uterus is fully formed before
+the tenth week of pregnancy and at a time when women are usually
+almost unconscious of the fact that they are pregnant. Such
+impressional changes as we have referred to, if produced after this,
+must be in the nature of backward growth or an inversion of trophic
+influences or a great perversion of embryonic life. They have nothing
+to do with the formation of the child, since that is completed. They
+are as much accidents as if the child should fall after it was born.
+We know how fetal limbs are amputated through the formation of
+amniotic bands, but that maternal impressions should influence the
+formation of these bands is of itself ridiculously absurd. That it
+should {464} influence them in a directive and selective way so that
+certain limbs may be amputated at a certain point reaches a climax of
+absurdity. A distinguished physician of our generation once said that
+one might as well hope to absorb a pencil case in one's vest pocket by
+medicine as to try to bring about absorption of fully formed
+connective tissue by drugs. We cannot think of any mental influence
+bringing about such absorption, yet to credit maternal impressions
+with the production of fetal amputations not only supposes the
+directive formation of connective tissue within the uterus, quite
+beyond the domain of the influence of the mother's nervous system, but
+also assumes the direction of the anomalous action of that connective
+tissue in its mutilating procedures in a very exact and definite way.
+
+Some curious things have been explained on the score of maternal
+impressions and it is this very exaggeration that is perhaps the best
+proof of how coincidence, imitation, and other factors play a role
+that has exaggerated the idea of maternal impressions into a causative
+factor. A typical illustration is the case cited years ago, half in
+joke, perhaps, half in earnest, by a distinguished professor of
+obstetrics. It occurred in the days when the elder Sothern was playing
+Lord Dundreary to crowded houses and when Dundrearyisms were the
+current witticisms and Dundreary ties and Dundreary clothes and
+Dundreary whiskers were all the rage. A young woman who was recently
+married became much taken with the actor and went to see him over and
+over again, secured an introduction to him, and showed the liveliest
+interest in him and the performance. Their acquaintance, however,
+remained merely that of chance friends. Some months after it began,
+not more than five or six at the most, a boy was born to her.
+According to the story this boy, when he began to walk some years
+later, developed that little skip in his gait which proved so taking
+to those who crowded the theaters to see Sothern as Lord Dundreary.
+
+By this time the play had lost something of its vogue and most people
+did not recognize the curious halt in the gait, but it was very clear
+to the mother and her friends. It was set down as due to a maternal
+mental impression. Mental transfer seems ludicrous in this case. It is
+much more likely that the mother was hysterical, and, wishing in a
+morbid way to attract attention to herself and her child, taught the
+boy the little skip, or perhaps some curious little skip once taken by
+the child attracted the mother's attention because of her memory of
+Sothern, and her surprise at the act impressed the peculiar action
+upon the boy's mind, who proceeded to attract further attention by
+repeating it. It is cases like this with their _reductio ad absurdum_
+of the whole process that have quite discredited the belief in
+maternal impressions.
+
+
+Some Figures and Coincidences.--The occurrence of mothers' marks in
+connection with various external incidents of pregnancy are only
+coincidences. Most young mothers dread lest something should happen to
+their children. About once in a thousand times an infant is marked in
+some way. Nine hundred mothers rejoice over the fact that their baby
+is not marked in spite of the fact that they feared it might be,
+ninety-nine of them never gave the matter any thought and one of them
+finds to her sorrow that her foreboding has come true. Occasionally a
+mother who has not dreaded such a result finds that her offspring is
+marked. Then she recalls all the happenings of her pregnancy and picks
+out something to which she thinks she may attribute the accident.
+{465} There must be some reason for it and she finds it. Sometimes she
+begins by saying that it must be because she was frightened at such a
+time, or fell down at such a place, or saw such a thing, and then a
+week later she tells the story with circumstantial additions which
+make it very clear to her friends that she knows exactly the reason
+and that she had thought about it before and feared it might be so,
+though the whole matter was hazy until it had been talked over a
+number of times.
+
+Coincidences have been the most serious detriment in drawing
+scientific conclusions in every department of medicine. Most of our
+diseases are self-limited and any medicine that was given being
+followed by recovery seemed to be the cause of that recovery and the
+more strictly self-limited a disease the greater the number of
+remedies. When stories of maternal impressions are analyzed it is
+found that a great many mothers have had forebodings as to their
+children being marked and their dreads have not come true. A few have
+feared and have realized their worst fears. Many women whose children
+are marked can recall no event in the course of their pregnancy which
+could have marked their child and they ask the doctor what he thinks
+must have been the reason. But unintelligent mothers can always find
+some cause by searching out unpleasant details of their experience
+during pregnancy.
+
+
+Intrauterine Nutrition and Nursing.--To explain the occurrence of a
+frog-like appearance or a mousey patch on a baby as due to its mother
+having been frightened by one of these little animals while nursing
+would be the height of absurdity. But it is no more absurd than the
+supposition that mental impressions in the late months of pregnancy
+can have the effects that are popularly ascribed to them. If a mother
+suffers from severe fright, or even if she has a fit of intense anger
+or other profound mental disturbance, her milk may disagree with her
+infant. Every physician has seen nursing infants made sick by the
+change in the milk superinduced by strong mental emotions in the
+mother. This, however, could have nothing to do with the production of
+a special lasting physical mark on the outside of the body.
+
+
+Maternal Solicitude and Superstition.--The wonderful stories that are
+told are nearly all in the older literature and are much more
+reasonably explained on the score of coincidence than on that of any
+possible direct connection of cause and effect. Mothers, then, may be
+reassured and made to understand that the better their own health, the
+less they worry about their condition, the more likely is their
+pregnancy to terminate favorably with a perfectly healthy offspring.
+This is the source of so much concern in the little world of
+child-bearing that it is worth while taking it seriously and making
+mothers understand that the old notions in this matter are but
+superstitions. Superstitions are not always nor exclusively religious,
+they are survivals from a previous state of knowledge, the reasons for
+which are now known to be false. Maternal impression, that is, the
+belief in the power of the mother's mind over the unborn child, is a
+superstition that we must now dismiss.
+
+
+Favorable Maternal Influences.--Every now and then a sensational
+newspaper has an article on how mothers will tend to make their
+children physically handsomer by gazing at beautiful works of art,
+beautiful scenes in nature, and seeing only handsome (one feels like
+inserting well-dressed in the category, also) people during pregnancy.
+The reading of good books {466} containing moral lessons of the
+highest quality are supposed to have something of the same influence
+on the child's character. There is no doubt at all that the more
+carefully and simply and beautifully and healthily the mother lives,
+and the more her mind possesses itself in peace and happiness, the
+better will be her own nutrition and consequently that of her
+offspring, and, all things considered, this will contribute to the
+perfection of the infant's body and so give the best instrument for
+the expression of its soul. That these supposed favorable influences
+have any more direct power than this over the state of the infant that
+is to be is doubtful. It is worth trying for, but if the indefinite
+influence for good emphasizes, as it apparently does in many minds,
+the presumed direct and definite influence for evil, then it is not
+worth dwelling on.
+
+
+Etiology of Deformities.--But if these curious deformities and
+markings are not due to maternal impressions, what, then, is their
+cause? To the question for many of the minor marks and slight
+deformities--naevi vascular and pigmentary, extra fingers, slight
+overgrowths, special peculiarities of bone and soft tissues--no
+satisfactory answer can be given. We must simply say that as yet we do
+not know. It is a good thing to say we do not know. Long ago Roger
+Bacon declared that the principal reason why man did not advance in
+knowledge more in spite of the amount of their work was that they were
+afraid to say "I do not know," and accepted inadequate reasons and
+insufficient authority in order to avoid this humiliating expression.
+On the other hand, there are many deformities and markings, the
+reasons for which have been found, and the more important they are the
+more we know about them, as a rule. Besides, with the advance of our
+knowledge of embryology we are getting to know more and more about
+these difficult problems and many things that were mysteries before
+are now clear. In addition to observation we have experiment and this
+is making observation more thoroughly scientific.
+
+The more we know of the intricacies of the development of animals and
+human beings, the greater is our surprise that deformities do not
+occur even more commonly than they do. All the openings of the human
+as of the animal body gradually close in with the production of the
+finished form. The slightest interference with growth in the
+neighborhood of these openings, which involve nearly all of the front
+of the body, leaves various deformities. Nature has surrounded the
+developing embryo with fluid so that it is saved from jars of all
+kinds and from contact with other tissues that would disturb growth.
+Cell is laid on cell as brick is laid on brick in the building of a
+house, and the predetermined plan in the immense majority of cases is
+followed without accident to the minutest detail. That more mishaps do
+not occur, considering the delicacy of the process and the perfection
+of the finished structure, is hard to understand.
+
+There are many factors likely to intrude in every pregnancy that may
+lead to the production of unfortunate results. Literally millions of
+cells are growing with apparent freedom from constraint in many
+portions of the fetus, yet all are directed with definite purpose
+corresponding to other cells and are destined to meet in due course of
+time. Each one of them or at least each group seems to be independent
+in its growth. Each growing cell doubles by dividing every few hours,
+yet all are co-ordinated to a definite end. We admire the men who
+begin at the two ends of a tunnel far distant from one another and
+work without any communication except through the engineer's plans
+{467} made long before, and yet make two bores that can be depended on
+to meet with but a few inches of divergence. The bridges of tissue
+that are built across the openings of the body jut out to meet one
+another in this way and in more than ninety-nine out of every one
+hundred cases there is not the slightest divergence. Many things may
+occur to disturb conditions--not connected with mental influences, but
+with distinctly physical factors--missteps, trips, jars on stairs or
+getting off and on cars, on the sidewalk, etc. These, and not the
+mythical factors that make up so-called maternal impressions, are the
+causes of deformities and mothers' marks.
+
+
+{468}
+
+SECTION XII
+
+
+_GENITO-URINARY DISEASES_
+
+
+CHAPTER I
+
+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,
+{469} 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 {470} 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 {471} 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, {472} 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.
+
+
+
+CHAPTER II
+
+SEXUAL NEUROSES
+
+
+Anything that disturbs the sexual sphere in either sex, no matter how
+trivial it may be, becomes a source of worry and depression quite
+beyond its real importance. It is not unusual for men and women to
+become so worried over some trifling affection of their sexual organs
+that they become convinced that serious pathological conditions are
+developing and that there is little hope of anything like a complete
+cure. This is particularly true of young patients, but holds also for
+those of older years. Slight discomforts are exaggerated into nagging
+aches and pains which produce extreme depression of spirits.
+
+{473}
+
+It is important, then, for the physician to recognize this and to
+treat the patient's mind by reassurance while conducting whatever
+other therapeutics may be required. There is danger always in these
+cases of either making too little or too much of the affection. If too
+much is made of it, an unfavorable influence is produced in the
+patient's mind and the discouragement leads to so much inhibition or
+even actual physical disturbance that the affection will not improve.
+If too little is made of it, patients get discouraged and are prone to
+think that the physician does not understand their cases. Then they go
+to the advertising specialist in men's diseases who works upon their
+fears and makes them feel much worse than before, though in the end he
+may lift the cloud of anxiety from their minds and pretend to have
+cured them. He always leaves them, however, with the impression that
+something serious has been the matter, and this acts as a nightmare
+and a source of dread in after time.
+
+In men the unfavorable suggestions occur particularly as a consequence
+of affections of the external organs. In women the same suggestions
+are likely to make themselves felt with regard to the internal genital
+organs. We all recognize the exaggeration of feeling and even physical
+reaction that takes place with regard to slight sexual ailments in the
+male, because it is easy to recognize just exactly what pathological
+conditions are present and how trivial they may be and yet produce
+serious depression and all kinds of symptoms, reflexly referred to
+many other organs. There is a tendency to listen to the complaints
+from women more seriously because the actual pathological condition
+cannot be determined and there is always the fear that some serious
+affection may be at work. It must not be forgotten, however, that the
+complaints of pains and aches, the disturbance of sleep, of digestion
+and of the intestinal function, the mental and physical lassitude and
+the over-reaction to irritation which occur in both sexes as a
+consequence of sexual affections may be due entirely to mental
+solicitude and not to any real pathological change.
+
+
+Trivial Afflictions--Varicocele.--It is curious what a little thing
+will sometimes set off the explosion of a train of sexual symptoms.
+Every physician has probably had some young man come to him with the
+look and the tone that there was something the matter that he knew was
+serious and would affect all his after life. The patient then goes on
+to say that he wants to know all and is brave enough to face it, and,
+though he has lost sleep for two or three nights and is not looking
+well for the present moment because his health has been disturbed by
+the loss of sleep, still he has the strength to know the worst and it
+is to be told him and he will bravely battle on in spite of the
+suffering that must come. Or he will submit to a serious operation if
+it is necessary for his relief. With a prelude like this, the
+inexperienced physician might expect strangulated hernia or some
+preliminary symptoms of brain tumor, but what he usually finds is a
+varicocele, and a small one at that. By chance the patient has
+discovered it and slept none the following night, went round in an
+agony of dread next day meaning to go to a physician, but too fearful
+to be told the worst, losing another night's sleep and then finally
+coming to a friend to be told all the ill that is in store for him.
+
+There is no need for alarm in these cases; they merely illustrate the
+role of the mind disturbing the body. Nearly one-fourth of the male
+world carries its {474} varicocele around with it and never bothers
+about it. A few sensitive individuals are annoyed by a sense of weight
+and a feeling of distention from congestion in connection with it. In
+a few, because of special pathological conditions or congenital
+defects, the varicocele becomes so large that it has to be supported
+by a special bandage. In people who ride horseback, in athletes, and
+those who indulge in severe exercise, this sort of a bandage may be
+necessary or at least may make the wearer more comfortable even in
+slighter forms of the affection. Severe cases may be much relieved by
+it.
+
+On first discovery of his varicocele nearly every young man, because
+of concentration of attention on it, is so much annoyed that he thinks
+he must wear a bandage. After a time, however, he often finds that the
+bandage itself is a source of more annoyance than the varicocele, and
+then he learns to forget it and its feelings--and that is all about
+it.
+
+I have dwelt on this succession of events that takes place so often
+with regard to varicocele, because it is typical of the effect that an
+affection of the sexual organs has upon the mind. It exerts an
+unfavorable influence entirely disproportionate to the physical cause
+that is at work. If, as sometimes happens, a young man hesitates to
+confide in some one capable of undeceiving him with regard to the
+supposed significance of his affection, he may work himself into a
+decided nervous condition and lose much weight before he discovers his
+mistake. This physical running down confirms his exaggerated notion of
+the significance of the affection. He is sure that it constitutes the
+reason why he is losing weight and declining in health and he rather
+congratulates himself on the fact that he discovered the cause so
+shortly before the serious effects began.
+
+If under these conditions he places himself in the hands of any of the
+men who advertise themselves as curing "men's diseases," or as
+relieving the "awful" symptoms that are likely to follow varicocele,
+instead of being reassured he will be told that he has come just in
+time and that while his cure will require a long time and will cost a
+great deal of money, yet it can surely be effected. In nothing can men
+or women be more easily imposed upon than with regard to affections
+involving their sex organs. They lose their power of judgment and
+their control over their feelings and so plunge sometimes into
+profound depression. Every year we have a number of suicides among
+young men, the most important element in whose depression is due to
+unrelieved occupation of mind with the thought that they are suffering
+from some incurable sexual disease which will unsex them, and that
+even death is to be preferred to the alternative of being recognized
+generally--as they are sure they will be--as sexual defectives.
+
+As a rule, these young men are suffering from only some slight ailment
+that could be easily cured if they were frank about their state of
+mind and described their symptoms to a reputable physician. Oftener
+than not their supposed ailment is something so common as to be of no
+significance, so far as any serious results may possibly be
+anticipated, and their only real ailment is the mental condition which
+has developed because of concentration of mind on this one phase of
+organic life and the consequent inevitable exaggeration of symptoms
+and feelings. It is sometimes not easy to disabuse them of their
+unfortunate notions, but there is probably no set of cases in medicine
+where psychotherapeutics means more than it does with regard to the
+curious {475} neurotic and psychic conditions which develop in those
+who are suffering from any sexual ailment, real or imaginary.
+
+
+Long Prepuce.--Much has been said in recent years about the influence
+of a long prepuce in the male in producing various reflexes the
+effects of which may be seen in serious disturbance of even distant
+organs. The kidneys are sometimes said to be thus reflexly affected,
+and occasionally the digestion and the bowels--even, sometimes, mental
+processes are said to be influenced unfavorably by the diffusion of
+reflexes from the irritation consequent upon this sensitive structure
+being too long. A whole system of nosology exists in some minds due to
+an over-long prepuce. There are, of course, cases in which
+circumcision should be performed. There is a larger number of others,
+however, in which the redundant prepuce is neither adherent nor
+constricted and is only slightly longer than it should be.
+Occasionally something arouses the attention of the possessor of the
+redundant tissue and he gets the idea that it is the source of reflex
+irritation even for distant parts of his organism. It is an
+interesting study in suggestion to see how symptoms develop in various
+organs as a consequence of the cultivation of this thought. Urination
+becomes frequent, the patient even wakes at night to urinate and the
+urine, as in many neuroses, becomes more abundant and of lower
+specific gravity--the typical nervous urine of the hysterical, and
+there may be much worry and emotional disturbance.
+
+These symptoms, however, are not effects of the long prepuce, but are
+results of the neurotic influence of concentration of mind on it. It
+will often be advisable, in young men particularly, to have
+circumcision performed, but in most cases this is unnecessary, and if
+the patient can be made to understand how the symptoms have developed
+he will learn a precious lesson in not interfering with his functions
+by over-attention to them. Of course, there are many surgeons who will
+continue to hold, as they seem to now, that nature was quite at fault
+in the production of this organ and that it should be removed in
+nearly every human being. The majority of men, however, have lived
+their lives quite well and happily without such intervention and there
+are certain inconveniences attached to the condition which remains
+after operation that may in their way be quite as bothersome as the
+symptoms due to the long foreskin.
+
+
+Psychic Impotence.--An important sexual neurosis, at least in the eyes
+of sufferers from it, is what physicians have come to know as psychic
+impotence. Young married men, because of over-anxiety with regard to
+themselves for a number of reasons, but without any physical factor to
+disturb them, find it impossible to complete the sexual act. Naturally
+this creates a serious disturbance of mind. The patient will either
+hurry to a physician at some place on his wedding tour, or his wedding
+tour will be shortened and he will return to consult a friend. He
+presents a lively picture of despair. He has not been sleeping, his
+appetite is disturbed, he feels lassitude and weakness, and if he has
+a lively imagination he is inclined to think that the fatal
+termination of some serious nervous disease of which he has heard, and
+which is accompanied by the symptom of sexual impotence, is impending
+over him. His condition is quite pitiable, though largely imaginary.
+
+
+_Reassurance_.--The treatment of the condition is not so difficult as
+it might seem if the patient has a reasonable confidence in his
+physician. If he {476} goes to an advertising "specialist," as
+occasionally happens, because he concludes that the ordinary physician
+cannot know all the details of these intricately complex nervous
+diseases, he is sure to suffer severely in general health before cure
+is obtained. His morbid ideas will be fostered because he is ready to
+pay any amount of money in order to stop the progress of the presumed
+serious disease. An investigation of these "specialists" in New York,
+made a few years ago by a committee of the New York County Medical
+Society, showed to what an extent the terrors of these unfortunate
+patients are exploited for monetary reasons.
+
+A physician of even a little experience in these matters, however,
+recognizes at once the entirely neurotic character of the case and by
+reassurance soon enables the young man to dispel many of his worst
+terrors. His general health can be regulated, his constipation, which
+so frequently exists, is relieved, and he can be told, what is very
+true, that the excitement consequent upon the preparations for his
+wedding and the exhaustion due to the overwork so frequently necessary
+in order to enable him to take the time off for his wedding journey,
+have made him so nervously irritable that the ordinary mechanism of
+the sexual act, which is extremely delicate and requires nice
+co-ordination for proper function, has been disturbed. Just as soon as
+this fatigue and the over-excitement of mind consequent upon the
+unfortunate experience are mitigated his potency will return. This
+assurance can be given almost at once.
+
+His fears, however, will delay his recovery. His dread of incapacity
+will become an obsession. Probably the most effective means of
+treating this is to forbid him to attempt the sexual act for a
+definite length of time, say two or three weeks. This must be
+impressed upon him. There is a good reason for insisting that he shall
+not irritate his already excited sexual system by such attempts.
+Usually at the end of a week or ten days he will come back with a
+smiling look of confidence in himself and his physician, to confess
+that he has violated the injunction, but that he was not disappointed
+as before.
+
+
+_Subconscious Obsession_.--In most of these cases the young men have
+been victims of sex habits of some kind or of drug addictions, and
+they have heard that occasionally individuals who have had such
+experiences may suffer from sexual impotence later in life. This is a
+strong suggestion to them and in some cases becomes a haunting
+obsession, and produces the unfavorable effect upon the organism. It
+is necessary to remove this obsession before a cure can be effected.
+The patient's confidence must be obtained and the physician's
+personality and persuasive powers used to change his point of view.
+Occasionally I have seen cases in which the patients themselves seem
+to be scarcely aware of this strong suggestion or obsession at work in
+them. It seemed to be more or less subconscious. An idea with regard
+to the evil effects of the old habit had been implanted and remained
+in their minds, occasionally making itself felt but more often
+apparently lying dormant. In these cases it is important that the
+physician should make this underlying factor clear to the patient. In
+some of these cases hypnosis is necessary. Usually the hypnoidal
+condition, with suggestions in the waking state, is all that is
+necessary and ordinary suggestions will often effect the purpose
+completely.
+
+
+Organic Impotence.--Certain forms of sexual impotence are really
+preliminary signs of serious organic nervous disease. Sometimes it is
+the first {477} symptom of paresis or of locomotor ataxia. Oftener it
+is a very early symptom of syphilitic spinal myelitis. In practically
+all of these cases, however, there is a history of syphilis and the
+presence of this should always be a warning not to think of functional
+or psychic impotence until the possible influence of the syphilis
+itself or of some of the parasyphilitic diseases is thoroughly
+excluded. Unfortunately, not a few people who have had syphilis are
+nervous and anxious about themselves and by their very anticipation of
+possible developments may auto-suggest themselves into a state in
+which these symptoms will develop. It is cases of neurasthenia that
+develop after secondary syphilis in persons who have been studying
+syphilis and its possible effects, which present the most difficult
+problems in diagnosis that come to the nerve specialist. Many
+simulated symptoms are unconsciously developed and this makes
+differential diagnosis extremely hard. As a rule, the psychic
+impotence is merely functional and patients need reassurance more than
+anything else.
+
+
+Nocturnal Emissions.--One of the sexual neuroses that gives rise to a
+high degree of solicitude centers around the question of involuntary
+seminal emissions. Young men who are living normal healthy lives and
+who are in robust health with no indulgence of sexuality are likely to
+experience more or less regular involuntary emissions. If for any
+reason they become nervous or anxious about their sexual functions,
+especially at times when they are under much mental strain, these
+phenomena of emptying the seminal vesicles may occur rather
+frequently. If they have been reading some of the literature, or
+hearing some of the exaggerated notions that are often expressed with
+regard to the evil effects that may come from this, they are likely to
+suffer much mental anxiety over it. Occasionally they lose sleep,
+frequently they feel so wearied and worried the day after the
+occurrence as to be disturbed at their work, sometimes they are sure
+they are so tired that they are unable to fulfill their ordinary
+duties, and I suppose every physician has known young men who were
+even sure that the loss of the seminal fluid was seriously interfering
+with health, hampering many physical functions and bringing them to an
+untimely grave. They had no appetite and in consequence of not eating
+enough they were constipated and then a whole round of physical
+troubles, headache, lassitude, over-fatigue, to which they are almost
+sure to add loss or disturbance of memory, began to annoy them.
+
+In those cases it is not the physical effect of any loss of seminal
+fluid that is the disturbing factor of their health, but their worry
+over the losses. Just as soon as their minds can be taken off the
+subject, the supposed physical effects begin to disappear. So long as
+the solicitude continues the emissions themselves increase in number
+and the condition is made worse. These patients must be taught that in
+every normal healthy man in whom there is no regular occasion for the
+emptying of the seminal vesicles, nature provides for an evacuation
+about every ten days or two weeks. In some it is more frequent than
+this. In those who are much indoors and in whom oxidation processes
+are low this emptying takes place more frequently. In those who lead a
+sedentary life with the consumption of much proteid food the same
+thing seems to be true. Any anxiety about it is sure to cause frequent
+repetition of the evacuation processes. Over-solicitude about the
+bladder will have just the same effect. If the patient will take his
+mind off the subject, will eat normally, will get out in the air more
+than before, tiring himself thoroughly {478} if he is young and
+vigorous, and will not allow the sexual side of his being to be
+excited by stories or pictures, plays or voluntary thoughts, his
+affliction will soon disappear.
+
+
+_Prophylaxis_.--Certain directions are helpful and by occupying the
+patient's mind will overcome certain physical factors that underlie
+the affection. It is important that the bladder should not be allowed
+to be full, above all, not to be over-distended at night. Some care
+should be exercised in not taking too much to drink shortly before
+going to bed and the bladder should be faithfully emptied before
+retiring. The weight of a large amount of urine in the bladder
+pressing down upon the seminal vesicles situated below and behind it
+causes them to contract rather easily. This is particularly true if
+the patient sleeps on his back and occasionally in certain
+over-irritable patients for a time at least an arrangement may have to
+be made by means of small pillows that will prevent him from sleeping
+on his back. On the other hand, it must not be forgotten that too
+great abstinence from fluid will cause the urine to be more
+concentrated and this will irritate the bladder and either wake the
+patient up at night, which of itself is undesirable, or else will
+cause congestion in the prostatic region which will irritate the
+seminal vesicles to the point of evacuation. While five or six glasses
+of water a day should be taken besides the ordinary fluid taken at
+meals, the only regulation necessary is of the amount of fluid taken
+in the evening after the last meal, that is, if more than three hours
+intervene before retiring for the night.
+
+Besides the physical conditions in the bladder, an accumulation of
+fecal material in the rectum may cause irritation of the seminal
+vesicles. It is important, moreover, to remember that thoroughly free
+movements of the bowels, by preventing to a great extent the
+reabsorption of material from the intestines which may prove irritant
+when excreted through the kidneys and when present in the bladder, is
+of itself an excellent therapeutic measure in cases of irritability of
+the genital organs. The setting of the patient's mind to thinking
+about his rectum, his bowels, and his bladder instead of his genital
+tract is an excellent psychotherapeutic measure that will soon bear
+fruit.
+
+The consumption of various foods, condiments and drinks enters into
+the underlying condition which produces frequent emissions. We have
+already suggested that the use of a large amount of proteid materials,
+especially in people who live a sedentary life, often predisposes to
+this condition. An abundance of the carbohydrates, however, by
+supplying more heat than is necessary may have a like effect. Certain
+spices seem to predispose to irritability of the sexual system. Red
+pepper has always seemed to those who saw much of these cases to be
+particularly at fault. Mustard, curries, peppers generally, however,
+and even other spices seem to have a corresponding effect. As a rule,
+young folks suffering from this disturbance or from the tendency to
+eroticism in other ways should be warned about this irritation of
+spices. In neurotic individuals tea and especially coffee has the same
+effect. Probably this is only an indirect influence of tea upon the
+nerve centers, making them more irritable, but coffee, by raising the
+blood pressure, seems to have a direct unfavorable effect.
+
+All alcoholic drinks are contraindicated in these cases and must be
+forbidden. Certain of them seem to be more harmful than others.
+According to French tradition warm wine or mulled ale as it is used in
+England is {479} especially likely to excite sexuality. Warm alcoholic
+drinks of any kind are absorbed more rapidly than are cool drinks,
+which is the main reason in modern times for having these liquids
+cooled so that they will not be absorbed too rapidly and disturb the
+equilibrium. Champagne also has, by tradition, a special effect,
+sometimes said to be due to the increased hyperemia of the stomach
+induced by the carbonic acid gas and the consequent more rapid
+absorption.
+
+The prohibition of spices and alcoholic drinks has a good effect in
+itself. It acts constantly as a suggestion to the necessity for care
+and guard over one's self. Besides the exercise of self-denial
+necessary to keep away from the use of such substances, especially
+under present social conditions, is of itself a good training that
+strengthens the will against certain tendencies to indulgence in
+sexual thoughts which predispose to the frequent emptying of the
+seminal vesicles.
+
+
+_Erotic Dreams_.--Very often these nocturnal seminal emissions are
+associated with erotic dreams. Patients are inclined to attribute the
+occurrence of these dreams to some fault of their own or to consider
+that they are at least in some way responsible for them. This thought
+often becomes a source of serious worry, making their condition worse.
+A study of this question has convinced me that in most cases there is
+practically no responsibility in the matter. Pressure on the seminal
+vesicles by an over-full bladder, or a distended rectum, leads to the
+production of nervous stimuli around which the erotic dream-ideas
+gather. A straightforward explanation of this will relieve many
+patients' minds, and keep them from bothering about the subject in
+such a way as to make their genital tract even more sensitive than it
+is because of their concentration of attention on it.
+
+
+Sexual Mental Troubles.--In our generation sex occupies a great deal
+of attention. Sexual tendencies are emphasized by suggestive reading
+of all kinds and by forced attention to sex matters. Most of the
+successful novels deal with the so-called sex problem, our plays are
+to a great extent sex problem plays and our newspapers are full of sex
+crimes and sexual divagations of many kinds. This acts as a strong
+incitement to sexuality and represents exactly the opposite of what
+nature intended in the matter. As a consequence, all the tendencies to
+over-solicitude with regard to sexual affections and all that
+instability of mind and over-reaction to all forms of irritation that
+comes in the midst of sexual excitation are noted. This seriously
+disturbs the minds of many patients and makes their health as well as
+their morals worse than they should be. The neurotic conditions seen
+in those who occupy their leisure with erotic subjects are fostered by
+this unfortunate over-attention to sexual matters. For general
+prophylaxis the physician needs to throw all the weight of his
+influence toward the correction of unfortunate tendencies in our
+present-day life and healthier subjects of thought should be
+encouraged.
+
+We often hear it said in our time that the great fact of life is sex.
+Indeed, this has been insisted on _ad nauseam_ in recent years. There
+is no doubt that without the sex element the race would not continue
+under the present dispensation. If sexual feelings did not mean so
+much to the generality of men and women it is doubtful whether
+marriage would be the success that it is, though so much is said
+nowadays about its failure. The analogy with all the beings lower in
+the scale than man shows how imperative and prominent {480} in life
+this instinct is and how much it signifies. Those who insist so much,
+however, on sex as the one great fact of life seem to forget that
+there are many other natural functions of quite as much importance to
+the individual at least, if not to the race. Without eating neither
+the individual nor the race could go on. Neither would the race go on
+without eliminating waste products. If there is one thing that our
+consideration of the problems of psychotherapy has made clear it is
+that whenever any of these animal facts of life is made much of and
+occupies attention to the exclusion of higher ideas, there is sure to
+be trouble. It matters not how apparently automatic and completely
+spontaneous a function may be, if exaggerated attention is given to
+it, it is sure to be disturbed in its functions and cause serious
+troubles in the organism.
+
+There is no need further to illustrate this with regard to such
+physiological necessities as feeding and excretion. At present the
+world is much occupied with sex problems because, unfortunately, its
+attention has been focused on this subject. Physicians, particularly
+if they are paying attention to nervous patients, are likely to know
+many individuals who have food problems, diet problems, digestion
+problems, bowel problems, and many others of similar nature because
+they have been focusing their attention on these functions of their
+being.
+
+The most distinguished psychiatrist of our generation, certainly the
+man whose works have done most to open up new vistas for us in mental
+diseases and who has added not only new knowledge but new
+possibilities of development, visited this country not long since and
+said, "Oh! here in America you are sex mad." He added, "I knew that we
+were madly following sex problems in Europe, but I thought that in
+this country, with so many other things to occupy the minds of men and
+women, you were not bothered so much with sex problems." What he said
+represents the impression of nearly every thoughtful foreigner who is
+surprised to find that wealth and luxury have brought to us this same
+degenerate interest in things sexual that occupies the so-called upper
+classes and their imitators in Europe.
+
+Livy, the Roman historian, said long ago, "Whenever women become
+ashamed of the things they should not be ashamed of, it will not be
+long before they will begin not to be ashamed of the things they
+should be ashamed of." Whenever in history men and women have occupied
+themselves, not with the rearing of families, but with the suppression
+of families to as great an extent as possible, sex problems have
+always become emphasized. The woman who is a mother, and especially
+many times a mother, usually has no trouble at all about sex problems
+and no tendency to have "affinities." With her there is usually no
+question of sex as the central factor of life nor of any other of the
+curious nonsense that has been talked about this matter as the result
+of giving sex a place of importance that it does not deserve. Until
+there is a reform in this matter we can look for many "neurotic,
+erotic and tommy-rotic" tendencies, as they have been called, due to
+over-attention to one set of organs. Any organic system in the body
+would be disturbed by such attention, but the sexual system is
+particularly susceptible to suggestion.
+
+The state of affairs thus emphasized is the result of interfering with
+an animal instinct. It will make itself felt properly and secure the
+due exercises of function if allowed to pursue the even tenor of its
+way under reasonable {481} control, but if it is fostered, thought
+about, discussed, excited in various ways, pampered by indulgence and
+perversion, it runs away with nature. The gourmet who constantly
+thinks about food, plans new modes of exciting the appetite, studies
+savors and odors in order to satisfy a palate that has been
+artificially stimulated, gets a certain animal enjoyment out of his
+food that other people do not; but he usually overeats, loses his
+appetite, and with it any real satisfaction in eating, and suffers
+from indigestion as a consequence of indulgence, so that the suffering
+much more than compensates for any slight additional pleasure that he
+has enjoyed. Besides, man is an essentially intellectual being, and
+occupation with the things of sense, that will manage themselves very
+well if let alone, takes up just so much of the precious time that
+should be devoted to other things to attain that satisfaction that
+makes life well worth living. Sexuality cultivated with the degree of
+attention that certain people devote to feeding, becomes a pest, ruins
+intellectual effort, hurts initiative, leads to the most serious
+disappointments in life and is the most fruitful cause of despondency
+and suicide that we have besides being the origin of many social evils
+that still further complicate life.
+
+One great modern nation has debauched its literature to such an extent
+that probably the major portion of its books treat of sex and sex
+problems. Practically all of its esthetic expression has been
+seriously hurt by the same fault. Its painting, its sculpture, its
+dramatics, its art of all kinds, have all gone the same road. The
+result is seen in the lowered moral fiber of its people. A recent
+census report showed that the nation has reduced some 20,000 in
+numbers and that this was only the beginning of the race suicide. They
+have been thinking, talking, writing, painting, chiseling, acting sex
+problems, but in the only phase of life in which sex really counts it
+has been so pushed into the background or perverted that there it is
+failing utterly to accomplish its one legitimate purpose. The younger
+generation as they grow up are given the idea that they are missing
+the most wonderful thing in life unless they have memorable sex
+experiences. These experiences must be varied in order to satisfy the
+artificial appetite that has been created. As a consequence, family
+life and the real meaning of love and the affection of man for woman
+rooted in the depths of their nature is spoiled by mere animal passion
+and its passing expression.
+
+Nature's own attitude with regard to over-attention to sex matters
+must not be forgotten. The purely sexual organs have been pushed into
+the background to as great an extent as possible and are intimately
+associated in both sexes with one of the two ugly excretory functions,
+urination, and placed in close relationship with the structures which
+subtend the other--defecation. Evidently nature intended that they
+should be the subject of as little attention as possible.
+Unfortunately, the paying of attention to them to any great extent
+lessens somewhat of the disgust naturally aroused by the excretory
+functions with which they are associated. Nature has provided as far
+as possible for deterrence from over-interest. One might expect that
+cleanliness and the cultivation of the feelings of refinement would
+serve as auxiliaries in the repression of sex indulgence. The lessons
+of history are that usually the great bathing nations have been most
+sexually divagant. Among the Greeks and the Romans the ugliest sex
+habits and proclivities found a place--among peoples who devoted
+themselves to the cleanliness of the body. The classes {482} who bathe
+most are often those with the strongest tendency to sexuality.
+Refinement instead of lessening the tendency to sexual indulgence
+rather increases it.
+
+Education and the development of intellectuality, far from being a
+barrier to sexual divagations, seem to predispose to the exaggeration
+of the significance of sex in life, unless the individual has a
+well-balanced character or has been thoroughly grounded in ethical
+principles. The ugly stories of Greek love at a time when the Greeks
+were at the climax of culture, as well as what we know about the
+relations of the freedmen to their masters among the Romans during the
+classical period, is all confirmed by the revelations of corresponding
+tendencies in recent generations among the intellectual classes even
+at the universities. Development of mind apparently does not
+neutralize to any extent these sexual tendencies. Evidently the rule
+of life for health's sake must be to push sexuality as much into the
+background of the mind as nature has put the sex organs in the human
+body. Reason does not protect knowledge but increases suggestion. Only
+absorbing occupation of mind with other subjects that will bring about
+neglect of these functions, as of all other physiological functions,
+leaving them to nature, serves to keep them in their proper place and
+condition.
+
+
+
+CHAPTER III
+
+SEXUAL HABITS
+
+
+As was emphasized in the preceding chapter, sexual symptoms are
+usually the subject of so much worry and disturbance of mind and
+become the center of so much unfavorable suggestion, that the only way
+to ameliorate the conditions which develop is by securing relaxation
+of the attention and diversion of mind. Mental influence is much more
+important than any other remedies that we have at our command in these
+cases, not only for their relief but for their ultimate cure.
+
+A state of depression of mind similar to that which develops in
+patients frightened by seminal emissions is often seen in those who
+have for some time indulged in the habit of self-abuse. Rather
+frequently a physician, especially if he is known to be interested in
+nervous diseases, has to listen to the story of a patient who is sure
+that his health is completely undermined and that his future is the
+darkest possible, because of this habit in younger days. Usually the
+patient is a young man who has been reading some of the literature of
+the advertising "specialists" who distribute reading matter which
+pictures appalling and almost irretrievable effects from such sexual
+habits. The consequence is that the patient is in highly nervous
+condition, has lost his appetite, is not sleeping well, is avoiding
+society, because he fears that some one may recognize his condition
+and its cause, and he is really in a pitiable state. Such patients are
+usually sure that little can be done for them. Sometimes they have
+already been through the hands of several "specialists," particularly
+of the mail-order variety, and the literature provided for them and
+the letters written to them have all helped to make them worse and
+much more solicitous about themselves.
+
+{483}
+
+Unfortunately some of the exaggerated notions with regard to the
+effect of these habits that are so widely diffused by the exploiters
+of the young have been adopted by moralists with the idea that they
+can thus deter youth from certain practices and scare the victims of
+such habits out of them. It is extremely doubtful, however, whether
+self abuse of itself, unless practiced in very early years or indulged
+in to a degree that is possible only in those of unbalanced mind, ever
+works anything like the serious harm that is claimed. Certainly
+physicians who are most familiar with its results are not ready to
+confirm the opinions usually advanced as to the awful harmfulness of
+the practice. Personally, I have had a number of patients confess to
+me that they had indulged in the habit to some extent for twenty years
+and longer and yet had never suffered anything more than passing
+physical discomfort. It is unfortunate, then, that the exaggerations
+of the quack should by receiving the approval of the well-intentioned
+moralists, be emphasized so as to add to the neurotic disturbance of
+mind which makes these patients so miserable and for a time may
+seriously interfere with their health. Occasionally even suicides are
+reported in which the underlying motive seems to have been the dread
+on the part of a young man that a sexual habit has so undermined his
+health that cure is impossible and that physical and mental
+deterioration to a marked degree is inevitable. The opinions of
+conservative physicians tend to show that there is no good reason for
+thinking that in normal healthy persons such habits ever have the
+serious effects thus set forth.
+
+Patients can be assured that whatever evil effects follow the practice
+will not remain after it has been given up. There are no serious
+enduring sequelae, with one or two exceptions in very special cases,
+that perhaps should be noticed. Most men of considerable experience in
+the matter are now decidedly of the opinion that self-abuse does not
+produce any more serious consequences than the same amount of ordinary
+sexual intercourse. It is possible for sexual intercourse indulged in
+excessively, as it sometimes is in early marital life, to produce the
+same feelings of exhaustion, lack of control over the vasomotor system
+and disturbance of the gastro-intestinal tract which are noted in
+self-abuse. In both cases the symptoms promptly disappear upon proper
+regulation of life. This is a very different opinion from that which
+used to be expressed in this matter and it is given only after due
+deliberation and consultation of many authorities both in writing and
+orally. Its expression, far from taking away one of the best deterrent
+motives against the practice, rather forces an appeal to the manliness
+of the individual. The motive of fear never accomplishes much, while a
+frank statement of the real condition may be greatly helpful.
+
+While the habit of self-abuse as indulged in by the ordinary
+individual practically never has the awful consequences that have been
+sometimes pictured as resulting from it even long after its cessation,
+there is no doubt that it is productive of many physical symptoms
+during the time of its indulgence. There is almost sure to be a
+discouraging lassitude and a tendency to exhaustion after even
+comparatively small efforts. While this is true for ordinary muscular
+efforts it is also true for other bodily functions that involve
+muscular activity. In recent years we have learned that of the stomach
+functions the motor is more important than the chemical. In the bowels
+the motor function is extremely important. There are likely to be
+disturbances, then, in the gastro-intestinal tract as a consequence of
+the muscular condition that {484} develops in those patients. Probably
+more important even than the physical, however, are the psychic
+results of the habit. The patient feels discouraged and cast down at
+his inability to conquer himself and is likely to avoid such exercise
+and diversion of mind as would make normal healthy function possible.
+
+
+Mental Disturbances.--It is the custom to say that mental
+deterioration almost surely follows the habit. Those familiar with
+mental cases often see self-abuse practiced with serious results by
+young folks whose mentality is deteriorated. In these cases the
+practice was indulged in with great frequency and with direct physical
+consequences, such as loss of sleep, of appetite and the like. It is
+not the habit, however, that has caused the mental deterioration. The
+young patients are going crazy, but not because of self-abuse. Their
+habit of self-abuse had originated and become exaggerated because they
+were already mentally unbalanced. Their extreme indulgence in it is
+especially due to their lack of control over themselves, because they
+are not possessed of strong will power with regard to any thing. A
+vicious circle is formed and the insane young man gradually deepens
+his insanity by hurting his physical condition through over-indulgence
+in the habit and all this further lessens his self-control; but were
+it not for the original mental weakness the habit would not have been
+indulged in to so great an extent.
+
+
+Effect on Prostate.--There is one phase of the ill effects of
+self-abuse that it is well to recall as having the confirmation of men
+of large experience and conservative views. There is a definite
+impression among specialists in genito-urinary diseases that
+enlargement of the prostate in some cases is due to the frequently
+repeated irritation and the prolongation of that irritation of the
+prostate during the practice of self-abuse. When such men as Bangs and
+Keyes are agreed on a subject of this kind, then even though in a
+certain number of cases the changes in the prostate leading to its
+enlargement are evidently inflammatory, it is well to consider that
+the functional over-activity of the gland superinduced by the practice
+may lead at least to an enlargement of the glandular elements with the
+consequent interference with urination which so frequently comes in
+old age.
+
+
+Physical Factors.--Besides mental elements that predispose to the
+formation of sexual habits there are physical factors that are
+important in these cases. They must be particularly looked for and
+treated carefully if found, or there can be little hope of relief for
+the conditions. The most prominent of these is the existence of a long
+foreskin, especially if its opening is small, thus leading to the
+retention of urine, the deposition of urinary salts with the formation
+of preputial concretions or so-called calculi. These are intensely
+irritant, cause frequent itching and thus predispose to these sexual
+habits. Even where the preputial opening is free and allows egress of
+urine without residue, the accumulation of smegma often causes
+considerable irritation and if the most scrupulous cleanliness with
+cleansing at least once a day is not maintained, irritative conditions
+arise, especially in hot weather, that may give occasions for sex
+habits.
+
+Under these conditions the habit is sometimes seen in extremely early
+years. The youngest case I ever saw occurred in a child not quite
+nineteen months old whose mother said that for several months she had
+noticed certain curious actions that she could scarcely understand
+until finally the truth dawned on her. Then she was morbidly sensitive
+about it, sure that the habit was due {485} to a fault of her own and
+it was some time before she consulted a physician. This was her fourth
+child and, strange as it may seem, it was only at the conception of
+this child that she first knew what sexual pleasure was. She feared
+that her feeling had been in some way sinful and that as a consequence
+of her sin this curious habit had developed in such early years in her
+baby boy. As is usually the case in these instances, I found that the
+prepuce was very tight indeed, having scarcely more than a pinhole
+opening in it. During urination this ballooned and there remained in
+the pouch-like process at the end of the penis a certain amount of
+residual urine after every urination. From this urinary salts had been
+precipitated and had formed scaly concretions which remained in the
+preputial pouch and were extremely irritant. As a consequence of this
+irritation the baby had been very itchy and it was in the endeavor to
+relieve the itching by the natural process of scratching that the
+pleasure of the sensations aroused had been discovered and the sexual
+habit had been formed.
+
+Not infrequently in young men a condition resembling this to some
+degree at least is found and then, of course, the question of its
+removal must be taken up at once. It is surprising how often in youths
+in their late teens concretions are seen. The constant irritation
+makes it practically impossible for the patient to keep his hands from
+the parts, and so circumcision is absolutely necessary. Not
+infrequently when the preputial condition is not nearly so bad this
+operation may also be at least advisable if not necessary. The matter
+of cleanliness must be attended to, preferably after getting up in the
+morning and not before going to bed at night, for the reaction after
+cold water may cause congestion of the organ. After a time the
+frequent use of cold water seems to make the parts much less reactive
+to irritation of any kind.
+
+
+Physical Effects.--The super-excitation of nerves consequent upon the
+more or less general erethism that is induced, lessens resistive
+vitality. Victims of the habit are more liable to colds, to various
+infectious diseases, and are subject to fatigue and lassitude, with
+incapacity to work to their full power. They lose control over their
+vasomotor system to some extent as a result of this systemic erethism.
+They blush easily, they perspire easily, there is a tendency in many
+of them to flash as if of heat and cold, they become pale under
+excitement or anger more than formerly, they are likely to suffer from
+cold hands and feet, and the surface of the body is inclined to be
+cold and as a consequence patients are tremulous. This represents a
+waste of nervous energy and as a consequence sleep may be disturbed
+and digestion interfered with.
+
+It is important, therefore, to consider these cases as really needing
+medical care. For their treatment the most important consideration is
+prophylaxis, not alone of the habit itself, but of each of the acts.
+Prophylaxis of the habit is an ethical question that we can scarcely
+do justice to here. Prophylaxis of the acts requires consideration of
+the physical and moral factors that predispose to their commission.
+While the habit may have secured such deep control that the patient
+almost despairs of relief from it, when care is taken to remove
+physical and moral predispositions the conquest of the habit becomes
+comparatively easy. Over and over again I have seen cases that have
+lasted for years in which the patients were surprised at the ease with
+which they were able {486} to drop the habit just as soon as they took
+the measures necessary to prevent predisposing conditions.
+
+
+Breaking the Habit.--Once physical factors predisposing to it are
+removed, the habit is not so hard to break as it would seem to be from
+the suggestions to that effect made in sensational literature. It is
+neither so deleterious in its physical effects nor so deteriorating as
+regards character as is usually stated. Anyone with a reasonable
+amount of firmness can break it off if he really resolves to. Over and
+over again I have seen patients quite surprised at the ease with which
+they were able to avoid the practice for weeks once they made up their
+minds in the matter. Indeed this is one of the unfortunate features in
+completely conquering the habit. It is comparatively so easy to break
+it off when the mind is made up that there comes the feeling that now
+it must be absolutely facile to keep away from it. This is, however,
+never true. Relapses are extremely easy. If the patient allows himself
+to read vicious books, or suggestive literature of any kind, or
+permits himself an indulgence in the reading of several columns of the
+account of a sex murder trial, or goes to see a sex problem play with
+its suggestions, or exposes himself to sexually exciting conditions of
+any kind, he will be almost sure to lapse into the old habit.
+
+Relapses are almost inevitable. But it is easier to break the habit
+the second time than it was the first and it becomes increasingly easy
+if the patient keeps up the effort of regulating his life so as to
+avoid the occasions of the habit. Relapses are quite as sure to occur
+as with regard to alcoholism if occasions for the taking of liquor are
+not sedulously avoided. The patient always seems to need a
+confidant--someone to whom he can go for help and who assures him of
+the ability that he has to overcome himself if he only will. The
+practice of confession in the Roman Catholic Church makes it
+comparatively easy for serious people of that faith to overcome the
+habit. The physician must be taken into confidence in the same way and
+for a time, at least once a week, the patient may have to be perfectly
+frank with regard to his condition in order to have the help afforded
+by such confidences. The physician can often, particularly at the
+beginning, make the physical conditions such as to help in the
+breaking of the habit. Bromides taken to the extent of a dram or more
+a day are almost a specific for superirritability of the nervous
+system, and if taken for two or three weeks the patient will usually
+have little or no difficulty in overcoming the habit. They are not of
+much avail after this time unless the patient's character has been
+aroused to determined helpfulness in the matter.
+
+In obstinate cases it may be necessary to have a patient come every
+day, or at least every second day, for some time and give an account
+of how he has succeeded in resisting his habit in the interval. At
+least he must be asked to report whenever there is a lapse. It is
+surprising how much the anticipation of having to tell someone else of
+a drop back into the habit means in helping the patient eventually to
+overcome it. Very slight motives serve to cause relapses, but almost
+any external personal aid, if pursued with confidence, will avail
+effectually to break it. I talk from an experience of many cases and
+know how much can be accomplished even though patients insist that
+they have tried all the resources of their will power and of prayer
+without avail. They have really not tried, they have not willed in
+reality; sometimes they {487} have reached a point where they cannot
+will without the moral support of another personality. This can be
+readily supplied to them by a firm, sympathetic physician whom they
+respect. It will take time to overcome the tendency to relapse
+whenever the will is relapsed, but the habit itself can be broken
+without much difficulty in a few days.
+
+Certain times are particularly dangerous for relapses into the habit.
+These are just before going to sleep at night and before getting out
+of bed in the morning. At these times the mind must be occupied or
+else the patient will almost surely find his habit recurring. Often
+the habit of reading in bed, properly supported by pillows and with
+abundant light at an angle that makes reading easy, seems to be good
+for these patients, because they may read until their eyelids get
+heavy, then pull the chain of their light to extinguish it and turn
+over to sleep. In the morning prompt rising after waking is important.
+Bed clothes that are too heavy and too great warmth of clothing
+predispose to sexual excitation and must be avoided. The room should
+be cool rather than warm and the mattress rather hard.
+
+The more tired the patient is the less liability will there be to
+difficulty in these matters. But air is even more important than
+exercise in giving the tiredness which superinduces deep sleep. A
+lessening of the normal amount of oxygen seems to relax the inhibitory
+power of the higher centers over the sexual centers in the cord.
+People who are drowned, those who are hanged, and those whose supply
+of oxygen is shut off by the inhalation of the heavier gases are
+likely to have involuntary seminal emissions. These are probably
+consequent upon the shutting off of the air.
+
+The important element in the treatment is to make the patient feel
+that, if he really wants to, he can conquer in this matter. The old
+motives of fear, and especially fear of physical consequences, were
+quite unworthy, and inasmuch as they had any effect rather produced a
+deterioration of character than a strengthening of it. The patient
+must understand that if he is a man he can overcome it. Religious
+motives will help much. I do not know that I have ever seen a case
+where religious motives were not the most important element in the
+cure, but that may be due to the conditions in which I have been
+placed. I have seen a number of these cases in men and women because
+clergymen have sent them to me in order that they might be helped in
+the work of reform, and while there are many relapses and some had
+apparently given up the effort in despair of their power to overcome
+themselves, nine out of every ten of those who have seriously faced
+the problem have succeeded in overcoming themselves, and as a result
+have a better knowledge of their own characters and more respect for
+themselves. They are better men in every way than if their improvement
+had come about through selfish fear of physical consequences.
+
+
+After Cure.--After the habit of self-abuse has been conquered the
+seminal vesicles will have a tendency to evacuate themselves rather
+more frequently than before and as a consequence they will nag at
+certain sexual nerve endings. They are used to having their contents
+emptied and distention is followed by rather ready evacuation. During
+the course of this evacuation sexual thoughts are awakened in dreams
+and this may lead to dream states in which there seem to be lapses
+into the old habit. This constitutes a serious difficulty in getting
+rid of the habit entirely in young and vigorous men. They may even
+become disheartened by it. It should be explained to them that they
+must let {488} contrary habits form gradually and permit nature to
+accommodate herself to the new state of affairs. The bromides are a
+useful adjunct for body and mind.
+
+
+_Supposed After-effects_.--At times a patient suffering from some
+exhausting or serious disease, consumption, heart disease or the
+various forms of Bright's disease, will be discouraged by remembrance
+of the fact that in earlier years he allowed himself for some time to
+fall into the habit of self-abuse. If he has read, and very few men
+have not, some of the literature issued by the advertising
+"specialists" and has heard the unfortunately exaggerated ideas
+commonly entertained with regard to the influence on health of this
+habit, he will become more or less disheartened by the idea that he
+thus undermined his constitution and that one reason why he is not
+able to react better against his affection is that he seriously
+diminished his resistive vitality. This idea must, of course, be
+overcome or it will act as a constant source of unfavorable
+suggestion, lessening appetite, tending to disturb sleep, banishing
+peace of mind to some extent and thus inhibiting the patient from
+releasing such stores of vital energy for his recovery as would surely
+be in his power under favorable conditions.
+
+
+Female Habits.--The habit is more rare in women than in men, but when
+it occurs is a little harder to break. In men it usually develops in
+youth, but oftenest in women who are past thirty-five and unmarried.
+In these cases it is much harder for the patient to regain
+self-control, because the class of women patients who acquire such a
+habit have less character, as a rule, than the men who fall into the
+same condition. In all sex matters, once passion is aroused or habit
+formed, the woman is likely to lose control of herself more than is
+the man. Even in women, however, it is not only possible, but under
+favorable circumstances, quite easy to secure a break in the habit,
+though relapses are more frequent than in men. Certain occupations
+seem particularly to favor the development of the habit. These are
+mainly sedentary occupations that can be followed without the
+necessity for such attention as to prevent the mind from wandering off
+into thoughts that may prove provocative of sexual sensation.
+Dressmakers seem particularly likely to suffer from the affection, and
+those who run sewing-machines are predisposed by the movements
+involved in their occupation to the development or, at least, to the
+persistence of the habit.
+
+For women even more than men religion and the motives it supplies are
+the most efficient factors for the ultimate cure of the habit. In
+general, the greater difficulty of overcoming it in them is due in no
+small degree to the fact that they live indoors much more than men,
+often have sedentary occupations, and are more frequently alone. These
+afford opportunities for introspection and for the harboring of
+thoughts that lead to relapses into the habit. Besides, women are more
+prone to read novels and stories relating to sex problems and the
+details of sex murder trials and the like which constitute
+ever-recurring sources of mental erethism. If their habits can be
+modified, especially if they can be made to realize the necessity for
+being out in the air as much as possible, and for keeping their
+windows open at night, as well as for thorough cleanliness--for every
+gynecologist notes the necessity for this and how frequently it
+happens that neglect of it leads to irritability of the external
+organs that is of itself a serious factor--then it would be no more
+difficult for women to overcome the habit and get beyond the relapses
+than it is for men. {489} Sometimes we have to overcome a morbid dread
+of touching themselves even for cleansing purposes which allows the
+accumulation of irritant material and predisposes to relapse.
+
+
+Sexual Perversion.--Sexual perversions are sometimes considered as
+different from sexual neuroses, but such they really are. They are
+oftener due to habit than to anything deeper. Much has been said about
+the unfortunate natural inclination of some people to indulge in
+sexual perversion, but such talk partakes of the nature of similar
+remarks with regard to habits of other kinds. The alcohol habit, for
+instance, is formed by many men as the result of their environment and
+a weakness of character, with lack of resolution to support themselves
+in self-denial when they are tempted to drink. In recent years it has
+been only too often the custom to excuse or to justify many of these
+cases. There are a few persons in whom, owing to weakness of
+character, alcoholism is more or less inevitable if occasions for
+indulgence occur. And in the same way there has been much maudlin
+sentimentality wasted on sexual perverts, as if most of these men
+could not avoid the actions that the rest of humanity abominates.
+There are, perhaps, a few individuals who because of a failure on the
+part of nature to define sex in them properly--as if she had not quite
+made up her mind which sex they should belong to--are more to be
+pitied than held to account for their delinquencies in this matter.
+Compared to the whole number of sexual perverts, however, these are
+very few. Under the protection of the pity awakened for these, a large
+number of others find quasi-justification for their acts.
+
+Anyone who knows much about these patients realizes that their story
+is, as a rule, very different from what it would be if they were
+inevitably impelled to the commission of the acts in question. Many of
+them had the greatest abhorrence for it at the beginning, were
+attracted to it out of curiosity and morbid sexualism, because they
+had allowed themselves to think and read and dream about sex matters
+overmuch. They are usually idle people who do not take life seriously
+and who have an inordinate curiosity about sex subjects. At the
+beginning the commission of the perverted sexual act was associated
+with an intensely deterrent rather than an attractive feeling, but
+gradually this was overcome and a contrary habit has been formed. It
+is difficult to break this habit and to get away from the morbid
+sexual ideas that have been allowed to develop and grow strong in
+connection with it.
+
+This opinion is somewhat different from that held by many men who are
+recognized as authorities on this subject and who find many excuses in
+the nature of their patients for these perversions. If it is recalled,
+however, that whenever wealth has brought luxury to a people and
+luxury has brought over-refinement, such sex perversions have been
+particularly noted, it will be realized that not nature, but the ways
+of men are responsible for their development. Whenever men pay much
+attention to their bodies, exercise for the sake of their muscles,
+bathe not for cleanliness but for luxury, sex perversions become
+common in history. The story of Greek love is well known.
+Corresponding conditions developed at Rome under similar
+circumstances. According to good authorities, the English universities
+became tainted with it a generation ago. Our athletic clubs in this
+country have rightly or wrongly fallen under suspicion in this matter,
+though the tendency to exaggeration with regard to such things, and
+popular credulity in such matters must be recalled. {490} Some
+confirmatory evidence undoubtedly there was. Sexual perversions then
+would seem to be due in most cases to definite conditions and our
+knowledge suggests readily what should be the prophylaxis.
+
+In the course of some studies with Professor Magnan at L'Asile Ste
+Anne in Paris I saw a number of these curious cases of sexual
+divagations, exhibitionism, sex perversions and similar conditions.
+Some of his cases were clearly curious examples of natural tendency,
+at least, to mental hermaphroditism. Occasionally men of normal
+development otherwise have a woman's waist and woman's torso above the
+waist, and many womanly coquettish ways that point to this curious
+mixture of sexes. Occasionally women are lacking in all the sex
+characteristics of the upper portion of the body, have no breasts and
+have the hirsute characteristics of men on the face and even on the
+chest. In such cases one may be tempted to let one's pity override
+one's better judgment and feel that resistance to the temptations to
+indulge in perverted sexual feelings may be so difficult for these
+people as to be almost impossible. Even in such cases, however, under
+Magnan's gentle tutelage, under his faithful care and sympathy, men
+and women lost most of the tendency to commit unnatural acts and
+certainly found it easier to live normal lives than before.
+
+For the majority of these sexual perverts, however, it is as with
+regard to drug addictions, alcoholism, and obesity, just a question of
+willing not to indulge in certain appetites that serves to help them.
+There is no doubt that it is a difficult matter to break a habit that
+has become a second nature, and it is almost impossible that it should
+be accomplished without a number of relapses. If the patient really
+wishes to correct the evil habit, however, this is perfectly possible.
+
+The talk of a third sex with homo-sexual inclinations is quite beside
+the mark. Certain of this class have a weakness of intellect and of
+will that is at the root of their trouble, but not a few of them pride
+themselves on their intellect and will power in most other things and
+must not be permitted to deceive themselves as to their weakness and
+its significance. It is not nature but self that is at fault and the
+disease can be completely eradicated.
+
+
+{491}
+
+SECTION XIII
+
+_SKIN DISEASES_
+
+
+
+CHAPTER I
+
+PSYCHOTHERAPY IN SKIN DISEASES
+
+
+The place of mental influence in the treatment of skin diseases will
+be best realized from the role that we know the mind plays in the
+production of various skin manifestations. There is a whole series of
+skin affections which depend to a considerable extent on mental
+conditions, worries, anxieties, shocks, frights and the like, and a
+number of skin affections that have been labeled hysterical which
+occur in nervous persons, due to over-attention to self and their
+conditions. It has been well said that it is possible to make the feet
+warm by thinking about them. Certainly attention to any part of the
+skin surface causes a tingling and hyperemia may follow. Blushing is
+an illustration of mental influence on the skin, and anything that
+would tend to make this endure for some time would give rise to
+erythematous conditions. We know the creepy, uncomfortable, hot
+feelings that come over us in times of suppressed excitement when we
+are waiting for something to happen; and, on the other hand, there is
+a pallor and tremor that accompanies fright or fear, which points to
+mental influences over the vasomotor system in the skin.
+
+
+Urticarias.--Certain skin diseases, especially those allied to the
+urticaria group, are prone to occur in connection with excitement and
+worry. In the chapter on Neurotic Intestinal Affections attention is
+called to the fact that many patients who suffer from intestinal
+idiosyncrasies and have excessive reactions to special kinds of food,
+as cheese, strawberries, or the like, sometimes also suffer from skin
+lesions and intestinal disturbance through worry or excitement. While
+preparing for examinations or undergoing some physical trial or
+suffering from worry or anxiety such persons may have urticaria or
+even wheals on the skin. There may be some dietary disturbance to
+account for them, but they would not occur, or at least would not be
+so serious and annoying, but for the disturbed mental condition. Under
+these circumstances dermatographia is a common manifestation. It used
+to be considered a symptom of many physical conditions, but will occur
+in almost any nervous person during the course of an examination by a
+strange physician or when some important medical decision is pending.
+
+
+Eczema.--Not only these passing conditions of the skin, however, but
+more lasting affections have been connected with mental disturbance.
+Probably every skin specialist has noted in a number of his cases that
+a first attack of eczema came after a period of worry or excitement,
+or sometimes followed directly on a fright. When relief from the
+condition has been brought about {492} by treatment, relapses occur
+during periods of business worry or family anxiety or mental stresses
+of one kind or another. Cabinet crises in England are found to be
+likely to be followed by the recurrence of eczematous conditions in
+older members of the Cabinet or by first attacks in some of those
+whose skin has been irritated by some internal condition. Unless
+business worries can be removed or family anxieties allayed the cure
+of eczema becomes a difficult matter. Men or women who worry about
+their eczematous condition apparently prolong it. This is particularly
+true if they have little to do and are likely to be much occupied with
+themselves and their condition.
+
+
+Herpes.--Herpetic conditions resemble urticaria in their response to
+mental conditions. Herpes preputialis and herpes progenitalis occur
+particularly in people who worry over the possibility of some
+infection of the genitals. The lesions are likely to be indolent until
+the state of mind with regard to them is relieved by reassurance as to
+their comparatively innocuous character. Even herpes zoster is prone
+to come on after a period of worry and anxiety. It is due to
+infection, but the infection becomes more possible after a lowering of
+resistive vitality in the nervous system. This is particularly true as
+regards herpes facialis. It has been noted again and again that facial
+neuralgia is most likely to occur after fright, deep emotion, or
+prolonged anxiety. Treatment of these cases will only be successful if
+the mental state is set right. This is particularly true with regard
+to Bell's palsy. Patients who worry much about it and who fear that it
+may have lasting results are likely to prolong its course and to put
+off complete cure for a good while.
+
+
+Vasomotor Disturbance.--There is a series of skin affections connected
+directly with the vasomotor system of the skin which are largely under
+the influence of emotional or mental factors. These represent
+particularly the milder forms of Raynaud's disease and the parallel
+forms of Weir Mitchell's disease. In the one case there is a spasm of
+the arterioles causing what the French call "dead fingers," and in the
+other paralysis of the vasomotor system with venous congestion in the
+parts. They are seen particularly in persons of highly nervous
+organization and especially after periods of emotional strain or
+stress. There is a series of affections related to these,
+characterized by numbness, paresthesiae, going to sleep of the fingers
+or members, tingling, and even milder forms of itchiness--sometimes
+dignified as pruritus--which are largely due to mental factors. Some
+physical condition will need to be corrected, but they will only
+disappear if the mind is set at rest and if the patient is kept from
+occupying his attention much with them. Concentration of attention
+will make them chronic.
+
+
+Scurvy.--Scurvy is not usually thought of as a skin disease, though it
+has many local manifestations on the skin and mucous membrane. It is a
+deep nutritional disturbance of such nature that it would seem the
+mind could have but little influence over it. When scurvy was common,
+however, it was often noticed that any change of attitude of mind in
+affected persons brought amelioration or deterioration of condition.
+Scurvy develops with special virulence during discouragement; it gets
+better with the dawn of hope. It has been known to be much improved by
+the prospect of a naval engagement when all the sick men wanted to get
+into the fighting. The famous case of the Siege of Breda in 1625 is
+often quoted. The city was about to capitulate because so many of the
+soldiers were suffering from the disease. The Prince of Orange, {493}
+however, sent word that a new and powerful remedy had been discovered
+that was sure to cure the affection, and that he had secured some of
+it and it would not be long before they would all be well. What he
+sent was a remedy that had been used with indifferent success for
+scurvy when taken in large doses. He could send only enough to give a
+few drops to each patient. This small dose was wonder-working in its
+effect and proved to have the healing virtue of a gallon of the
+liquor. Most of the patients got better and surrender was put off.
+
+
+Warts.--A striking evidence of the influence of the mind upon the skin
+is given by what we know of warts. All sorts of charms have been not
+alone suggested for them but found to work in certain cases. Lord
+Bacon in his "Natural History" tells the story of the charming away of
+warts and exemplifies it by his own experience. When he was about
+sixteen a number of warts--at least 100--came out upon his hands. One
+of these had been there from childhood. The manner of their cure he
+details as follows:
+
+  The English Ambassador's lady, who was a woman far from
+  superstition, told me one day she would help me away with my warts;
+  whereupon she got a piece of lard with the skin on, and rubbed the
+  warts all over with the fat side; and amongst the rest that wart
+  which I had from my childhood. Then she nailed the piece of lard,
+  with the fat towards the sun, upon a post of her chamber window,
+  which was to the south. The success was that within five weeks'
+  space all the warts went away, and that wart which I had so long
+  endured for company. But at the rest I did not marvel, because they
+  came in a short time, and might go away in a short time again; but
+  the going away of that which had stayed so long doth yet stick with
+  me.
+
+Lucian, the Greek satirist, tells that warts were cured by magic in
+his time. Carpenter in his "Human Physiology," page 984, says: "The
+charming away of warts by spells of the most vulgar kind belonged to
+those cases which are real facts, however they may be explained." Dr.
+Hack Tuke in his "Influence of the Mind Upon the Body" says: "In
+visiting a county asylum some years ago my attention was directed to
+several of the patients who were pestered with warts and I solemnly
+charmed them away within a specified period. I had quite forgotten the
+circumstance until on revisiting the institution a few months
+afterwards I found that my practice had been followed by the desired
+effect and that I was regarded as a real benefactor." This feature of
+the method of removing warts, setting a date before which they shall
+disappear, is noted in most of the successful charms. Dr. Tuke tells
+of a case in which a gentleman on shaking hands with a young lady
+noticed that she had many warts. He asked her how many she had; she
+replied about a dozen, she thought. "Count them, will you," said the
+caller; and taking out a piece of paper he solemnly took down her
+counting, remarking: "You will not be troubled with your warts after
+next Sunday." Now it is fact that by the day named the warts had
+disappeared and did not return.
+
+
+Neurotic Pigmentation.--Pigmentation occurs very commonly as the
+result of neurotic conditions. Dr. Champneys, in his article on
+"Pigmentation of the Face and Other Parts, Especially in Women," in
+St. Bartholomew's Hospital Reports, Volume XV, has illustrated this
+very thoroughly. The pigmentations of women during the phases of
+genital life, menstruation, pregnancy, the menopause and the fact that
+eunuchs are usually fair and fat, while deep pigmentation in the white
+race is usually associated with sexual irritability, all make
+interesting studies in this subject. From comparative {494} anatomy
+and physiology the influence of the nervous system over pigmentation
+has been very well illustrated. Brücke in 1851 established the
+influence of the nerves on the color of the chameleon and of the frog,
+and there have been many confirmations of his work. Pouchet, in 1876,
+in the _Journal de l'Anatomie et de Physiologie_ proved that fish
+gained the power of changing color by practice and lost it by disuse.
+The influence in most cases, animal and human, which produces
+pigmentation is exerted by the nervous system through the vascular
+supply. The duskiness that sometimes comes with emotion, the pallor
+that accompanies strong mental disturbance, as well as the blushing
+states, show that the vasomotor system can be influenced in every
+part. Pigmentation often seems only a consequence of local continuance
+of such disturbance. Many of the feminine patients in whom even deep
+discolorations around the eyes occur in connection with menstruation
+are typical neurotic individuals. It is worry in combination with the
+physical disturbance that produces the pigmentation. There are some
+cases on record where emotional states have caused loss of pigment in
+the negro or other colored races, or in the hair, as when, in
+well-substantiated cases, people's hair has become white in a single
+night. In every case of pigmentary disturbance, then, the individual
+must be carefully studied and as far as possible all emotional
+disturbance must be eliminated. Without this other treatment usually
+fails.
+
+
+Pruritus.--Pruritus in the old is often a bothersome symptom. All
+sorts of remedies, internal and external, are recommended for it and
+successes are reported with them. Whenever there are many remedies for
+a symptom complex, it usually means that the suggestive element in all
+of them is large. For pruritus the influence of the patient's mind is
+extremely important. Often it will be found that these old patients
+are getting out scarcely at all, but are living in close confinement
+in their rooms, the air of which is scarcely ever changed. I have
+known even the keyholes to be stuffed and arrangements made by which
+the cracks between the door and the frame were rendered impervious to
+air. In these cases the most important feature of any treatment is to
+secure a proper amount of air. Sir Henry Thompson, the great English
+surgeon, in his advice how to grow old successfully, written when he
+himself was over 80, suggested that the cells of the skin needed an
+air bath every day. He advised that men should make all their toilet
+arrangements for the day without any garments on. Washing, the
+preparation of clothing, shaving, and whatever else was done in the
+early morning was to be accomplished after the night clothes were
+taken off and before other clothes were put on. He lived to be well
+above eighty and was sure that this practice had been of help to him.
+Stimulating rubbings, if done gently and without the production of too
+much reaction, will always benefit these people.
+
+If old people have no interest, nothing that attracts their attention,
+and if they once develop pruritus their mind gets concentrated on
+their cutaneous sensations and it will be impossible to relieve them
+by any treatment until their minds get occupied with something else.
+Anyone who wants to sit in a chair for a few minutes and think about
+his cutaneous sensations will soon realize how vividly these can be
+brought to mind and how annoying they can become. To sit and think of
+a portion of the body is to want to scratch it before long. Scratching
+produces a flow of blood to the surface that adds to the itchy
+feeling. The only way to get away from it is to get the mind {495}
+occupied with something else. Of course, where circulation is weak
+because of failing heart or disturbed because of arteriosclerosis,
+treatment directed to these conditions should be employed, but the
+influence of the mind on blushing and skin feeling must not be
+forgotten.
+
+When pruritus develops in the old in connection with phases of
+arterial degeneration--its most intractable form--it is important to
+remember that diversion of mind is the most important therapeutic
+agent that we have. The old have few diversions. They have given up
+their ordinary occupations, they are often no longer interested in
+reading, friends whom they used to know have died, and they are left a
+great deal to themselves. Under these circumstances anything the
+matter with them brings about a concentration of attention. This is
+even more true if they have been very well in earlier life and have
+had practically no experience with sickness.
+
+
+Hysterical Cutaneous Conditions.--There are certain cracks of the skin
+with ulcerative lesions which occur in hysterical patients in the
+neighborhood of the knuckles that represent a phase of unfavorable
+influence of the mind. When these patients begin to worry or be
+anxious they know that these skin lesions will follow. Expectancy
+seems to make it certain that the lesions will come and attention adds
+to their chronicity. It has been noted that "chapped hands,"
+especially when accompanied by deep cracks in cold weather, are made
+worse by anxiety or worry. In many neurotic patients it is impossible
+to treat such conditions satisfactorily unless the patient's mind can
+be put at ease. It is surprising how intractable these conditions can
+be, but that is usually because all the physician's attention is
+devoted to the skin instead of a considerable portion of it being
+given also to the patient's mental and nervous condition.
+
+
+Artefact Skin Lesions.--Of course artefact skin lesions produced by
+the application of carbolic acid or nitric acid or ammonia or some
+other chemical irritant, or by rubbing with pumice stone, or with the
+thumb as schoolboys make what in my schooldays were called "fox
+bites," are skin lesions connected with a special state of mind and so
+deserve a mention here. The physician finds them under the most
+unexpected circumstances at times and in patients apparently above all
+suspicion of their self-infliction. They can only be prevented by
+changing the patient's state of mind, though this is scarcely what is
+ordinarily thought of in psychotherapy. Where skin lesions are
+atypical it is well to bear in mind the possibility of this curious
+condition.
+
+
+The Mind in Dermatotherapy.--I have had old dermatologists assure me
+that they felt that the mind influenced materially the course of many
+forms of skin disease. Younger dermatologists are prone to be
+localists; as they get older the treatment of the patient's general
+condition is felt to be more important; after twenty years of
+experience they realize the place of psychotherapy in the treatment of
+their cases. What is said here is only meant to be suggestive, but
+certainly sufficient data are supplied to make it quite sure that the
+mind greatly influences skin conditions and must always be treated if
+success, especially in chronic cases, is to be secured. I have seen
+confidence in a particular physician or remedy do much for even the
+most sloughing and obstinate psoriases. Eczema follows the same law.
+If psychotherapy can help in the treatment of conditions that are so
+often intractable, it must surely not be neglected in other cases.
+
+
+{496}
+
+SECTION XIV
+
+_DISEASES OF DUCTLESS GLANDS_
+
+
+
+CHAPTER I
+
+DIABETES
+
+
+Diabetes is an affection of metabolism definitely recognized as due to
+serious organic changes, though existing in several forms. We are not
+as yet absolutely sure whether there may not be quite different
+organic diseases in the various forms. Of one thing clinical
+experience has given us assurance, that the condition of the patient's
+nervous system is extremely important. While certain forms of diabetes
+are due to pancreatic changes and others perhaps to changes in the
+liver or other abdominal organs, the nervous system itself can affect
+the consumption and excretion of sugar within the body. Certain
+injuries, especially, as pointed out by animal experiments, irritation
+of the floor of the fourth ventricle may produce passing diabetes. The
+symptom may also occur in connection with states of the nervous
+system. Glycosuria, or the passage of sugar in the urine, may occur
+simply as alimentary glycosuria; and while this is usually due to an
+excess of sugar in the diet, the glycosuria itself is predisposed to
+by neurotic conditions in the patient. Diabetic patients are made
+worse by worry of any kind and particularly by solicitude about
+themselves and their ailment. Hence, the place that psychotherapy has
+in the treatment of the disease.
+
+
+Unfavorable Suggestion.--In most cases of diabetes, however, probably
+the most important factor in the production of symptoms is the serious
+disturbance of mind. The patient has an incurable disease and is
+frankly told so. For the physician the word "incurable" means only
+that his remedies are as yet inefficient in preventing certain
+nutritional or metabolic disturbances, and that these will be likely
+to continue in spite of all he can do. For the patient "incurable"
+means that he has a disease for which the doctor confesses that he can
+do nothing--which is not true--and that it is almost surely
+progressive, while the many reports of death from diabetes of which he
+hears only confirm the impression that he has not long to live and
+that most of the time remaining will have to be spent in irksome care
+of himself and almost superhuman self-denial.
+
+As a consequence of this train of unfavorable suggestions, the history
+of practically every case of the milder form of diabetes in older
+people contains a period in which, shortly after the discovery that
+they had the disease, they suffered more severely from it than at any
+other time. As a rule, the discovery was accidental. The occurrence of
+a succession of boils, the development of a {497} carbuncle,
+occasionally an intractable eczema or a great itchiness of the skin,
+or an irritation of the external urinary organs, the occurrence of
+cramps at night, or neuralgia pains, have led to an examination of the
+urine and the finding of a considerable quantity of sugar. As a rule,
+the patients are at once put on a diet containing little starch and no
+sugar, and after a short time most of the bothersome symptoms of the
+diabetes have ceased. Their own worry, however, the strictness of the
+regimen, the craving for starches, the decrease in weight from the
+limitation of diet, have made them profoundly miserable. Their
+feelings have been translated into the definite conclusion that the
+disease must still be making progress since they feel so miserable,
+and they have suffered more from their mental state than from their
+diabetes.
+
+This is as true of physicians themselves when they are sufferers from
+diabetes as of ordinary patients. Indeed, it seems that physicians
+make themselves more profoundly miserable because of their supposed
+knowledge of the disease than other people do. I have had the
+confidences of more than a dozen physicians who were sufferers from
+diabetes, and all of them admitted that they had suffered more from
+their scare over the disease and from trying to maintain a sugar-free
+diet than from the effects of their ailment. The lowering of nutrition
+reacts upon the nervous system, already laboring under the strain of
+the persuasion that an incurable disease is present, and the
+consequence is a whole series of nervous and often mental symptoms,
+especially of the depressive kind, that still further disturbs
+digestion, interferes with peristalsis, causes constipation or
+alternate constipation and diarrhea, leads to wakefulness at night,
+inability to concentrate attention and a constant state of worry. All
+this reacts upon the system and further increases the diabetes, that
+is, the inability to use sugar properly, and adds to its elimination
+through the urine.
+
+
+Favorable Suggestion.--Just as soon as these patients realize that
+people have often had considerable quantities of sugar--two per cent.
+or more--in their urine for years without serious consequences and
+that most diabetics die, not from the affection itself, but from
+intercurrent disease, the reassurance of mind which ensues makes their
+nervous system cease to be a factor in the further disturbance of
+metabolism and they are able to consume more starch and sugar without
+increasing the amount of sugar in their urine. This is not true, of
+course, for the severe diabetes that attacks young people. These run a
+rather rapid course and usually end in from one to two years in
+diabetic coma or some complication connected directly with the
+diabetes.
+
+
+Danger of Over-treatment.--To strive to keep the urine of diabetic
+patients free or nearly free from sugar is practically always sure to
+produce a serious effect upon general nutrition and to disturb the
+patient's mind and nervous system. Very often, however, an attempt of
+this kind is made. Doctors who suffer from diabetes are too prone to
+watch their urine carefully from day to day and this only emphasizes
+their solicitude about themselves, impairs their digestion, and
+produces such preoccupation of mind that all their functions are sure
+to be disturbed. After a time they learn that their general condition
+is a more important question than the amount of sugar in their urine.
+If they can maintain their weight with reasonable freedom from the
+secondary symptoms of diabetes, then the primary symptom--the amount
+of sugar in the urine--may be almost or quite neglected.
+
+{498}
+
+Interval Treatment.--Van Norden has pointed out that if diabetic
+patients are occasionally made to observe for a couple of weeks at a
+time an absolute diet, these intervals seem to form a new
+starting-point for metabolism and enable the patient to increase his
+power of utilizing sugar and consequently to diminish his pathological
+elimination of it. Patients look forward with interest to these
+periods, provided that in the intervals they are allowed a certain
+amount of starch; and each one of them seems a landmark on the road to
+recovery. There is a strong element of suggestion in this that acts
+very favorably and greatly influences the actual power of such
+intermissions to help nature recover her lost metabolic faculties.
+This is certainly a better method of treatment than the attempt to
+keep up an absolute diet which so easily produces the other evil of
+nervousness that adds to the diabetes, so that there is question of
+choosing between two evils, and the lesser evil includes particularly
+the reassurance of the patient.
+
+
+The Individual in Diabetes.--While diabetes is a question of
+glycosuria and usually of hyperglykemia, and the consumption of any
+form of cane sugar or of starch convertible into it, will usually
+increase the diabetic tendency, not all the forms of starch which may
+change into cane sugar have the same effect in all individuals or
+undergo the same modifications. Some patients, for instance, stand
+milk better than others and may take large quantities of it so that
+there is less craving for starchy foods. Most patients can take
+potatoes better than bread even when there is the same equivalent of
+starch in each. Those who have been accustomed to potatoes from their
+early years sometimes stand them well and may be able to take them
+almost with impunity. I have noted in several cases that the Irish and
+Scotch, accustomed to oatmeal from their early years, seem to be able
+to take notable quantities of this food when suffering from diabetes
+without having a marked increase of sugar in the urine.
+
+There are forms of sugar that satisfy the craving of patients for
+sweets and may be taken in considerable quantities without seriously
+disturbing metabolism. Honey is one of these, its sugar occurring in
+the form of mannite, and there are other substances related to it that
+probably can be employed to advantage. It must not be forgotten that
+what seems to be sugar in the urine of certain patients, that is,
+grape sugar, has proved on more careful investigation to be one of the
+other chemical forms of sugar. We have a number of cases of pentosuria
+on record in which patients were excreting penatomic sugar, but had
+not glycosuria, though their urine responded to the ordinary tests for
+this. It seems well not only to be sure of the diagnosis in these
+cases, but to use what we have learned to make patients feel that
+their condition though not curable is by no means hopeless. Care must
+be exercised to take advantage of every possible individual
+peculiarity for reassurance, for the extension of the diet in any
+possible way, and for the satisfaction of the cravings which are so
+likely to come to these patients. Some of their craving is really due
+to the suggestion that they cannot have a particular article of diet.
+Whenever any human being knows that he cannot have a thing, the liking
+for it grows by suggestion and then it may become an obsession. To be
+allowed even small quantities of it is often enough to enable patients
+to overcome this and at least put them in a better state of mind.
+
+
+Physical Condition.--The most important element in the treatment of
+{499} the less severe cases of diabetes is exercise in the open air.
+Whatever the ultimate solution of the mystery of diabetes may be,
+there is no doubt but that the muscles are an important factor in our
+disposal of sugar within the body. The material which is burned up in
+the muscles during movement is a form of sugar derived directly from
+the starch and sugar ingested. When diabetics exercise freely much
+more of their sugar is consumed within the body and much less of it
+eliminated through the kidneys than when very little or no exercise is
+taken. It is interesting to note the difference in the amount of sugar
+in the urine when patients are taking abundant exercise and when they
+are taking practically none. Even on a much more liberal diet the
+percentage of sugar is likely to be less in the exercising patient.
+One of the results of the diabetic scare is likely to be almost a
+cessation of muscular exercise. This is partly due to the fact that
+one of the results of diabetes in many cases is a sense of fatigue in
+the muscles on comparatively little exertion. Indeed, this is
+sometimes the first symptom that is noted and that calls the attention
+of the patient to the fact that there is something seriously wrong
+with him.
+
+This occurs when there is a serious disturbance of sugar metabolism so
+that the patient who consumes large amounts of starch and sugar is
+excreting most of it. Just as soon as the diet is made a little more
+rigid and the sugar metabolism improves, then exercise can be taken
+and will benefit the patient. This is particularly true of women
+suffering from diabetes whose depression on being told that they are
+suffering from an incurable disease tempts them to remain within
+doors; the frequent tendency to urination further adds to their
+disinclination to go out. Under these circumstances they lose their
+appetites, do not sleep well, and become highly nervous, thus
+increasing their diabetic tendency. If they are required to go out and
+take exercise in the open air and rather long riding or walking
+periods every day, their general health will at once improve and the
+diabetes will become more manageable. I have seen this happen without
+exception even in patients well beyond middle age, and I am convinced
+that it is the diversion of mind as well as the salutary tiredness and
+thorough oxidation consequent upon outdoor exercise that is the best
+possible remedial measure for these cases.
+
+
+Solicitude.--It is important that diabetic patients should not be
+bothered by frequent reports upon their urine. Their improvement and
+the reduction of the amount of sugar excreted is at best but slow, and
+is subject to many variations. While improvements, especially at the
+beginning, are sources of great encouragement, the deteriorations that
+are likely to be rather more frequent are prone to overweigh the good
+effects and eventual discouragement results. It is not from the urine
+but from the general condition that the improvement in the diabetic
+condition is to be judged. So long as the patient feels strong, gains
+in weight (when they do not belong to the obesity type of diabetes),
+the diabetes itself is almost sure to be improving, even though there
+may be discouraging periods as regards the amount of sugar eliminated.
+
+
+Dangers of Rigid Diet--There are more dangers in a rigid diet than in
+a certain amount of liberty in the consumption of starches and sugars.
+The craving for these becomes so strong as to make life intolerable to
+many people unless a certain amount of these substances is allowed. It
+is rather easy to manage limitation while it is almost impossible to
+be sure that {500} patients will practice absolute denial. Besides,
+the almost complete absence of starches and sugars, even though their
+place is supplied by the fats, always seems to predispose patients to
+the development of the acid intoxication which results in the coma
+often so serious an incident of diabetes. It is for this reason
+particularly that mild diet regulations are clinically more judicious
+than the absolute denial which on chemical and physiological grounds
+seems to be the scientific ideal. A rather good therapeutic method is
+to have the patients maintain a rigid diet for some ten, fifteen or
+twenty days and then leave them practically without restrictions for
+the rest of the month. Continuous restriction of diet becomes
+appalling. Looking forward to a period when they can eat as other
+people do relieves the tedium, and makes it much easier to keep the
+restrictions. The mental influence of this moderate treatment is very
+favorable and encourages the patients in the thought that after all
+their disease is not so serious. This is the most important element in
+psychotherapy.
+
+
+
+CHAPTER II
+
+GRAVES' DISEASE
+
+
+Graves' disease, sometimes called Basedow's disease, though the Irish
+physician has a right to the name by priority, is often called
+exophthalmic goitre, because this term is descriptive of the two most
+marked symptoms. It must not be forgotten, however, that there are
+cases in which there is no exophthalmos and even no goitre, at least
+no enlargement of the thyroid gland that can be demonstrated
+externally. It is said that in these cases there must be an
+enlargement of the thyroid bound down by fascia and concealed by other
+structures of the neck so that it does not appear externally. It is
+probable, however, that there are cases of true Graves' disease
+without enlargement of the thyroid yet with the characteristic tremor,
+rapid heart and the mental symptoms of the affection.
+
+
+Etiology.--The symptoms of the affection often develop after a period
+of excitement or worry, or at critical times in life, if sorrow or
+misfortune proves a burden. Responsibility sometimes has a like
+effect. I have seen a woman patient on several occasions in the last
+fifteen years develop marked symptoms of Graves' disease when she was
+placed in a position of responsibility involving worry, while in the
+intervals when pursuing a simple ordinary life without trouble of mind
+no symptoms were present. Occasionally a fright seems to be at least a
+predisposing cause for the development of the symptoms. Emotional
+strains, mental stresses, play a large part in occasioning Graves'
+disease, though the cause of it is probably deeper in some structural
+defect. In recent years nearly all the medical attention has become
+concentrated on the idea that the disease is primarily due to
+hyperthyroidization. More detailed study, however, has shown that
+other ductless glands are probably also concerned in the etiology. The
+adrenals particularly seem to be associated closely with the thyroid
+and Graves' disease may be due to some disturbance of the
+co-ordination between these glandular systems. The thymus gland is
+usually {501} persistent in these cases and this must represent
+something in the affection and at one time the use of thymus substance
+for therapeutic purposes seemed to confirm this idea. The parathyroids
+have also been called into question and their use in therapeusis seems
+to justify this to some extent, though probably we know too little
+about them to be able to say anything definite in the matter.
+
+Even though the affection may be due directly to hypersecretion of the
+thyroid, it is possible that the mental and nervous state may be
+closely concerned in the etiology. Some patients have had an enlarged
+thyroid for years, without any symptoms of Graves' disease. Then
+during a time of stress and worry or anxiety and responsibility
+symptoms of the affection develop. The circulation of the thyroid is
+under the control of the cervical sympathetic. It is possible that
+this may be affected by states of mind to such an extent as to cause
+an increase of the circulation in the thyroid and as a consequence
+more of the thyroid secretion may get into the blood stream and
+produce its effect. Under these circumstances anything that would
+allay the excited mental condition and thus neutralize the unfavorable
+effect of the cervical sympathetic would cure or at least relieve
+Graves' disease.
+
+The affection is about five times as frequent among women as it is
+among men. This has sometimes been attributed to the fact that there
+seems to be some more or less direct correlation between the sex
+organs in women and the ductless gland systems. It has often been
+pointed out that the thyroid is likely to be engorged at the time of
+menstruation and, indeed, there are those who have attributed some of
+the symptoms of tremulousness, irritability, and tiredness at this
+time to over-functioning of the gland. In women who have borne a child
+the thyroid is usually somewhat enlarged. Good authorities in
+obstetrics have insisted that they could pick out of a group of women
+in evening dress, those who had borne children, from the appearance of
+their necks. Probably this is an exaggeration, but there is no doubt
+that the thyroid is intimately related to the genital functions in
+women. It has been said that a direct connection could be traced
+between disappointments in love or in sexual matters and the
+development of Graves' disease. To put much stress on this would
+easily lead to mistaken conclusions, though it represents a principle
+that should be recalled in certain cases of the affection. The
+frequency with which slighter disturbances of the thyroid occur in
+connection with the common genital incidents of female life and their
+comparative insignificance for health or strength, should make for the
+holding of a not too serious prognosis in the affection.
+
+
+Symptomatology.--There are four cardinal symptoms of the disease:
+rapid heart action, tremor, enlargement of the thyroid, and
+exophthalmos. At least two of these are largely dependent on mental
+influences. There are certain accompanying symptoms that are of
+importance and supposed to be connected directly with the disease,
+though oftener they can be traced to the influence of the state of the
+patient's mind upon the organism. Emaciation is common. It is due to
+the fact that the appetite is likely to be seriously disturbed by
+anxiety and solicitude. Anemia develops as a consequence and there may
+be slight fever which is sometimes inanition fever. Attacks of
+vomiting and diarrhea occur intermittently and sometimes there is
+constipation. The disturbance of eating consequent upon the affections
+seems largely {502} responsible for these. The disturbance of the
+vascular system gives rise to flashes of heat and cold and often to
+profuse perspiration. Certain of the symptoms of the menopause can be
+compared rather strikingly with those of Graves' disease and have been
+attributed to the disturbance of the external secretion of the ovaries
+which are now known to act as ductless glands as well as genital
+organs.
+
+With the exception of the enlargement of the thyroid and the
+exophthalmos, all of the symptoms of Graves' disease are of a kind
+that can be produced in states of excitement with nothing more present
+than a functional neurotic condition. It is true that the tremor is
+characteristic and differs from that of hysterical patients, being
+finer and at the rate of a little more than eight to the second. The
+rapid heart action, however, and the disturbance of the general
+circulation which causes flushing and pruritus and the sense of
+nervousness, as if the patients were in a constant state of fright,
+are always characteristically neurotic. The changes in disposition,
+often in the line of irritability, sometimes with severe mental
+depression, seem in many cases to be only a mental reaction to the
+patient's solicitude. The weakness of the limbs which sometimes
+amounts to a giving away of the legs, is connected with the tremor,
+but seems to be neurotic rather than of any more serious character. In
+spite of all our study of the affection its place among the neuroses
+must still be reserved for it, at least as regards many cases, and its
+treatment must be conducted with that idea in mind.
+
+
+Diagnosis.--The disease is easy to recognize when fully developed. At
+the beginning of cases, however, and in certain abortive types of the
+affection which the French have called _formes frustes_, the diagnosis
+may be difficult. Usually the first symptom is tremor and this of
+itself will often serve, especially in association with general
+symptoms of nervousness, to make the diagnosis. Tremor with
+tachycardia puts the case beyond doubt, as a rule, though of course it
+must not be forgotten that hysteria may simulate rather closely this
+much of the disease.
+
+The abortive types of the affection are important because they
+masquerade as forms of psychoneurosis, hysteria, and the like, though
+the patients are not suggestible, have very definite, not variable,
+symptoms and get better and worse according to the variations in the
+underlying affection. Occasionally they seem to be associated with
+certain other forms of neurotic conditions, especially those with
+vascular disturbances. There may be tinglings in the ends of the
+fingers, occasionally with suffusion, erythromelalgia--Weir Mitchell's
+disease--and even a tendency to the white "dead fingers" as the French
+call them, of Raynaud's disease. It seems not unlikely that further
+study will show that many of these affections involving disturbances
+of the vasomotor system are connected in some special way.
+
+
+Prognosis in Young Patients.--Some of the cases, especially in young
+people, are likely to seem quite discouraging and apparently to
+justify even a serious operation. I have in mind a young woman seen
+some fifteen years ago when she was about seventeen. The prominence of
+the eyes, the enlargement of the thyroid, the tremor and the rapid
+heart were all marked. The symptoms had been growing worse for over a
+year and the outlook was serious. Ten years later I saw her in another
+city in perfectly normal health, married and happy and the mother of
+two healthy children. The only trace {503} apparently of the
+disturbance of the thyroid to be noted in the family was that her
+children got their teeth very late, her first child, a boy, not
+cutting his first tooth until after he was fifteen months old. In
+every other way, however, the boy was perfectly well, rugged and
+strong, having passed through his summers without any serious
+disturbance and not being a particularly nervous or excitable child.
+Such complete relief from symptoms after the condition had been so
+grave would ordinarily have seemed quite out of the question. It
+emphasizes the fact that for Graves' disease as it occurs among young
+growing people, where perhaps the thyroid does not grow in proper
+proportion to the rest of the body, but for some reason overgrows, the
+prognosis of the case may seem to be much worse than it really is.
+
+
+Treatment.--The story of the various methods of treatment that have
+been reported as successful for Graves' disease serve to show very
+well how much the affection must depend upon psychic and neurotic
+conditions, for most of them have been positive in action at the
+beginning when their suggestive influence was strong, and quite inert
+after they had lost their novelty and their power to influence the
+mind. Sometimes even slight operations as on the nose, the removal of
+polyps, or of a spur on the septum, or an enlarged turbinate, have
+been found to bring relief of the symptoms of Graves' disease even in
+marked cases. Operations upon the tonsils have had a like effect and
+even shortening of the uvula has been reported as curative. A
+generation ago applications of iodin to the goiter were reported to
+have good effects. In lancing the goiter, sometimes evidently a cyst
+was punctured, but sometimes the lance was only followed by a slight
+issue of blood, yet the affection was favorably modified. More serious
+operations have followed by complete relief of symptoms for a time,
+though relapses are not infrequent and occasionally the patient was
+not relieved, though apparently all the conditions present were
+similar to those of other patients in whom the operation produced
+excellent results.
+
+The medical treatment of Graves' disease demonstrates interestingly
+the power of suggestion. About fifteen years ago a distinguished
+English observer announced that he was getting good results in the
+treatment of Graves' disease by the administration of thyroid
+substance. At that time our present theories with regard to
+hyperthyroidization as the etiology of the affection had not been
+formulated, though some vague connection between the thyroid secretion
+and the symptoms had been accepted. A number of patients were improved
+by taking thyroid. Other observers found, however, that not only were
+their patients not improved, but they seemed to be worse as the result
+of the thyroid feeding. The English physician therefore was asked to
+say exactly how he obtained his material and prepared it for his
+patients. Organo-therapy was then new and it was found that the orders
+given to the butcher for thyroid had been filled by him according to
+the directions by furnishing portions of a large gland situated in the
+neck of the calf. This was the thymus, and not the thyroid. Thymus was
+then deliberately used for a while and there were some reported good
+successes while the treatment was new and strongly suggestive. After a
+time it proved to be of no avail.
+
+A number of biological remedies were tried after this. Personally,
+after having made some studies of the parathyroids while in Virchow's
+laboratory, I resolved to try material from those glands. The first
+two patients to whom {504} the material was given, with a careful
+explanation of the theory on which it was administered, proceeded to
+obtain relief from their symptoms and an intermission in their
+disease. Just as soon as I purposely omitted to explain to patients
+how much might be expected from this new remedy and failed to make
+suggestions founded on the parathyroids, no improvement was noted. In
+the first two cases this had been more or less necessary in order to
+determine whether the patients could stand the doses suggested, which
+began very low and were gradually increased. The material seemed to
+have no ill effects, however, and a definite dosage could be used
+without the necessity of taking patients into one's confidence.
+
+A number of serums of one kind or another were reported as beneficial
+for Graves' disease. It was admitted that they did not benefit all the
+cases, but that in certain cases they did much good. Practically all
+of these were strikingly more efficient in their discoverers' hands
+than when used by anyone else. Thyroids were removed from animals and
+after some time serum from these animals, supposed to be of lower
+thyroid content, was injected into human beings with the idea of
+reducing the hyperthyroidization or perhaps neutralizing it by some
+substance present in the serum. One very interesting observation on
+most of these cases deserves remark. The animals deprived of their
+thyroids, such as goats and sheep, lived on absolutely unhurt by the
+operation, and as one experimenter expressly noted, sold for more
+money after being kept for a year under observation than they had cost
+him before dethyroidization.
+
+Most of our biological remedies for Graves' disease then are strongly
+reminiscent of the therapy of the affection in older times. It was
+particularly for Graves' disease, or at least for nervous symptoms
+closely resembling Graves' disease--those of fright, nervousness,
+irritability and tremor--that various more or less terrifying
+procedures and particularly deterrent substances were employed in
+medicine. These patients, for instance, were cured by the touch of a
+hanged criminal, and particularly by the touch of their goiter to the
+mark on his neck. It was especially for them that _Usnea_, the moss
+gathered from the skull of a criminal who had been hanged, was of
+benefit when administered internally. Mummy as a remedial substance
+remained in common use until well on into the latter half of the
+eighteenth century in England.
+
+In older times a dead snake wrapped around the neck was said to be an
+excellent remedy for goiter and especially those cases of goiter that
+caused symptoms of fright and nervousness. Evidently anything that
+produces a strong effect upon the patient's mind may prove helpful.
+Perhaps the suggestion enables the mind to control the cervical
+sympathetic and by that means the circulation in the thyroid gland,
+thus lessening the amount of blood that flows through and therefore
+the amount of secretion that is carried out. There is no doubt but
+that the sympathetic is largely under the influence of the emotions
+and that through it very important effects may be worked out in
+various structures. There seems no other possible explanation for the
+uniformly reported success of remedies when their suggestive power is
+strong and their failure quite as invariably later even in the same
+cases.
+
+
+_Operations_.--In recent years operations for the removal of portions
+of the enlarged thyroid have become popular and some very successful
+results have been reported. Those of us who know how easy it is to
+influence the minds of {505} patients in Graves' disease favorably
+hesitate as yet to pronounce definitely with regard to the indication
+for operation except under such conditions of pressure in the neck or
+projection of the eyeballs as may lead to serious symptoms. Not all
+the operators have been as successful as some who made a specialty of
+the affection. I have personal information which shows a number of
+unsuccessful cases after operation and the records of conservative
+surgeons as published indicate this. Unfortunately, a great many cases
+have been reported within a few months as cured; if they were
+comparatively without symptoms, surgical intervention is considered to
+have been eminently successful. For, be it noted, very few are
+entirely without symptoms, even after operation.
+
+Dr. William H. Thompson in his book on "Graves' Disease" points out
+that even so good an operator and so thoroughly conservative a surgeon
+as Kocher reports cases of Graves' disease as cured, which are still
+exhibiting symptoms that would make the medical clinician hesitate to
+agree with him and, indeed, rather lead him to expect that under the
+stress of worry and excitement there may be redevelopment of the
+symptoms. As the number of cases operated upon has increased there has
+been a growing feeling that relapses might be expected in certain
+cases even after removal of large portions of the thyroid gland. The
+fact of the matter is that we do not understand as yet what is the
+underlying pathological significance of the symptoms grouped under the
+term Graves' disease. When there are severe symptoms, as extreme
+exophthalmos, greatly enlarged thyroid pressing upon the important
+neck structures, or serious disturbance of nutrition, an operation is
+always needed; but as yet we cannot be sure that it will produce even
+complete or lasting relief.
+
+Many patients have been greatly benefited by operation, some of them
+perhaps permanently, but we need more of the after-history of these
+patients covering a long period of time, to be sure that the results
+flow entirely from the operation. There was a time when operations
+were reported as doing quite as much good for epilepsy as they are now
+for Graves' disease. As we have pointed out, a number of operative
+procedures that had nothing to do with the underlying basic pathology
+of the disease have proved the occasion for considerable improvement
+or sometimes what might be called a cure for a prolonged period. We
+can be sure, as a rule, that patients will be benefited immediately
+after operations. The rest, with care, the strong suggestion, the
+aroused feeling of expectancy, the confidence in the surgeon, all this
+would do much of itself. It remains to be seen how much more than this
+the operation does.
+
+
+_General Condition_.--The treatment of patients suffering from Graves'
+disease consists largely in having them take up some occupation that,
+while reasonably absorbing, does not make too great a demand upon
+them. Often when they complain most of their symptoms they are below
+normal weight and the first indication is to have them brought back to
+it. I have seen such cases over and over again almost entirely without
+symptoms when they were up to normal weight and with a good many
+symptoms when they were below normal. It would be easy to theorize as
+to why this is so, but the observation is the most important
+consideration for practical purposes, and we are not yet in possession
+of enough scientific knowledge with regard to the thyroid or {506} its
+possible connection with other organs that have an internal secretion,
+to be able to say anything definite about it.
+
+After weight and nutrition the most important indication is sleep. It
+is impossible for patients to get along with less than eight or nine
+hours of sleep. Most of them are much better if they have nine or ten
+every night. Late hours are particularly prejudicial to them. They are
+tired if they have been on their feet all day and they should be
+encouraged to take more sleep than others. Sleep is one of the most
+important considerations for sufferers from the abortive forms of
+Graves' disease and they must be encouraged to take it in the quantity
+that they need. This can only be decided by their feeling.
+
+
+_Diversion of Mind_.--Much more than other nervous people these
+patients need encouragement and require diversion of mind. They are
+prone to be discouraged, rather tired, and easily tempt themselves
+into a routine in which there is little recreation and no diversion.
+For them more than for most other patients it is necessary to
+prescribe that twice every week they shall have some engagement
+different from their ordinary routine to which they look forward for
+several days. This looking forward to a break in the routine does much
+to make life more livable for them and must be encouraged in every
+way. As to what the diversion is to be must depend entirely on the
+character of the individual. Some find complete diversion of mind in
+the theater or even in vaudeville. Others are bored by this after a
+while and need other recreations. I have known people who were bored
+by the theater find an evening a week spent in helping a poor person
+or an afternoon devoted to a visit to a hospital ward or to an ailing
+friend an excellent diversion. Some of those who do not care for the
+theater like music and are helped by it. As a rule, however, one must
+be careful about the indulgence of music for neurotic people since it
+seems to exert a serious emotional strain on many of them and as the
+phrase goes "takes a good deal out of them." This is particularly true
+for younger people who have a passion for music. Older people may be
+trusted more in this matter and the attendance on concert and opera,
+which is looked upon as a social duty by some, giving them an
+opportunity to greet friends and to display their gowns and jewels, is
+a harmless diversion of mind.
+
+
+_Mental Treatment_.--Graves' disease is, then, as we have said,
+especially likely to be influenced by the patient's state of mind.
+Nothing disturbs patients more than the declaration sometimes made by
+physicians that their condition is incurable or that they will have to
+doctor for it for many years. This must be avoided because our present
+knowledge does not justify any such positive declarations. Most cases
+of Graves' disease, while not particularly amenable to treatment by
+specific drugs, are very much improved if the patient's general health
+is brought up to the best standard and if all sources of worry and
+emotion are eliminated, as far as possible. Nothing is more serious
+for them, however, than the suggestion that they will not get well.
+Probably no one has ever seen a mild case of Graves' disease that did
+not improve so much as to be practically well after the lapse of some
+time. Recurrences take place, but if all sources of worry and
+irritation of the digestive tract and over-tiredness are removed, then
+patients will stay free from their symptoms for surprisingly long
+periods. Old people do not have these {507} favorable remissions so
+much as the young, but under twenty there can be, as a rule, definite
+promise of decided improvement and sometimes of results that seem like
+complete cure. For patients under thirty there is every reason to
+think that if they are in a run-down condition when the disease is
+first noted remissions of symptoms can be looked for lasting for long
+periods, during which they will be comparatively well.
+
+
+_Diet Suggestions_.--The changes in diet necessary to bring
+improvement in Graves' disease are different for individual patients.
+Prof. Mendel, in Berlin, found in his extensive experience that meat
+does not seem to be disposed of well by these patients and acts
+somewhat as an irritant. He reduces the meat taken and usually allows
+it at but one meal. If patients get on well as vegetarians, meat is
+gradually eliminated from their diet. On the other hand, there are
+patients who seem to develop Graves' disease during a vegetarian diet.
+Very often it will be found that there is an intermittent constipation
+and diarrhea in these cases, and that the bowels will act much better
+if a certain amount of meat is given, and then the symptoms of Graves'
+disease remit, as a rule. As in most of the major neuroses, as is
+known so well in epilepsy, any irritative condition of the digestive
+tract will surely revive neurotic manifestations and make many of the
+major neuroses much worse than they were before.
+
+
+{508}
+
+SECTION XV
+
+_ORGANIC NERVOUS DISEASES_
+
+
+CHAPTER I
+
+PSYCHOTHERAPY OF ORGANIC NERVOUS DISEASES
+
+
+Since we know that the basis of many nervous diseases is an
+obliteration of certain cells of the brain or of the spinal cord, or
+certain tracts of the central nervous system through which impulses
+must pass if they are to be effective as motion, sensation or function
+in some other form, we realize that we cannot recreate these portions
+of highly organized tissue and that therefore organic nervous diseases
+are beyond the action of any remedies we now know or may even hope to
+discover.
+
+The development of pathology has shown us that once there has been
+serious nephritis or cirrhosis of the liver certain portions of the
+glands are destroyed and therefore there cannot be any question of
+cure. There is no possibility of redintegration of destroyed tissues
+when they are of highly organized character, and so the patient will
+always be maimed. One might as well talk of causing an amputated
+finger to grow again as talk of curing diseases that involve
+destruction of specialized cells. When this first dawned on modern
+medicine as the result of the careful study of pathology a period of
+therapeutic nihilism developed during which physicians trained in the
+pathological schools were prone to distrust drugs entirely, or at
+least to a very great degree. The effect of this wave of nihilism has
+not entirely disappeared in our time, though we have learned that even
+where serious damage to an organ has been done by disease we may still
+hope to compensate for defect of tissue by stimulation of other organs
+and to replace its function by certain physiological remedies or
+biological products; and if we can do nothing more, we can at least
+alleviate the symptoms which develop as a consequence of the organic
+affection.
+
+
+Nature's Compensation.--Physicians are prone to forget nature's
+wonderful powers of compensation. Apparently even some regeneration
+may take place in diseased organs of highly organized type if the
+patient's general condition is kept up to its highest point of
+nutritive efficiency. How far this may go we do not know, but
+observations show some marvelous examples of unexpected regeneration.
+
+These counteracting processes can be stimulated sometimes by drugs,
+but oftener they can be best brought into play by keeping the patient
+in just as good condition of body and favorable condition of mind as
+possible for a prolonged period, so that nature accustoms herself to
+the defect and her powers of compensation have full play.
+
+{509}
+
+Unfavorable Suggestion.--What is true of organic diseases of all kinds
+is especially true of organic nervous diseases, and in spite of the
+fact that most of these are essentially incurable, so much can be done
+for patients that their condition is made more tolerable and indeed
+some of them improved to such an extent that they consider themselves
+quite relieved of their organic affection. One of the most serious
+burdens that the patient laboring under an organic nervous disease has
+to suffer is the consciousness drummed into him by successive
+physicians, by his reading, and by every possible means of suggestion,
+that his malady is incurable. This makes every symptom as severe in
+its effects as it can possibly be. Hope does not buoy up and
+discouragement weighs down every effort of the organism to compensate
+for the serious defect under which it is laboring. Nothing can be done
+for the disease itself, but much can be done for the patient. Many of
+the symptoms from which the patient suffers most are really due to his
+own discouragement, to that sluggish condition which develops in his
+body as a consequence of his lack of hope, to the absence of exercise
+and of air and of diversion of mind consequent upon the gloom that
+settles over him when he is told that his condition is incurable.
+
+
+_Adventitious Symptoms_.--If the adventitious symptoms that are always
+present in cases of organic nervous disease are eliminated, if the
+conditions which develop from the unhygienic condition in which the
+patient lives because of his discouragement and retirement are
+removed, as a rule he feels so much better that it is hard to persuade
+him that some change has not come in his underlying nervous disease
+and that a process of cure is not at work. It is because of this that
+irregular practitioners so often succeed in apparently doing much more
+for these patients than the regular physician. The irregular does not
+insist on the incurability of the disease, but, on the contrary, he
+promises a cure. He then proceeds to relieve many bothersome symptoms
+that are quite extraneous to the underlying disease, but thus makes
+the patient ever so much more comfortable than before, gives a
+cheerful air to his life for a time, makes him sleep better as a
+consequence and it is not surprising that the patient thinks that his
+disease has been bettered, if not cured.
+
+
+Suggestive Prophylaxis.--While we are optimistic just as far as
+possible since genuine nervous disease has declared itself, it must
+not be forgotten that we can by suggestion and warning often prevent
+or delay the development of nervous degenerations. This, too, is
+psychotherapy and must be employed wherever it seems advisable.
+
+Post-syphilitic nervous conditions of so many kinds are likely to
+develop that it is important to warn the patients who are sufferers
+from this disease from taking up the more strenuous forms of
+existence. This may seem an exaggerated view of the condition, but it
+is amply justified by the results of the opposite rule of life in
+almost any physician's experience in city practice. A man who has had
+syphilis must be warned of the danger, one may almost say likelihood,
+if he takes up any of the professions in which there is much mental
+strain and nervous worry, that he will almost surely not live out the
+normal span of life without some serious nervous incident. Locomotor
+ataxia, and, above all, general paralysis develop, as a rule, in men
+who, having had syphilis, have some occupation in life that calls for
+considerable mental strenuosity, and involves excitement and worry.
+Actors, brokers, soldiers and sailors, speculators of all kinds,
+race-track gamblers, these are the classes from {510} which victims of
+paresis and locomotor ataxia are particularly recruited. People who
+have suffered from syphilis and who live the ordinary unemotional life
+of a teacher, or a merchant, or a writer, do not, as a rule, develop
+the postsyphilitic and parasyphilitic conditions.
+
+Precocious apoplexy is especially likely to occur in patients who have
+had syphilis and who have then spent themselves at very hard work. I
+doubt if hard work alone, without some such antecedent condition, ever
+produces this result. Of course, it is not alone syphilis, but other
+serious conditions which affect the nervous system that ought to be
+guarded against in this same way. If there has ever been any affection
+of the kidneys, as a complication, for instance, of scarlet fever,
+then it has always seemed to me to be the duty of the family physician
+to warn such patients that their kidneys are more prone than those who
+have not suffered from such an incident to break down under any severe
+strain that may be put upon them by worry, especially worry following
+a period of strenuous work. In these cases the affection of the
+kidneys nearly always makes itself felt in the nervous system, and
+especially in the brain, and so this warning has a proper place here.
+Where there has been severe cerebro-spinal meningitis this warning
+seems also to be needful, though here our records have not been kept
+with sufficient care to enable us to speak positively of the necessity
+for the warning.
+
+
+Treatment.--It is important to remember that as physicians we do not
+treat disease but patients. We _care_ for patients, that is the real
+etymological significance of the Latin _curare_, we do not cure
+diseases in the modern sense that has come to be given to that term,
+of completely removing the _materies morbi_ and setting the patient on
+his feet once more just as well as he was before his illness.
+
+
+_Relieving Incurable Disease_.--A new cure for locomotor ataxia, for
+instance, is announced every now and then, and the evidence for its
+beneficial action is the testimony of patients who have been relieved
+of many symptoms that they thought connected directly with their
+spinal affection. All sorts of remedies have been employed with
+announced success. One man builds a particular kind of shoe for them
+and has a number of witnesses to his skill in curing them. Another
+does some slight operation on their nose or their throat or their
+urethra and straightway the patient feels so much better that he talks
+confidently about being cured. All the characteristic symptoms of the
+affection remain. Their knee-jerks are gone, their pupils do not react
+normally, they have some incoordination in their walk, but a number of
+other symptoms have disappeared and their walk is probably much
+improved because of their confidence and a certain amount of practice
+that they have gone through. The new hope born of confident assurance
+that they could be relieved gives them an appetite, makes their
+digestion better. This lessens the sluggishness of their bowels, gives
+them confidence to get out and see their friends, life takes on a new
+hope, they sleep better and it is no wonder they talk of having been
+helped or even cured.
+
+There is a definite relation between the nervous affection in these
+cases and many visceral symptoms. There is no doubt, for instance,
+that certain cases of intractable dyspepsia are associated with tabes
+and that in nearly the same way obstinate constipation frequently
+develops. Notwithstanding the connection of these symptoms with an
+incurable condition of the spinal cord {511} that is no reason for
+thinking that they cannot be relieved even though no improvement of
+the spinal-cord lesions is expected.
+
+Frequently, indeed, gastric dyspepsia is due more to worry over
+discomfort somewhere in the stomach region than to any real
+disturbance of the digestive functions. It may then be considerably
+ameliorated simply by the assurance that the trouble is local and is
+localized outside of the stomach itself, though there may be some
+sympathetic irritation of the gastric nerve supply. Probably Dr. Head
+and those who have studied reflexes so enthusiastically would not
+agree with this explanation of the relief of the gastric symptoms in
+some of the cases they have described, as due rather to suggestion
+than to the local treatment, and, as a matter of fact, we are not
+quite sure which factor may be the more important. Counter-irritation
+probably plays quite an important role in the relief of discomfort,
+but I am sure that the suggestive influence of acute sensory feelings
+at the surface produced by counter-irritation serves to divert the
+mind from the duller ache or the functional disturbance below.
+However, Dr. Head's paragraph should be given in his own words, for it
+furnishes a scientific basis for one aspect of these cases.
+
+  Throughout the study of cases of nervous diseases, evidence of the
+  relation between pathological condition of certain viscera and
+  sensory disturbances in the superficial structures of the body is
+  constantly manifested. For instance, a man with caries of the spine
+  suffered from a girdle sensation round the area of the eighth dorsal
+  segment. At the same time he was greatly troubled by flatulent
+  dyspepsia which was untouched by drugs. It was, however, greatly
+  relieved by counter-irritation applied to the maximum tender point
+  of the eighth dorsal area in the eighth space and mid-axillary line.
+
+_Optimistic Suggestions_.--Our most prominent neurologists have in
+recent years insisted on the necessity for encouraging patients and
+for not permitting them to brood upon the worst side of what is to be
+expected from their ailment. Patients are entirely too prone to read
+up about their disease and the worst symptoms of the extreme cases
+impress their minds and are constantly recurring as suggestions of
+possible ills to come. Prof. Oppenheim in his "Letters to Nervous
+Patients" states in a striking way the optimistic view that it always
+seems advisable to give a patient in the initial stages of a serious,
+incurable or even progressive nervous disease. That letter is worth
+quoting:
+
+  I cannot conceal from you the fact, which you have already
+  ascertained from other sources, that you show the premonitory
+  symptoms of a disease of the spinal cord. This admission is not,
+  however, as you fear, synonymous with the sentence "the beginning of
+  the end." There is no reason for you to despair. We doctors regard
+  and welcome it as a marked advance in our scientific knowledge that
+  we are now in a position to diagnose a nervous disease of this kind
+  in its first commencement. This is undoubtedly a great gain for the
+  patient, as on account of this knowledge a judicious, experienced
+  physician may, at least in many cases, by the timely regulation of
+  the mode of life and the prescription of certain remedies, arrest
+  the progress of the disease or retard its development. This advice
+  may, however, and should as a general rule, be given without the
+  patient himself being made aware of the diagnosis, for the ideas as
+  to the nature of this disease which prevail in lay circles, and
+  indeed among many doctors of the old school, arise from the
+  knowledge of the disease in its advanced and fully established form,
+  since it was only in this completely developed stage that it was
+  recognized. Then, indeed, its very noticeable symptoms were obvious
+  even to the uninitiated. This picture, sad enough indeed in itself,
+  was rendered still gloomier by {512} the misery and despair which
+  popular fancy has associated with the conception of locomotor
+  ataxia.
+
+
+_Arteriosclerosis_.--Even with regard to so serious a disease and, of
+course, absolutely fatal in its progress as arteriosclerosis, it must
+not be forgotten that much can be done for the patients and especially
+for the nervous symptoms that develop in connection with the
+condition. For the progressive hardening of the arteries on which the
+nerve symptoms depend absolutely nothing can be done. A man is as old
+as his arteries, and we cannot bring back the years even though the
+patient has become prematurely old. For the symptoms so frequently
+seen in connection with arteriosclerosis, the paresthesia, the
+burnings, the numbness, the pruritus, the pains around joints and the
+difficulties in connection with them, even for the intermittent
+claudication which develops, much can be done. Above all, the patient
+must not be allowed to cherish the notion that his disease is not only
+incurable, but that nothing can be done for it. It is inevitable and
+progressive, but then according to one definition, life is a
+progressive disease and every day brings us nearer death. "Life is a
+dangerous thing at best," as an American humorist once said, "and very
+few of us get out of it alive."
+
+These patients can be relieved of many physical symptoms, they can be
+encouraged, their attention can be diverted from their symptoms, and
+it is concentration of mind on them that often makes them intolerable,
+while occupation with something, especially if it is interesting, will
+often prove an efficient remedy for the discomforts complained of. Old
+people who have no interests, who have retired from business, who did
+not have the opportunity when young to acquire tastes in art and
+literature, above all, those who have no interests in children, no
+grandchildren nor close relatives near them, are likely to become
+centered on their ills in the midst of their arteriosclerosis, and
+this more than the advancing degeneration of arteries itself is at the
+root of their symptoms. The ideal old age is that which is passed in
+the midst of younger people, with an occasional happy hour during the
+day with children in whom one is deeply interested. This is the best
+psychotherapeutic factor that we have.
+
+Prof. Oppenheim has given the optimistic side of arteriosclerosis so
+suggestively that most patients suffering in this way should have the
+opportunity to read it. It occurs in his "Letters to Nervous
+Patients":
+
+  An eminent physician for whom I have much esteem has told you that
+  your troubles, especially your vertigo, are caused by calcification
+  of the arteries. You, sir, heard in this your death sentence, and
+  since then the encyclopedia has revealed to you all the sufferings
+  and terrors with which you may expect to be overtaken.
+
+  I would, however, explain to you, as the result of the most careful
+  examination and the most absolute conviction on my part, that your
+  anxiety is unfounded.
+
+  Since you have a certain amount of information and scientific
+  knowledge, I may speak to you upon this matter almost as a
+  colleague. One is certainly justified, when a man of your age
+  complains of vertigo, in suspecting calcification of the arteries to
+  be the cause of the trouble, since it constitutes the common senile
+  change, and vertigo forms one of its most frequent symptoms.
+  But--apart from the fact that in senile calcification of the vessels
+  this vertigo is frequently a temporary and not always a serious
+  sign--one is by no means justified in assuming that the appearance
+  of this symptom in later life is in itself, and without further
+  evidence, the sign of such a cause. This is an error which in my
+  experience is {513} far too frequently made, to the detriment of the
+  patient. It is first of all essential to closely examine and analyze
+  the symptom in itself. . . . Two years ago, after having overloaded
+  your stomach, you had a real attack of vertigo, which was repeated
+  several times during the day, until, by vomiting and diarrhea, the
+  contents of your stomach were evacuated. Since that time the fear of
+  vertigo has overpowered you. In my experience it is neither new nor
+  uncommon to find that a man who has shown his intrepidity and his
+  contempt of death on many a battlefield, who is a hero in war, may
+  be overcome by some dread of illness, by some anxiety, or even by
+  some pain, and may be distressed by it in a way that is in sharp
+  contrast to his whole personality. Your remembrance of that vertigo
+  is so lively that the mere idea of it suffices to reawaken the
+  symptom, or at least an imitation of it which very nearly approaches
+  the reality. That this idea is present in your case is quite certain
+  from the consideration of your symptoms. You admit that you almost
+  never have vertigo at home, but as soon as you leave the house, and
+  especially if you find yourself alone in the street far from home,
+  the remembrance of the vertigo comes over you, puts you into a state
+  of anxiety, and is followed by a sensation of tottering and swaying,
+  so that you have to stand still; and at last it has gone so far that
+  you no longer venture to go out alone. And so the hero of X sits
+  like a timid woman in his arm chair, making life bitter for himself
+  and for those around him.
+
+  Even were I to find that signs of arterial calcification were
+  present, I should still be satisfied that your vertigo is not due to
+  this cause, but that it is a vertigo of recollection and of fear.
+
+
+
+CHAPTER II
+
+CEREBRAL APOPLEXY
+
+
+Cerebral apoplexy is an extremely serious organic disease that seems
+surely to be an affection for which psychotherapeutics can mean little
+or nothing. When an artery has burst in the brain and blood is either
+actually flowing out or has flowed out in damaging quantities into the
+delicate brain tissues, seriously injuring and perhaps destroying some
+of them forever, no amount of mental assurance will do any good for
+the organic lesions that have been produced. All that can be hoped is
+that the hemorrhage will not prove fatal and that the powers of nature
+will be sufficient to deal with it, and though not able to cure it in
+the sense of restoring tissues to former conditions, will compensate
+for the lesion in some way and dispose of its products so effectually
+that but little interference will result with nerve functions within
+the skull.
+
+There is no pretence that by psychotherapy or any appeal to mental
+powers anything can be done for the underlying pathological process.
+And it may be frankly said that no remedy of any kind, physical or
+mental, will avail much, while some of those that have been suggested
+are just as likely to do harm as good. Position, with the head
+elevated and quiet of mind and body are the only remedial measures
+that promise definite help. Excitement greatly increases the danger.
+Reassurance does more than anything else to lessen blood pressure and
+lessen also the danger of a hemorrhage producing fatal effects. In
+nervous, excitable people the first stroke is often fatal.
+Occasionally the phlegmatic have three or more ruptures of brain
+arteries before death supervenes. Psychotherapy, then, has a definite
+role even at the time of the apoplexy.
+
+{514}
+
+The Mind Before and After.--Much can be accomplished for the patient
+by proper attention to his state of mind both before and after
+cerebral hemorrhage. There are many symptoms which point to the
+possible occurrence of the rupture of a cerebral artery, and older
+people are likely to know something about these and to dread them so
+much that to some extent they may by worrying precipitate the evil
+they fear. Many people, having read vaguely about apoplexy, having
+seen a case or two of it perhaps, and having heard of others, develop
+a dread of its occurrence in themselves that makes them miserable.
+Finally, the shock of a cerebral hemorrhage is very great and its
+after-effects likely to be very disturbing. It affects the whole
+personality and often makes a strong, vigorous, healthy man a decided
+hypochondriac. All of these associated mental states may be greatly
+benefitted by psychotherapy.
+
+A number of neurotic symptoms are always added to whatever
+manifestations of mind and the somatic system may develop as a
+consequence of the cerebral apoplexy, and these are treated more
+effectually by mental reassurance than in any other way. Besides,
+apoplexy confines people to the house who have often been vigorous and
+active before, and this confinement with deprivation of exercise and
+air and consequent disturbance of appetite and digestive functions,
+acts as a serious factor in the production of neurotic symptoms. Tears
+and hysterical manifestation are not uncommon, and for these
+psychotherapy is the most important remedial measure.
+
+In the period preceding true apoplexy there may be such symptoms as
+persistent headache with peculiar sensations in one hand. These
+sensations are variously described as creepy feelings or as of "pins
+and needles," and occasionally as if the fingers and sometimes the arm
+were asleep. The group of symptoms known as paresthesia are rather
+common as premonitory symptoms of cerebral apoplexy. When these are
+combined with headache patients often become seriously disturbed and
+begin to dread the occurrence of apoplexy. While these are premonitory
+symptoms of cerebral hemorrhage in those whose arteries are
+degenerated, patients must be made to understand that just because the
+fingers or hand or arm go to sleep occasionally, even though there may
+be complaint of headache, these are not indications of impending
+apoplexy unless other objective symptoms are present. Subjective
+symptoms alone can never mean much as regards organic disease. It is
+particularly neurotic individuals who are likely to exaggerate the
+significance of their subjective sensations, who are also prone to be
+so solicitous about apoplexy that they work themselves into a state of
+fear with regard to it. Even children have their hands go to sleep
+rather frequently, and at all ages if the arms or legs are placed in
+certain positions or under certain conditions of pressure, they are
+likely to develop that numbness which ends in the prickly "pins and
+needles" feeling that is spoken of as "going to sleep."
+
+
+Diagnosing Arterial Sclerosis.--Unless, then, some of the arteries at
+the periphery of the body show signs of such degeneration as to
+indicate advanced arteriosclerosis, any subjective symptoms, no matter
+how bothersome, must not be allowed to depress the patient. Usually
+they mean nothing at all, and would pass quite unnoticed but for the
+patients' nervousness about themselves. If the temporal arteries are
+not prominent and visibly thickened and tortuous, and this may be seen
+at a glance, the patient may be assured almost without more ado. If
+his radial arteries on careful observation show no signs {515} of
+degeneration, then it is extremely doubtful if there is sufficient
+arterial change in the brain to justify a fear of arterial rupture. In
+examining the radial artery it must not be forgotten that the pulse of
+nervous people, especially such as have exerted considerable mental
+control over themselves in order to come and see a physician about
+what they think is a serious condition, is likely to be of high
+tension. When the artery is rolled under the finger, then it may seem
+that there is some thickening in its walls, though it is only
+heightened blood pressure from emotion that causes the feeling. This
+high blood pressure may, of course, of itself be an indication of
+danger whenever there is heart or kidney disease, but it often occurs
+as a passing event in nervous patients whose vasomotor control is so
+capricious that arterial tension and blood pressure may change at very
+short intervals as the result of excitement.
+
+It may not be easy to obliterate the pulse in the usual way in many of
+these cases and as a consequence the illusion of a thickened artery
+may remain even when the vessel is quite normal. The important rule is
+to ascertain whether the artery is tortuous. Whenever there is
+thickening of the arterial wall the artery is lengthened as well as
+thickened. If the artery is not lengthened the degenerative changes in
+it are so slight, as a rule, as to be negligible. Indeed, the very
+beginning of arteriosclerosis may thus be diagnosed. When this cannot
+be found, patients may be completely reassured that their suggestive
+symptoms have no significance as regards any possibility of cerebral
+hemorrhage from the ordinary causes of advancing years and arterial
+degeneration.
+
+
+_Differentiation_.--Occasionally such paresthesiae as have been
+described especially when associated with headache, point to an
+intracranial growth, or to a developing syphilitic brain lesion, and
+these must be carefully eliminated, but they constitute quite separate
+problems which always present other accompanying symptoms that make
+diagnosis possible once a suspicion as to the nature of the lesion is
+aroused. Above all, these occur in much younger patients than are, as
+a rule, the subjects of cerebral apoplexy.
+
+
+Symptoms.--_Dreads--Dizziness_.--There are other symptoms of which
+people have heard as preliminary signs of brain hemorrhage which
+occasionally disturb them to a great degree and set up a set of dreads
+that may be difficult to banish. Probably the one that is spoken
+oftenest of is dizziness. There is no doubt that under certain
+circumstances this may be a symptom of impending cerebral hemorrhage,
+especially if it is accompanied by headache and by objective signs in
+the arteries, but dizziness by itself is not enough to justify any
+anxiety in even elderly people. If, when a man stoops over and then
+straightens up rapidly everything becomes black before him and he must
+immediately take hold of something to keep himself from falling, it is
+probable that a pathological condition of his cerebral arteries is
+present. This interferes with brain circulation and may have seriously
+impaired the elasticity of the arteries which is so necessary to
+overcome the rapid variations of the influence of gravity on the blood
+current when there are sudden changes of position. Fits of dizziness
+that come on immediately on rising in the morning, or that attack the
+patient when he sits up suddenly in bed may have the same serious
+significance. None of these signs are significant, however, unless
+there are, as we have said, objective signs in the arteries.
+
+{516}
+
+But dizziness may come from many other causes besides degeneration of
+arteries. A very common cause of it is the presence of gas in the
+stomach which interferes with the heart action mechanically and so
+disturbs the circulation. The column of blood to the head is more
+easily affected than the rest of the circulation because it must be
+pumped up directly against gravity when we are in a standing position,
+and so any, even a slight, interference with the heart action is felt
+at once in this portion of the body. Besides, the brain is extremely
+sensitive to changes of circulation and even a slight disturbance of
+the blood supply to it may cause dizziness. There occurs also
+undoubtedly a feeling of dizziness that is entirely subjective. The
+patient for some reason loses confidence in himself and has a feeling
+of dismay, as if he could not support himself. Such a patient may
+complain that when he comes down stairs, at the first step or two,
+particularly of a high stairs, he has the dread that he may pitch
+forward. Such people have never actually fallen, but they have to
+grasp the railing and they have a dread of some accident of this kind.
+This is, however, rather a form of akrophobia than a true dizziness.
+Prof. Oppenheim has dwelt on vertigo as a dread (see preceding
+chapter).
+
+
+_Vertigo_.--Besides, there are pathological conditions that cause
+dizziness yet have no connection at all with the dizziness that is a
+premonitory symptom of apoplexy. Menière's disease, for instance, even
+in its milder forms, causes at times a vertigo that is extremely
+annoying and that frequently gives rise to the fear that a serious
+brain lesion is either actually occurring or is impending. I have seen
+even comparatively young patients suffer so much from this dread that
+life became miserable to them and they were unable to do their work
+properly. A few words of explanation and reassurance literally work
+wonders for such patients. In one case the young woman assured me over
+and over again that my explanation meant a new lease of life for her.
+She still has occasional dizziness, but now she knows that it is due
+to her accompanying ear trouble and it does not worry her.
+
+
+_Motor Symptoms and Over-solicitude_.--Besides dizziness, there are
+other symptoms of which patients complain and which may indicate that
+an apoplexy is impending or may mean only that a patient is occupying
+himself too much with himself and his symptoms. Not infrequently when
+there is degeneration of arteries in the brain there will be slight
+weaknesses of the limbs or awkwardness in the use of them.
+Occasionally women will complain of the fact that they do not button
+dresses as they used to. Sometimes men will complain that they do not
+button their collar or their suspenders at the back with facility, or
+that they are awkward and grow fatigued easily in such strained
+positions.
+
+These symptoms may be indicative of some disturbance in the motor
+areas of the brain, but it must not be forgotten that all of these may
+be simulated by nervousness, especially if the person knows the
+meaning that is attached by doctors to these symptoms. In this matter
+particularly a little knowledge is a dangerous thing. We are only just
+getting a generation of trained nurses to the age when they are likely
+to suffer from dread of apoplexy and some of them are over-anxious
+patients because of their knowledge without the balance of complete
+practical experience with the meaning of such symptoms. Doctors
+themselves are prone to be disturbed by such thinking more than {517}
+almost anyone else. The delusion of thinking apoplexy is not at all
+uncommon in elderly physicians. In men it is important to insist that
+objective symptoms are the only details of real value and that
+subjective feelings are utterly illusory. If this cannot be brought
+home to them they make themselves extremely miserable and may even
+help to precipitate through worry the fatal complications they dread.
+
+
+Prophylaxis.--There is no doubt but that heredity plays an important
+rôle in apoplexy. In certain families most of the members terminate
+existence by rupture of an artery in the brain, sometimes at
+comparatively early ages. Apparently the resistive vitality of their
+arteries is only sufficient to enable them to maintain themselves for
+a limited length of time against blood pressure. They are destined to
+have arterial degeneration that will predispose to arterial rupture
+sometime before they are sixty. Father, grandfather and
+great-grandfather had their apoplexies from fifty-five to sixty-five
+and the son must realize that he probably will go the same way. Even
+the delay of a year or two is important. Anything that will save the
+wear and tear of existence may bring about such a delay and it is not
+by drugs, nor even by dietetic precautions, so much as by attention to
+the patient's state of mind that this decided benefit can be best
+secured.
+
+
+_Over-indulgence_.--People with such an unfortunate heritage should be
+made to understand reasonably early in life that they must save
+themselves from as much arterial wear and tear as possible. There are
+certain occupations involving intense emotion and excitement that are
+barred to them if they want to live out their lives, even to the
+extent usual in the family. There are three causes that weaken
+arterial walls. When the question of causation of aneurism is
+discussed it is usually said that it is especially the devotees of
+three pagan deities--Venus, Bacchus and Vulcan--who suffer from this
+form of arterial trouble. Just this same class suffer particularly
+from the tendency to early arterial rupture in the brain. Under the
+head of devotees of Vulcan, the hard workers, must now also be placed
+the advocates and exemplifiers of the strenuous life, who are
+perpetually doing, though often it is hard to see what they
+accomplish; the money-getters, who are really overworking as much as
+the forced laborers of olden time. People with an apoplectic heredity
+should not take up such professions as that of the actor, the broker,
+the speculator of any kind, the lawyer absorbed by the strain of trial
+work, perhaps not even that of the surgeon. Physicians generally are
+not long lived because of the irregularity of their hours of eating
+and sleeping and the responsibility of their professional life.
+
+Many men will not be guided by such considerations and insist on
+living their lives in their own way in spite of the possibility of the
+family inheritance shortening their career in the late fifties. More
+than one has said that he would prefer to have the life of the salmon
+rather than that of the turtle. The strenuous life alone appeals to
+them.
+
+  "Better fifty years of Europe than a cycle of Cathay."
+
+This would be an admirable response if what these men accomplished
+during their lives amounted to anything. Most of these who run out
+their existences in the midst of excitement, however, only do harm by
+adding to the swarm of speculators in life, or accomplish very little
+because of the intense {518} excitement under which they labor. It is
+the quiet lives, doing a few things and doing them well, outside of
+the strenuous current of the bustle of existence, that accomplish most
+for mankind. The others may attract attention for the moment, but they
+soon pass out, often having done rather harm than good.
+
+
+_Life-direction_.--It is perfectly possible for the physician to make
+this clear to a young man with a dangerous heredity and perhaps change
+the current of life so as to make it effective in simplicity and
+serious patient work. The young man will usually be quite impatient to
+think that anything thirty years ahead should be expected to influence
+his decision as to how or what he shall do with life, yet this motive
+added to others may help to get at least some of this and the next
+generation from wasting their lives in an over-strenuous existence
+that at most merely accumulates money, often accumulates it only in
+order to lose it, with consequent disappointment and worry, and
+frequently leaves no real accomplishment but only the problem of the
+disposal of accumulated wealth for future generations. Where large
+wealth is left to the succeeding generation there is usually little
+use to give any advice with regard to the possibility of early
+apoplexy, because excitements of other kinds than those of business,
+of the heart rather than the mind, are likely to wear out existence
+even before the time when the family life of arteries ordinarily,
+though precociously, runs itself out.
+
+Certain people have what is called the _apoplectic habitus_, that is,
+they are short in stature, rather stout, with short necks and florid
+complexions. It seems not unlikely that the mechanical arrangement
+within their bodies by which the distance from their heart to their
+brain is so much shorter than in ordinary persons is responsible for
+the tradition so generally accepted that there is a definite tendency
+in such people for apoplexy to occur at a comparatively early age.
+Such people should be warned gently but firmly of the danger that they
+incur if they subject themselves to a life of excitement or emotional
+stress or permit themselves to get into circumstances in which they
+will worry much. It may seem as though a warning of this kind would
+precipitate the worry of mind that it is meant to ameliorate, but in
+present-day publicity such people are likely to have heard of the
+meaning of their particular constitution of body and consequently
+worry about it, but usually after it is too late to do any good. In
+this matter, as in heart disease, the warning must come before there
+are any symptoms, or else must not be used at all.
+
+
+_Certain Abuses_.--In most of these cases definite warnings with
+regard to habits of life and indulgence in stimulants and narcotics
+should be given. Both Prof. Von Leyden and Prof. Mendel of Berlin
+insist that for patients in whom there is any likelihood of the
+development of early apoplexy indulgence in alcoholic liquors is
+almost sure to be serious, but in addition to this generally accepted
+warning, both of them also insist that smoking has a tendency to
+produce serious, premature degeneration of arteries, especially in
+people who already have tendencies in that direction. Overeating and
+high living in general without moderate exercise causes a plethora of
+the circulation that must be avoided. On the other hand, violent
+exercise, running especially to catch trains or cars, haste in the
+ascent of stairs or hills, heavy lifting, straining at stool, and the
+like, are particularly prone to have serious consequences for such
+people. This warning is all the more needed because many a short,
+{519} stout man acquires the idea that gymnastic work and various
+exercises indoors may help him to reduce his weight and restore the
+activity of his earlier years. This is practically always a delusion
+and indoor gymnastic work is always of dubious value.
+
+What these people need is not more muscle and the wearing off of fat
+but more air and the burning of it off by increased oxidation. Such
+patients must be taught to lead tranquil lives without any of the
+excitement and strenuosity that, after all, accomplishes so little.
+The sacrifice when first suggested, appears too great a one to make,
+but after a few years patients instead of feeling that it was a
+sacrifice at all pronounce it to be a blessing in disguise and are
+proportionately grateful to their physician. Life for many of these
+people may be prolonged not for a few years of hustle-bustle, but for
+many years of good work in quiet and peace, without hurting others by
+competition, but helping many because there is time in their
+considerate lives to see something of the sorrow and suffering around
+them and to relieve it.
+
+
+_Change of Occupation_.--In the matter of prophylaxis it is
+particularly important to insist on the fact that when men have worked
+at hard manual labor when they are young and then, about middle life,
+have turned to intense intellectual labor, such as the management and
+administration of important affairs, they are a little more liable
+than are the general average of humanity to have an apoplectic seizure
+at sixty or a little later. Apparently inurement to a particular kind
+of labor when young makes for the capacity to stand it longer than
+would otherwise be the case. In this matter, however, the most
+important factor is heredity. Men who come from long-lived families
+are likely to live long--indeed far beyond the ordinary term of human
+life. Even in them, however, certain of these directions are helpful
+in securing the full measure of life.
+
+
+After the Stroke.--After a stroke of apoplexy when it becomes clear
+that nature is about to reassert her control over the circulation in
+the brain and dispose of the remains of the old hemorrhage,
+psychotherapeutics is more important than anything else that we have
+for the treatment of these patients. As a rule, they have been active,
+vigorous men who are stricken and who suffer more from doing nothing
+and waiting to get better than from any pain they have to undergo.
+They know that another stroke may come at any time. It is no wonder
+that introspection plays its part, that every feeling that they have
+becomes exaggerated in significance, that their appetite fails them,
+that their bowels become sluggish, that they do not sleep, or that
+after having fallen asleep they wake up and then for hours lie awake
+thinking.
+
+
+_Lack of Air and Exercise_.--As they usually have no exercise of any
+kind, do not get out into the air, and have very little diversion of
+mind, it is easy to understand that neurotic or hysterical symptoms
+develop, that they lose all confidence of recovery and make themselves
+even worse than they are by dwelling on their condition. The only way
+that this group of symptoms can be treated is by favorable suggestion,
+by encouragement, by mental reassurance and by occupation of mind.
+
+I have always felt that the condition of affairs which developed in a
+family immediately after the occurrence of an apoplexy usually makes a
+very unfavorable environment for the treatment of these cases. It is
+practically impossible for those who come to visit the patient or for
+the members of the {520} family for some time to wear anything but the
+resigned air that indicates that they fear the worst.
+
+
+_Sympathetic Care_.--After the stroke at once when survival is assured
+comes the question of the management of the patient. A devoted
+daughter seems to be able to do more for an apoplectic father than
+anyone else. Somehow her youth appeals to him sympathetically, and he
+has not that feeling of sadness mixed with a little envy that comes so
+readily to all men when they find themselves slipping out of life
+while their contemporaries and friends and relatives are left behind.
+It is as if the idea of his daughter being young and strong, even
+though he has lost vitality, docs not touch him poignantly because he
+has always expected that she should have health and strength after he
+was gone. On the other hand, a daughter is not always a good nurse for
+a mother. Just why, is hard to say. A hired nurse must take, as a
+rule, the place close to the mother which, in the case of the father,
+so naturally falls to the daughter. These ideas may be founded on too
+few cases to generalize very much about, but I have discussed them
+with many physicians, including some women physicians, and they agree
+with them, in general principle at least.
+
+
+_Trained Attendance_.--As a rule, then, the first thing that has to be
+done for a patient who has had apoplexy and who is beginning to
+recover, is to have trained attendants near him who talk
+professionally to him and reassure him and do not make him feel
+constantly the possibility of an approaching end. If his improvement
+has begun his family must not be allowed to bother him, his affairs
+should not be talked over and, as far as possible, some occupation of
+mind should be secured for him. He needs new interests at once. These
+must be gradually awakened and he must be made to feel as early as
+possible that though he may be more helpless than before and most of
+his ordinary occupation in life may be cut off, there are still many
+interests in life which he may thoroughly enjoy. I shall never forget
+hearing Thomas Dunn English, the dear old poet to whom in his earlier
+years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the
+University of Pennsylvania that he used to think that all the good
+things of life were somehow contained in its first eighty years, but
+that now since he had past his eightieth birthday (he was at the time
+in his eighty-third year) he was beginning to agree with Bismarck, who
+declared under similar circumstances that he had found many interests
+in the second eighty years of life. At the time English was quite
+blind, was almost completely deaf, had been seriously ill for several
+months, and had suffered a rather severe stroke some years before; and
+yet he made the best speech at the dinner that evening and had the
+youngest heart of us all--joyous, uplifting, encouraging, optimistic.
+
+
+_Outlook_.--Men who have been great workers are prone to think that a
+stroke of apoplexy means the end of all serious work. Of course, it
+means nothing of the kind for the majority of patients. Many men find
+not only enjoyment in life after their recovery from even a serious
+stroke, but also possibilities of accomplishment sometimes better than
+they had done before. It has even been known that men who had been
+occupying themselves with things scarcely worth while, with the mere
+accumulation of money without any purpose, were awakened to a sense of
+their responsibilities to life and to their fellowmen by a stroke and
+planned in the after years institutions or aids to {521} existing
+institutions that did much to make life more livable for others.
+Nothing makes a man face life in a better mood to do really effective
+service for mankind than the prospect of possibly soon having to go
+out of life.
+
+
+_Encouraging Examples_.--On the other hand, many men have been able in
+spite even of a severe stroke to go on after a time with the work they
+had been at before and, though feeling its effects, accomplish the
+best achievements of their lives. A typical example is the case of
+Pasteur, the great French bacteriologist, to whom we owe most of our
+modern preventive medicine and to whom Lord Lister frankly attributes
+the germ idea of the antiseptic theory. When little past fifty,
+Pasteur after years of hard work and worry suffered from a severe
+stroke of apoplexy followed by several of slighter character. It
+seemed absolutely the end of his labors. For more than a year he was
+able to do nothing. For all his after life he was seriously lame as a
+consequence of his stroke. In spite of this, which would seem to
+preclude the possibility of great intellectual work, Pasteur's most
+important discoveries were developed after this time and he continued
+for over twenty years to be the leader of biological science. Had he
+died at the age of fifty or given up his work we would scarcely know
+him for the great scientist that he afterwards proved.
+
+It is worth while to be able to tell the stories of such lives as
+examples to patients who are dispirited and downhearted after a
+stroke. Of course, men must be prevented from doing hard work or from
+worrying during the time immediately following the hemorrhage of the
+brain, and, indeed, for some months. Work and worry, though worry much
+more than work, might easily hasten a recurrence of the seizure. It
+has always seemed to me, however, that it is impossible to keep the
+human mind utterly unoccupied. Men must think about something during
+their waking hours, and if they have not some interests close at heart
+they worry about themselves. Of the two things, worry is much harder
+on the tissues, raises blood pressure more, disturbs the circulation
+of the brain to a greater degree than does work. Anything that a man
+will interest himself in, then, should be allowed to him, provided, of
+course, that he is kept from getting into the state of mind which
+precipitated the rupture of the artery in his brain. It is a change of
+mental occupation above all that is needed and this is secured by
+deliberate attempts to interest his mind in various ways and keep him
+from dwelling on himself and his ills. This injunction cannot be
+repeated too often.
+
+
+_Change of Mental Interest_.--I have already insisted in the chapter
+on Diversion of Mind that so far as we know at the present time
+different portions of the brain are occupied with different subjects
+in which we may interest ourselves. When a man by business worries,
+occupation with financial affairs, or with political troubles, has
+apparently worn out one portion of his brain, he may still use other
+portions to decided advantage. Hence the necessity for finding new
+interests for the apoplectic after their attack. The best interests
+for them are those associated in some way with their fellows, because
+these are accompanied by feelings of consolation, of encouragement, of
+desire to live and do good to others. These do more to take men out of
+their moodiness, their morbid introspection, and their
+self-centeredness, than anything else. With the help of a good nurse,
+herself of broad interests, this must become the main purpose of the
+physician's treatment.
+
+{522}
+
+_Misplaced Sympathy_.--After the first few days, when the shock is
+over, a strong, healthy man who has been suddenly taken down with
+apoplexy, then rendered helpless as a consequence of the lesion in his
+brain, rather resents the sympathy and, above all, the frequent
+expression of the feelings of his friends towards him. Time is needed
+for him to recover, there is no way of hastening it, he is already
+impatient at the delay and words of sympathy do him very little good
+and often add to his impatience. He is to be taken absolutely with
+professional calm, made to understand that time is the most important
+element in his cure, provided he will not worry and will have patience
+to wait and to help as far as he can. I nearly always feel that it is
+better for these patients to be away from home as soon as they can be
+moved with safety. This enables them to avoid without much difficulty
+what they are apt to consider the intrusive and obtrusive sympathy of
+friends. Especially is this true of business friends, themselves in
+good health, who come to offer their condolences.
+
+Their hysterical condition is largely influenced by the fact that they
+are indoors and have so little diversion of mind. Just as soon as
+possible they must get out of doors. Over and over again I have found
+that patients did not care to expose themselves to the inquisitive
+gaze of neighbors and preferred to stay in the house, though the
+outing would be of much benefit to them. Hence the necessity for
+getting them away from home, among people whom they can observe
+without attracting too much attention themselves and, above all,
+without being the subjects of such obtrusive pity as will disturb
+them. None of us likes to be pitied and least of all the strong,
+vigorous man who often has had nothing the matter with him all his
+life and is now suddenly stricken. It requires years of experience to
+enable one to take sympathy properly and without resenting it.
+
+
+_Outings and Human Interests_.--When patients care for carriage riding
+I have found that the city park is an excellent place for patients
+suffering from the effects of apoplexy, who require outdoor air and
+diversion of mind, yet without exercise or much exertion. The children
+in the park, if they play around, serve as a better diversion of mind
+than almost anything else for elderly people thus stricken, for they
+seem to renew their youth at the sight of the little ones.
+Grandchildren make the best possible consolers even when they seem to
+probe deep into old wounds by asking questions and by talking about
+death. The talk of death from young lips has not the same disturbing
+effect as from older people. The games of children interest the old
+once more, and if there is occasional music and the chance to see the
+passing throng of carriages and motor cars and the pleasure boats and
+all the rest there is refreshment and reinvigoration in it all that
+soon brings back to the patient deep, satisfactory, even dreamless
+uninterrupted sleep at night, and appetite and strength. At first
+there will usually be some objection to being thus treated as an
+invalid, but only a few days of experience are needed to convert even
+the most morbid to the idea that this outing will do them good. As a
+rule, friends must be warned not to spoil the effect of it by fearing
+lest the patient should be lonely and so go to the park to entertain
+him. If the drive, the lake and the children, as well as the
+passers-by, do not suffice to give the patient sufficient diversion of
+mind, the visits of friends will not have any favorable effect. As a
+rule, it is better for them to see the {523} patient at home and even
+that not too often unless they are of his immediate family.
+
+Where people are able to go away and, above all, where they can have
+some pleasant companionship, a seaside resort is an ideal place for
+those recovering from apoplexy. The long ride in a wheel-chair on the
+boardwalk at least several hours in the morning and afternoon soon
+acts marvelously. There is constant diversion of mind at any season of
+the year, for there are lots of people to be seen in all sorts of
+costumes and the shops and the shows and the passing throng all have
+their interests. Then the sea air is bracing and tempts to
+sleepfulness and just as soon as sleep improves courage comes back. I
+have known patients so hysterical that they were crying every day and
+that seemed to have given up all hope, improve so much in two weeks at
+Atlantic City that it seemed little short of marvelous. What is
+needed, however, is not a stay of a few weeks but of several months.
+
+
+Prognosis of Strokes.--While, of course, any single stroke may be
+fatal and no one can tell anything about the prognosis of a rupture of
+a brain artery, there are many favorable things that can be said to
+patients, and they are so prone to think of all the unfavorable things
+that this better side should be presented to them at once. The
+physician is tempted to present the worst side of the case lest it
+should be thought that he did not realize how serious the condition
+was. All the seriousness of it may be impressed upon friends, but the
+patient must be told all the possibilities of good. I have always felt
+that the tonic quality of hope was worth more in preventing further
+damage and in encouraging the beginning of repair than any drug that
+we have. If patients have been unconscious, just as soon as
+unconsciousness disappears, they should be told that very probably
+this is the beginning of recovery and that the great majority of
+people who have a stroke recover. The more rapidly the symptoms
+disappear the better is the ultimate prognosis. Many a man who has had
+a stroke has done years of good work afterwards and very few men who
+recover fail to accomplish something that is of supreme satisfaction
+to them. They have a new outlook on life as a consequence of the near
+vision of death.
+
+Those who have had one stroke usually die in a subsequent one, though,
+of course, some intermittent disease such as pneumonia or some organic
+complication may anticipate the second stroke. Those who have had two
+strokes and survive are often much worried by the old tradition that a
+third stroke is always fatal. I am reasonably sure that many old men
+have not survived their third stroke when they felt its premonitory
+symptoms and knew just what was coming from their previous experience,
+because they had given up hope on account of this old tradition.
+Ignorant people or those of the lower classes who have not heard this
+axiom often survive their third stroke and I have seen a man who had
+suffered from seven apoplectic seizures.
+
+
+Complications.--Occasionally a patient, especially if of the educated
+classes, may be much worried by the fact that while one side is
+distinctly lamed after his stroke, yet there is also a pronounced
+weakness on the other side of the body. This sometimes gives rise to
+the rather appalling thought that there was perhaps a simultaneous
+rupture on both sides of the brain. It needs to be explained to such
+patients that this slight weakness, sometimes quite distinct, however,
+on the side opposite that which is most affected is extremely {524}
+common. Ordinarily the rupture of an artery on one side of the brain
+causes a paralysis on the other side of the body. This paralysis or
+loss of control over muscular action is due to disturbance of the
+motor tracts of nerves through which muscular action is controlled and
+directed by the brain, and these normally cross to the other side on
+the way to the periphery. In nearly everyone the tracts remain
+uncrossed to some slight extent. In some so much of the pyramidal
+tract remains uncrossed that there may be decided weakness on the same
+side as the lesion in the brain.
+
+
+
+CHAPTER III
+
+LOCOMOTOR ATAXIA
+
+
+How much can be done for organic nervous disease by attention to the
+individual patient and by favorable suggestion is illustrated in
+locomotor ataxia. This is, of course, an absolutely incurable disease.
+We know definitely that certain tracts of nerves in the spinal cord
+are entirely obliterated and their functions can never be restored.
+Occasionally the disease gives rise to severe localized pains called
+crises, for which even our strongest anodyne remedies are of little
+avail. As a rule, the patient grows more and more helpless and though
+he may live for twenty or thirty years after the beginning of the
+disease, and usually dies from some intercurrent affection rather than
+from any direct effect of his disease, the condition is burdensome and
+the outlook is most unfavorable and depressing. It is for locomotor
+ataxia, however, that the irregular practitioners have succeeded,
+apparently, in working wonders. Some of them, indeed, have made quite
+a reputation for the cure of the disease. This was not because they
+did the impossible and cured genuine cases, but because individual
+patients can, in many cases, be so much improved by attention to
+particular symptoms, and so much can be done to make life more livable
+for them, that it is no wonder that so many of them are ready to
+proclaim that they have been cured, though only certain symptoms, are
+bettered and their underlying disease remains in essence unchanged.
+
+One thing that constantly happens in the progress of locomotor ataxia
+is a yielding of joint capsules and attachments so that there is more
+motion permitted in joints than is possible in the normal individual.
+As a consequence of this relaxation of tissues around the hip joint
+the leg may be stretched up along the trunk when the patient is lying
+down, the foot being placed over the shoulder almost as a gun is
+placed at carry-arms. Patients often walk with a distinct "back knee"
+because of the yielding of the tissues around the knee-joint. The
+ankle nearly always yields and a specially severe form of flat foot
+develops. This causes muscles to act at a disadvantage and produces
+great fatigue and even a painful muscular condition when the patient
+stands much on the feet. This form of flat foot is hopeless so far as
+cure is concerned, but it can be greatly relieved by the wearing of
+flat-foot braces or even, to a greater degree, by the wearing of
+specially fitted shoes. This does not seem much to do for a patient
+suffering from the serious organic nervous disease of locomotor
+ataxia, and yet a lot of patients for whom properly fitting shoes
+{525} were made, thought themselves so much improved and relieved by
+this simple measure that they allowed themselves to be persuaded that
+their locomotor ataxia was cured. In some cases, where the brunt of
+the disease was borne by the feet, this relief really did so much to
+afford the patients freedom from most symptoms of their affection that
+they thought themselves on the road to recovery.
+
+
+Value of Favorable Suggestion.--If once the idea of the awful
+hopelessness of their cases is removed from locomotor ataxia patients
+they will suggest their own betterment so powerfully that they easily
+persuade themselves that their affection is considerably improved. It
+is evident, then, that the regular physician must take advantage of
+this wonderful power for the relief of human suffering and depression
+that proves so helpful to the irregular. We cannot cure the tabes of
+the spinal cord. We cannot re-create the nerve tracts that have been
+obliterated. We realize that there is no use trying to do so any more
+than there would be in trying to make an amputated finger grow to its
+full size again. We can treat the patient, however. We can remove many
+symptoms that sometimes bother him more than those necessarily
+connected with his spinal affection. We can relieve annoyances of all
+kinds that add to his misery and as a consequence we can give him
+hope, keep him from brooding about himself and thus perform the proper
+function of a physician. We shall not forget that we can only rarely
+cure, but we can almost always relieve pain and we can always help the
+patient in some way. The ataxic patient needs consolation, and this
+can be given without in any way deceiving him. The loss of sight seems
+an irreparable ill to those who see, yet the blind are quite happy,
+are much more cheerful than many seeing people, and have learned to
+stand their affliction not only with equanimity but really without
+much depression. In the olden times, before proper care was taken of
+the blind, they had little occupation, they had nothing to do with
+their hands, the future was blank and they suffered severely from
+depression. As a rule, they did not go out enough and their bodily
+health suffered and the disturbance of their functions still further
+heightened their depression. All of this happens now with the ataxic
+patient. A host of symptoms not at all necessarily connected with his
+spinal affection develop and prove sources of annoyance. Many of them
+can be removed entirely, all of them can be ameliorated. If, while
+doing this, we succeed in impressing a discouraged patient's mind with
+our power to benefit in spite of an underlying incurable disease, we
+have another triumph of psychotherapy.
+
+
+Removing Unfavorable Suggestions.--The general experience with those
+suffering from locomotor ataxia has been that the depression
+consequent upon the announcement that they have the disease and the
+stigma that is supposed to attach to it in our day leads them to a
+great extent to avoid going out into the air. This adds woefully to
+their depressed condition. Take a healthy man, let him stay inside a
+great part of the time without any exercise, seeing no new faces,
+without any interests in life, and at the end of three months he will
+have a set of neurotic symptoms on a basis of depression that will
+make him supremely miserable. This will be true even though he has not
+the threat of an incurable disease hanging over his head. He must be
+made to realize that every neglect of any law of health in his
+condition is even more serious in its effect upon him than it would be
+were he in good health. Above {526} all, it must be made clear to him
+that while his neglect of hygiene may perhaps not shorten his life, it
+will greatly add to the mental suffering, much more unbearable in its
+way than the physical suffering which he will have to endure during
+the progress of his disease.
+
+
+Treating Accessory Symptoms.--Nearly every ataxic patient who is not
+directly and almost constantly under the care of a physician, is a
+sufferer from two conditions that are so constantly present that they
+are sometimes thought to be consequences of the primary affection.
+These are loss of appetite with consequent loss of weight and
+constipation. Almost without exception neither of these symptoms or
+syndromes are at all connected with the locomotor ataxia. They are the
+result of the unhygienic life that the patient is living and of the
+depressed state of his mind and lack of diversion. They are mutually
+connected, for a man who does not eat enough will not have regular
+movements of his bowels, and constipation reacts to produce further
+depression. A vicious circle in pathogeny is formed and the patient is
+likely to get into a very debilitated and depressed condition. Both of
+these troublesome symptoms may be corrected to the manifest
+improvement of the patient by proper advice and ordinary care for his
+well being.
+
+Appetite is largely a function, as the mathematicians say of something
+that depends on something else, not of exercise, as is often thought,
+but of fresh air. In the tuberculosis sanatoria patients with fever
+are not permitted to take exercise, yet if they are out in the air
+most of the day and if their rooms are well aired at night, they can
+eat heartily and digest their food well. Of course, appetite is
+largely a psychic matter and the thoroughly discouraged man will have
+no care for food in spite of abundance of air. A little persuasion,
+however, of the necessity for making the best of a bad job will
+usually arouse even a locomotor ataxia patient in the early stages of
+his disease to the necessity for eating a reasonable amount. If he has
+suffered from gastric crises and fears that eating normally may
+precipitate these, he must be persuaded that this is not the case,
+that the presence of food, or its amount, or quality, has nothing to
+do with the initiation of these painful attacks so far as we know, and
+that even though at the beginning of his affection before his
+locomotor ataxia was recognized, his gastralgia may have been declared
+by his physicians, as is so often the case, to be connected with some
+form of gastritis or indigestion, that idea may now be given up and he
+may eat plentifully with confidence that it will not increase his
+pains. On the contrary, limitation of food seems to have a distinctly
+unfavorable effect in increasing the number and severity of these
+attacks.
+
+The same thing must be made clear to him as to intestinal and rectal
+crises. It seems likely that tendencies to constipation by irritating
+peripheral nerve endings may have some effect in bringing about the
+explosion in sensory nerves which have been called intestinal or
+rectal crises. In general, however, these are dependent on spinal and
+not peripheral conditions, and no thought of any connection must be
+allowed to disturb the consumption of a proper amount and variety of
+food. It seems clear that when patients are much run down, have lost
+considerable in weight and are in a generally depressed condition,
+their nervous system is much more irritable than it would otherwise be
+and they are likely to suffer more frequently from crises of various
+kinds. Once a patient is made to understand that his general {527}
+nutrition may affect not only the course but the occurrence of
+symptoms in the disease, as a rule it is not difficult to get him to
+eat enough and to do so with the definite feeling that it is going to
+do him good. Even though it should be necessary to use tonics, and
+often they will have to be prescribed, it is clear that this treatment
+of the patient's general condition is the physician's first duty,
+though it does not and cannot affect the specific disease.
+
+
+Neurotic Complications.--There can, of course, be no doubt that the
+crises of locomotor ataxia represents extremely poignant attacks of
+pain. But on the other hand, anyone who has seen many of them is prone
+to think that not a few of them are really attacks of pain resembling
+those which occasionally develop in hysterical subjects. The pain of a
+gastric neurosis may, indeed, so simulate the gastric crises of
+locomotor ataxia as to make what is only a case of hysteria seem
+beyond doubt one of locomotor ataxic. Locomotor ataxia patients are
+prone to think much about themselves and to fear the recurrence of
+these painful crises once they have had experience with them. As a
+consequence they sometimes suffer from what are pseudo-crises, that
+is, from neurotic painful conditions which simulate genuine crises
+mainly in the amount of reaction they produce in the patient. True
+tabetic crises yield more readily to ordinary anodyne drugs than do
+these pseudo-crises. Nearly always the true crises are associated with
+and exaggerated by neurotic symptoms due to the depression of the
+patient, the yielding to his feelings, the conclusion that his pain is
+inevitable and is going to be worse each time, while successive crises
+are, as a matter of fact, often milder until they disappear for good,
+and this element in the case must always be borne in mind. Much can be
+done for the relief by psychotherapy, that is, by making the patient
+see the realities of his condition, suggesting to him that succeeding
+crises are less painful and that if his general condition is as good
+as it should be he becomes better able to stand the pain of his crises
+and the shock of them is not so disturbing to his system.
+
+
+Mental Attitude.--Prof. Oppenheim, in one of his "Letters to Nervous
+Patients," advising a patient suffering from an incurable organic
+nervous disease, evidently locomotor ataxia, though that is not
+explicitly stated, outlines emphatically the favorable side of that
+disease. This is absolutely needed. Ever so many unfavorable
+suggestions with regard to his affection find their way to the
+patient. The very fact that it is pronounced absolutely incurable is
+disheartening. Prof. Oppenheim's words, then, may be a precious help
+and to have them repeated from time to time renews the suggestion:
+
+  Now, however, we neurologists know that that disease frequently runs
+  a very mild course, that a man showing certain early symptoms of
+  such a disease may for ten to twenty-five years and even longer
+  retain his capacity for work and enjoyment. This for a man of thirty
+  to forty years is almost tantamount to the expectation of a whole
+  normal lifetime. But on the other hand, what danger to the peace of
+  mind, what destruction of happiness in life may be caused if the
+  knowledge that such a disease has begun to develop is imparted to
+  the patient without being combined with the consoling information as
+  to the nature and course of the benign forms of this trouble! In
+  unceasing anxiety and fear, in daily expectancy of some fresh
+  symptoms, of some increase or aggravation of his troubles, does the
+  poor man waste his life; and I have frequently found that this
+  wretched apprehension and excitement cause a nervousness and mental
+  depression which in their effects are much more momentous than is
+  the commencing spinal disease.
+
+  From this miserable condition I desire to protect you, and I would
+  ask you to {528} take this advice deeply to heart: do not bear
+  yourself as one who is condemned; as one who, affected by a
+  progressive, incurable disease, will soon fall a victim to
+  paralysis. On the strength of my own experience I give you the
+  assurance that your condition of health will not necessarily in ten
+  years' time be essentially different from what it is at present. But
+  I would also strenuously exhort you to observe all the precautionary
+  rules laid down for you, to avoid all unaccustomed strain or
+  indulgence such as can only be undertaken with impunity by a man in
+  full vigor and absolute soundness of health. I would advise you also
+  to be thoroughly examined once a year by an experienced physician.
+  But apart from these restrictions, you should as far as possible
+  feel yourself and bear yourself like a healthy man, remaining
+  attached to your work, and not withdrawing yourself from the
+  pleasures of social intercourse.
+
+
+Relearning Muscular Movements.--Perhaps the most interesting evidence
+of how much may be done for organic nervous disease in spite of the
+fact that the underlying lesion is absolutely incurable, may be
+obtained from what is accomplished by Frenkel's method of treating
+locomotor ataxia. As is well known, by reteaching the movements
+necessary for walking, ataxic patients regain control of the movements
+of their limbs to a marked extent. As a consequence, bed-ridden
+patients are enabled to walk once more even though they may have to
+carry a cane and be supported, and patients who have had to use two
+canes get along with only one, or may even eventually be able to walk
+without any artificial support.
+
+Just how the improvement is brought about we are not quite sure. It
+seems probable that the eyes become trained to replace the muscle
+sense to a noteworthy degree, but there is in addition apparently a
+re-education of the muscle-sense. Perhaps there is also a transfer of
+the function of certain degenerated nerves to other tracts than those
+in which muscle impulses originally traveled. The improvement in
+muscular control originally obtained is a striking illustration of how
+much nature is able to compensate for even organic lesions and is a
+lesson in the necessity for never ceasing to try to do something even
+when the case seems hopeless. Certainly locomotor ataxic patients
+would seem the least likely to be benefited by training in movement
+and yet this movement therapy for tabes has had some wonderful
+results.
+
+The story of how this mode of treatment came into existence is
+interesting and instructive as an illustration of how happy chance in
+our time, as so often with regard to drugs in the past, came to assist
+the rational development of therapeutics. A German professor wished to
+demonstrate to his class the varying inco-ordination of a series of
+tabetic patients. Some of them had their main inco-ordination in the
+legs, others in their hands. He went over the cases in his wards so as
+to arrange the demonstration for the next day. He told each patient
+that he would ask him to perform a particular set of movements before
+the class which would illustrate strikingly a particular phase of
+muscular inco-ordination. His patients were interested in the
+announced demonstrations and during the afternoon they went over the
+movements that they were expected to perform. They practiced them as
+assiduously as their condition permitted for the exhibition. As a
+consequence the most striking features of their inco-ordination
+disappeared. After having practiced the movement for a certain length
+of time they could do it ever so much better than before. The special
+feature of the professor's demonstration was spoiled, but a great
+contribution to our knowledge of nature's compensatory powers {529}
+was made and fortunately the hint of its significance for treatment
+was taken and developed.
+
+
+Effect of Favorable Suggestion.--How much can be accomplished for the
+relief of the general symptoms of locomotor ataxia and for the placing
+of patients in an attitude of mind that makes most of their symptoms
+of vanishing importance, can be judged from some recent experiences
+with a new cure for the disease. This consisted only of some rather
+conventional treatment of the urethra by applications and dilatation,
+yet patients were relieved so much of the symptoms of locomotor
+ataxia, or at least persuaded themselves that they were, that both in
+this country and in Europe the discoverer of the new "cure" soon had
+scores of patients. The active therapeutic agent undoubtedly was the
+fact that patients who had been told that their disease was incurable
+and who had settled down in a state of discouragement and apathy in
+which their power over their muscles, their general health and their
+strength and vitality were at the lowest ebb, and their tendencies to
+discomfort emphasized and made poignant by the supposed hopelessness
+of their situation, became aroused to new vitality by the promise of
+cure and then, under the repeated suggestion of a treatment said to be
+sure to cure them and that had cured others, became so much better,
+that is, released so much latent energy, that they felt better, ate
+better, walked better, got out more and had their general health
+improved, and all to such a degree that their disease seemed cured.
+
+Another interesting illustration of what would seem to be the power of
+suggestion over the symptoms of tabes occurs in a recent article in
+the Archivos Españoles de Neurologia Psyqiuatria y Fisioterapia of
+Madrid   [Footnote 39] on the improvement of tabes dorsalis by
+antidiphtheritic serum. It is quite impossible that the serum should
+affect favorably any of the underlying lesions of the disease any more
+than that these should be ameliorated by the wearing of shoes of
+special character or operations on the urethra. The patient in this
+case, however, was distinctly improved in many ways _after_ the
+antidiphtheritic serum was injected. There were some interesting
+sensory manifestations, pains in the arms and legs after the
+injection, but these were removed by santonin or methylene blue. Both
+of these drugs are eminently suggestive in their action, so that one
+would be prone to think the pains rather neurotic than actual. After a
+dozen injections had been given, the patient's sensations improved,
+his power to pick up small things was better, and the sense of walking
+on carpet had disappeared to a marked extent and he was able to walk
+much better than before and without support. Probably any attention
+given to him to the same degree would have produced like results.
+
+  [Footnote 39: Tomo 1 No. 7, July, 1910.]
+
+We have had previous examples of this kind in the history of the
+treatment of locomotor ataxia. Certain drugs when given in the past
+with the definite promise of cure and pursued for a good while with
+frequently repeated favorable suggestions, have often seemed to
+benefit patients, though subsequent experience has shown their total
+lack of value to modify the disease. Nitrate of silver was one of
+these in the old days and many locomotor ataxia patients acquired an
+argyria as a consequence of the amount of silver absorbed and
+deposited in the skin. Arsenic was another and some of the aluminum
+{530} compounds were also used. When we recall the suspension
+treatment and its reported good effects--and failure, the
+over-extension treatment with the same history and many others in the
+past, the real place of the mental in the therapeutics of tabies is
+revealed. Once this is practically realized, we find that we have
+ready to hand and easy to use, the one really efficient factor in all
+these treatments--that is, the influence on the patient's mind. It is
+for the physician to devise thoroughly professional ways and means of
+using that in each particular case so that his patients may be
+benefited as much as possible. Certainly it would be foolish for us to
+leave to the irregular practitioner the use of this extremely valuable
+remedial measure, when we may do so much good with it, for the relief
+of symptoms at least.
+
+
+
+CHAPTER IV
+
+PARESIS
+
+
+Paresis would seem to be one of the affections so inevitable in its
+course, so positively helpless as regards any medication, and so
+hopeless in its absolutely sure termination in idiocy and death, that
+nothing can possibly be done for it through the patient's mind, yet it
+is probably one of the diseases for which most can be accomplished by
+psychotherapy. Mental treatment for it naturally divides itself into
+three periods: that of prophylaxis, that of the early stage and that
+of the severer stage with remissions. Prophylaxis is much more
+important than is usually thought. It is very generally known at
+present that paresis is usually a parasyphilitic disease, that is, an
+affection not due directly to syphilis, but which develops by
+preference and perhaps exclusively in a soil prepared for it by an
+attack of syphilis. As a consequence of the diffusion of this
+knowledge men who have suffered from syphilis sometimes become
+supremely fatalistic as regards the development of locomotor ataxia or
+paresis in their cases. Worry is a prominent feature in the causation
+of paresis, and it is, therefore, extremely important to neutralize
+this.
+
+I have had university graduates tell me their histories and ask
+whether I thought they had suffered from syphilis, and when I replied
+affirmatively have seen a look of despair come into their faces. One
+of them, a graduate of a large eastern university, said, after hearing
+my opinion, though it was given with every assurance that my
+experience with Fournier in Paris taught me the absolute curability of
+the disease, "Well, there are three men of my class who have already
+developed paresis, and I suppose I will go the same way." With a
+persuasion like this haunting him night and day, exhausting nervous
+energy and making his central nervous system less and less resistive,
+it would be almost a miracle if paresis did not develop. It is
+particularly in those who have had nervously exhaustive
+occupations--brokers, speculators, actors, and the like--that paresis
+does develop. The strain upon their nervous systems seem to be so
+great that the syphilitic virus still remaining in their system has a
+peculiarly degenerative effect upon nervous tissue. A man may be in
+the least worrisome of occupations, however, and if he is constantly
+brooding over the possibility of the coming of the hideous specter of
+paresis, {531} he puts himself in the condition most likely to
+encourage the development of the pathological changes that underlie
+the disease.
+
+
+Prophylaxis.--As a rule patients who have had syphilis and who dread
+the development of paresis should be warned with regard to their
+occupations in life. After a patient has had tuberculosis which
+developed in particular surroundings, if it is at all possible, we no
+longer permit him to go back into the surroundings in which his
+disease developed. We are coming, more and more, to apply the
+principles of preventive medicine and this is as important in paresis
+as in anything else. Even though there may be many monetary or
+economic reasons in favor of certain occupations, the danger may
+overweigh these. Those who have had syphilis should be warned of the
+risk they run if they continue in occupations that require much mental
+excitement or the strain of anxiety and the speculative factor of
+uncertainty with the inevitable occurrence of disappointments. It is
+unjustifiable to permit a patient whose central nervous system is
+subjected to the deteriorating influence of the virus of syphilis,
+still in his body even after ten years, to submit to the nerve-racking
+irritation of occupations which require all the vigor of a healthy,
+undisturbed organism to survive their wear and tear.
+
+
+_Sources of Worry_.--One of the symptoms which neurotic patients are
+sure must be a preliminary sign of paresis is a disturbance of memory.
+Patients have heard that paresis causes memory disturbances and
+fearing the development of the disease, they disturb themselves very
+much by finding real or supposed defects of memory. Most of them have
+had only a very vague idea of the sort of memory they possess and
+cannot tell whether it is worse than before, but finding a certain
+difficulty in recalling things they conclude that it is deteriorating.
+Occasionally their supposed defect of memory is founded on nothing
+more serious than the fact that they are paying so much attention to
+themselves, that they cannot concentrate their attention enough on
+what they wish to remember so as really to impress it on their
+memories. It is curious how persistent some patients are in making
+themselves believe they have serious lacunae in their memory when
+there are only certain conventional disturbances of it. The paretic
+has defects of memory, but he is, as a rule, quite unconscious of
+them. He has to have them pointed out to him. Patients who are
+supremely conscious of their supposed defects, by that very fact show
+their possession of good intellectual faculties.
+
+Tremor is another symptom that may develop in the midst of the
+solicitude of those who dread paresis. The power to hold the limbs in
+a given position is due to a very nice balancing of flexor and
+extensor muscles. There are many people, especially those a little
+awkward in the use of their muscles, who lack this power to some
+extent. To stand without swaying is rather a difficult task in one who
+is nervous or anxious about himself. Patients who are worrying about
+paresis and its possible development will almost surely disturb their
+power over their muscles and cause at least a slight tremor or
+swaying.
+
+In other words, in all of these cases a series of dreads, or mental
+obsessions which interfere with various functions which may cause
+tremor, or some stuttering, or at least some apparent difficulties of
+speech and which will surely revive any old-time difficulties of this
+kind, may develop in nervous persons and must not be allowed to pass
+as signs of developing paresis. The {532} diagnostic tests, of course,
+consist in the knee-jerks, the pupillary reactions, the difference in
+disposition, the delusions of grandeur, and, in general, the
+characteristic symptoms of a physical degeneration running parallel
+with a mental deterioration.
+
+
+_Prophylactic Reassurance_.--The first point in psychotherapy, then,
+is to give just as much reassurance as can be given. Probably not one
+out of a thousand of those who have suffered from syphilis afterwards
+develops paresis. Nearly always there is something in the history
+besides syphilis that seems to be an essential etiological factor. A
+great many of the people who develop this disease have some hereditary
+taint of mental incapacity at least, if not of actual insanity. Very
+often there is a personal or family history that indicates some mental
+unevenness or at least some lack of intellectual vigor. When people
+are sanely intellectual and have no unfortunate hereditary tendencies
+they can be almost completely assured as to the possibility of the
+development of paresis, provided they take reasonable care of
+themselves.
+
+
+_Alcohol_.--It is still an unsettled question whether alcoholism has
+anything to do, even in a subsidiary capacity, with the etiology of
+paresis. Probably it helps to predispose nerve tissues to degeneration
+by lowering their resistive vitality to the direct pathogenic action
+of the virus of syphilis. It seems clear, besides, that men who have
+acquired syphilis sometimes take to over-indulgence in alcohol, at
+least to a greater degree than would otherwise be the case, because of
+the discouraging dread that develops as a result of their worry over
+this constitutional taint. A warning in this matter of indulgence in
+intoxicants is important because there are many nerve specialists who
+insist that alcoholism is probably one of the prime factors in
+paresis.
+
+
+Unconclusive Diagnosis.--When the first symptoms of paresis have
+developed so that the physician is almost certain that the disease is
+present--the cumulative experience of recent mistakes on the part of
+the most careful experts seems to show that he can never be entirely
+certain--then it is important not to announce the worst to the
+patient, but to let him learn the reality of his condition gradually,
+so that all the awfulness of it does not overwhelm him. What have
+seemed typical cases of paresis, so diagnosed by excellent
+authorities, have occasionally proved to be something else, or, at
+least, to be wayward and very irregular forms of that disease with a
+long course and marked remissions. There are forms of paranoia in the
+middle-aged which sometimes exhibit symptoms so strongly simulant of
+paresis as to deceive even the expert. There are forms of nervous
+weakness--neurasthenia--some of which are really cases of mental
+exhaustion or incapacity--the modern psychasthenia--which often lead
+even experienced physicians to think of and sometimes to diagnose
+paresis. There are cases of dementia praecox that only time can
+differentiate.
+
+
+Prognosis.--_Seeing the Worst_.--There is a tendency in most
+physicians to see the worst side of the story rather than the better.
+This is not because of any desire to be a harbinger of evil tidings,
+nor, as is sometimes said, to show the patient, should he get better,
+from what a depth of affliction he has been rescued, but it is rather
+due to the very natural tendency existing in most of us to look on the
+worst side of things. Besides, we have found by experience that if
+patients are to be aroused to the necessity of care for themselves
+they must be scared a little, and so we have formed the habit, not of
+consciously {533} and deliberately telling the worst, but of stating
+the unfavorable possibilities of a group of symptoms, in order that a
+patient may take due precautions and that he may realize, if the worst
+does happen, that we were not ignorant of it. If he gets better he is
+correspondingly grateful for this. If the unfavorable happens and we
+had not warned him, he is more or less justifiably resentful.
+
+
+_Consoling Hesitancy of Final Judgment_.--Patients suspected of
+suffering from paresis can then without any violation of truth be
+reassured that their cases may not be incurable until the epileptiform
+incidents of the disease bring on that happy obscuration of mentality,
+that either takes away all the terror of the disease or lessens so
+much its awful significance that the patient is spared the worst.
+There are cases of reported cures in the literature even after what
+seemed to be characteristic epileptiform attacks had occurred.
+
+We cannot be sure, in any case, of the future course of an affection
+exhibiting symptoms resembling paresis. The patient can always be
+given the advantage of this doubt then and the awful word incurable or
+even the diagnosis paresis need not be mentioned to him. It is
+perfectly possible, as a rule, to take other means to prevent
+unfortunate incidents from tendencies to violence or serious loss from
+foolishness, without overwhelming the patient with an absolutely
+unfavorable prognosis, and the diagnosis of paresis, involving as it
+does, now that so much more is popularly known of the disease than
+before, the dread of inevitable idiocy. In this way much of the
+depression that constitutes so large a part of the really sane period
+of the early stage of paresis and which inevitably hastens the course
+of the disease may be avoided. On the other hand, failure to announce
+absolutely the diagnosis of paresis until there can be no particle of
+doubt, can do no harm and will do good to the patients themselves, as
+well as save their anxious friends from the trial of having to think
+of the awful possibilities of the disease. A single sensible member of
+the family may be selected as the confidant and the situation saved.
+
+
+Rôle of Psychotherapy.--While it is important that someone closely
+connected with the patient should know the doctor's suspicions, he
+should be bound to absolute secrecy as regards the patient himself and
+especially as regards women friends and relatives. The attitude of
+mind assumed by women relatives, and especially those nearest and
+dearest, is sure to be communicated to the patient, if not directly at
+least indirectly and inadvertently, and makes for anything but relief
+from the depression that is sure to be his if he has any gleam of
+understanding of his condition. Indeed, so much of pain and suffering
+is needlessly inflicted on relatives of paretic patients in the early
+stages of the disease by a premature announcement of the diagnosis
+that it is especially important to insist on care in this matter. The
+family will usually clamor to know just what is the matter, but it is
+the physician's duty to care for his patient and save the sufferings
+of the patient's family, regardless of their unwitting insistence.
+Once the disease has developed and the patient's mind becomes affected
+it may be thought that psychotherapy is no longer of value. As a
+matter of fact, these patients as a rule become more childlike and are
+much more affected by suggestion than in their normal states. All this
+is worthy of careful attention on the part of the physician who feels
+that it is his duty to treat patients and not merely their disease.
+
+The psychic care of the patient is the most important element in any
+{534} scheme of therapeutics during the longer remissions of paresis,
+which are sometimes so complete that it is difficult to understand
+that the patient, who is now as sensible as he ever was, only a few
+months before was doing the most foolish things under the influence of
+his delusions of grandeur and probably within a few months will be
+quite as insane as before and perhaps hopelessly demented. The brevity
+of these remissions in most cases seems to depend directly on how much
+the patient is persuaded that his disease will return without fail and
+run its inevitable course. It is well worth while to lengthen these
+remissions by setting the patient's mind just as much at rest as
+possible. Instead of the attitude which is so often assumed of
+absolute assurance on the part of the physician that the old condition
+will inevitably return, it is advisable always to give the opinion
+that the previous mental derangement was paranoiac rather than
+paretic, or was perhaps only a passing syphilitic condition and that
+the ultimate outlook is not as hopeless as might be thought. This
+opinion is thoroughly justified by certain surprising results in a
+number of recently reported cases. Some patients whose symptoms have
+been diagnosed as paresis by excellent diagnosticians, have, after a
+time, experienced a cessation of their symptoms which looked very much
+like a remission occurring in the midst of the inevitably progressive
+paretic degeneration and then to the surprise of their physicians have
+not exhibited any further symptoms of the affection. Syphilis of the
+nervous system sometimes simulates paresis to such an extent as to
+deceive the most expert, and proper antisyphilitic treatment will
+sometimes produce results that are little short of marvelous. It is
+beyond all question, then, for the good of the patient suspected of
+paresis that his physician should give him the benefit of every doubt.
+
+
+
+CHAPTER V
+
+EPILEPSY AND PSEUDO-EPILEPSY
+
+
+EPILEPSY
+
+
+With regard to the major neuroses generally, very much more
+therapeutic benefit can be secured than in any other way that we know
+by reassuring the patient's mind, by careful regulation of his life
+and by such modifications of his occupation as will take him out of a
+strenuous existence, so likely to be harmful to a nervous system
+laboring under these serious handicaps. In recent years we have come
+to realize that epilepsy, for instance, is more favorably influenced
+by a simple outdoor life in the country without worries and cares,
+with carefully regulated exercise in the open air and special
+attention to the digestive tract, than by any formal remedial measures
+or drug treatment. The fewer the emotional storms the less likelihood
+of repetitions of attacks of epilepsy. No medicine is so effective in
+prolonging the intervals between attacks as this placing of the
+patient in favorable conditions of mind and body. Our experience with
+the colony system has emphasized the fact that drug treatment is quite
+a subsidiary factor in this general care for the patient. The most
+important element in this treatment is the effect on the {535}
+patient's mind and the consequent gain in poise and in resistive
+vitality against emotional explosions which are so often the immediate
+occasion of attacks. This lessens their number and it is well known
+that frequent repetition is likely to be associated with that
+deterioration of the physical nature and mental condition which is
+most to be dreaded.
+
+
+Mental Influences.--When living a quiet placid life without worry
+about himself or his concerns, the number of the epileptic attacks
+goes down in a noteworthy degree and the intervals between them become
+longer and longer. After years of quiet country living epileptics who
+had two or three attacks a week have scarcely more than one a month,
+if, indeed, that often, and their general condition is greatly
+improved. We have had many remedies for the affection, only a few of
+which have proved to be really therapeutic. The remainder have had
+their effect through the mental influence that went with them, the
+assurance of relief and the confidence that it aroused.
+
+First attacks of epilepsy are not infrequently the result of an
+immediately preceding fright or sudden emotion of some kind or other.
+Gowers tells the story of a sentinel posted near a graveyard who was
+very much disturbed by his proximity to the dead and who, during the
+night, saw a white goat run past him, jump over a low wall and
+disappear. He was sure it was a ghost. He had his first attack of
+epilepsy shortly after. Children not infrequently have their first
+attack after a scare from a dog or a rough-looking stranger who has
+come near them. After the affection has established itself attacks of
+epilepsy follow vehement mental disturbances of any kind. Sometimes
+after a long interval of freedom from attacks a sudden strong emotion
+is followed by a fit and then the epileptic habit is reestablished. In
+order to be as free as possible from the affection patients must be
+protected from emotional storms.
+
+
+Power of Suggestion.---A strong proof of the favorable influence of
+suggestion upon epilepsy was given when operations for epilepsy became
+common about twenty years ago. A number of patients were operated on
+by trephining, even though almost nothing else was done except to open
+the dura and examine the brain, for often no definite pathological
+condition to justify surgical intervention was found. But these
+patients did not suffer from attacks of epilepsy for months and
+sometimes years afterwards. Many surgeons reported these cases as
+cured, as they apparently were when discharged from the hospitals, for
+no attacks had recurred; but physicians had to treat them later when
+their epilepsy redeveloped. The surgical procedure, as indeed might
+have been expected from the findings, had given only temporary
+betterment. The real therapeutic factor at work had probably been not
+any definite change within the skull, but the suggestive influence of
+the operation, the period of rest with favorable suggestion constantly
+renewed, and the confidence of recovery inspired during convalescence.
+Even in cases where adhesions were found between the dura and
+calvarium and these were broken up, the relief afforded was usually
+but temporary. The succession of events, the relief afforded and
+subsequent relapse, probably represented the same influence of
+suggestion as in the preceding cases with perhaps a slight physical
+betterment in addition.
+
+An important factor in the psychotherapeutics of epilepsy is to
+relieve the patient as far as possible from the haunting dread of
+insanity, which, especially if he has read much of the disease, is so
+likely to hang over him as {536} a pall because of the absolutely bad
+prognosis which often occupies so prominent a place in older
+text-books and articles on epilepsy. There is no doubt that in a great
+many cases epilepsy is a progressive degenerative disease and that a
+state of lowered mentality will eventually develop. There are many
+cases, however, in which epilepsy is only a series of incidents which
+does not seem to affect the intellectual life and which is quite
+compatible not only with prolonged existence, but with mental
+achievements of a high order and, above all, with a personality that
+may be commanding in its power over others. This knowledge, which
+unfortunately is not usually given in text-books because they are
+studies in the pathology rather than in the psychology of epilepsy, is
+extremely important for the epileptic. This view is of special
+significance for those sufferers from the disease who are well
+educated and in whom mentality means so much.
+
+
+The Individual in Epilepsy.--In epilepsy, indeed, the individual
+counts much more than his ailment, and even in severe cases of
+epilepsy there are individuals to whom the recurring convulsions are
+only annoying occurrences of life, somewhat dangerous because of the
+risks encountered during unconsciousness, but without any ulterior
+significance for degeneration of character or intellectual power. As a
+matter of fact, there are many men in history who were epileptics and
+who yet succeeded in great work of many kinds, even purely
+intellectual, unhampered by this condition, and some of them have
+proved to be leaders in achievement. In his paper read before the
+National Association for the Study of Epilepsy and the Care and
+Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew
+Woods discussed what certain famous epileptics had accomplished in
+spite of epilepsy. He takes three typical examples--Julius Caesar,
+Mohammed and Lord Byron--the founders, respectively, of an empire, a
+religion and a school of poetry--with regard to whom there is
+convincing evidence that they were epileptics. A fourth name, that of
+Napoleon, might easily have been added. Greater accomplishments than
+these epileptics made in their various departments are not to be found
+in the history of the race.
+
+Many other names of epileptics distinguished for achievement might
+well have been added to the list. The argument that would be founded
+on their lives is not that epileptics are necessarily or even usually
+of high intelligence, but that some of them, at least, retain in spite
+of the major neurosis, or even serious brain disorder, whichever it
+may be, all their intellectual qualities undisturbed. Lombroso,
+arguing from the other standpoint, has pointed out that there is a
+close relation between genius and insanity, and he sets down epilepsy
+as one of the forms of insanity (mental un-health) often associated
+with extraordinary mental qualities. A study of this subject is
+extremely reassuring to the epileptic who is prone to think from
+traditions with regard to the disease that his fate is almost sure to
+be a gradual lapse into imbecility. No epileptic is likely to be at
+all worried over the suggestion that epilepsy and genius are allied,
+for since he has the one he is quite willing that the other shall
+follow.
+
+
+Treatment.--Reassurance is especially important when patients develop
+epilepsy in adult life. There is an unfortunate social stigma attached
+to the disease which adds to the unfavorable suggestions that are
+likely to run with it. This probably cannot be overcome, for it is a
+heritage, not alone of many {537} generations, but of many centuries.
+Our better knowledge of epilepsy, however, should gradually take the
+disease out of the sphere of suspected mystery in which it has been
+popularly placed and set it among the diseases to which human nature
+is liable, but which is surely as physical in its character as any
+other. If a favorable attitude of mind on the patient's part can be
+secured there is less necessity for many of the disturbing drugs that
+are used and there seems to be no doubt that even in producing the
+effect of these, such as it is, suggestion of a favorable character
+plays a large role. Over and over again in the history of the
+affection we have had remedies introduced which have seemed to be
+quite efficient in producing longer intervals between attacks, making
+the patient less nervous and putting him in better physical health.
+After a time, however, these have proved to be quite useless, or at
+most of but very slight value. It was suggestion that gave them their
+apparent value, and this suggestion must be used without the drugs
+whenever possible.
+
+The bromides have done good in the treatment of epilepsy, but they are
+the only drugs that maintain the reputation they first had. All the
+others accomplished whatever benefit they conferred on the patient,
+and some of them for a time seemed to excellent authorities of large
+experience to give marvelous results, through their influence over the
+patient's mind. Nothing can produce more confidence in the physician
+who is using suggestion for epilepsy than this fact. Even the
+bromides, unless used carefully, easily do more harm than good and
+they have often worked mischief. Favorable suggestion cannot do harm.
+At the present time those of largest experience in the treatment of
+epileptics, the directors of farm colonies, as Dr. Shanahan of Craig
+Colony, insist that diet, hygiene, especially hydrotherapy, are of
+much more importance than drugs, but that the patient's attitude of
+mind towards himself and his malady and the future of it is even more
+important. He must have occupation of mind so as not to worry about
+himself. He must have recreation so as to relieve the gloom so likely
+to come in the disease. He must have outdoor air and proper exercise,
+which these patients are so prone to neglect.
+
+Those who have studied the subject most in recent years agree that the
+great majority of cases of epilepsy are not primarily due to acquired
+causes, but to some congenital defect, so that there is an inherent
+instability of the nervous system. This makes the patient liable to
+explosions of nerve force, figuratively represented as boilings over
+of nervous energy, when not properly inhibited. Once such a paroxysm
+occurs it is likely to happen again, and very often it brings on
+gradual degeneration of the nervous system and of mentality. In many
+cases, however, this degeneration can be delayed or even completely
+kept off by putting the patient under favorable conditions. These
+patients need, above all, to realize that they cannot live the
+strenuous life nor even the ordinary busy life of most people. They
+are as cripples compelled to limit the sphere of their activities. If
+they will but take this to heart, however, and not attempt too busy
+occupations, they may live quite happy lives for many years, and if
+mentally content and without worrying anxieties they will have so few
+attacks as to incur only to a slight degree the dangers inevitably
+associated with fits of unconsciousness. To get the epileptic's mind
+into a condition of satisfaction with his condition must be the main
+portion of the treatment.
+
+
+{538}
+
+PSEUDO-EPILEPSY
+
+
+There is a large and important field of psychotherapeutics in a class
+of cases so closely related to epilepsy that it is often extremely
+difficult to make the differential diagnosis between the two varieties
+of seizure. Fifteen years ago, while I was at the Salpêtrière, there
+was much discussion of a variety of attack called hystero-epilepsy, in
+which the patients' symptoms were such that it was difficult if not
+practically impossible to decide whether the case was true epilepsy or
+merely hysteria. Personally I do not think there is any third,
+intermediate variety deserving a separate term. The attacks are either
+hysterical, or, to use a less objectionable name, neurotic, or they
+are genuinely epileptic, that is, due to some as yet not well-defined
+change in the brain, and therefore not likely ever to be completely
+relieved. To decide whether a given case is neurotic or epileptic,
+however, is sometimes quite out of the question until long and careful
+study of it has been made. It is true that such signs as full loss of
+consciousness, biting of the tongue, the so-called epileptic cry,
+involuntary urination, dangerous falls and the like in the midst of an
+attack, have often been declared to be signs of true epilepsy, but
+there are cases in which one or other of these signs has been present,
+yet the subsequent course of the affection has shown them to be
+functional and not organic in origin.
+
+
+Neurotic Simulation of Epilepsy.--Nearly every physician who has
+reasonably large experience with neurotic patients has seen cases in
+which there were recurrent attacks of loss of consciousness that came
+on sometimes at most inopportune moments, that rendered the patient
+quite incapable of caring for himself for the moment, yet lacked many
+of the signs of true epilepsy. Teachers sometimes complain of a
+complete lapse of memory that begins without warning and then recurs
+at intervals, making their work very difficult. Preachers sometimes
+bring the story of having lost the thread of their discourse and
+forgetting absolutely what they were talking about, there being a
+complete blank for some seconds at least. Occasionally such lapses are
+associated with falls that resemble fainting spells and seem to be
+accompanied by complete loss of consciousness. Usually after them
+there is a distinct tired feeling and an inclination to sleep, though,
+as a rule, there is a more marked tendency to want to get away from
+observation. Some of the cases are much more severe than those
+described and the conclusion that they are true epilepsy seems
+inevitable, yet they recover so completely that this conclusion is
+negatived.
+
+Occasionally such attacks occur only when the patient has been
+strenuously exerting mind or body for a much longer period than usual.
+In teachers it is likely to occur toward the end of the year or in the
+midst of the hard work about examination time. In students this same
+period is likely to be a favorite starting point for the attacks and
+they recur oftener at this time than at others. Very often there is a
+story of some digestive disturbance in connection with the attacks. At
+times it seems possible to trace them to some interference with the
+cerebral circulation through a distended stomach pressing upward
+through the diaphragm and interfering with the heart action. In such
+cases stomach resonance will sometimes be found as high as the fifth
+rib {539} and the apex beat may be pushed out to the nipple line or
+beyond it. This may be true though there are no signs of valvular
+lesions and no symptoms or physical signs of dilatation or hypertrophy
+of the heart.
+
+
+_The Suggestive Element_.--Analysis shows the real course of the
+trouble in these cases. The sufferer is usually following a sedentary
+occupation, not getting much exercise or diversion and prone to
+introspection. Many symptoms of themselves of no importance have been
+emphasized by concentration of attention on them. Especially is this
+true of any heart irregularity. The patient has dreaded for some time
+lest the feeling of pressure in the precordia and of discomfort in the
+heart might not sometime interfere with him in the midst of his
+teaching or preaching duties. Some day when he is feeling much worse
+than usual, in the midst of his work, there comes over him the feeling
+that now his intellect is going to stop action because there is
+something the matter with him. The sudden concentration of his
+attention on this with the fear of the consequences and the
+uncomfortable feeling that he will not be able to go on with his flow
+of ideas, cuts off the thread of what he is thinking about and puts
+but one single object before him--this possibility of failure of
+mental action. Usually the first attack is only such an interruption
+as is thus indicated. The fear of subsequent attacks, the worry over
+what has happened, the dread that some serious mental affection or
+nervous disease is at work emphasizes introspection and subsequent
+attacks are even more likely to be serious, and especially to last
+longer than the first.
+
+The more the cases are studied the more the conclusion comes that in
+many of these instances it is nothing more than auto-suggestion that
+is responsible for the mental lapse. It is true that some physical
+condition may be the occasion, though the mental state is the active
+immediate cause. Suddenly concentrated attention on the dread of
+mental interruption inhibits mental action and what was dreaded
+follows almost necessarily. It is a sort of auto-hypnotism in which
+the patient's train of thought is interrupted by a momentary or longer
+hypnotic state the causes of which can be traced. Even when there is a
+real organic lesion of the heart, the lapses of memory and even of
+reasoning power that occasionally occur, have often seemed to me to be
+due rather to the patient's dread than to any real physical condition.
+I cannot think that there is a sufficient interruption of the cerebral
+circulation, even though only for a moment, to cause such a lapse. It
+is a question of nerve interferences rather than of blood supply. If
+the blood were diverted, even though only for a moment, or if there
+was a stoppage, the consequences would be more serious and more
+lasting than they are.
+
+What evidently happens is some disturbance of neurotic connections
+within the brain brought on by sudden dread or emotion. The will has
+lost control or has seriously disturbed the conducting apparatus. The
+best proof that this is what happens and that it is not the result of
+organic change is found in the fact that when the physical occasion,
+that is, the digestive disturbance or the heart palpitation which is
+the initial factor in these states, is relieved, the attacks do not
+take place. Patients in whom they have occurred even for years cease
+to have them. This improvement does not begin, however, until their
+solicitude over their condition has been lessened by a confident
+declaration to them that they are suffering from merely functional and
+local reflex conditions apart from the brain itself. Usually it needs
+to be made clear {540} to them, too, that their anxiety in the matter
+means much more for the continuance of the attacks than any physical
+condition.
+
+Almost invariably patients somewhat resent this suggestion. Their
+response to this explanation of their ailment usually is that the
+attacks come on them when they are not particularly expecting them and
+that there is first some physical symptom which might readily be taken
+for a sort of aura to a genuine epileptic attack and then the attack
+itself comes on. It is this preceding symptom, pain or discomfort, or
+whatever else it may be, that provokes the suggestive element and
+brings about the state of quasi-hypnosis, which is the main part of
+their attack.
+
+
+Neurotic Syncopal Attacks.--Some of the cases of pseudo-epilepsy are
+very mild, though if the word epilepsy has been mentioned there
+naturally arises a feeling of dread in patient and friends with
+consequent unfavorable suggestion. A type not infrequently seen has
+for its main symptom a period, usually of but short duration, in which
+there is an intense tired feeling so that even the eyelids droop and
+require effort to lift them. During such attacks the respirations may
+slow down to fifteen or below, though usually the pulse is inclined to
+be rapid. The feeling of fatigue is almost entirely subjective, in the
+sense that, if patients are required to do something, they are able to
+accomplish it by a little urging, though a moment before they were
+sure that they could not. Such attacks are invariably functional, have
+no organic basis and do not deserve the name of epilepsy. If called
+hysterics this will cause the patient, who is often a woman, to rouse
+herself and so gradually overcome them. They are really a loss of
+confidence in one's power to do things and a passing astasia-abasia.
+The use of the word hysterics may cause the patient to lose the
+sympathy of her friends, though she may need it; for often there is an
+underlying pathological condition not in the nervous but in the
+somatic system. Sometimes the patients are anemic, sometimes they have
+an abortive form of Graves' disease, and sometimes they are low in
+nutrition.
+
+These conditions give the indication for treatment. What is needed is,
+of course, improvement of the general condition, but, above all, a
+restoration of the patient's confidence in herself. Once it is made
+clear to her that the attacks are largely subjective, that is, are due
+to a feeling of prostration because of the fear that she is unable to
+do something, then the intervals between the attacks will gradually
+grow longer. It is important that long hours of sleep should be
+advised with plenty of fresh air, and that whatever disturbances of
+the digestive system are present should be carefully treated.
+
+
+Pseudo-Epilepsy and the Menopause.--A number of these cases of
+pseudo-epilepsy occur at the menopause. They seem particularly likely
+to occur in women who have not much to occupy themselves with.
+Childless women who have no cares and enjoy every luxury sometimes
+seem to have these pseudo-epileptic attacks as equivalents for the
+flushings of the ordinary menopause. During "a rush of blood to the
+head" they lose control of themselves. Occasionally mothers who have
+two or three daughters and who get their menopause late in life, that
+is, well after fifty, are especially likely to suffer in the same way.
+The solicitude of those near them seems to eliminate some of their
+power of inhibition and makes them think overmuch of themselves. If
+then they keep much at home, as women at this time are prone to do,
+have few {541} diversions of mind, little fresh air and exercise,
+there is an accumulation of unused nervous energy which dissipates
+itself in explosive attacks very like epilepsy. It is with regard to
+these that the term hystero-epilepsy almost seems justified. Just as
+soon as occupation and diversion of mind and relaxation of the
+solicitude of friends for them is secured they begin to get better.
+
+The differential diagnosis of these cases is made from the absence of
+certain of the pathognomic signs of true epilepsy. The tongue is not
+bitten, involuntary urination does not take place, and when the
+patient falls she does not hurt herself as a rule, though occasionally
+the fall may result in accidental abrasions or bruises, but these are
+quite trivial. If stress is laid upon the fact before these patients
+that they do not present any or all of the symptoms of epilepsy, some
+of them are likely to occur a little later. Slight abrasions on the
+tongue will be noted and the sputum will become a little bloody. Even
+very cleanly women will sometimes wet themselves. It is not a
+deliberate attempt at deception, but their curious psycho-neurotic
+condition causes suggestion to act upon them. Their attacks are really
+auto-hypnotic and during these the remarks made by the physician occur
+as suggestions and then are accomplished. If the suggestions in this
+matter have been carelessly made by previous physicians the attacks
+will so closely simulate true epilepsy that it will often be almost
+impossible to differentiate them with assurance.
+
+In the preliminary diagnosis of these cases, as well as of all other
+cases of pseudo-epilepsy, we must, as far as possible, avoid the use
+of the word epilepsy, even of hystero-epilepsy. The unfavorable
+suggestion attached to such terms will have the worst possible effect.
+There is no need to fear that the patient will be any less taken care
+of, if the disease is called by some other name, for instance,
+neurotic paroxysms or nervous attacks.
+
+
+Cure by Suggestion.--Such patients are often cured by remedial
+measures of one kind or another that are administered with the
+confident declaration that they will get well. A number of cases of
+epilepsy which were really of this character have been reported cured
+by Eddyism. A number also have been very favorably influenced by
+osteopathic treatment. Needless to say, the reports of such cured
+cases have not been diminished in significance by the publicity
+bureaus of these various cults. Mental healing has relieved a number
+more. Usually this relief has been afforded these cases after they had
+tried regular physicians who had treated them in the ordinary way with
+bromides, without doing anything more than causing them to miss a few
+attacks for a temporary period of relief, if even that, giving them
+bromism and further increasing their solicitude about themselves by
+unconsciously emphasizing their ideas as to how serious epilepsy can
+be. The cures of these cases are not due to the various treatments to
+which the patients proclaim their debt of gratitude, but to the
+confident assurance given them that their condition is not serious,
+and will be cured. After analysis of their attacks has shown them to
+be neurotic and not genuinely epileptic, the regular medical
+practitioner can readily do as much and even more; for psychotherapy
+has much more to do in affording relief in these cases than any other
+form of treatment. It must be applied with confidence and the results
+are often most favorable.
+
+
+{542}
+
+
+CHAPTER VI
+
+PARALYSIS AGITANS
+
+
+This is a chronic affection of the nervous system having for its most
+characteristic symptom a tremor, but with marked muscular rigidity and
+weakness. It is much more common in men than in women, in almost the
+reverse proportion of Graves' disease. It is usually a disease of the
+old, but may occur in early middle life and has been known to develop
+even early in the twenties. In the old days when malaria was a common
+diagnosis for many different conditions, paralysis agitans apparently
+followed malaria so often that there was thought to be some connection
+between the two diseases. The more we have learned of malaria the less
+likely this seems to be. Continuous exposure to cold for long periods
+and to dampness during the daily occupation for years, or repeated
+severe wettings, have been considered as causative elements. None of
+these physical factors, however, has been as directly connected with
+the occurrence of the affection as various emotional conditions, and
+the thought is suggested that even in cases of severe exposure the
+worry and fright and solicitude incident to the fear in an elderly
+person that this exposure will have serious consequences, is an
+important etiological element.
+
+
+Psychic Factors.--_Fright_.--Practically all the authorities agree
+that mental conditions are prominent factors in the production of the
+disease. Serious business cares and worries and anxieties have often
+long preceded its development. Fright is mentioned by nearly all those
+who write on the subject as at least an occasion for the development
+of paralysis agitans if not a cause. One of my own most interesting
+cases occurred in the sheriff of a county of the Southwest who had
+earned for himself the deep enmity of an Indian by arresting him. Not
+long afterwards one Sunday morning when the sheriff quite unarmed came
+round a corner he found the Indian just in front of him wildly drunk
+and armed with a rifle. At once the rifle went to the Indian's
+shoulder, but he did not want to kill his man without having his
+revenge by torturing him, so he did not pull the trigger, but
+announced to him in vigorous though broken English that he had him now
+and was going to kill him. The sheriff tried to parley and for a
+moment the Indian permitted him to do so, apparently in order to
+prolong the agony. They were not more than two yards apart at the
+beginning, and the sheriff took his only chance and jumped and knocked
+the gun up. It went off just as he did so, the bullet singeing his
+hair. He succeeded in arresting the Indian and throwing him into jail,
+but the next day a tremor developed in the arm which had grasped the
+rifle. This spread and finally became typical of paralysis agitans. He
+was a man only slightly past fifty and there had been no preliminary
+symptoms.
+
+
+Mental Control of Symptoms.--Many similar cases following fright or
+vehement emotion have been reported, so that it is easy to understand
+the feeling that the affection has a large psychic element in it,
+though evidently from its persistency and its continued development,
+there is some underlying pathological condition. The tremor may be
+controlled in voluntary {543} movements, while emotion exaggerates it.
+There is no doubt, however, that concentration of will and the
+definite effort to control the symptoms enables the patient to rid
+himself of them to a great degree for a time at least. It has been
+noted frequently that when a consultant physician is called the
+patient will be better for the day of the consultation than he had
+been for months before. The visits of particular friends will often
+arouse a sufferer to such efforts as greatly lessen his rigidity,
+decrease his tremor and make him capable of getting around better than
+before. The state of mental depression that commonly develops in these
+cases exaggerates the symptoms, adds neurotic and even physical
+conditions that develop from lack of exercise and air, and makes the
+patient's general state much worse than it would otherwise be.
+
+
+Pathology.--Our scanty but growing knowledge of the pathology of
+paralysis agitans makes it clear that the disease is, in typical
+cases, probably due to an overgrowth of connective tissue, the
+neuroglia cells, in the central nervous system. Just what causes this
+overgrowth of connective tissue is not clear. It is an exaggeration of
+a normal senile process. Apparently one of the processes of age in man
+is a decadence of the vitality of important higher tissues with a
+corresponding increase of vitality in the lower or connective tissues.
+When Flourens declared at a meeting of the French Academy of Sciences
+that such an overgrowth of connective tissue was natural with
+advancing years, he added that this probably accounted for the
+slowness with which older men come to conclusions. The old members of
+the Academy did not accept this new-fangled doctrine with equanimity.
+They were inclined to think that their conservatism and deliberateness
+were due to greater poise of intellect.
+
+There seems to be no doubt that at least a comparative overgrowth of
+connective tissue is characteristic of the brain in advancing years.
+In some people this occurs to a greater extent and is more precocious
+than in others. Just what causes are responsible for individual
+differences we do not know. Paralysis agitans is seen often in those
+who have worked hard most of their lives, but, on the other hand, may
+occur in those who have lived sedentary lives, and in people of all
+occupations. Over-indulgence in alcohol, though this is often thought
+to predispose to the disappearance of the parenchyma of organs and to
+the overgrowth of connective tissue, does not seem to have any place
+in the etiology of this affection. Its occurrence is a part of that
+mystery by which the equilibrium of different kinds of cells in the
+body is maintained or diminished. In a mild way paralysis agitans
+represents such a change in the central nervous system.
+
+
+Mental Influences.--With an overgrowth of connective tissue as the
+pathology of the disease there would seem to be no question of any
+relief of its symptoms or any benefit to be derived from
+psychotherapy. Anyone who has much to do with cases of paralysis
+agitans, however, knows that they are extremely susceptible to mental
+influences. Whenever there is anything that interests them, any
+business that they feel they must do, any special event that they look
+forward to, they will for days at a time be so much improved in
+general symptoms as to be greatly encouraged themselves and make their
+friends feel hopeful with regard to them. When they give in to their
+condition, however, and make no special effort at self-control and
+stimulation their symptoms increase very much. Their rigidity
+particularly increases, their {544} tremor becomes more marked and
+various inconveniences associated with these two cardinal symptoms are
+emphasized.
+
+
+Methods of Treatment.--_The Vibrating Chair_.--It is interesting to
+recall some of the forms of treatment which have been reported as
+beneficial in paralysis agitans, because they illustrate how much the
+influence of the patient's mind has over his bodily condition and how
+much the interest aroused in any new and particularly in any unusual
+form of treatment has in mitigating symptoms and how often it seems to
+bring about remissions in the progress of the disease. Twenty years
+ago Charcot suggested the use of a mechanically vibrating arm-chair.
+He had noticed that patients who travelled by rail seemed to have
+their symptoms improved for the time at least by the shaking up in the
+train. This treatment undoubtedly made patients much less rigid and
+much less tremulous. The improvement lasted sometimes for hours and
+sometimes for days. It was tried rather extensively and everywhere
+with reported good results, when first tried at least. After a time it
+was found that it failed to have the desired effect. Apparently
+whatever therapeutic value it had was due to the interest aroused in
+the patient's mind and the consequent effort that was made to control
+his muscles.
+
+
+_The Suspension Treatment_.--When the method of treatment by
+suspension became popular for cases of locomotor ataxia, the idea came
+to try the same thing for paralysis agitans. Accordingly suspension
+apparatuses of many kinds were used with reported good results.
+Patients were suspended by the neck for some minutes and some of them
+got used to the treatment and could stand it for a prolonged period.
+The effect was always a distinct mitigation of symptoms. The rigidity
+particularly became much less marked, but the tremor also was lessened
+and besides certain secondary symptoms were bettered. Constipation was
+improved, partly because patients were more cheerful, ate more
+heartily and, above all, were willing to make some effort in order to
+get out regularly into the air. There was a variety in life, different
+from the solitary sitting at home into which these patients so often
+drift. Sleep was better at night and the subjective sensations of heat
+and cold were lessened. Patients were encouraged to think of
+improvement and used all their available nervous energy. In the same
+way when overstretching of the spinal cord by forcibly bending of the
+body at the hips was tried with reported success in tabes it was also
+applied to paralysis agitans with similar improvement of symptoms.
+Both methods of treatment have gone out for both these affections and
+evidently their observed therapeutic efficiency at first was entirely
+due to their effect upon the mind.
+
+
+_Psychic Elements and Other Remedies_.--When organo-therapeutics
+became the fad paralysis agitans was treated also by this method. Some
+cases were treated with reported good results by thyroid. Later when
+the parathyroids attracted attention they were administered with
+reported good success in even very severe cases. I think that there is
+a report of some cases of paralysis agitans being improved by
+injections of diphtheria serum. In other words, anything that was
+given to a patient with the promise that he would be better after it
+and that produced a definite effect upon his mind was likely to do him
+temporary good. If the remedy had some special theory behind it, if
+there was a story of some new scientific significance for the material
+employed or the method of giving it, then this improvement was sure to
+take place. {545} In the drug treatment of the disease the same
+principles applied. Earlier, when nitrate of silver was the main
+recourse for organic nervous diseases, cases were reported improved by
+its administration. When the alterative properties of arsenic became a
+therapeutic fad this produced good effects. Atropin had for some time
+a reputation of relieving patient's symptoms. After a time all of them
+ceased to be used to any extent.
+
+
+_The Frenkel Method_.--In recent years the application of the Frenkel
+directed movement method, modified somewhat from its application in
+tabes, has attracted attention in the therapeutics of paralysis
+agitans. It is interesting to note how often a mode of treatment that
+has been applied successfully to one of these diseases has also proved
+successful with the other. The two diseases are, of course, very
+different in etiology and pathology; but have one thing in common. The
+control over muscles has been lost to some degree in both cases in the
+progress of the disease, and a special effort of attention is required
+on the part of the patient in order to regulate movement. Anything
+that will arouse the patient to make this special effort will relieve
+the symptoms for a while and in tabes may bring about a lasting
+improvement, because the habit becomes easier after a time, though
+apparently this does not occur in paralysis agitans, except perhaps in
+the younger patients. It might very well be expected, then, that
+Frenkel's method in many cases would do good in paralysis agitans and
+it has proved to be another adjunct in the treatment of the affection.
+It must be used with great care not to exhaust the patient, but this
+is true also in tabes. The real source of its therapeutic quality
+seems to be the patient's interest in it and if this cannot be aroused
+it usually fails to do good. The success of these various mechanical
+methods makes it easy to understand why these patients often improve
+for a time under osteopathic treatment.
+
+
+_Psychotherapy_.--It is clear, then, that the most important aid for
+these cases is the arousing of mental interest in some form of
+treatment that promises to be of benefit to them. New forms of
+treatment cannot always be invented and mental occupation must be
+secured by interest in other things. Patients suffering from paralysis
+agitans are prone to allow themselves to give up efforts to do things
+in which their interest would be aroused. They must be encouraged to
+do many things. Carriage riding, automobiling, train excursions,
+because of the effort required to resist vibration, are all helpful.
+They must not be allowed to drift into vacuous habits in which they
+make no effort for themselves. They can thus be made much more
+comfortable and most of their symptoms can be relieved to a marked
+degree. This requires constant attention and ever-renewed efforts to
+arouse the patient's mind and to have him make such efforts as will
+overcome rigidity and control the tremor to some extent; but with care
+an amelioration of the condition can always be brought about and can
+be maintained, at least to the extent of making the patient much more
+comfortable than would otherwise be the case.
+
+
+{546}
+
+
+CHAPTER VII
+
+HEADACHE
+
+
+In spite of the improvement in the general health of the community,
+due to more hygienic living, more healthy food and better ventilation,
+headache, instead of decreasing, has increased to a great degree. Any
+number of headache cures are advertised in the daily papers, in the
+street cars, on the signboards, even in medical journals, and besides
+these nearly every druggist has his own special preparation for
+headache, so it would seem as though literally many millions of doses
+of these headache cures must be taken every week. It would seem as
+though there must be some special unhygienic factor at work to produce
+headaches at a time when all other pathological conditions are being
+reduced in number and severity.
+
+A study of the patients who are especially affected by headache seems
+to furnish evidence as to the special factor that has led to the
+increase of the affection. It occurs much more frequently in women
+than in men. It is complained of particularly by those who have less
+regular occupation, and the notable increase has come with the
+opportunity for leisure on the part of large numbers of the community
+due to the growth of wealth.
+
+A feeling of discomfort in the head to which much attention is paid
+will become such a painful condition as to deserve the name of ache,
+if it develops in those who have no serious occupation in life and no
+interests that demand peremptory attention. With the noise of many
+children around them in the olden times women suffered comparatively
+little from headaches. Most of our grandmothers scarcely knew what it
+was to have a headache. Now most business men are likely to say the
+same thing. Very rarely do they suffer from headache. When they do,
+there is some specific reason and when this is removed the headache
+disappears. There are many women of leisure who have regular headaches
+for which they must have some remedy at hand or the pain becomes
+intolerable, but there are few women strenuously occupied with
+business affairs or with interests in which their attention is
+absorbed who find themselves under any such necessity.
+
+It is evident that certain conditions predispose to headache. The
+principal of these is having sufficient time to advert to certain
+uncomfortable feelings in or around the head. Few people who stop to
+think of what their head feelings are but will find there is some
+unusual sensation somewhere in or outside the head which if dwelt upon
+becomes emphasized into an ache. If the mind can be diverted it
+disappears. If there has been some injury of the head or some
+pathological conditions set up by congestion or anemia, the feelings
+may become emphasized and occupy the center of attention, and even
+after the injury has disappeared or the pathological condition been
+ameliorated some sensations remain which with advertence produce achy
+feelings of discomfort. This is the history of a great deal of the
+increase of headache in our time. There are, of course, real headaches
+due to definite pathological conditions, but the great majority of
+headaches complained of {547} are the result of over-attention to
+certain sensations, some of them normal, some of them only slightly
+abnormal, which are emphasized by concentration of attention on them
+until they become a torment.
+
+Two main classes of headaches come to the physician for treatment. One
+class is seen in patients who suffer from real and even acute pain
+that cannot be distracted by diversion of mind, that is usually worse
+when they try to sleep, as toothache is, and is evidently due to
+definite physical disturbance. In the second class are the many queer
+feelings about the head called headaches, though the patient suffers
+rather from annoyance than from pain. It is said that the Chinese in
+olden times put criminals to a lingering death by fastening them in
+such a way that a drop of water fell every minute on their heads. It
+was impossible to avoid the falling drop, and its constant recurrence
+became an awful torture. Any feeling that engrosses consciousness will
+be followed by the same sense of torment. The constant exercise of
+function of any nerve without rest is of itself physically disturbing
+to a serious degree. This must be realized with regard to many forms
+of headache which, though trivial in origin, are the source of bitter
+complaint.
+
+
+Attention Headaches.--Professor Oppenheim, in his "Letters to Nervous
+Patients," has a paragraph with regard to headache that is worth
+recalling for the benefit of patients who suffer from low-grade
+headaches. Doubtless these were at the beginning real aches due to
+some local condition. They are now due merely to exaggeration of more
+or less normal feelings within the head which have come into the realm
+of the conscious because of the attention attracted to them when the
+intracranial affection was first noted. Professor Oppenheim says:
+
+  Your headache also I ascribe to this source. Originally it may have
+  been a real headache, the result of your nervous shock. There is no
+  one who has not at some time had a transient feeling of pain in the
+  head or in some other part of the body, quite apart from those
+  caused by injuries or painful diseases. Out of a thousand various
+  kinds of causes I will mention only an extremely common one: the
+  pains which result from straining muscles or nerves. Every sudden
+  awkward movement may in this way cause pain in different parts of
+  the body, but very specially so in nervous persons, in whom the
+  mechanical excitability of the nerves--that is, their sensitiveness
+  to pressure and strain--is usually exaggerated. As a rule, however,
+  this pain is quite transient. But here again the law of which I have
+  been already speaking comes into force: under the stimulating
+  influence of introspection the tiny, perishable seed-grain of pain
+  grows into the firm, strong, enduring tree of neuralgia or
+  psychalgia.
+
+The first condition for the successful treatment of headache, then,
+must include the recognition of the possibility of some rather simple
+pathological condition being exaggerated by over-attention to a
+disturbing affection, or of some affection, now past, having produced
+a suggestion that, in a mind given to introspection, continues to have
+influence even to the inveteration of sensations for which there is no
+longer a physical cause.
+
+These patients insist that their medical status is that of real pain.
+Hysterical patients describe a sensation as if a nail were being
+driven into the forehead--the so-called clavus hystericus. In nervous
+people the sense of pressure increases from one of mere discomfort to
+a positive pain, as a consequence of attention to it. In most cases of
+headache, however, what is most needed is a distraction of the
+attention from the ailment. Over and over {548} again I have found
+that when all remedies failed the deliberate search for an occupation
+of mind that would interest the patient during many hours of the day
+was the only thing that promised relief and in many cases the relief
+afforded was so complete that patients were effusive in their
+gratitude.
+
+
+_Power of Distraction_.--The proof that these so-called headaches are
+really not aches is found in the comparative ease with which many of
+them may be suppressed. Almost any interesting occupation will make
+the sufferer forget them entirely and they will not return immediately
+after the occupation ceases, but usually only when the patient is
+alone and attention is once more directed to this symptom. These queer
+feelings about the head that are often raised to the dignity of
+headaches by attention and auto-suggestion may be distracted away
+completely. That they are not pain is shown by the fact that the
+ordinary remedies which ease pain so promptly often fail to relieve
+these or soon cease to have any effect on them.
+
+
+_Lack of Distractions_.--The apartment hotel system has multiplied the
+victims of headaches. When a woman has nothing in the world to do
+except get her clothes fitted and attend to what she calls her "social
+duties," it is no wonder that her head bothers her. Blood is
+constantly going to the brain and interchange of nutritive elements is
+taking place, yet there is no real function of cells and no
+consumption of material, or at least function is so slight that
+consumption of material must be trivial. There is no reason why these
+women should get up in the morning. Their breakfast is brought to
+their rooms, and some of them do not get around until eleven o'clock.
+Women used to have a morning occupation in going out to market or else
+in planning the household day with housekeepers, but of course there
+is no more of that. In olden times, too, many of them had religious
+practices. Now women are likely to be unemployed until the afternoon,
+which must be occupied at most with so-called social duties that may
+be done if one wishes to do them, but that may be put off for many
+reasons and there are constantly recurring reasons for not making any
+special exertion. Also, the rooms these women live in must be kept at
+a high temperature because the poorer the air that we breathe the
+higher must be its temperature for comfort, while stimulating fresh
+air may be quite low in temperature and yet produce only a brisk
+reaction instead of chilly feelings.
+
+Children used to be the best possible remedy for these non-occupation
+headaches, but either there are no children any more or there are but
+one or two and these are largely cared for by _bonnes_ at home and by
+various schools once they have reached the age of three. The old idea
+that children should not leave home until six put upon the mother the
+burden of their early education, but since the coming of the
+kindergarten she is relieved of responsibility of this and the mother
+of one or two children might now almost as well be childless as far as
+any serious occupation from care of her children is concerned.
+
+If patients are told all this bluntly there will be a vigorous protest
+from most of them, for to them their pains are very real. It must not
+be forgotten that a pain in the mind is often worse than in the body.
+Some of these women save themselves from having their unused mental
+faculties disturb them from very lack of something to do, by becoming
+interested in charities, in clubs, in social movements of various
+kinds, in art and in literature. It is {549} not to these that I
+refer. On the contrary, if women have nothing else to do I would
+insist that they find some cause or movement in which they may become
+deeply interested. Their interest will save them from self-annoyance,
+though it may not exactly add to the gayety of nations in its effect
+upon other people. As a physician, however, I am only interested for
+the moment in the good of particular patients.
+
+
+Source of Pain.--I would not be understood as saying that all
+headaches are not real aches nor pains in the most literal sense of
+the word, for some of them are agonizing tortures. With regard to all
+headaches, however, even the most genuine variety, there are certain
+considerations that are of value from the standpoint of
+psychotherapeutics. The most important of these is assurance as to the
+source or location of the pain. Most people think that it is the brain
+itself that is suffering pain and not a little of their suffering is
+due to the fact that they dread the effect of such pain upon the
+cerebral tissues and its possible consequences upon their mental
+state. These people will be much relieved to be told at once that the
+brain tissue itself is not sensitive, that when exposed it may be
+touched with impunity without causing any pain. It is the structures
+surrounding the brain that are sensitive. As a rule the lesion that
+causes pain is not progressive and all dreads with regard to serious
+after effects may be put aside.
+
+
+Pressure Headaches.--It is important to insist on the fact that, as a
+rule, headaches and pains in the head are not due to the brain, but to
+extraneous structures within the skull. It is true that brain tumors,
+gliomatous and cystic and, above all, the overgrowth of the pituitary
+body in acromegaly give rise to agonizing pains. The cause of these
+headaches is undoubtedly pressure. It is not the pressure upon the
+brain tissue itself, however, that is the underlying cause of the
+pain, but pressure upon the sensitive structures connected with the
+brain. The same thing is true with regard to congestive headaches.
+Pain is produced not because vascular congestion presses on sensitive
+brain tissues, for we have no reason to think that any such exist, but
+because the congested brain exerts pressure upon sensitive filaments
+in its integuments. Neuralgia may be unbearable and yet it is borne
+with more equanimity, and less dread of results, because it is felt to
+be in a comparatively unimportant structure. One of the most serious
+elements in severe headache is the fear of lasting results in the
+brain tissues, that may lead to disturbance of mentality or to injury
+affecting mental processes. Patients find their pain much more
+bearable as soon as they are assured that headaches do not lead to
+mental disturbances and that, as a rule, even the growth of a tumor
+does not disturb mentality.
+
+In the relation of the brain to the intellectual faculties that are so
+closely associated with it, we must remember that direct connection
+between the two has not been demonstrated and that the relations of
+the brain and the mind are almost as mysterious as they ever were.
+There are some who still think that the frontal convolutions are
+especially concerned in carrying out mental operations. All that we
+know about them in pathology, however, is that they are the silent
+convolutions. When a lesion occurs in other portions of the brain we
+see the effect of it practically always without delay, in some way,
+either in the sensory or motor functions of the body. Large lesions in
+the frontal region, however, often give no sign. Large tumors have
+been found {550} pushing frontal convolutions from their ordinary
+positions without any noticeable effect upon the individual.
+
+
+Hard Study and Headache.--It is worth while to impart this knowledge
+to patients who suffer from headaches, because it at once improves
+their outlook on life. I have known hard students--men who had spent
+twenty or thirty years in work at a special subject--live in constant
+dread that sometime their minds would give way because they frequently
+suffered from headaches, or at least from some uncomfortable
+sensations in their heads, which they feared as a portent of ultimate
+mental breakdown. The assurance that such a thing is utterly unlikely
+and quite apart from the physician's ordinary experience, not only
+relieved their anxiety and made their headaches more bearable, but in
+a dozen of cases in my note-books the headache has gradually
+disappeared as certain habits of life were corrected and modified, as
+their habits of eating were varied, as bodily functions were
+controlled and as diversions of mind were introduced into lives that
+had before been too unvaried for healthy functions.
+
+I do not think that I have ever seen a case, and I have been closely
+in touch with hard students for over twenty years, where I felt that
+the cause of a headache was mental overwork. I have known men who at
+the age of seventy or over have taken but four or five hours of sleep
+and who have worked at their favorite subjects for the better part of
+half a century. They never complained of headaches. Of course, there
+are others whose physical and mental power is less and who cannot be
+expected to stand a strain that for large-minded men is only the
+normal exercise of function. It has not been the mental work that they
+were doing, however, that was the source of whatever central nervous
+disturbance was to be found in lesser minds, but worry and anxiety and
+dread over what they were doing, anxiety as to what they were going to
+do that constituted the real pathological agents at work.
+
+
+_Local Conditions_.--A striking case that impresses patients much more
+than the physician's declaration and is more likely to be remembered
+and is therefore of psychotherapeutic value, is that of Von Bülow, the
+German musician. He suffered for many years from excruciating
+headaches. They were so severe as almost to drive him crazy. His only
+relief was morphine and he and his friends lived in the midst of no
+little dread that sometime or other either the pain or the process
+which caused it would bring about a deterioration of mentality. After
+his death an autopsy was made. It was found to be a small nerve fiber
+pinched by a scar in the dura as a consequence of an injury received
+when Von Bülow was very young. Many other stories of this kind have
+been told.
+
+It must not be forgotten that in many cases the pain is not within the
+skull itself or at least its cause is not and other sources should be
+carefully looked for. The connection of the eyes with headache has
+been so well worked out, owing to the initiative of S. Weir Mitchell,
+that nothing more need be said of it. One feature perhaps deserves to
+be mentioned. While strain of accommodation is a frequent source of
+headache and is at once looked for by ophthalmologists, there seems no
+doubt that some headaches, much fewer than accommodation cephalalgias,
+are due to muscle difficulties, that is, a lack of balance among the
+external muscles of the eye, whose full pathological significance has
+perhaps not yet been worked out. Headaches are {551} frequently due to
+sinus troubles, especially to disturbances in the frontal sinus and to
+intranasal difficulties. These must be eliminated before the patient
+can be helped. Sometimes these nasal and sinus difficulties are signs
+of a deeper constitutional disturbance, due to lack of fresh air and
+exercise and are relieved promptly by the establishment of hygienic
+habits.
+
+
+Congestion Headaches.--Some headaches require changes of habit and
+persuasion of the necessity for arranging the day's work so as to give
+proper intervals for relaxation. Much experience with persons whose
+absorption in their work causes them to miss a meal or delay taking it
+for seven or eight hours from the last time of eating has shown me
+that this disturbance of the routine of vegetative life is
+particularly likely to be followed by headache. This headache is not a
+mere dull ache and is much more than a sense of discomfort; it is
+often an excruciatingly painful condition that usually does not come
+on until toward the end of the day and then may seriously disturb
+sleep. An interesting thing about this class of headaches is that
+nearly always they are increased by lying down. Often only a faint
+preliminary symptom of it is apparent when the patients go to bed,
+though they may be wakened after two or three hours of disturbed
+slumber by a headache that prevents further sleep, and pass the
+remainder of the night in painful wakefulness.
+
+Usually it becomes impossible to continue lying down. The head must be
+raised and much relief is afforded by sitting up. The headache does
+not disappear at once but it will gradually pass away and sleep may be
+resumed after a half an hour of sitting up, though the sleeper will
+have to be in a sitting posture. Older people get up and sit in an
+arm-chair. I have found that placing a chair with a rather long back
+beneath the mattress, the mattress slanting along the chair back at an
+angle of about forty-five degrees and then an arrangement of three or
+four pillows above that, will enable these patients to get to sleep
+better than anything else. The ordinary remedies for headache afford
+some relief, but even very large doses of the coal-tar products will
+not relieve the pain entirely unless some arrangement is made for
+keeping the head quite high and immovable.
+
+The headache is evidently due to congestion. The reason for it is
+perhaps the failure of the blood to be recalled from the brain to do
+its usual physiological work at the digestive tract, with a consequent
+distention of arterioles in the brain so that a little later they do
+not react to prevent congestion. Usually with the headache there is
+some digestive disturbance, a feeling of unrest, flatulency with
+perhaps acid eructations. Accordingly the headache is often attributed
+to digestive disturbance. But both would rather seem to be effects of
+the same cause--the failure to supply the digestive apparatus with the
+proper amount of material to work on at the time when it expects it,
+while the mental absorption naturally attracts blood to the head. We
+know from delicate experiments made in physiological laboratories that
+at times of mental work there is an appreciably larger amount of blood
+in the head. A proof of the connection between the lack of a meal and
+the headache seems to be the fact that with most people even a glass
+of milk and a cracker, taken at the time when the meal is normally
+eaten, is sufficient to prevent the otherwise inevitable headache.
+
+Whenever some such simple explanation as this for a headache is found
+and the patient made to realize its truth on his own observation, the
+{552} significance of the headache at once dwindles and it becomes
+much easier to bear it. Before the very real pains of it were
+emphasized by the dread of the consequences that would result from it.
+If it was really a brain ache patients would find it hard to
+understand how under its influence even serious changes might not take
+place in the brain. This is only a rational suggestion, but it is
+mental healing of the best kind.
+
+Many of the aches which are spoken of as headaches are really forms of
+tenderness associated with the integuments of the skull. Certain of
+the muscles particularly are likely to suffer from achy feelings which
+are spoken of as headaches. This is true of certain feelings of
+discomfort in the frontal region and also of those that occur on the
+occipital region. External applications of many kinds relieve
+headaches in these regions, particularly in the frontal region. It is
+easy to understand that such applications do not affect the contents
+of the skull.
+
+
+Some Occipital Aches.--Occasionally I have found that people who
+complained of a sense of weight at the back of the head, with some
+muscular tenderness, were sleeping on pillows that were too high. They
+were over-exerting these muscles and this gave a sense of fatigue,
+which when much attention was paid to it, became such an ache or at
+least discomfort as is often found in the occupation neuroses. I have
+seen schemata according to which headache complained of at the top of
+the head meant digestive disturbance, headache in the anterior portion
+of the head was referred to the eyes or the brain, and headache at the
+back of the head spinal exhaustion or severe neurasthenia, but these
+are at most very uncertain and I do not think that the tabulation of
+cases justifies any such diagram of absolute causes and effect.
+Usually there is some local condition that calls particular attention
+to a special part of the head and then the attention being
+concentrated complaint is made of that part.
+
+
+Local Head Discomfort.--Usually a headache, accompanied by a localized
+sense of pressure or weight or constriction, occurs in highly neurotic
+people or those inclined to think much of themselves and whose
+attention becomes concentrated on some part. At all times we have
+sensations streaming up to our consciousness from every portion of the
+body and anyone who wants to think about them, or a particular set of
+them, can make them sources of considerable discomfort by
+concentration of attention. Sometimes there are special conditions
+that predispose to these localized sensory disturbances. I have known
+tight hats to produce such effects. It is sometimes surprising how
+tightly hats are worn. Nervous people are prone to overdo everything,
+and they overdo the pulling down of their hats. At times the wearing
+of a heavy hat will be the root of the trouble. I have known nervous
+men accustomed to wearing high hats all their lives who began to
+complain of headache when they were in the midst of busy worries and
+troubles of late life, find considerable relief by abandoning their
+high hats.
+
+
+Toxic Headaches.--There are headaches that are due to the taking of
+stimulants, as is well known from common experience. The mistake is
+often made, however, of thinking that only alcoholic stimulation will
+cause a severe headache. Tea and coffee headaches may be quite as
+severe. Whenever people complain much of headache it is important to
+revise their dietary as to the consumption of tea and coffee. Of
+course, the headaches following {553} alcoholic stimulation are
+usually recognized as such, though occasionally a man accustomed to
+taking much alcohol without any such after effects is surprised in the
+midst of the worry incident to business stresses to find that he is
+having headaches. These are due to the combination of stimulants and
+congestion consequent upon an excess of alcohol with the increased
+brain work that is demanded, or even with the same amount of brain
+work from a tired brain. Gradually stopping the alcohol will do more
+to relieve these headaches than anything else. To advise the sudden
+stoppage of regular quantities of spirits that have been taken for
+some time, will sometimes produce an anemic headache and defeat the
+purpose of the advice.
+
+When for some other reason tea or coffee or alcoholic stimulants are
+suddenly omitted after they have been taken to excess for some time,
+patients' complain of a headache. Some of this is probably imaginary,
+or at least is due to the idea that their craving for the stimulant,
+whatever it may be, must have a local manifestation, and the head
+sensation is exaggerated as a consequence. Tea and coffee cravings may
+here give more trouble than the longing for alcohol. Sometimes there
+may be a real disturbance of the circulation from the lack of the
+heart stimulant to which the system is accustomed and therefore an
+uncomfortable feeling in the head from brain anemia. This can be
+overcome by not cutting off the stimulant, whatever it may be, all at
+once, but by bringing about its gradual cessation. These patients,
+however, are very prone, even with the best of good will in the
+matter, to deceive themselves and find an excuse for not having their
+favorite tipple, be it tea or coffee or alcohol, taken from them, so
+that they readily create symptoms by auto-suggestion.
+
+
+Direct Mental Treatment.--For both congestive and anemic headaches
+mental treatment is important. For those suffering from the congestive
+kind the physicians's business is not so much the cure of any one
+attack of headache (for this can be accomplished by various now rather
+familiar anodyne drugs as a rule), but the discovery and removal of
+the cause for the recurring attacks. These will be found in some habit
+of the patient which must be corrected. Drugs are seldom needed for
+the underlying condition which occasions the headache, for when it is
+due to such organic affections as brain tumors or other intracranial
+lesions, drugs can accomplish very little. In less serious conditions
+benefit may be obtained by having the patient change his attitude
+towards certain important details of his life, such as eating,
+sleeping, attention to business or to study and the like, so as to
+prevent the mistakes of daily habit that predispose to headache.
+
+With regard to anemic headaches, especially those which occur in
+persons who are very much run down in weight, the most important
+element of treatment is to bring about an increase in weight. This can
+be accomplished much better through the mind than in any other way.
+Appetite is a function of the will, and patients should have an
+increase of diet dictated to them and then be persuaded to follow
+that. I have seen many a headache disappear among teachers, and
+religious workers particularly simply as the result of this measure.
+
+As regards headaches for which no definite cause can be found mental
+treatment is the only efficient remedy. Practically nothing but a
+change of mental attitude towards the affection and its underlying
+causes, whether these {554} be neurotic or psychic, will bring about
+relief, and each patient is a problem quite distinct from any other.
+
+There is no pretense that this use of mental healing for headache is
+new or even modern. Many stories show that in olden times headaches
+were often relieved by this means, and that suggestion was looked upon
+as an important element in the treatment for their relief. In the
+chapter on Great Physicians in Psychotherapy the quotation from Plato
+with regard to Socrates curing the headache of his young friend
+Charmides illustrates this very well.
+
+In the old stories of Greek medicine there are a number of references
+to headaches cured by suggestion or at least by mental influence. Miss
+Hamilton, in her book on "Incubation," [Footnote 40] tells the story
+of Agestratos and his headaches and how they were cured at Epidaurus.
+Agestratos had a combination of headache and insomnia, the description
+of the ailments having a strangely modern air. Just as soon as he came
+to the Temple at Epidaurus he fell asleep and had a dream. The God of
+Medicine, AEsculapius, whose cult was practiced assiduously at
+Epidaurus, came to him in his sleep and promised him the cure of his
+headache and at the same time taught him wrestling and advised its
+practice. When day came he departed cured, and continued to practice
+wrestling. Not long after he competed at the Nemean Games and was
+victor in the racing. The suggestion that his headache would get
+better had come to him and at the same time he had been given a
+suggestion that provided him with occupation of mind and body. Many of
+the people who suffer from persistent headaches need this advice more
+than anything else. Probably every physician has had the experience of
+headaches being cured by some interesting exercise, especially if
+taken in the open air. The important factor is the change of mental
+attitude, though changes in exercise, diet, amount of sleep and the
+like are helpful auxiliaries.
+
+  [Footnote 40: London, 1906.]
+
+
+{555}
+
+
+SECTION XVI
+
+_NEUROSES_
+
+
+CHAPTER I
+
+NERVOUS WEAKNESS (NEURASTHENIA)
+
+
+Neurasthenia, from the Greek roots, _neur_, meaning nerve, and
+_sthenos_, strength, joined by the negative particle _a_, turning
+strength into weakness, means nothing more than nervous weakness. To
+tell a patient that he or she is nervously weak, or is suffering from
+nervous weakness is usually not satisfactory, but it may be absolutely
+true and may represent the limit of our knowledge with regard to the
+particular case. To tell them that they are sufferers from
+neurasthenia is satisfying as a rule, because then they have a nice,
+long, and imposing word with which to talk to their friends about
+their ailment. To discuss with friends one's own nervous weakness is
+just a little absurd; to talk over neurasthenia and its symptoms,
+however, adds importance to those symptoms and makes them seem
+manifestations of some interesting underlying condition.
+
+The discussion of symptoms always does harm, but the internal
+complacency with its constant auto-suggestion of the underlying
+nervous disease is still more harmful. Neurasthenia seems to most
+people to signify a new and serious disease of the nervous system
+which has developed as the result of our high-pressure civilization
+and the modern strenuous life, and, therefore, has a special interest
+and an exaggerated importance. All of this makes for an unfavorable
+attitude of mind towards the affection and encourages the
+intensification of symptoms by attention to them. The opposite state
+of mind in which symptoms would be given their proper value by the
+term nervous weakness would act as a constant source of favorable
+suggestion. I believe that if the word neurasthenia must be used, it
+should be translated for the patient and the absolutely functional
+character of the affection insisted on in order to neutralize its
+suggestive influence.
+
+Probably the most serious objection to the use of the word
+neurasthenia comes from the number of organic affections having vague
+nervous symptoms, including especially tiredness, a certain incapacity
+to do what was readily done before with tired feelings and a general
+feeling of unfitness, that have come to be grouped under this head. In
+this it resembles the word rheumatism rather strikingly. The
+diagnostic general principles seem to be: tired feelings equal
+neurasthenia; achy feelings (especially if worse on rainy days) equal
+rheumatism. So whenever either word is used, patients are apt to think
+of cases they have known which were labeled by one of these two terms,
+{556} rheumatism or neurasthenia and ended by developing some serious
+condition. The unfavorable suggestion consequent upon this has made
+many patients miserable and has prevented them from using their
+nervous energy to relieve their condition.
+
+The use of the word neurasthenia has another decided disadvantage in
+that the facile recourse to it often keeps the physician from
+examining his patient sufficiently to detect an underlying
+pathological condition. The term can be made to cover so much that it
+has done great harm in this way. I feel, therefore, that in the
+discussion of what can be done for patients suffering from nervous
+weakness we should first of all describe and set aside a number of
+forms of disease that have sometimes masqueraded as "neurasthenia" and
+that have given the affection stronger unfavorable suggestiveness. Sir
+William Gowers, whom no one would suspect of either minimizing the
+significance of the word or of the affections that have come to be
+grouped under it, nor of wishing to attract attention by differing
+from others, has in one of his recent smaller medical works
+[Footnote 41] emphasized both of these unfortunate connotations of the
+word. Because his expressions as applied to other medical terms that
+are too general in their significance, will help physicians to get at
+the real meaning of them I venture to quote his opinion at some
+length:
+
+  [Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy
+  and Other Lectures," Philadelphia, 1904.]
+
+  The history of the word "neurasthenia" is noteworthy. ... I have to
+  confess to the authorship of two words. One, "myotatic," was always
+  a puny infant, and I doubt whether it still maintains an independent
+  existence. The other, "knee-jerk," instantly attained universal use,
+  and indeed, I think has seemed to most persons to have sprung
+  spontaneously from the thing itself, without suggestion--perhaps the
+  greatest compliment a word can pay its author. But the general use
+  at once achieved by "neurasthenia" was in spite of a strong
+  objection to it which was felt by many. The Royal College of
+  Physicians of London could not include it in their "Nomenclature of
+  Disease," and yet it is now one of the most common of medical words
+  in every language. It would be instructive in more than one way to
+  have a careful study of the forces which have influenced its career,
+  but that I cannot attempt. We must, I think, admit that not only is
+  it a satisfying word to those who suffer, but it has a certain
+  convenience which has also compelled many to employ it who at first
+  objected. If I may be pardoned for a partial paradox, its
+  convenience is not the less real because this rests on features that
+  are illusory. Remember that the word is a name which should have
+  little meaning, even to those who use it. You may employ it to
+  collect the symptoms of the case under a general designation, but do
+  not let it cover them as a cloak.
+
+
+Neurasthenia and Melancholia.--A serious mistake of diagnosis, though
+it is often not a mistake of knowledge but of medical judgment, is the
+confusion, apparent or real, of neurasthenia with melancholia. The
+word melancholia has come to have a definite serious significance, as
+it should, in the minds of many persons and as a consequence
+physicians sometimes hesitate to use it, and employ instead the
+all-embracing term neurasthenia, or neurasthenic depression. It is
+popularly well known that melancholies are likely to commit suicide if
+their condition is serious, while neurasthenia is not at all connected
+with the idea of suicide. As a consequence, patients are often not
+guarded as they otherwise would be and so we have suicides every {557}
+month of so-called neurasthenics who were really sufferers from
+melancholia. This sad state of affairs reflects in two ways to the
+detriment of medicine. First, it leaves melancholies without due
+protection. Second, it leads many of the neurotic patients whose
+ailments have been labeled neurasthenia and who read the stories of
+these supposed neurasthenics, to think that they, too, are tending
+toward suicide and so they are less capable of reacting against their
+neurotic condition and in general are much worse for the unfortunate
+dread of some such fatal termination.
+
+
+Neurasthenia Simulation by Organic Disease.--Neurasthenia is
+especially a dangerous term since, like other words of this kind with
+wide connotation, many quite disconnected diseases may in early stages
+simulate it and give rise to the thought that there is only a
+functional nervous disease present, when the symptoms are really a
+manifestation of an underlying organic disease, heightened somewhat by
+a nervous organization or by worry on the patient's part. So-called
+neurasthenia in the old must always be looked upon with suspicion.
+Neurasthenia in the young may be a purely functional nervous disease,
+though it is probable that in most cases the nervous system is
+congenitally defective, or at least is unable to perform the functions
+which have been assumed by the patient. If a nervous organization has
+stood the strain of the trials of early and middle life, which are
+usually severe enough to try out individuals from the physical side,
+if they are in moderate circumstances, or from the mental side if they
+are wealthy, it will not, as a rule, be overborne by the burdens put
+upon it by age unless some organic disease has come to seriously
+disturb it.
+
+
+_Neurasthenia and Arteriosclerosis_.--There are many serious
+conditions that masquerade as neurasthenia. Perhaps the most important
+is precocious arteriosclerosis. That a man is as old as his arteries
+is now recognized as an absolutely sure maxim of internal medicine. In
+many people the arteries wear out before their time and in all there
+is an inevitable wearing out in the course of years. With the
+beginning of degeneration of the arteries there are likely to be many
+symptoms that closely resemble neurasthenia. In the elderly these are
+nearly always symptoms of defective circulation because of lack of
+elasticity in the arteries and their failure to accommodate themselves
+to the variations of pressure in the circulation as the consequence of
+changes of position, variations in the barometer, heat and cold, and
+the like.
+
+In these cases a study of the blood pressure will give the
+differential diagnosis when the actual thickening of the arteries
+cannot be felt, but it must not be forgotten that nervous excitement
+may greatly heighten blood pressure on occasions so that a number of
+observations have to be made.
+
+
+_Neurasthenia and Bright' s Disease_.--Other general diseases almost
+inevitably produce nervous symptoms. It is curious how often a severe
+exacerbation of Bright's disease, which has been in existence for some
+time but has given no specific indication, is preceded by a series of
+neurotic symptoms thought to be due to nothing more than neurasthenia.
+Men of thirty-five to forty-five, the favorite time for the occurrence
+of the severe forms of Bright's disease, begin to complain of
+tiredness, especially on waking in the morning, of inordinate fatigue
+in the evening, of some stomach symptoms and occasionally a tendency
+to diarrhea. All of these are ascribed to a neurasthenic condition.
+Early in these cases an examination of the urine should be made {558}
+as a routine practice, because if there is nothing in it the patient
+will be just that much more reassured, while if it contains any
+pathological elements he need know no more about it than his physician
+deems proper, yet the real nature of the case and its indications will
+be appreciated. Without this a physician will often find himself
+suddenly confronted by serious symptoms in a patient when nothing of
+the kind was anticipated because the condition was thought to be
+entirely functional.
+
+Occasionally the symptoms of Bright's disease seem to develop
+suddenly, as it were a storm in the organism out of a clear sky. As a
+matter of fact, however, there have been for some time before more or
+less indefinite symptoms pointing to some serious process at work,
+which if valued at their proper worth might have led to a much earlier
+diagnosis of the impending nephritis. Such patients are labeled as
+neurasthenics for months and at times even years before the serious
+conditions develop which make the recognition of their ailment
+comparatively easy. One case of this kind has come under my
+observation that is interesting in its lessons. A medical student had
+during the first year of his course exhibited every now and then what
+seemed to be neurotic symptoms. He was inclined to complain of
+headache for what seemed very slight reasons, and of pains and aches
+whenever there was a change in the weather and especially a fall in
+the barometer. He often had stomach symptoms and was anxious about his
+heart; in general he was looked upon as one of the nervous,
+complaining kind. During the course of a lesson in clinical pathology
+in his fourth year, he was asked to furnish a sample of urine which it
+was supposed would be normal, for comparison with an abnormal sample
+that was being investigated in the laboratory. To the surprise of the
+professor and to his own consternation, his urine was loaded with
+albumin. Up to that time there had been absolutely no objective
+symptoms and only the vague indefinite subjective symptoms mentioned.
+The next day his feet swelled. Even this for a time was considered to
+be rather an index of the neurotic tendency in him to react to very
+slight causes. It was hoped that the albuminuria was functional, as
+the examination was made in the full tide of digestion, and that it
+would pass off. Subsequent examinations, however, showed not only
+albumin but also casts. There was a slight intermission of symptoms
+and then an exacerbation. Within a month after the chance examination
+of his urine and its unexpected result he had a convulsion. Two weeks
+later, altogether six weeks after the albumin was first discovered, he
+died in nephritic coma.
+
+Such cases are not so rare as they are thought, though they are seldom
+so fulminant. There is a story told of a professor at one of our
+American medical schools who, some twenty years ago, took a sample of
+his own urine in order to demonstrate the normal characteristics of
+healthy urine, and to his utter surprise he found albumin and casts in
+it. Within six months he was dead from Bright's disease.
+
+
+_Nervous Diarrhea and Organic Disease_.--Other internal conditions may
+be called neurotic when they are really due to definite pathological
+entities. For instance, in three cases I have seen what had been
+pronounced by several physicians to be chronic diarrhea of nervous
+origin, proved to be due to quite other and serious pathological
+conditions of internal organs. In one of them a chronic diarrhea of
+several years' standing finally culminated in death in {559} early
+middle age from nephritis. After the event, there seemed to be no
+doubt but that the diarrhea, which no ordinary means of treatment had
+succeeded in benefiting more than temporarily, was really due to the
+effort of the intestinal mucosa to supplement the defective work of
+the kidneys. In this case apparently one of the strongest evidences
+that the affection was of nervous origin was the fact that whenever
+the patient was away from home, eating rather plentifully of a varied
+diet, his intestinal condition was better than when he was eating much
+more simple and unvaried food at home. The change of scene and
+surroundings proved a tonic to his kidneys and perhaps also to his
+skin, thus saving his intestines some of the extra work they had
+assumed.
+
+
+_Neurasthenia and Diabetes_.--Another serious disease that may in its
+earlier stages be mistaken for neurasthenia is diabetes. There is no
+doubt that some patients have been passing sugar for a long time
+before any sure symptom can be noted in their general health, or,
+indeed, before there is anything to call attention to the possibility
+of glycosuria. In many of these cases, however, there is a feeling of
+muscular tiredness and a sense of inadequacy for occupations which
+were before easy, that may be attributed to neurasthenia. When this
+muscle tiredness changes to crampy feelings that should be enough to
+lead to an examination of the urine.
+
+Undoubtedly one of the reasons why neurasthenia is sometimes called
+the American disease and is thought to be more frequent among us than
+it is in Europe is this confusion with the beginnings of serious
+organic disease because of failure to examine patients carefully in
+order to detect underlying organic conditions. In recent years this
+neglect has become rarer and the consequence has been a reduction in
+the numbers of so-called neurasthenia cases. Our morbidity statistics
+of twenty years ago, for instance, seemed to show that we had only
+half as much diabetes to the population as they had in Europe. One of
+the reasons for this was undoubtedly the ease with which the diagnosis
+of neurasthenia might be made at the beginning of diabetes, and that
+the terminal stages of the affection were often masked by the
+development of the tuberculosis so frequent in diabetic conditions or
+of albuminuria with symptoms pointing to Bright's disease. Even at the
+present time it would be quite possible to reduce the number of
+neurasthenia cases by more careful attention to diagnosis.
+
+
+Simulated Neurasthenia Due to Over-attention.--While there is danger
+of confusing neurasthenia on the one hand with more serious disease
+there is a distinct liability on the other hand to exaggerate the
+significance of certain minor symptoms by employing the word when it
+is only over-attention of mind to certain portions of the body that
+constitutes the disease in its literal sense. If something has
+particularly attracted a patient's attention to some part of his
+anatomy and if his attention is concentrated on it and allowed to
+dwell long on it, his feelings may be so exaggerated as to tempt him
+to think that they are connected with some definite pathological
+condition and he may even translate them into serious portents of
+organic disease. If a patient once begins to waste nervous energy on
+himself because of solicitude with regard to these symptoms then it
+will not be long before feelings of tiredness, incapacity for work, at
+times insomnia and certain disturbances of memory are likely to be
+noted. Then the neurasthenic picture seems to be {560} complete. This
+is the process so picturesquely called "short-circuiting" by which
+nervous energy exhausts itself upon the individual himself instead of
+in the accomplishment of external work. Many of the worse cases of
+so-called neurasthenia have their origin in this process. It is true
+that this set of events is much more likely to occur among people of
+lowered nervous vitality, but under certain conditions it may develop
+in those who are otherwise in good health up to the moment when the
+attention happened to be particularly called to certain feelings. The
+physician can start these patients off anew after improving their
+physical condition, if he can only bring them to see how much their
+concentration of mind upon themselves is the cause of their symptoms.
+
+It has been well said, though to some it will doubtless seem an
+exaggeration, that we human beings are a regular boiler factory of
+sensations which, fortunately for our sanity, mental and physical, we
+have learned to neglect to a great extent. Wherever our clothing
+touches us, wherever the air touches us, wherever shoes or belts
+constrict us, there are definite sensations. These continue, but
+attract no attention unless they exceed a certain limit to which we
+are accustomed. Habit in this matter is very different in different
+individuals. After men and women have grown used to tight shoes or
+tight corsets these no longer produce disturbance. The chance visitor
+in a boiler factory or loom room of a cotton mill thinks he could not
+live in such din. But after a time people get so used to the din that
+silence and quiet may even become oppressive to them. City dwellers
+from the slums, especially children, find the peace of the country
+disturbing when they are first taken for vacations.
+
+Over-attention to sensations, often scarcely abnormal, is indeed the
+real source of many of the symptoms that can so readily be exaggerated
+into pathological portents when attention is directed to them. Every
+portion of our body is connected with the central nervous system.
+Every square inch of surface touched either by clothing or the
+movement of the air producers a sensation at every moment of our
+waking life. Ordinarily we pay no attention at all to these
+sensations. We can recognize their presence by turning our attention
+for the moment to any portion of the body and recognizing at once that
+there are sensations coming from it, though the moment before we did
+not notice them. If we think of the point of our big toe on the right
+foot we find, though we were totally unaware of it a moment before,
+that a certain pressure is being exerted in it. If we continue to
+think of it queer feelings develop in it. We may get a sense of
+numbness that proceeds up along the tendons that lead to it. We can
+follow them up to the insertion of the muscles in the shin. If we
+dwell on the subject we have curious prickly sensations and numb
+feelings, all of which were there and were neglected a minute before
+but now are acutely felt.
+
+This same thing is true of all the manifold sensations that come
+streaming into the brain. We learn almost to enjoy them though we are
+paying no attention to them. To be without them would mean very often
+a fright lest there should be something the matter. Usually we think
+of the outside of our body as the main source of sensation. It must
+not be forgotten, however, that our viscera have also certain
+sensitive nerves and while these are not as closely distributed as
+those on the surface they are there and their presence is often a
+source of pleasure or at least of satisfaction, but may be the source
+{561} of poignant discomfort. We are constantly disregarding ordinary
+messages from these, too. Something may easily call our attention to
+these sensations, however, and then we may translate them into
+pathological terms though they are really only physiological.
+Ordinarily man may put a couple of pounds of food and drink into his
+stomach and not feel it at all. If anything particularly calls
+attention to our stomachs, however, and we dwell on it, then this
+weighty feeling may seem to indicate serious indigestion because of
+the discomfort that is produced. This is what nervously weak persons,
+the so-called neurasthenics, are constantly doing. It is this habit
+that by suggestion and training they must be taught to break.
+
+There is a tendency to the substitution of one neurotic symptom for
+another whenever by psychotherapy and mental discipline one condition
+is overcome. Often the substitution is of something just as bad or
+even worse. I have known cases where people when properly persuaded
+gave over paying too much attention to their stomachs and then
+proceeded to pay too much attention to their sleep with the result
+that insomnia developed. On the other hand, I have known patients to
+get over insomnia and then develop a series of complaints of queer
+feelings in their head which they usually spoke of as headache, though
+when asked to describe them carefully they confessed that they were at
+most a sense of pressure or of unusual feeling in some part of the
+head.
+
+These curious substitutions take place particularly if for any reason
+special attention is called to another part of the body, either by
+accident or by some therapeutic manipulation or remedial measure. I
+have known a patient who complained of headache and was advised to
+take up exercise in the open air, do much stooping and lifting while
+cleaning snow from the sidewalk, develop a tired condition in the
+lumbar muscles and straightway this was thought to be rheumatic.
+Liniment was employed and the counter-irritation which developed
+attracted the patient's attention to that portion of the body for a
+week. The headache was no longer complained of, but lumbago was
+considered to have developed. I have known a person who suffered from
+headache develop what seemed to be a retention of urine for which
+unfortunately the doctor thought it necessary to use a catheter and
+after this there was no complaint of the headache, but the patient
+became almost unable to hold any amount of urine in her bladder and
+could not go out for social or other duties because of the fear of
+imperative urination.
+
+
+
+CHAPTER II
+
+CHOREA
+
+
+This twitching affection, so familiar that it need not be described
+particularly, is sometimes classed as a pure neurosis, sometimes as a
+nervous disease with perhaps some organic basis and sometimes is
+placed among the ailments related to rheumatism and attributed to some
+pathological condition of the circulation.
+
+
+Etiology.--Two elements must be considered in the problem of the
+etiology {562} of the disease--the predisposition and the direct
+occasion. The affection occurs particularly in nervous children who
+are made to occupy their intellects too much while their muscular
+systems are kept quiet for long hours. Often a preceding running down
+in weight is noticed, though sometimes the child only fails to
+increase in weight as it should in proportion to its growth. It occurs
+quite frequently among chlorotic girls just before or about the time
+of puberty. Anemia generally seems to predispose to it, but the
+affection may occur among children who seem to be in excellent
+physical health, though usually a distinct nervous heredity is found.
+
+
+_Immediate Causation_.--Fright is one of the most frequent immediate
+causes or occasions of the development of chorea. Mental worry of any
+kind may have the same effect. Scolding has produced it; a sudden
+grief has seemed to be the occasion; a slight injury, and still more,
+a severe injury, or a surgical operation, even a slight one, may be
+the forerunner of it.
+
+
+Pathology.--No definite lesions have been found to which the disease
+can be attributed, though a careful search has been made for them.
+Endocarditis is an extremely common accompaniment. It is probably
+present in three-fourths of the cases that have come to autopsy. Osler
+found it in sixty-two out of seventy-three cases in the literature.
+The association of the affection with rheumatism is insisted on by the
+French and English particularly, and certainly in a considerable
+number of cases there is a history of preceding or coincident
+rheumatism, that is, an acute rheumatic arthritis. Often these attacks
+are concealed under such names as "growing pains" or "colds in the
+joints" but it is not hard to elicit a history of a red and swollen
+joint with some fever. In children mild cases may occur of genuine
+acute rheumatism with the involvement of but a single joint and that
+not severely. These mild forms are often found in the history of cases
+of chorea.
+
+It seems likely that the heart affection is often responsible for the
+symptoms and it is probably through the endocarditis that whatever
+connection there is between chorea and rheumatism exists.
+
+All the elements in the disease point to the influence of the mind
+over it. The predisposition is caused by over-use of the mind at a
+time when many claims are being made on the nervous system because of
+the growth of muscles. There must, as a rule, be a pathological basis,
+natural or acquired, that is, something that tends to produce a defect
+in the circulation, but even without this certain children suffer from
+the affection. If the patient is an object of solicitude or of
+curiosity at home or at school, the symptoms rapidly become worse. At
+any time the consciousness of observation makes them worse. The
+symptoms do not occur during sleep, or at times when the patient's
+mind is much occupied with some absorbing interest. They lessen just
+to the degree that the patient's own attention is not called to them
+or the consciousness not allowed to be concentrated on them. Chorea
+often occurs in bright, intelligent children and always seems worse in
+them.
+
+
+Treatment.--The story of the therapeutics of chorea in recent years
+strongly confirms the idea of the place of mental influence in the
+cure of the disease. We have had a whole series of remedies,
+introduced with a promise of cure by distinguished authorities, used
+for a time with apparent success by many physicians, and then
+gradually falling into innocuous desuetude. It was recognized that any
+remedy would have to be used over a rather {563} prolonged period, at
+least from five to ten weeks. It was appreciated, also, that the
+patient must be kept quiet, both in mind and body, emotional
+disturbances especially being avoided, that all physical functions
+have to be set right and that the nutrition particularly must be
+corrected if in anything it is abnormal. Where all this is done
+patients recover without any remedy quite as promptly in most cases as
+with any of the supposed specifics. Expectant treatment, supplemented
+by symptomatic treatment, has proved in many institutions to give
+excellent results without the necessity of troubling the patients with
+more or less dubious drugs. It was important that the patient should
+be given certain medicine and impressed with the idea that this
+medicine was expected to do them good, a suggestion automatically
+emphasized at every dose, but it is probable that few men of
+considerable clinical experience now hold the notion that we have any
+genuinely curative remedy for chorea, though we have certain tonic,
+alterative remedies which, in conjunction with the setting of the mind
+at rest, help to put the patient in a condition where the affection is
+gradually overcome.
+
+The most important object in the treatment of chorea must be its
+prevention or its early recognition, and its immediate treatment; then
+there is little likelihood of relapses and, above all, the condition
+does not last long. Children who have had an attack of acute articular
+rheumatism or who have suffered from growing pains or any other of the
+rheumatic simulants of childhood should be watched carefully during
+their growing period and at certain critical times in early life. They
+should be especially regarded immediately after being sent to school.
+The first sign of involuntary twitchings should be taken to mean that
+the children are overborne and a period of rest from anxiety and study
+and over-exercise should be afforded them. Of course, all this
+watchful care must be exercised without attracting the little
+patient's attention, or the very purpose of the care will be defeated
+and the mind disturbed.
+
+Rest does not mean that patients should be kept absolutely in bed even
+after chorea has frankly developed, but that there should be hygienic
+rest. Long hours of sleep, interesting occupations without much
+exercise, a period of lying down in the afternoon, but, above all,
+such occupation of mind with simple pleasant things as keeps their
+attention from themselves. Visitors should not be allowed to see them;
+above all, they should not be conscious objects of over-solicitous
+care on the part of father and mother or the relief of symptoms will
+be delayed and the condition will be made worse. As a rule, children
+do not worry about themselves nor their physical ailments, but they
+can be made to do so by seeing the over-anxiety of others. A good
+nurse of sympathetic nature with power to interest the child, is
+better than its mother for a constant companion, though family life,
+the playing with brothers and sisters and the regular routine of home
+is the best possible mental solace and occupation. Grandmothers are
+useful adjuvants in the treatment late in the affection. At the
+beginning their over-solicitude nearly always does harm.
+
+
+Habit Following Chorea.--In certain nervous children after the chorea
+itself has subsided there remains a habit of twitching that often is
+almost more intractable than the chorea itself. This is particularly
+likely to be manifest in children who have an unfortunate nervous
+heredity or in those whose {564} nervous systems have been impaired by
+preceding infections disease as anterior polio-myelitis, syphilis or
+one of the forms of meningitis. Occasionally it is seen in children
+without nervous heredity, but they are usually children surrounded by
+solicitous relatives, made the centre of pathological interest and
+constantly fussed about. The habit is not surprising and would remind
+the observant physician of the whoop that by habit sometimes clings to
+children in any cough that they may have for months after they have
+had whooping cough. Often it will be found that these children are
+capricious eaters, that they take tea and coffee, that their diet
+instead of being the simple nutritious food that they should have
+consists of many things that their mothers obtain to tempt their
+appetites and that the children can really have anything they crave
+for and get it much oftener than is good for them. To continue any
+form of presumedly specific treatment in these cases does no good. If
+arsenic is used over long periods, or any of the salicylates because
+of the supposed connection of chorea and an underlying rheumatic
+diathesis they will certainly do harm. The patients' diet can be
+regulated, nerve stimulants of all kinds must be denied them, and
+their appetites must be brought into order by the proper care of a
+nurse who will not yield too readily to their caprices, and then the
+solicitous environment must be changed. These cases represent a good
+many of the so-called prolonged choreas and are really habits or tics
+due to concentration of mind and a certain hysterical tendency to
+continue to attract attention which may be noted.
+
+
+
+CHAPTER III
+
+TICS
+
+
+Without any good reason in the etymology or the history of the word,
+the term "tics" has now been generally accepted to signify certain
+involuntary movements, frequently recurrent, of which, by habit,
+certain persons usually of diminished nervous control, become the
+victims. For the psychotherapeutist, however, they have an interest
+quite beyond that which they have for the ordinary student of nervous
+diseases. They represent the possibility of the formation of habits in
+the nervous system, originally quite under the control of the will,
+but which eventually become tyrannously powerful and quite beyond
+management by the individual. They deserve to be studied with
+particular care because it is probable that they represent objectively
+what occurs also on the sensory side of the system, but which not
+being manifest externally, is spoken of as entirely subjective. If
+nerve explosions of motor character can, through habit, get beyond the
+control of the patient, it is not unlikely that sensations, primarily
+of little significance, may, in persons of low nervous control, become
+by habit so likely to be repeated as to make the patient miserable.
+Hence the study of tics as here presented.
+
+As a result of the studies of Gilles de la Tourette, we realize that
+there is an essential distinction between involuntary movements of
+various kinds, and that spasms and tics must be separated from one
+another. Tics consist of various movements of the voluntary muscles.
+Probably the most familiar {565} is that of winking. Everybody winks
+both eyes a number of times a minute quite unconsciously, though the
+unconscious movement accomplishes the definite and necessary purpose
+of keeping the conjunctiva free from irritant particles. When this
+same movement is done more frequently than is necessary, or is limited
+more to one eye than to the other, or is repeated exaggeratedly in
+both eyes, then it is a tic. There are many other facial tics. Most of
+them represent movements of the lips or of the nose or of the skin of
+the forehead and all of them are identical with movements that are
+occasionally performed quite voluntarily. There are movements of the
+lips as in sucking, or smacking sounds may be made, or such movements
+of the features as are associated with sensations of taste or smell.
+Sometimes changes of facial expression may be tics and without any
+reason there may be recurring expressions of emotion, of joy, or
+grief, or fright, or even pain. Sometimes the tics affect structures
+that are internal, as various motions of the larynx accompanied by the
+production of grunting or sighing sounds or sometimes even of
+particular words. In children the tendency is prone to manifest itself
+in the utterance of forbidden words, usually vulgar, sometimes
+indecent.
+
+Besides these facial and throat tics any of the voluntary muscles of
+the body may be affected. There may be the gestures that accompany
+certain mental states, or there may be twisting or turning movements
+as if the patient were in an awkward position and wanted to get out of
+it, or as if the clothes were hampering movement and there was an
+effort to relieve some discomfort. The head may be lifted and lowered,
+or may be twisted from one side to the other and, indeed, various
+nodding tics are extremely common. Almost any ordinary movement may,
+in nervous people, come to be repeated so frequently as to be a tic.
+
+Practically all of the convulsive or quasi-convulsive movements
+associated with respiration are likely to become the subject of tics.
+Yawning, for instance, involuntary to some degree, usually a reflex
+with a physical cause, but so readily the subject of imitation, may
+become so frequent as to be repeated a couple of times a minute and
+this repetition kept up for many days. Sneezing may also become a tic,
+though it is usually a definite reflex due to palpable physical
+causes. Hiccoughs may easily become the subject of a tic. The
+occurrence of a persistent hiccough is in popular medicine a sign of
+unfavorable prognosis in serious diseases, especially such as involve
+the abdominal region. In connection with neurotic affections of the
+abdomen, however, hiccoughs are not uncommon and are of no serious
+significance.
+
+
+Varieties of Tics.--There are many more tics than are ordinarily
+supposed. Indeed, there are few of us who escape them entirely. Nearly
+all the curious phrases that people interlard so frequently into their
+conversation, usually quite unconscious of them, or of the ridiculous
+significance they often have, must be placed under the tics. Some men
+cannot say a dozen words without interpolating "don't you know."
+Others use some such expression as "in that way." I once knew a
+distinguished professor of elocution who by actual count used this
+phrase forty times in an hour. Some say "hum" or "hem" every sentence
+or so. Whenever there is a bit of obscurity in their thought these
+voluntary but unconscious expressions are sure to pop out. No one who
+has had much experience in public speaking ever succeeds in keeping
+entirely out of such bad habits. It is curious how phrases will insist
+on repeating {566} themselves. One year one set of words, or a pet
+phrase, or mode of expression, creeps unconsciously here and there
+into an address. Then either because the speaker has been reading
+dictated copy, or because some good friend has the courage to tell him
+of it, he finds out the bad habit and suppresses it.
+
+Word formulas senselessly repeated are only one of many forms of tics
+that public speakers are prone to indulge in. Gesture which begins as
+an artificial adornment of speech, very appropriate in itself, after a
+while may settle down into certain forms that not only often lack
+elegance but that are really disturbing to an audience. Of these
+gestures and movements men are often quite unconscious. They have
+become habitual and in the absorption of mind with the thought and the
+words, they are reproduced quite involuntarily though they are all
+originally voluntary movements. Nearly every public speaker needs a
+mentor to correct him of such faults. It is rather difficult to break
+some of these habits and it requires no little concentration of effort
+and attention to be successful in eradicating them. It can be done,
+however, provided the habit is not too inveterate, and this is the
+best evidence that tics of other kinds can also be eradicated if the
+patient really takes the matter in hand and is not of a weakened will.
+
+
+_Teachers' Habits_.--Indeed it is almost impossible for public
+speakers and teachers not to acquire certain habits irritating to
+their auditors at first but amusing as they grow used to them, and
+students particularly learn to look kindly at the ridiculous side of
+many of them. I remember an old professor of literature who used to
+lecture at some length on each of the important contributors to
+English prose and poetry. We soon observed that whenever he came to
+their deaths he took out his handkerchief and blew his nose. This was
+as inevitable and as invariable a rule as the laws of the Medes and
+the Persians. It was, as it were, his tribute of sympathetic
+condolence with humanity for the loss of a brilliant contributor to
+English literature.
+
+Occasionally the effort to break up these habits will seriously
+interfere with modes of thought and habits of expression, for the time
+being at least. A professor at a certain university had a habit every
+now and then of plucking at a button on his coat. His students could
+tell when his hand was going to find this object of its occupation and
+knew from experience that he would twist it a certain number of times.
+He was not what would ordinarily be called a nervous person. One day
+he happened to take off his coat shortly before a lecture and one of
+the students surreptitiously removed the button. At the end of the
+first few minutes of his lecture his hand went up to find the button
+as usual but failed. For the moment there was a hesitancy in his
+speech; then he tried again. A little later his hand went up
+unconsciously and was disappointed; then he stammered and lost the
+thread of his discourse. The last half hour of that lecture was
+seriously impaired because of the absence of that button.
+
+
+_Tricks of Speech_.--There are many other curious tricks of speech
+that are really tics. Women often indulge in them and sometimes even
+pretty women spoil their appearance by bad habits. All of us know the
+pretty woman who talks very fast, but who every now and then projects
+her tongue a little beyond her teeth. Occasionally there is a tendency
+to wrinkle the nose or the forehead. Most of us have seen the woman
+who sets her face into a definite smile of a particular kind whenever
+her company manners are in {567} use, though there is a vacancy behind
+the smile that is rather disturbing. Some people have habitual
+movements of the fingers that are really tics, and even positions
+assumed on sitting down that are very ungraceful, or that are very
+noticeable, sometimes partake of this character.
+
+
+_Fussiness_.--A very common form of tic that is quite difficult to
+control is that tendency to be doing something with some of their
+muscles which characterizes many men. They must handle a pencil or a
+knife, or they must swing on their chair or tilt back on it, or keep
+one of their limbs swinging over the other, or twirl their moustaches
+or stroke their beards, or rumple their hair, and they cannot find it
+quite possible to sit still. The difference between men and women in
+this regard is remarkable. Women are conceded to be much more nervous
+than men, but men are ever so much more fidgety than women. The author
+of "The Life of a Prig" in his book "The Platitudes of a Pessimist"
+has some striking paragraphs with regard to this subject. He says:
+
+  To look nearer home, the British bar affords splendid examples of
+  nervous fidget. Observe barristers pleading a cause. How they
+  torture a piece of red-tape, how they twirl their eye-glasses or
+  spectacles, and how they hitch at their garments, as if they
+  momentarily expected them to desert their finely proportioned
+  figures. But worse than the Queen's Counsellors, and even worse than
+  the domestic peripatetic, is the villain who is abandoned to a
+  performance vulgarly known as "the devil's tattoo"--drumming with
+  the fingers.
+
+
+_Writers' Tics_.--Writers, and above all writers for the daily press
+and such as have to do their writing in a rush and therefore get
+nervous and anxious about it, are especially prone to develop tics,
+though others who write leisurely may do so. Some of these are curious
+and others are only expressions of nervousness common to all people.
+Many of them chew their nails, some of them bite at their fingers
+round the nails and make them sore, many of them chew the ends of
+their pens and find it practically impossible to keep a pen with a
+long handle to it. Some of them run their hands through their hair
+until it is in a greatly rumpled condition, some of them pluck at
+their eyebrows. I have one patient who when he is going through a
+particular nervous strain plucks out the middle portion of his right
+eyebrow so that he has a distinct bald spot at this point.
+
+The tradition in newspaper offices is that these curious expressions
+of the tendency of the body to occupy itself with something while the
+mind is occupied are more or less inevitable in nervous people. They
+continue for many, many years. They are only habits, however, that it
+would have been rather easy to break in the beginning, though they
+become extremely difficult to modify after they have once secured a
+firm hold. Occasionally I have fastened a piece of adhesive plaster
+over a much battered eyebrow, but that made it difficult for the man
+to go on with his work. His hand would go up involuntarily time after
+time and while plucking at his eyebrow would not disturb in the
+slightest his train of thought, just as soon as his fingers touched
+the unusual object a serious distraction occurred and work was not
+only slower, but much more difficult.
+
+
+_In Games_.--The tendency to the formation of curious habits of
+associated movements can be seen very well in most games where skill
+is combined {568} to a certain degree with chance. It is most
+noticeable, perhaps, in bowling. Few men are able to restrain
+themselves from making some special movement just as the ball strikes
+the pin. This is sometimes a motion of the head, oftener it is a jerk
+of the trunk, sometimes it is an associated movement of the arms,
+occasionally it is a kick or a stamp. In billiards the same movements
+are noticeable if a man is much interested in making a difficult shot.
+Usually there is some movement of the body or of the hands or of the
+head that would indicate his desire to move the ball in a particular
+direction. Women who play these games do not usually have these
+associated movements to such a marked degree and this may be due
+either to their better restraint to movement in general, for as we
+have said men do not acquire the habit of self-restraint in small
+matters of deportment as women do, or to the fact that such associated
+movements might disarrange their clothes. Perhaps, also, they are not
+as much interested in the games as a rule as are the men. Of course,
+similar associated movements may be seen in outdoor sports that
+require skill yet have an element of chance in them. For it is, as it
+were, to overcome this that the additional movement is made.
+
+
+_Children's Tics_.--Some tics consist of some very curious habits.
+Occasionally children hear some obscene or vulgar expression and
+repeat it. The repetition of it produces such a look of shock to
+propriety on the part of some of the other little ones who happen to
+be present that they repeat it in the spirit of bravado and then
+continue to utter it until it becomes a habit that is hard for them to
+break. After all, the use of blasphemy later on in life is really a
+tic, a habit of uttering words no longer expressive of any particular
+feeling, as a rule, unless in exceptional circumstances but just the
+result of a tendency for the speech organs to repeat certain words.
+They tell a good story of the Rev. Sydney Smith who, wishing to break
+an acquaintance of the habit of indulging in expletives, interlarded
+his speech with "fire tongs and sugar tongs" every ten words or so and
+when his auditor protested that that added nothing to the significance
+of what he said the Rev. Sidney suggested that that was also true of
+various blasphemous expressions that his acquaintance was accustomed
+to use.
+
+At the Salpêtrière they tell the story of a little boy who had the
+habit of saying the French word which the corporal in Victor Hugo's
+"Les Miserables" made use of when anyone told him that it was because
+Wellington was a greater general than Napoleon that the French Emperor
+was defeated at Waterloo. Nothing seemed to be able to break the boy
+of the habit of interjecting this word into conversations sometimes in
+which he had no part and sometimes toward which he was expected to
+take only a respectful and childlike attitude of silence. He was sent
+to the Salpêtrière. The ordinary remedies had failed entirely. One day
+he was allowed to go outside of the hospital, or rather stole out of
+the gate and played marbles with some street gamins in front of it.
+During the game he used the word in question and they proceeded to
+give him a good thrashing. It is Charcot who tells that this broke him
+effectually of the habit.
+
+One of the childish customs that sometimes disturbs parents very much
+because it seems to be such an unaccountable lapse into barbarism,
+though it is really nothing more than a tic in the strict sense of the
+word, is the habit that some children acquire of removing portions of
+hardened material {569} from their nose and then putting it into their
+month. Refined parents are apt to be so seriously disturbed by this
+that they fear for the child's mentality. Really the habit is not
+nearly so rare as is usually thought by some grown-ups who have
+forgotten about their own and others' childhood. In country places the
+habit is very common. It is not alone the dull children who do it but
+some very bright ones. Indeed, the tendency to the habit is so common
+that one wonders whether there is not something in nature that tempts
+to it. Parents who are fearful lest their children may be seriously
+hurt in health by the awfully insanitary habit may be reassured that
+after all a certain amount of the drainage of the nose is normally
+carried off through the posterior nares to the stomach and that no
+danger to health seems ever to have resulted from the practice. As a
+rule, the habit can be broken rather easily by a little judicious care
+and insistence, though I know of cases where relapses occurred and the
+habit continued surreptitiously.
+
+
+_Motor Tics_.--Motor tics frequently develop as a consequence of some
+injury to a nerve or some intense overuse of it. Winking habits follow
+an herpetic involvement of the superior branch of the fifth nerve.
+Bell's palsy is sometimes followed in the face by a tendency to
+twitching on the unaffected side that makes the patient quite
+uncomfortable. Herpes zoster is sometimes followed by a catching of
+the breath, probably due to a little spasm in the muscles supplied by
+the nerve thus affected. Some of the yawning tics have this origin.
+Any neuritis may in the course of its betterment be followed by this
+curious tendency to explosion along the nerve that has been affected,
+as if the pathological process had more seriously interfered with
+inhibition than with the actual function of the nerve. Examples of
+over-exertion followed by twitchings are not rare. A scrubwoman who
+has seen better days and now has to carry a heavy bucket and use her
+right hand much with the brush may develop a twitching of the right
+arm. A janitor's wife who sweeps much may have a tendency to
+twitchings of the fingers as a consequence of the unusual exertion of
+holding the broom. Twitchings in the limbs of men who work at a foot
+lathe or other machine requiring foot power are not unusual though
+they are more often seen in the leg on which the workman habitually
+stands than in the other one and it seems to be oftener a strain on
+muscles than actual over-exercise that precedes the development of
+these tics.
+
+
+Heredity.--Heredity plays as large a role in tics as it does in
+stuttering and other functional nervous disturbances. Occasionally the
+direct inheritance of some habit will be found, though there is nearly
+always more than a suspicion that a trick of speech or of act, which
+constitutes the tic, was learned by imitation rather than transferred
+directly. Besides, it is a case of a similarly constituted nervous
+system reacting in the same way to a similar environment, rather than
+any definite tendency existing by heredity in the nervous system. It
+is surprising what close observers children are and how easily they
+learn to imitate any habitual action of father or mother or, for that
+matter, of nurses or those who are close to them.
+
+
+Mental Treatment.--The most important element in the psychotherapy of
+tics is their prophylaxis. They run in families, not by any inevitable
+hereditary influence, but as a consequence partly of imitation and of
+corresponding tendencies resulting from certain weaknesses in the
+family. Wherever they are known to be likely to occur, parents should
+be warned of the {570} possibility and the first symptom of any motor
+habit should be considered the beginning of a tic. As we have said,
+they are likely to begin in muscles that have been overstrained for
+any reason, especially when patients are run down. They are often seen
+after herpes and certain facial neuralgias.
+
+There is probably no tic, no matter how long or how serious, that can
+not be eradicated, or greatly modified, if the patient will take the
+trouble and if the treatment is conducted so as gradually to get rid
+of it. Peculiar movements cannot be done away with at once. They can
+be lessened in intensity and in frequency and then gradually the
+patient will be encouraged by their becoming less noticeable than
+before to make renewed efforts. The habit must be gradually undone and
+this will take as long as it did to form it originally. The exercise
+of contrary muscular movements carefully carried out, and of gentle
+repression with definite times of exercise during the day, gradually
+increasing the length of the intervals of repression, in the end
+proves successful. Only a determined struggle will effect a cure. It
+depends on the patient's will. Like a drug addiction, or a tendency to
+overeat, or a craving for alcohol, it must be gradually overcome and
+then care must be exercised to prevent relapses; for when the
+condition is somewhat better, to relax vigilance and give up effort
+will allow the old condition to reassert itself with startling
+rapidity. People suffering from severe tics will often give up.
+Without the patient's hearty co-operation cure is impossible. With
+good will its gradual diminution gives the patient a confidence in
+self and an uplift in character that is extremely valuable, not only
+for physical but for mental conditions.
+
+
+
+CHAPTER IV
+
+STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC.
+
+
+The difficulty of speech called stuttering has usually been considered
+rather as an unfortunate lack of control over the organs of
+articulation, somewhat corresponding to muscular awkwardness of any
+other kind, than as a pathological condition deserving the physician's
+attention. If anything was done for it formally, the first effort of
+the parents or the teacher was to correct the supposed bad habits and
+this failing the affection was relegated to someone who claimed to
+produce wonderful results by some special method. Perhaps, even
+oftener, stuttering was considered one of those affections,
+fortunately decreasing in number, that the child may be expected to
+outgrow. Often there was noted an hereditary element which was
+supposed to indicate incurability.
+
+Stuttering deserves special treatment in a work on psychotherapy
+because it illustrates very strikingly one phase at least of mental
+influence over bodily function. While in the study of the etiology of
+the disease much has been made of anatomical features, nerves and
+muscles and anatomical anomalies of the speech organs and the
+respiratory tract, the sufferers from stuttering are certainly quite
+up to the average both in the physiology and anatomy of these regions.
+They are of all ranks and conditions of life, of all sizes and build,
+and it is evident that the trouble is not physical, but mental. They
+{571} pay too much attention to their speech and to the co-ordination
+of the many muscles engaged in speech production and the consequence
+is that they impair their power to use these organs. Practically all
+the cures recommended contain some element which distracts the
+attention from the speech to something else and so permits the
+function of the speech organs to proceed undisturbed.
+
+A number of conditions develop in nervous individuals that resemble
+stuttering. There are disturbances of swallowing, disturbances of
+walking (astasia abasia), neurotic disturbances of writing, and of
+other uses of the hands and of the legs.
+
+
+State of Mind.--It is perfectly clear to anyone who has closely
+observed the ways of stutterers that the state of mind is extremely
+important in these cases and indeed probably constitutes the
+underlying factor in the speech disturbance. Stuttering and all speech
+defects are much worse when the patient is laboring under excitement.
+This is so amusingly true that the impotence of a stutterer to say a
+word when he wants very much to say it is a commonplace in the cheap
+drama and never fails to raise a laugh. In ordinary conversation with
+friends the stutterer may have little difficulty. As soon, however, as
+he begins to talk with those with whom he is unfamiliar his speech
+defect becomes noticeable. When the others present are entire
+strangers and, above all, strangers whom he wishes to impress
+favorably, then his stuttering becomes pronounced. The mental element
+is the most important factor. Just as soon as consciousness of the
+task supervenes his power of co-ordination fails and stuttering
+begins.
+
+
+Stuttering in Complex Activities.--There are many actions that become
+habitual and people are thus saved from the necessity of constantly
+performing them under the control of the will and the consciousness.
+Walking is a typical illustration of this and is seldom disturbed by
+consciousness, but there may be a stuttering in the gait of sensitive
+persons if they become overconscious when passing people who are
+watching them. Talking is even a more striking example of elaborate
+co-ordination without conscious effort. We have to bring into play
+more than a score of muscles whose movements are nicely and accurately
+co-ordinated, or else the effort at articulate speech is a failure. We
+have to change the positions of most of these muscles many times every
+minute, yet we do it without a thought of how it is done and most of
+us accomplish it with ease and perfection.
+
+
+_Stuttering Walk_.--Stuttering, after all, comes most naturally under
+the head of dreads in the classification of the psychoses. Stuttering
+is not a physical difficulty so much as a nervous apprehension, and
+there may be a stuttering in any co-ordination as in speech. I have a
+patient under observation who, if people are looking at her, finds so
+much difficulty in walking because of a trembling that comes over her
+that she fears she may not be able to keep from falling. Boys at
+school whistle a certain air that requires a little halt in the gait
+to keep time with it, as their schoolgirl friends go by, and it is
+impossible for these not to drop into the peculiar gait indicated by
+the time of the tune.
+
+
+_Stuttering Writing_.--There are many men who become so nervous about
+writing their signatures that they cannot sign while anyone is
+present. There are others whose penmanship becomes very irregular, or
+at least exhibits many signs of nervousness, whenever they think
+someone is watching them. Most of {572} the difficulties seen in
+speech may, indeed, be exhibited in writing. The same difficulty in
+beginning, the same elision of letters under stress of excitement, may
+occur.
+
+Writer's cramp is, after all, much more of the nature of a stuttering
+in writing than a real cramp. Over-action, added motions, and,
+finally, incomplete power to act as desired are seen in both cases. It
+might be expected that this would not affect so simple and familiar a
+set of motions as those required for a personal signature, but it
+does, as many cases illustrate. A typical example was the treasurer of
+a large trust company who had to sign a number of bonds, some thirty
+thousand. At the rate of 200 an hour, over three a minute, as he did
+the first day with others making it easy for him, it looked as though
+he could complete the task, huge as it was, in a month. At the end of
+a week, however, the rate had fallen to 120 an hour and, toward the
+end of the second week, one a minute on the average was all that could
+be accomplished. At the end of the month his signature, while
+retaining certain of its original characteristics, had become very
+different from what it was at the beginning and signing had become an
+extremely difficult matter. He had to take a rest from business for
+several weeks after accomplishing this apparently mechanical
+procedure.
+
+
+Emotional Ataxia.--Dr. S. Weir Mitchell in his article on "Motor
+Ataxia from Emotion" in the May number (1910) of _The Journal of
+Nervous and Mental Disease_, discusses some cases in which inability
+to write even a signature came as a consequence of nervousness and
+emotional disturbance.
+
+In one of Dr. Mitchell's patients, other manifestations of ataxia
+occurred as the result of the consciousness that people were watching
+the patient. At times he is compelled to leave a dinner table, since
+with strangers it is almost impossible for him to eat. If there are
+two or three at the table with him, however, and especially if he is
+worried about himself, he may become almost helpless, requiring both
+hands to get a cup of coffee or a glass of water to his mouth. A
+patient of mine with like symptoms has described to me equivalents of
+various kinds to his own difficulties in his sisters. One of them
+cannot play the piano before strangers, though an excellent musician.
+The other cannot crochet with any success if any but intimate friends
+are present. How much of this family trait is due to suggestion or
+psychic contagion would be hard to say. The state that comes over
+amateur actors and which makes them forget their lines, stammer in
+their speech, walk awkwardly, and trip easily, are really
+manifestations of this same incapacity to control even familiar sets
+of actions when there is great self-consciousness and over-attention.
+
+
+Mental Influence.--The correction of these conditions comes through
+soothing the mind of the patient and getting him or her not to be so
+self-conscious as to disturb action by thought about it. It is easy to
+say this and extremely difficult to do it. In certain nervous
+organizations it is quite impossible to overcome the tendency to this
+ataxia or inco-ordination of voluntary movements. Much can be
+accomplished, however, by proper training and discipline in all cases,
+and, while the patient can never be completely cured, great
+improvement may be brought about by patient habituation under
+favorable circumstances. In Dr. Mitchell's cases the taking of a glass
+of whiskey or of wine sometimes stimulated the patient so that
+co-ordination became possible where it was impossible before. In
+nearly all cases of writer's cramp {573} and writing difficulties the
+power to write is restored for a time by such stimulation. Strong
+coffee will sometimes serve the purpose as well as alcohol. It is easy
+to understand, however, how dangerous is the resort to such
+stimulation.
+
+
+_Practice in Self-Control_.--The excitement and nervousness incident
+to appearance before an audience which make thought and speech so
+difficult and action so awkward and so exaggerated gradually disappear
+as the individual becomes habituated to appearing in public. In most
+people there is never a complete loss of self-consciousness with
+entire freedom from nervousness, but the conditions are much improved
+so that there is no noticeable interference with ordinary actions and
+speech. Whenever there is some reason for additional excitement,
+however, as when a new play is being put on, or when some special
+audience is being entertained, there is a reappearance of many of the
+old symptoms due to a self-consciousness.
+
+
+Stuttering in the Young.--The prognosis of stuttering when it develops
+at a certain period is much better than at others. The stuttering of
+the very young can usually be overcome by a little careful training,
+if it is taken early and treated patiently by a competent teacher. Not
+infrequently a certain amount of stuttering develops at puberty when
+the voice changes, partly due to the inability of muscles and nerves
+to co-ordinate so easily as before upon the rapidly-enlarging vocal
+chords and larynx, and partly to that greatly increased
+self-consciousness amounting almost to painful bashfulness which
+develops in boys about this time. Breathing exercises and especially
+slow expiration is an excellent thing in these cases and distracts
+their attention from themselves and their speech.
+
+The chest has usually developed rather rapidly at this time and the
+muscles have to some extent lost control over it, and it will be found
+on careful observation that the breathing is particularly superficial,
+that the descent of the diaphragm is quite limited and that the use of
+this important muscle of respiration requires practice in order that
+it may be controlled properly.
+
+
+In Women.--Perhaps the most interesting thing about stuttering is that
+it is ever so much rarer in women than it is in men. Something less
+than one-fourth as many women suffer from it as men and this is true
+for all periods of life. Women are usually more bashful and
+self-conscious than men, but this rarely goes to the extent of
+disturbing their speech faculties. Ungallant observers have suggested
+that the sex quality of ready speech is too profoundly seated in
+nature to be disturbed by mere bashfulness, but there seems to be no
+doubt that the breathing of women has much to do with the difference
+between them and men in the matter of speech defects.
+
+When stuttering occurs in women the defect is much less tractable and
+is usually dependent on a more serious disturbance of the psyche or of
+the central nervous system. The prognosis of cases of stuttering in
+women is not so good as in men, but remarkable cures are sometimes
+effected by mental treatment of the self-consciousness which causes
+the speech defect.
+
+
+Correction of Respiratory Defects.--This last point, the correction of
+all pathological conditions in the respiratory tract, is especially
+important. Many stutterers are for one reason or another mouth
+breathers. If they are mouth breathers because they have adenoids,
+these must be removed. This must {574} be done early in life,
+certainly not later than the third or fourth year, or else there will
+come a serious deformation of the chest and that chicken-breastedness,
+which is not undesirable in itself, but which hampers to some extent
+the action of the diaphragm because that muscle cannot act as well in
+the deformed as in the natural chest. Not all who are chicken-breasted
+have any defect of speech, nor any tendency to stutter, but when there
+is a natural tendency to a lack of inco-ordination because of
+sub-normal nervous ability the presence of such a deformity makes the
+prospect of cure much less favorable than would otherwise be the case.
+If the mouth-breathing is due to stoppage of the nostrils, this must
+be relieved.
+
+
+Realization of Allied Conditions.--A helpful suggestion for stutterers
+is found in the recognition of the fact that there are so many
+conditions allied to stuttering and so many people afflicted with
+them. Under the heading Neurotic Esophageal Stricture stuttering in
+swallowing is treated of. In the chapters on urinary symptoms
+stuttering in urination is discussed. Any set of muscles requiring
+careful co-ordination may thus be disturbed. The stutterer is apt to
+look upon his affliction as a very special individual annoyance. When
+he learns that in practically every set of muscles requiring nice
+adjustment for function like difficulties may occur, that in every
+action requiring careful co-ordination of muscles there may be a
+similar disturbance, and yet that in most of them careful mental
+discipline, especially training in self-control, proves a source of
+relief, he takes new courage to face the struggle necessary to
+overcome the self-consciousness which is the root of most of these
+troubles.
+
+A striking form of inability to co-ordinate muscles so as to enable
+them to perform their ordinary function is aphonia, or mutism,
+sometimes spoken of as hysterical mutism. After some sudden emotion or
+fright or accident a neurotic person proves to be quite unable to
+talk. He cannot utter a sound. In Prof. Raymond's clinic at the
+Salpêtrière I once saw the classical case described by Charcot and
+presented at his clinics several times. It was a man whose wife had
+run away from him and been taken back three times. Each time on her
+disappearance he had an attack of aphonia, inability to utter a sound
+of any kind. It lasted for from several weeks to a few days. The cases
+are much commoner in women. After a disappointment in love or a scare
+the patients become unable to speak. Sometimes they can whisper but
+cannot phonate. The affection is entirely functional or neurotic, and
+if the patient's mind is properly predisposed speech returns without
+difficulty or delay. A little massage of the muscles of the throat or
+of the tongue by means of a tongue depressor or the use of Politzer's
+bag in the nose with the assurance that after proper swallowing
+movements the ability to speak will return, have proved successful.
+Occasionally hypnotism is recommended for these cases, but many of
+them are too highly neurotic to be readily susceptible to hypnotism
+and, besides, suggestion in the waking state proves just as effective.
+
+After several days of speechlessness it seems little short of
+marvelous to make a patient talk readily after a little massage of the
+throat. It is all dependent, however, upon confident assurance and the
+suggestion to talk. The physician himself must possess absolute
+confidence in his power to bring this about, for the slightest sign of
+doubt or hesitation will make it impossible {575} to influence the
+patient and will completely destroy his psychotherapeutic efficiency.
+
+
+_Neurotic Esophageal Stricture_.--A rare but interesting form of
+neurosis, which should be studied in connection with stuttering
+because of the light shed on both by their relations to each other, is
+that seen in the sufferers from so-called neurotic esophageal
+stricture. These patients are unable to swallow solids except after
+determined deliberate effort and occasionally the discomfort caused by
+this effort leads them to eat much less than is sufficient for their
+nutrition. The physician is sometimes tempted to overcome the
+spasmodic closure or partial closure of the esophagus by bougies and
+dilators, and these the patients learn to pass by themselves. I have
+never known any of these cases to be benefited more than temporarily
+by this treatment and I have seen two that were made distinctly worse.
+Forcible dilatation by concentrating attention on the affected parts
+hampers the proper flow of nervous impulses and the ordinary reaction
+to these which should occur.
+
+To appreciate how closely related to stuttering this spasmodic closure
+of the esophagus is, it is necessary to see these patients swallow
+when they do not know that they are under observation. For when they
+are on exhibition for the physician, when their condition is
+intensified by the excitement of the occasion and by the definite
+purpose to make the doctor appreciate how serious is their case, they
+swallow with more difficulty. Nearly always they have more difficulty
+in eating in public than with friends, and it is only with those with
+whom the patient is on a footing of perfect familiarity that the best
+swallowing power is obtained.
+
+In sufferers from esophageal stricture of the neurotic type the
+muscles by an unfortunate perversion of nerve force contract in front
+of the bolus instead of behind it. This contraction may be so complete
+as to prevent even the swallowing of liquids. Usually, however,
+liquids can be swallowed without much difficulty. Such patients, then,
+if they become much run down in weight, must be fed on milk and eggs
+and ice cream and the gruels and soups until they gain in weight.
+While they are much under weight their condition is distinctly worse
+and their power of co-ordination much less. It is, however, not hard
+to make them gain in weight. This gain in weight acts as a strong
+suggestion which persuades them that they are getting better and this
+of itself soon helps them to control their muscles. Local treatment
+does harm rather than good. Ice in small pieces swallowed shortly
+before a meal seems in some patients to have the effect of making the
+muscles less prone to follow the inco-ordinate nervous action and thus
+renders swallowing much easier. In some, and especially in nervous
+people, warm liquids have the same effect, while ice produces further
+irritation. Acids nearly always increase the spasmodic condition.
+Sucking a piece of hard candy for some time before a meal, especially
+if it is not too sweet nor flavored with acid, helps some people.
+
+Nearly all of them when carefully questioned prove to have special
+foods that are more difficult of deglutition than others. Not
+infrequently these idiosyncrasies for food are found to follow ideas
+with regard to their digestibility. If the patient is hurrying for any
+reason and suddenly becomes conscious that he is not masticating
+sufficiently, swallowing at once becomes much more difficult.
+
+{576}
+
+The main element in the treatment, however, must be as far as possible
+to get the patient's mind off his condition. The more attention he
+gives to it the worse it will be. No treatment that we have will cure
+it any more than stuttering can be cured, though a deliberate effort
+to form a habit for the control of the swallowing muscles will often
+do much to lessen the discomfort and the inability to swallow.
+
+It is important in all these cases to be sure that there has been no
+incident in childhood which might have caused the production of scar
+tissue in the esophagus with a consequent stricture. Sometimes it is
+many years before this manifests itself and, as in the case of the
+urethra, even ten to twenty years may pass before serious trouble
+comes. When the first symptoms are noticed, the actual stricture may
+be so slight as scarcely to be possible of diagnosis by the bougie.
+Occasionally the first symptom of a cancer of the esophagus is an
+inability to swallow, and cancers of the esophagus have been known to
+occur in quite young people, especially young men. I remember seeing a
+case at autopsy in Vienna where the first symptom had been the
+difficulty of swallowing and the man, at the recommendation of
+friends, swallowed a glass of beer with some black peppers in it and
+these stuck in his esophagus and produced death. Such cases are
+exceptional but must not be forgotten. Neurotic esophageal stricture
+is entirely benignant and its prognosis altogether favorable.
+
+
+Treatment.--The treatment of stuttering presents the best example that
+we have of the influence of the mind over neurotic difficulties of any
+and every kind. Many forms of treatment have been announced as
+successful, most frequently in the hands of men who have themselves
+been stutterers and who have helped themselves by them. This would
+seem to make it clear beyond all doubt that discoveries in direct
+therapeutics had been found. As a matter of fact, however, when a
+review of all the methods is made, they are seen to be so different
+from one another and founded on such essentially diverse principles
+that the only common connecting link to be found is in the occupation
+of mind with something else besides speech which all these methods
+recommend. We have had successful cures announced by surgery, by
+discipline, by making speech more difficult by obstacles of various
+kinds, by special positions of the tongue--up against the palate or
+down against the floor of the mouth--by associated movements, by
+rhythmic speech, by special control of the muscles of respiration, and
+of many other structures much less related to speech. The interesting
+phase of all this is the uniform success claimed by different
+specialists using many different methods.
+
+From the beginning of history cures have been suggested. That idea,
+still held among the non-medical, that the sufferer from a difficulty
+of speech is tongue-tied and needs to have the frenum cut, is as old
+as the history of medicine. Galen suggested cauterization of the
+tongue. Aetius, the first prominent Christian physician of whom we
+have any record, divided the frenum of the tongue. So did Paul of
+AEgina. Of course, in the Renaissance, when the old medical classics
+were revived, this became a favorite method of treatment. Hildanus is
+sure that it accomplishes great things. This idea has never been
+entirely given up, and recurs from time to time in the practice of
+those who do not reason much, but who look for some ready explanation
+and, above all, some direct method of treatment. Much more {577}
+serious surgical intervention has been suggested from time to time,
+however. Velpeau advised division of the extensor muscles of the
+tongue. Of course a number of surgeons have quite properly insisted on
+the removal of the tonsils, uvula, polyps in the nose and other
+obstructions of respiration.
+
+
+_Singing in Treatment_.--A number of the stuttering cures employ
+singing as a method of training in forthright utterance. Few people
+stutter when they sing. Most people can be given confidence in
+themselves and their power to talk right on by being shown that as
+soon as they try to follow a set of notes there is little or no
+difficulty in utterance. The teaching of singing, then, is of distinct
+value in many cases. Taking advantage of this a number of those who
+correct stuttering endeavor to introduce a certain rhythm into speech.
+So long as the rhythm can be maintained stuttering does not occur. As
+Kussmaul has pointed out the rhythmus acts as an efficient
+will-regulator, so that nerve impulses go down regularly and are not
+interrupted by consciousness and by the sudden starts and stoppages
+due to fear and tremor and mental uneasiness. Undoubtedly the lesson
+of this method of teaching is extremely important as an index of how
+stuttering may be relieved.
+
+
+_Regulation of Respiration_.--A number of systems to correct
+stuttering depend on the regulation of breathing. It has been shown
+over and over again, and notably by Prof. Gutzman of Berlin,
+[Footnote 42] that one of the most important differences between
+stutterers and those who talk naturally is that the normal individual
+talks during expiration as may be seen in Fig. 23, while the stutterer
+begins at the end of inspiration or at least where normally on the
+respiratory curve expiration is just about to begin, but instead of
+permitting his diaphragm to go up as in ordinary expiration, the
+stutterer makes it sink lower and lower in a forced inspiration.
+
+    [Footnote 42: See my translation of one of his clinical
+    lectures In _The International Clinic_ for July, 1899.]
+
+  [Illustration: Fig. 23.--Normal Diaphragm Curve in Normal Breathing.
+  Expiration as we Talk Normally.]
+
+
+  [Illustration: Fig. 24.--Curve in Diaphragm Before and During Talking
+  by a Stutterer.]
+
+
+_Attention to Something Besides Speech_.--The attention must be
+centered on something besides speech itself. This is the important
+element in any method of treating stuttering. If it is allowed to
+occupy itself with that {578} nothing will save the individual from
+getting tangled in the efforts that he makes to co-ordinate the
+complex movements necessary, though if he would only allow them to
+proceed automatically, as do the rest of mankind, there would be no
+difficulty at all. Washington Irving, so ready with the pen, could not
+utter two successive sentences at a banquet without having to sit
+down, with expression absolutely inhibited from excitement.
+Expression, thought, utterance--all may be inhibited by overconscious
+attention, which may also disturb all other complex activities.
+
+The most interesting methods of treatment for stuttering are those
+which involve the use of various hindrances to speech and which would
+seem to be least likely to make it possible for a person already
+laboring under speech difficulties to talk with more ease. The secret
+is, of course, that the added impediments so distract the attention of
+the patient that he is unconscious of the co-ordination necessary for
+speech and so accomplishes it without difficulty. It is because of
+over-attention to himself that the disturbance occurs. These methods
+developed very early in history. We all know the tradition of
+Demosthenes overcoming his impediment by placing pebbles in his mouth.
+One of the most earnest advocates of a similar method, who had himself
+suffered very seriously from stuttering was the Rev. Charles Kingsley,
+one of the most distinguished of English literary men. He cured
+himself, or at least greatly relieved his symptoms, by keeping a cork
+fast between his back teeth.
+
+There have been many other curious suggestions for the cure of
+stuttering. What was known as the American method had great vogue in
+the early part of the nineteenth century. It was probably invented by
+Yeats of New York, though it came to be known as the Leigh method.
+Yeats, himself a physician, seemed to fear that he might fall into
+professional disrepute if he advertised the method in any way, so he
+had his daughter's governess, a Mrs. Leigh, open an institute for the
+cure of stuttering in which this method was practiced and it proved to
+be very successful. The entire secret of it was to have the patient
+raise the tip of the tongue to the palate and hold it there while
+speaking.
+
+Another mode of treatment that attracted considerable attention
+consisted mainly of just exactly the opposite maneuver, that is,
+keeping the tongue as far as possible firmly placed on the floor of
+the mouth during speech. It is evident that neither of these
+suggestions does anything more than occupy the patient's attention
+with an additional activity, so that his speech function may be
+allowed to proceed automatically of itself, as it will if not
+disturbed by attention to it and by conscious attempts to regulate the
+various activities of it. Instruments were invented to help the
+patients to secure various positions of the tongue. Itard, for
+instance, during the second decade of the nineteenth century invented
+a golden or ivory fork to be placed beneath the tongue, so as to
+support it.
+
+After the various methods of managing the tongue, the most popular
+curative maneuver has been that of regulating the breathing. During
+the nineteenth century there were at least a dozen different methods,
+all of which had a number of reported successes, of treating
+stuttering by means of breathing exercises.
+
+Very simple methods of diverting the attention from speech are quite
+{579} sufficient in many cases to bring improvement. For instance, the
+insertion of extra letters that are themselves easy to say between
+words or preceding consonants that are hard to utter has been a
+favorite method among the specialists in stuttering. Johann Müller, as
+I said, suggested an e. Others have suggested an n. Occasionally
+stutterers themselves form the habit of using an m or a to and find
+that it aids their facility in uttering difficult sounds over which
+they would otherwise halt and stutter. A combination of these methods,
+as, for instance, an e between all words and the placing of an easy n
+before the most difficult sounds, has been repeatedly revived as an
+infallible method of treatment.
+
+All this serves to show that in patients whose functions are being
+interfered with by over-attention diversion of mind must be the main
+remedy. If this can be secured, the function they are disturbing will
+be allowed to proceed unhampered. What will prove effective for one
+patient will fail with another, however. After the patient gets used
+to a particular form of diversion another must be tried. Simple
+methods are sometimes sufficient to secure good results. The one thing
+is not to be discouraged and to proceed from one effort to another,
+satisfied even if relief is obtained for a while, for after relapse
+another method of treatment may always be tried.
+
+
+_Suggestion for Stuttering_.--There are many systems to train people
+out of the spasmodic inco-ordination that constitutes stuttering. All
+of these systems have their successes, but, as is well known, all of
+them have their failures. When the patient has confidence in the
+teacher and his method there is practically always quite a remarkable
+improvement, at the beginning. This improvement is more noticeable
+during the first month than at any other time. Not infrequently after
+this there is a tendency for patients to drop back into old habits,
+apparently discouraged, as a consequence of loss of confidence. It is
+the mental element that means more than anything else. It is the old,
+old story that we have to repeat with regard to every chronic ailment.
+
+
+_Distraction of Mind_.--Each inventor is sure that his method is the
+best and his "cured cases" support his claim. Others who try his
+method, however, never succeed as well as he does and those who are
+interested invent methods of their own. I have on my desk, as I write,
+six different, infallible--to their authors--methods of treating
+stuttering. I am sure that none of them succeed absolutely, that is,
+none of them will cure every case and most of them will not succeed
+beyond a moderate degree, except where the enthusiasm and the
+confidence of the inventor or an immediate disciple of his is behind
+them to make them efficient. There are all sorts of elements in these
+cures, but most of them depend on their power to distract the patient
+from his over-attention to himself and what he is doing when he talks,
+so as to permit without hindrance the automatic movements which are so
+necessary for the complex function we call speech. Those who have
+spent most time in treating stutterers confess that the effect
+produced upon the patient's mind is an extremely important part of the
+treatment and that, if this cannot be secured, failure is almost
+certain. If the patient has no confidence that he can be cured and by
+this particular method, failure is inevitable from the very beginning
+and just as soon as a patient loses confidence improvement ceases.
+
+
+{580}
+
+
+CHAPTER V
+
+TREMORS
+
+
+Two types of tremors come to us for treatment: those that are quite
+involuntary and occur when muscles are at rest, and those that are
+associated with voluntary movements. The most common type of
+involuntary tremor is that seen in paralysis agitans to which a
+special chapter is devoted. After this, though coming for treatment
+much less frequently, is senile tremor which may, however, also be
+increased by voluntary movement. The tremors associated with voluntary
+movements are spoken of as intentional tremors. They may occur as the
+result of organic disease of the nervous system and the most
+characteristic type is that seen in multiple sclerosis. They are more
+frequent, however, with functional diseases of the nervous system and
+with emotional disturbances of various kinds. They are especially
+frequent as the result of dreads. Usually the idea of tremor is
+associated only with the head and the hands. Tremors may occur in
+other parts of the body, however, and tremors of the legs are
+particularly important. A familiar type is the tremor and unsteadiness
+of the legs which occur as a consequence of the dread of heights when
+a person unused to such situation attempts to walk across a narrow
+path a great distance above the ground.
+
+
+Senile Tremor.--The most common of the involuntary tremors is that
+associated with old age. It develops in practically all very old
+people, but it comes to some who are comparatively young. Its
+occurrence at the age of fifty-five usually gives the sufferer a
+severe shock which is emphasized by the attitude of mind of friends
+toward the affection. They seem to be always sure that it is the index
+of rapidly advancing age and that it is practically a signal of
+approaching dissolution. As a matter of fact, when unassociated with
+gross pathological lesions, the senile tremor has no such
+significance. When associated with definite lesions it is the
+prognosis of the special condition and not any supposed significance
+of this particular symptom of tremor that expresses the genuine
+outlook in the case. Many people who live to a very old age develop
+tremor before they are threescore. Most of those who live to be eighty
+or more have some tremor that develops about or just after the age of
+seventy.
+
+
+_Significance_.--Senile tremor is supposed to be due to, and in most
+cases probably is the result of, an overgrowth of connective tissue in
+the central nervous system which disturbs the ordinary conduction of
+nerve impulses, rendering them wavering and uncertain. This seems to
+indicate that it will not be long before the advancement of this
+sclerotic process will make serious inroads on the vigor of the
+individual. As a matter of repeated observation, however, the ordinary
+involuntary tremor of old people may last twenty years.
+
+
+_Reassurance_.--The main principle in the treatment of tremors of the
+old is to make the patients realize that the symptom has no such bad
+prognosis as is usually attributed to it. Of course, they will find
+this out for themselves after a few years, but what they need is
+assurance at the beginning lest during the period of depression
+consequent upon the conclusion that the end is not far {581} off,
+which seems to be forced on them by their fears and the foolish
+sympathy of friends, their resistive vitality should be so lowered as
+to permit the invasion of some serious disease. In spite of
+apprehensions on the part of themselves and friends, tremor is rather
+a good sign than a bad one. It indicates the formation of connective
+tissue in the central nervous system, but this is always a slow
+process and is usually quite benign. As a matter of fact, most
+sclerotic processes are so chronic as to be compensatory in their
+action for many other degenerations. Those in whom tremor develops
+early often seem to be better protected against rupture of cerebral
+arteries, as if the growth of connective tissue was a conservative
+process here also. Information of this kind helps patients not to
+borrow trouble because of their condition.
+
+
+Intention Tremors.--The tremors that occur in association with
+voluntary movements are often very troublesome and may be difficult to
+manage. The worst cases are entirely functional. They are typical
+neuroses and often develop as a consequence of some serious crisis
+through which the nervous system has passed. In older people they
+sometimes pass over into paralysis agitans or a close simulant of that
+affection. The incident of the Texas sheriff and the Indian related in
+the chapter on Paralysis Agitans illustrates how these tremors may be
+induced.
+
+
+_Tremors from Fright_.--Frequently the tremors have no direct
+connection with any action, though they may be the result of fright. A
+little girl bitten by a dog and much shocked may, for some time
+afterwards, be quite unable to stand when she sees a dog on the
+street, so disturbing is the tremor that comes over her. Tremors of
+the same kind have been connected with horses after the patient had
+been run down in the street, and, in one case that I saw even when the
+patient was only thrown out of a carriage during a runaway.
+Occasionally fright by a burglar may cause a distinct tremulousness
+that supervenes whenever the patient thereafter is wakened suddenly at
+night.
+
+
+Influence of Dread.--Tremors of all kinds can be made worse by the
+dread of them. In the chapter on Dreads we discuss the disturbance of
+function by dreads and especially the tendency to exaggeration of
+pathological conditions of any kind when the patient's mind becomes
+concentrated on it. Steadiness in any position is due to a nice
+balancing of extensor and flexor muscles requiring the sending down of
+a continuous stream of impulses. The equilibrium is attained and
+maintained in spite of the fact that, as a rule, the flexor muscles
+are stronger than the extensors and better situated to exert their
+mechanical force. If anything happens to disturb this balance even to
+a slight degree, the mind becomes attracted to it and there is a
+corresponding result as in stuttering, or other complex function when
+surveillance is too great. It is important to remember this at the
+beginning of all cases of tremor, for the patient nearly always
+exaggerates his tremor by attention to it and can be made so much
+better by reassurance and diversion of mind that he is much encouraged
+and his general health usually improves, making him feel, even though
+his affection is organic, that he is being cured.
+
+Tremors may occur in connection with almost any set of actions
+requiring special co-ordination of muscles, but they are especially
+likely to occur when a feeling of dread disturbs the control over
+muscles. A typical example of this is noted in shaving. There are many
+men who cannot shave without trembling so as to cut themselves. The
+feeling that they have a sharp instrument in their {582} hand with
+which they may cut themselves sets up the tremor. There are others who
+cannot shave because they dread that while using the instrument over
+the important organs of the neck, and especially the blood vessels,
+they may be tempted to cut their throats. This is, of course, purely a
+dread and not a tremor. Some men find both the dread and the tremor
+much worse at times when they are tired and worried, and can shave
+very well at other times. Some men can shave very well when they are
+not under observation, but if anyone is looking at them they tremble
+and cut themselves. The safety razor usually does away with these
+troubles, large or small, but if it should happen that by particularly
+inexpert use they cut themselves even with a safety razor, especially
+in the throat region, the old dread and tremor reassert themselves and
+shaving becomes almost as difficult as before.
+
+
+Self-consciousness.--Almost any position or action in which a man
+feels himself under observation may cause one of these tremors. As a
+consequence this particular set of actions may become the source of so
+much discomfort as to produce an intense sense of fatigue. It may,
+indeed, become quite impossible of accomplishment. Some teachers
+cannot do demonstrating work on a blackboard before a large unfamiliar
+class, at least not without serious efforts to control themselves,
+though they may be facile demonstrators before a small class. I have
+known men, however, who practically could not do blackboard work at
+all because of nervousness. Their writing went all askew and very
+often their thoughts would not follow one another in such order as to
+make demonstrations possible. Sometimes they were good talkers, so
+long as they did not turn their backs to the class and feel the eyes
+of all on them. The same thing is true of such religious services as
+Mass in the Catholic Church, where some of the clergymen have this
+feeling. I know of priests who have not said Mass publicly for years
+and others who can only say it in a small chapel before a few people
+because of the intense discomfort of the fatigue caused by this state
+of mind.
+
+
+_Stage Fright_.--It is not alone the hands and the arms that tremors
+are likely to affect, for they may also occur in the legs. A typical
+and familiar case is the tremor that occurs upon the first appearance
+before large audiences of orators or actors or clergymen. Owing to
+excitement, they are unable to make flexor and extensor muscles
+exactly balance each other and the consequence is a tremulous movement
+that may be complicated by some swaying. Some people never lose this
+in spite of long experience in public appearance. Young people may
+have it upon being introduced to persons of whom they think a great
+deal. This passes off with years, as a rule, but in some it persists,
+and any excitement causes tremor of the legs and swaying movements.
+The effort to control this is often severe and causes intense fatigue.
+
+Any set of movements requiring even slight co-ordination of muscles
+may be the subject of disturbance by a tremor. Since the writing of
+the book on Pastoral Medicine, a text-book of medical information
+meant to be of assistance to clergymen,  [Footnote 43] I have had some
+rather interesting tremors associated with the performance of clerical
+duties brought to my attention. One of these is a trembling of the
+legs which makes standing at a high altar almost impossible. Another
+troublesome tremor is that associated with the giving of communion.
+{583} Most priests find no difficulty in the performance of the rite.
+Some of them are much worried and anxious about it, however, and
+develop a slight tremor. Others become so nervous in performing the
+ceremony that they cannot succeed in placing the Host on the tongue of
+the communicant without certain false movements. These may cause them
+to touch the lips or the cheeks of the recipient and after this has
+happened a few times the giving of communion becomes practically
+impossible for them. Occasionally the men thus affected have no other
+nervous symptoms and often they are very intelligent, strong-minded
+men.
+
+  [Footnote 43: O'Malley and Walsh, "Pastoral Medicine." Longmans, 1906.]
+
+
+The General Health.--Tremor patients always complain more of this
+symptom when they are in a run-down condition. One of them is a
+wealthy merchant who, when he can be persuaded to take a vacation,
+comes back with nearly all the manifestations of his tremor latent or,
+at least, well under control. Another is a broker who at the end of a
+long winter of excitement and worry is at his worst, but who after a
+vacation in the North Woods is quite well again. Slight symptoms of
+this kind are not unusual in teachers, especially women, though I have
+seen them also in men, and are much more complained of at the end of
+the year when the individuals are in poorer general condition than at
+any other time. The symptom itself is annoying because of the notice
+that it attracts, but their dread that it may have some serious
+significance, indicating the development of a progressive lesion of
+the central nervous system, constitutes the worst part of their
+ailment. When the intentional tremor is intermittent and occurs only
+at times of excitement, or when the patients are under observation,
+they can be reassured that it is merely neurotic and that no ulterior
+development is to be anticipated.
+
+
+Treatment.--The treatment of these conditions consists first in
+bringing the patient's health up to its normal condition as far as
+that is possible. Many of the sufferers from tremors are under weight.
+Whenever they are, a definite, determined effort must be made to bring
+them up to it. This must be done even though they insist that they
+have never been heavier and that to be rather underweight is a family
+trait. In many cases it will be found that this family trait, instead
+of being due to some inevitable hereditary tendency, is only the
+result of family habits in the matter of eating. Many of these people
+do not eat substantial breakfasts. Their tremor, too, is likely to be
+worse in the early morning than at any other time during the day,
+unless, of course, they have become overtired during the day, when the
+tremor will reassert itself with vigor. Most of them are much less
+disturbed in the afternoon than before. The drug treatment of the
+affection consists mainly in the use of nux vomica, but, not in the
+small doses of five or ten drops so often employed, but, according to
+the size of the individual, beginning with fifteen or twenty minims,
+thirty or forty drops, and gradually increased to physiological
+tolerance, when the dose should be set somewhat below that.
+
+
+_Mental Control_.--The main treatment must consist, however, in
+enabling the patient to secure psychic control over himself and his
+muscles. This is not an easy matter. Most of them are quite
+discouraged, but their attitude of mind must be changed and the real
+significance of their affection made clear to them. As a rule, they
+have either heard or read or been told by a physician that their
+intentional tremor is significant of a serious pathological lesion of
+the central nervous system. Some of them have heard of multiple
+sclerosis {584} and are much disturbed. They must be reassured and it
+must be made clear to them that their disease is really due to
+over-consciousness and consequent lack of control. A good deal of
+reassurance can be given by telling them of patients who suffer from
+ailments not unlike theirs, showing how multiform the affection is. A
+man who has trouble with his signature may be told about the man who
+finds it difficult to drink when under observation, then, as a rule,
+he will better realize the neurotic character of his affection. With
+hysterical women this method must be used with care or the story of
+another patient will act as a suggestion and the physician will
+subsequently be treated to an exhibition of the symptoms which he has
+described.
+
+
+_Self-Discipline_.--Persistent quiet discipline is the one thing that
+eventually does any good. When patients are first told of this and are
+persuaded to attempt it, they make such a determined effort to
+overcome the affection that they make themselves more conscious of it
+than before with the result that their tremor and spasmodic movements
+are emphasized. It is the old story of the man trying to stand so
+straight that he falls backwards. It must be made clear to them that
+discipline, to be of any value, must be carried out as much as
+possible without consciousness of it and with all available artificial
+aids. The man who has trouble with his signature may be shown that he
+can overcome much of the tendency to tremor and spasm of the forearm
+muscles that are at the root of his difficulty by sitting at a higher
+chair, so that his arm swings free of the table and so that, in
+Gowers' phrase, if a pen were attached to his elbow it would write the
+same thing as the pen in his hand. The man who trembles as he drinks
+may be taught for a time to raise a cup to his lips while resting his
+elbow on the table and bringing his head well down. Nearly always
+methods of performing particular actions that require less effort can
+be found, until the habit of over-consciousness and loss of control is
+overcome.
+
+
+_Hypnotism and Waking Suggestion_.--Occasionally hypnotism is
+effective in these cases, but there is likely to be a relapse unless
+there is some discipline before and after its use. Suggestion in the
+waking state is often very effective. Patients need to be talked to
+and even though intelligent they need to be reminded at regular
+intervals for some time that their ailment is merely functional and
+not organic. Nearly always it will be found that they trace its
+beginning to some pathological event: occasionally there has been a
+severe accident, but sometimes only a slight accident seems to them a
+sufficient explanation. Sometimes it follows an attack of pneumonia,
+oftener still typhoid fever. In these cases the patients become
+convinced that this is one of the marks left after the accident or
+disease and so it is rather hard to persuade them that they can be
+cured. All such impressions, which act as auto-suggestions for the
+continuance of their tremor and lack of control, must be combated,
+otherwise there is very little hope of improvement. The preceding
+disease is not the direct cause, though the weakness consequent upon
+it may predispose to the tremor. Overhaste in attempting to resume
+their occupations before their strength has returned is often the real
+cause. It is the patient's mind more than his body that needs to be
+set in order, but this will not be possible unless the physical
+condition is normal and thorough reassurance can be given.
+
+
+{585}
+
+DISORDERS OF THE PSYCHE
+
+
+SECTION XVII
+
+_PSYCHO-NEUROSES_
+
+
+CHAPTER I
+
+PSYCHO-NEUROSES (HYSTERIA)
+
+
+As the derivation of the name indicates, psycho-neuroses are
+functional nervous affections dependent on states of mind. They are
+not necessarily originated by the mind, though they may be. Their
+spontaneous occurrence as pure psychic phenomena, however, is rather
+rare. There is practically always some slight physical cause. This may
+be severe, for all diseases have neurotic accompaniments that disturb
+the nerves involved and exaggerate the original symptoms. In most
+cases the patient has no serious interest to divert his or her mind
+from this occupation with self, and as a consequence the particular
+feeling fills up the whole of consciousness, and as it is painful to
+begin with, the pain, following Cajal's law of avalanche, may become
+almost intolerable.
+
+It is of primary importance to remember, however, that there is
+practically always a physical basis for these curiously interesting
+affections which are so difficult to treat and which have so often
+proved the despair of physicians. While the attitude of mind must be
+changed, the physical state itself must be corrected. These two things
+must be secured at the same time, however, for attention to the
+physical state without correction of mental attitude will usually only
+emphasize the condition by calling further attention to the symptoms.
+This is especially true of local treatment. The mind must, above all,
+be treated and diversion of attention secured. Psycho-neuroses may
+occur in connection with sensory or motor nerves. The patient may
+either complain of intense pain in some part of the body for which
+there is but a very slight basis, or may be unable to move certain
+muscles, or there may be a combination of sensory and motor symptoms
+with complaint of pain on movement. The painful conditions are most
+important because they prove a source of worry and anxiety to the
+patient's friends, as well as often of such annoyance at unsuitable
+hours as deprives those near them of rest to a degree that may
+undermine health.
+
+{586}
+
+
+FORMS OF NEUROTIC SIMULATION
+
+
+Every possible painful condition is simulated by these psycho-neurotic
+conditions. They occur probably with more frequency in the abdomen
+than elsewhere; they may be thought to be colicky in nature and, as a
+rule, some accumulation of gas will be found. This gas is sometimes
+swallowed air and sometimes gaseous products that have been diffused
+apparently from the blood in the intestinal walls. This always
+produces discomfort but nothing like the discomfort that the patient
+complains of. The condition if treated by carminatives will nearly
+always be emphasized rather than relieved. Local treatment by heat
+will help oftener, but may exacerbate it. When chronic constipation is
+present, calomel in divided doses is suggestive as well as medicinal.
+
+There may be gastric crises that recall those of tabes, and there may
+be vesical and rectal crises of a similar nature. I have seen a
+patient complain of every symptom of stone in the kidney. At the
+beginning the pains were vague, but after she had been to several
+physicians and had been asked certain questions intended to elicit
+pathognomonic signs of stone these questions were answered in the
+affirmative. Her attacks became strikingly like renal colic. After a
+consultation, at which two physicians and a surgeon were present, she
+was operated upon for stone in the left kidney. No trace of it was
+found. But after this she was well nearly a year. Then she had another
+crisis of pain in the early morning hours, a time when her painful
+condition always came on, apparently because it attracted more
+attention and caused more disturbance at this time, and now all the
+symptoms pointed to the right kidney. She was treated on the principle
+that it was a neurosis, was made to gain some fifteen pounds in
+weight, has since then had no attacks, has not passed any stones, and
+there seems no doubt but that the whole case was merely neurotic.
+During her attacks instead of having suppression of urine, she had a
+free flow of urine and no blood. It is not unlikely that the physical
+basis of the attacks was that condition of the kidney which allows
+urine to flow through very freely during neurotic conditions and which
+somehow got into the sphere of her consciousness and being
+over-attended to became extremely painful.
+
+
+Secretory Neuroses.--Lying between the pain and motor neuroses and
+dependent on psychic elements to some extent at least, there is a
+series of neuroses that have as their principal symptoms an increase
+or decrease of secretion. Occasionally, of course, they are
+complicated by motor neuroses, especially in connection with the
+viscera. There are various stomach affections, represented by an
+increase or decrease in stomach secretion, and accompanied by pain,
+discomfort, and decrease or increase of peristalsis. There are biliary
+neuroses accompanied by increase or inhibition of biliary secretions.
+There are gastric neuroses associated with vomiting, often very
+intractable, in which there seems to be sometimes a hypersecretion of
+gastric juice and sometimes a lessened secretion. All of these occur,
+as is said, spontaneously, but there will usually be found a history
+of some exhaustive work or worry during the weeks or months just
+before. Apparently nervous control is lost and then the secretory
+neurosis manifests itself sometimes in conjunction with painful or
+motor affections.
+
+
+Neurotic Vomiting.--Persistent vomiting occurs in these cases but is
+not {587} so serious as it seems and patients do not lose weight, as
+might be expected. There is sometimes even a probability that some of
+the food ingested finds its way through the pylorus and is used for
+nutrition, though the vomiting may come on not long after ingestion.
+Practically always nature asserts herself and stops the vomiting when
+serious conditions seem about to develop. The solicitude of relatives
+may be calmed by this assurance, and just as soon, as a rule, as they
+show less anxiety about the patient, the first symptoms of improvement
+will be noted. The fasting girls exploited in the newspapers, in
+connection with these neurotic conditions are often frauds and
+investigation has shown on a number of occasions that they were
+obtaining food surreptitiously. It must not be forgotten, however,
+that, even though these cases have been discredited, we have a number
+of cases on record of men and women who have taken absolutely nothing
+nutritious and only water for from ten to forty or even fifty days.
+Until at least ten days have passed in one of these gastric neuroses,
+then, there is no need for urgent solicitude, and this of itself, when
+properly explained, makes an excellent favorable suggestion for these
+patients, and, above all, for their friends.
+
+
+Simulant Appendicitis.--Some of these abdominal psycho-neuroses may
+simulate serious pathological conditions that, in recent years, have
+come to be looked upon as surgical. I have seen a number of cases,
+especially in women who have been constipated for some time, in which
+there was considerable discomfort in the right lower abdominal segment
+and occasionally surgeons thought that an operation should be
+performed. Usually in these cases there is no localized tenderness and
+no mass of any kind to be felt in this region. Sometimes tenderness is
+complained of, though when the patient's attention is diverted even
+deep pressure may be made without their wincing. Whenever there is no
+history of an acute attack, no temperature and no increase in pulse
+rate, unless there are very definitely localized symptoms, the
+question of operation is always to be answered in the negative.
+Disturbances of the pulse may mean little. The history must guide. I
+have seen these cases operated on, improved for a while, but relapse
+afterwards just as soon as there was a resumption of their
+constipation. As a rule, when the appendix has been removed, either
+because its function has something to do with the inhibition of
+putrefactive processes in the lower bowel, or because as the result of
+the operation and consequent adhesions, the colon was not so active in
+its peristalsis, the constipation seemed to be worse than before,
+unless special care was exercised. If there is relapse after an
+operation the patients' attacks are almost sure to be more frequent
+than before and their discomfort likely to be more pronounced.
+
+Lest it be thought that such cases are mainly confined to women or
+that the most striking cases occur only in women, I may say that the
+most interesting case of this kind I ever saw was in a young, vigorous
+German soldier. He was admitted to Koenig's clinic in Berlin with a
+story of abdominal tenderness and pain, the tenderness being located
+in the right iliac region. There seemed even to be some distention of
+the abdomen after a time and the development of greatly increased
+diffuse tenderness. The pulse was considerably disturbed, but there
+was only a slight rise in temperature, and for a time it was thought
+that this might be a case of appendicitis without fever. A surprising
+feature of the case was the presence in the right iliac region of
+{588} a scar which, on careful investigation, proved to be double.
+Apparently the patient had been opened twice before in this region.
+His history was carefully investigated. He had had a fall from a horse
+about two years before and afterwards had considerable abdominal
+discomfort. He was quite sure that something serious had happened
+within his abdominal cavity as the result of the fall and his
+attention was concentrated on his right iliac region. At the time of
+the accident his symptoms were considered to be a psycho-neurosis or
+perhaps an exaggeration of symptoms with malingering tendencies.
+
+Shortly after his term of service expired, however, some acute
+symptoms developed and there was swelling, or at least tympanitic
+distention of the abdomen with disturbance of the pulse, and he was
+operated on in the hospital and his appendix removed. There proved to
+be nothing the matter with it and no pathological condition was found
+within his abdomen. He seemed to recover completely. After six months
+he was admitted to another hospital with the same symptoms. He seemed
+to have the habit of swallowing air which found its way beyond his
+pylorus, or else gas leaked from the blood vessels in the walls of his
+intestines, producing a symptom-complex not unlike the tympanitic
+distention consequent upon general peritonitis. Once more this was
+taken to mean very probably a ruptured appendix and another operation
+was done. This operator went through the old scar, but to his surprise
+found no appendix and found everything within the abdomen normal. The
+third time the patient came to Koenig's clinic and, owing to his
+military record, his hospital experience was available and a third
+operation was not done. Instead, according to the story current at the
+time, the patient was tattooed with the legend "no appendix here." The
+case is interesting as an example of the extent to which an abdominal
+psycho-neurosis may simulate a ruptured appendix.
+
+
+Pseudo Biliary Colic.--A similar state of affairs to that with regard
+to the appendix has developed in all that concerns the gall bladder
+and the biliary tract generally. Any complaint of discomfort in the
+right upper quadrant of the abdomen, if persisted in, is almost sure
+sooner or later to be diagnosed as due to a calculus. Now that
+operations for gallstones are more common than they used to be, it is
+probable that almost as many gall bladders are found without
+pathological conditions as appendices without justifiably operative
+lesions. In treating individuals who have a history of recurrent
+symptoms of intestinal reaction to various foods complicated by
+urticaria, it is important to remember that there may probably be
+lesions corresponding to those in the skin in portions of the
+intestinal tract which may functionally involve either the appendix or
+the biliary passages. Some of these cases are extremely difficult to
+handle because often there is pain, definite tenderness and some fever
+with the attacks, and very localized symptoms. The history, however,
+will be helpful. Operation will not relieve the patient from liability
+to recurrence. There are, however, other cases where the discomfort is
+much more vague, where there is no tenderness, no disturbance after
+jolting rides and where there has never been any severe pain. These
+should not be set down as biliary calculi without further
+developments. The possibility of a stone being present should not be
+hinted to the patient until some definite pathognomonic sign is
+discovered.
+
+
+Other Simulated Conditions.--There are many painful conditions of the
+{589} head that are psycho-neurotic. Many forms of headache are due to
+sensations of pressure or tension or constriction, usually in the
+external integuments of the skull, which are dwelt on and then become
+painful achy conditions. This is particularly true of so-called
+headaches in the back of the head. As we emphasize in the chapter on
+Headache, probably most of the headaches of patients who have not much
+to occupy themselves with, are due rather to queer feelings in the
+head emphasized by the concentration of attention on them than to real
+pains. Earache may occur in the same way. Nearly always when one has
+been out in the wind, there is likely to be an uncomfortable sensation
+in the ear. By attention to it this may readily be exaggerated into an
+earache. Occasionally the physical basis of an ache in the region of
+the ear seems to be an unconscious performance of Valsalva's
+experiment while blowing the nose when catarrhal conditions are
+present.
+
+All sorts of painful conditions of the arms and legs may develop in
+the same way. Unusual tiredness, or some special exertion of the
+muscles, may produce a sense of fatigue readily exaggerated by
+attention to it, into severe pain. This condition is not a voluntary
+simulation, but is due to lack of diversion and a certain inborn
+tendency in these people to pay attention to anything that is the
+matter with them. Very seldom does the physical condition need much
+treatment, though nearly always something can be done for it with
+advantage, but the mental state needs alteration and, above all, the
+patient needs to be diverted from over-concentration of mind.
+
+
+Motor Neuroses.--As has been said, beside painful conditions, various
+forms of motor trouble may develop. These usually consist of inability
+to move certain groups of muscles. They have sometimes been spoken of
+as hysterical palsies or paralyses. The word hysterical, by its
+derivation connected with the Greek word for womb, apparently
+indicates that these conditions are limited to women. It is well known
+now that they are extremely common among men and especially among
+young men and have absolutely nothing to do with the genital system.
+As with painful psycho-neurotic conditions, there is practically
+always a physical basis. This sometimes requires careful questioning
+to locate exactly. There is some injury of the muscles of a particular
+region, or some over-use of them, or some employment of them under bad
+mechanical conditions with over-fatigue, and then attention to this
+leads to incapacity to use the muscles or inability to co-ordinate
+them properly.
+
+Neurotic palsies, to use a term that carries much less unfavorable
+suggestion with it than the word paralysis or the word hysterical, may
+occur in any limb or group of muscles. They may occur in the legs with
+the production of complete paraplegia. One well-known form,
+astasia-abasia, inability to stand or to walk, affects the muscles of
+the trunk as well as of the lower limbs. These conditions often remain
+for long periods in spite of treatment, frequently recur, are often
+called by all sorts of names and continue to be a source of annoyance
+to the patient, until a definite successful effort is made to change
+the patient's mental state to one of less attention to the particular
+part.
+
+There is, it seems to me, an unfortunate tendency to think that our
+observations upon these cases are comparatively recent. Sir Benjamin
+Brodie, nearly a century ago, insisted that at least four-fifths of
+the female patients among the higher classes of society supposed to
+suffer from diseased joints were really sufferers from neurotic
+conditions, or, as they called them then, {590} hysteria. Sir James
+Paget, in his Clinical Lectures and Essays, thinks that Brodie has
+exaggerated the proportion, for in his own practice, though, of
+course, he includes his hospital cases and the poor as well as the
+rich, he found less than one-fifth suffering from neurotic joints. The
+hip and the knee, which are the most frequent seats of genuine
+pathological conditions, are also most frequently the subject of
+neuroses. Next in order, but much more rarely, the metatarsal and
+metacarpal joints are affected and then the elbow and shoulder. In Sir
+James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a
+number of cases which show how clearly psycho-neurotic affections were
+recognized in his time. He tells the story of a young man who had been
+overworking for examinations and who "after a three-hours'
+mathematical cram, fainted and when he rallied set up a very close
+mimicry of paraplegia which lasted many weeks." He insists that "such
+mimicry is found not only or chiefly in the silly selfish girls among
+whom it is commonly supposed that hysteria is rife, but even among the
+wise and accomplished, both men and women."
+
+
+DIFFERENTIAL DIAGNOSIS
+
+
+For the differential diagnosis of psycho-neuroses from definite
+organic conditions, the most important element is the patient's
+previous history and a knowledge of the condition of the nervous
+system. Where this is known the diagnosis is comparatively easy, but
+when the patient is seen for the first time it may often be extremely
+difficult. It is, above all, important not to jump to conclusions, for
+every nervous specialist knows of cases in which the diagnosis was
+considered to be surely a neurosis, yet a fatal termination showed
+that a serious organic condition was at work. It must not be forgotten
+either that neurotic patients may develop serious organic disease in
+the midst of their neurotic symptoms and care must be taken not to
+miss the significance of special symptoms. When the patient is not
+well known, the presence of certain stigmata, as they have been
+called, enable the physician to recognize the probability that a
+neurotic condition is present. Patients who are subject to neuroses
+are likely to have certain areas of the skin surface and of the
+palpable mucous membranes more or less sensitive than normal. There
+are likely to be spots of hyperesthesia or hypesthesia or even
+complete anesthesia somewhere on the skin. These should be carefully
+looked for and in serious cases an examination of the whole skin
+surface should be made. Not infrequently anesthesia or a decided lack
+of sensitiveness to irritation will be found in the throat or in the
+nose. Occasionally the conjunctiva is much less sensitive than usual.
+
+These used to be called hysterical stigmata. The word hysteria carries
+an innuendo of imaginativeness or occasionally of affection of the
+sexual organs that is unfortunate. It would be better, therefore, not
+to use the term in any way. The presence of these areas of
+hyperesthesia, hypesthesia and anesthesia indicates that association
+fibers are abnormally connected in the brain for the moment at least,
+and that as a consequence there is over-attention to certain portions
+of the body with lack of ordinary attention to others. This will
+account very readily for the occurrence of painful conditions in
+certain cases and palsies in others. When over-attention is paid,
+there may be a {591} hyperesthesia corresponding to that seen in the
+skin in any organ of the body. When, for any reason, there is a
+disturbance in a particular part, there may be a lack of motility due
+to nervous influences, just as there is a lack of sensation. In all of
+these cases the one essential element is to correct the nervous state
+through the mind as far as possible. Experience has shown that this
+can be done in nearly all cases. It must be the principal effort of
+the physician.
+
+
+
+TREATMENT
+
+
+Strong Mental Impression.--In the treatment of these affections two
+periods are to be considered, one during, the other after the attacks.
+During the attack a strong impression must be made upon the patient's
+mind so as to divert the concentrated attention. We have well
+authenticated stories of the various expedients resorted to by
+physicians who were confident of their diagnosis in order to secure
+such a strong mental impression. I once knew an old physician who was
+summoned to a childless wife whose adoring husband was in manifest
+agonies of solicitude over her and whose mother and mother-in-law had
+been caring for her for days with all anxiety, walk into the room of
+the patient, take one of her hands in his, slap her on the cheek, tell
+her to get up and walk and she would have no more of that supposed
+inability to walk which had caused the family so much anxiety. He
+succeeded. It can be imagined what would have happened had he not
+succeeded. We know of cases where an alarm of fire or a burglar scare
+or some sudden emotion has produced a like result. We cannot prescribe
+these things, however, and at the most, after one or two successes in
+a particular patient, they would fail.
+
+The only thing that we can do as a routine practice is to relieve by
+direct treatment the slight physical condition that is usually present
+and then try and influence the patient's mind. If a thorough
+examination is made in the course of which the physician is able to
+show the patient that he understands the condition and that he can
+demonstrate for himself and them that there is nothing serious the
+matter with important organs, he can make them feel that their pain or
+disability is entirely due to concentration of attention on a
+particular nerve or set of nerves. With many patients this will
+succeed, not at once, but after two or three seances of positive
+suggestion, even in the waking state. If the patients are bothering
+their relatives very much it may be necessary to give some opium as an
+adjuvant. As a rule, the needle had better not be used, but a
+suppository given. This is not nearly so attractive to the patient's
+mind as the use of the needle and is not likely to be called for so
+often. Every physician has had the experience that after giving opium
+two or three times, either per rectum or hypodermically, almost
+anything can be given, provided the patient is persuaded that the drug
+is being given again. A reasonably large dose may be used the first
+time, but certainly after the second or third time a much smaller dose
+will produce the same effect and often a simple gluten suppository,
+provided it looks like the other, will work just as well as an opium
+suppository.
+
+
+After Treatment.--The after treatment of these cases is directed
+mainly to such alterations of the mental attitude and physical
+condition as shall prevent {592} recurrences. The general condition of
+the patient must be improved in every case where there is indication
+for this. Many of these patients are under weight for their height.
+They must put on weight. Weir Mitchell's success with the "rest cure"
+consisted to a great extent in his power to cause these patients to
+put on weight. This supplies reserve energy, but, above all, replaces
+discouragement by hope and buoyancy. Gain in weight can be
+accomplished mainly by two methods. First, by seeing that the patient
+gets an abundance of air and, secondly, by dictating how much shall be
+eaten. In this matter details are important and it may be necessary to
+suggest the actual diet for each meal. This must be liberal and must
+consist of simple but particularly nutritious materials. Patients'
+dislikes need not be taken into much account, their likes are often
+helpful. When there is insistence on lack of appetite and decided
+objection to chewing, eggs and milk should be given in increasing
+quantities, until five or six eggs and some twelve glasses of milk are
+taken every day. Besides this, a good portion of meat should be eaten
+at one meal with some vegetables. By firm insistence, day after day,
+it will not be hard to get patients whose appetites are seriously
+inhibited to take this amount of food. To secure this, a good, firm,
+sensible nurse is invaluable. Appetite, as we have emphasized in the
+chapter on Appetite, is largely a matter of will, and anything that is
+eaten, provided it stays down, will do good unless there is organic
+disease.
+
+A certain amount of exercise is important in these cases, but not
+nearly so important as an abundance of fresh air. Patients must not be
+allowed to overtire themselves. Riding in an open carriage or on the
+top of a bus, especially where there are distracting scenes and many
+human interests, is particularly beneficial. Automobiling is often
+likely to be more tiresome than is good for these patients when they
+are run down, though it is one of the best of therapeutic measures for
+those who are physically capable, that is, up to weight, even though
+they may complain of feeling weak.
+
+
+_Diversion of Mind_.--It is in these cases particularly that diversion
+of mind is of prime importance. Many of these patients have either no
+serious interest or at most certain interests with which they may
+occupy themselves if they wish, but that are not engrossing and
+attention to which may be put off whenever they care to. Duties that
+are inevitable and that call for the occupation of so much time that
+the patient has little opportunity to think of herself are often the
+salvation of these patients. As I mention in the chapters on
+Occupation and Diversion of Mind, I have seen a number of cases and I
+am sure that every physician of reasonable large experience has seen
+similar cases, where women, particularly, who in the midst of
+prosperity have been constantly suffering from some form of
+psycho-neurosis, great or small, have, after some sudden turn of
+fortune, been completely relieved from their nervous symptoms by
+having to devote themselves seriously to some occupation for a
+livelihood.
+
+Occupation, particularly with children, with the weak and the ailing,
+with the poor and those who are unable to help themselves, is
+specially likely to be helpful to such patients when they are women.
+Such interests affect them deeply and by the sympathy they arouse
+through contact with real physical suffering, they prevent
+over-attention to themselves. I have seen the care of a cancer
+patient, and especially of a relative affected by cancer, do more for
+{593} a psycho-neurotic sufferer than all that doctors had been able
+to accomplish in years. It is often difficult to find occupation and
+diversion of mind for these patients, but this is the therapeutic
+problem the physician must solve if he is going to secure relief from
+present conditions and prophylaxis against further attacks.
+
+
+Oldtime Cures.--Many of the remedies for obscure abdominal conditions
+show how well the real character of the affection was duly recognized
+and appreciated in the past. It is in these cases particularly that
+the pillulae micarumpanis, the bread pills, of the olden times, were
+so commonly used with good effect. We have quoted examples in other
+chapters. Many of the drugs that are employed with reported success
+for these affections have a strong suggestive element in them.
+Valerian probably is a good tonic and yet there is no doubt that the
+suggestive quality of its nauseating smell and the almost inevitable
+eructations that occur after to emphasize it, are helpful in curing
+certain internal psycho-neuroses. Another drug that has been much used
+in the same way is asafetida, whose disgusting taste and odor have
+been excellent auxiliaries. Fresh pills of quinine and red pepper
+uncoated and therefore producing definite effects on the taste before
+swallowing and on the mucous membrane of the stomach after swallowing,
+often prove the best remedy for persistent vomiting or for enduring
+nausea. A drop of nux vomica, taken every half hour with the definite
+warning that the patient must by no means take more, and that the
+bottle must be carefully protected lest anyone else should be
+poisoned, is often very efficient. These remedies have a slight
+physiological action and a large psychic action, but that exactly
+corresponds with the etiology of the affection for whose treatment
+they are employed.
+
+
+Dominant Ideas.--During the attack it is often possible to find either
+from the patient or from friends that there is some dominant idea
+which is bringing about the mental short-circuiting that leads to the
+concentration of attention. From the oldest times it has been
+recognized that in young women a disappointment in love may prove to
+be the occasion for a psycho-neurotic or, as they used to call it,
+hysterical attack. This is, however, not a specific cause. It is the
+disappointment much more than the sex element in the case, as a rule,
+that produces the unfavorable effect. It was easy to conclude that the
+sex factor was extremely important in older times when women's sphere
+of activity was largely limited to the home, and marriage was the one
+legitimate object of their ambition. Now that we have had more
+experience with the business woman, we know that serious
+disappointments of any kind have a tendency to initiate
+psycho-neurotic conditions in susceptible and especially suggestive
+individuals. A failure to secure promotion in a store, or to secure
+some position that is eagerly sought for, a loss of money in business,
+etc., especially when they have been preceded by weeks or months of
+solicitude and worry over the event that now happens, may lead to the
+development of a psycho-neurosis.
+
+This is particularly notable with regard to educational interests of
+various kinds. Young women readily overdo application to study, or,
+rather, anxiety over it, and as a result get into a state of mind in
+which a failure to pass an examination, or to secure promotion, or
+even the failure to win a prize, may give rise to a highly nervous
+condition in which tears and laughter come unbidden and in {594} which
+further developments may bring on a typical psycho-neurotic attack.
+All sorts of pains and aches and motor incapacities may occur in these
+states. The supreme occupation with the single idea present in their
+minds at all times, waking and sleeping, while they try to study, or
+when they read or even when they are supposed to be diverting
+themselves, finally precipitates a nervous explosion along nerves that
+have been irritated for some reason, though the pathological condition
+present may be quite insufficient of itself to explain the affection
+that ensues. These are the popular nervous breakdowns, not difficult
+to treat once their real character is diagnosed.
+
+Sorrows of various kinds may produce a like effect. Worry or anxiety
+about the serious illness of a near relative, especially an inevitably
+fatal illness, such as cancer or tuberculosis or the disturbing mental
+affections, may have a similar result, but usually not in those who
+are occupied with the actual care of the patients. The mental states
+constitute the psychic elements underlying the neurotic condition that
+develops.
+
+Almost needless to say, successful treatment must include a faithful
+attempt to lessen the significance of the mental state that is so
+important in the case. Usually the mere obtaining of the patient's
+confidence is enough to lessen greatly the irritation produced by the
+mental condition. A sorrow shared is halved. It is, above all,
+secretive individuals who become depressed over their sorrows. While
+the patient who insists on constantly sharing them with everyone
+becomes a nuisance, it is always a little dangerous not to have a
+confidant to whom worries and anxieties are entrusted. If they are
+kept to one's self they are nearly always exaggerated--they are seen
+out of proper perspective and have a much more depressing influence.
+Calm, judicious reasoning with the patient over the significance of
+the condition as presented, is often of great help.
+
+Often these ideas, so potent for mental and bodily disturbance, are
+almost entirely unconscious or exist in the patient's subconsciousness
+and are recalled only under such special conditions as remove the
+bonds of the patient's occupation with himself or herself at the
+present time and allow memories to come back without interference.
+There are many curious stories of such cases. A child is frightened or
+very much disturbed by having a cat kill a favorite bird. The cat
+becomes a deterrent object. Gradually this deterrence grows. As a
+consequence, there may develop one of those intense dreads of cats
+which makes life miserable if near that animal. There may even be
+physical effects produced by the continued presence of a cat in the
+same room. Often in these cases the beginning of this mental attitude,
+or at least its occasion in the incident of the killing of the bird is
+forgotten, or at least not consciously referred to as an etiological
+element in the dread.
+
+Patients have been known to develop states of mind which made them
+object to certain figures or names because of earlier associations
+with them that were unpleasant. There is the story of a man who would
+never take a car with an odd number though this was sometimes a source
+of annoyance and delay and who could not explain to himself or his
+physician how this objection had developed, until his memory was
+searched and it was found that, years before, he had witnessed the
+death of a child under the wheels of a car with an odd number. He had
+completely lost the sense of the direct influence of this, but it
+existed in subconscious memory and proved the source of much {595}
+annoyance to him, for if with a friend he were not able to avoid
+taking an odd numbered car he would feel quite miserable during the
+ride. Frights of various kinds may produce this same effect. I have in
+my notes the case of a man who is unable to sleep at night without a
+light in his room, because of a fright. Once while asleep in the dark,
+he awoke conscious that someone was in the room and sat up and
+demanded who was there. The answer was a revolver shot and a bullet,
+passing not far away from him, pierced the head of the bed. As he sank
+back the burglar leaped from the window and escaped. He realized that
+this was the cause of his fear of the dark, but lesser incidents might
+easily become subconscious yet continue their influence.
+
+
+Psycho-Analysis.--In recent years Freud has suggested that in many
+puzzling cases of psycho-neurosis, where, so far as is known, there
+seems to be no dominant idea bringing about the concentration of
+attention, careful analysis of the patients' memories will bring out
+the fact that there is a subconscious idea as the underlying
+substratum of these affections. Freud has developed what is called the
+process of psycho-analysis in order to bring out these ideas which are
+sometimes exerting their influence unconsciously to the patient. The
+subconscious is one of the fads of the hour, so that Freud's
+announcement attracted much attention. Psycho-analysis, however, is
+not advanced so confidently even by its inventor as a positively
+curative measure, as it was at the beginning. It has been found that
+after the dominant idea in the subconsciousness has been found and
+neutralized with a consequent amelioration of the psycho-neurotic
+symptoms, there may be a relapse, when another dominant idea will have
+to be found, and that there seems to be the possibility, in some cases
+at least, of an almost endless succession of such ideas to account for
+further and further relapses.
+
+Undoubtedly psycho-analysis has its place in psychotherapy and is of
+great value in certain cases. There is no doubt, however, in my mind
+that in most of these cases reported as cured after psycho-analytic
+methods had been employed, what really happened is that the patient's
+mind became diverted to another idea--that of marvelous cure through
+mind searching which relieved the previous concentration of mind
+underlying the psycho-neurosis. These are the cases that used to be
+cured by hypnotism. Before hypnotism was developed they were cured by
+mesmerism. Before mesmerism they were cured by magnets or by the
+Leyden jar, and during the past century they have been cured by
+electrical methods or by osteopathy or by Eddyism. Many of the cures
+were effected by stroking and touches, the use of Perkins' tractors,
+or Greatrakes' methods, or anything else that attracted attention very
+strongly. They were given a new idea which occupied them very much and
+so saved them from that preoccupation with themselves and their
+feelings and whatever slight ailment might be present that was the
+physical occasion for psycho-neurotic symptoms. This happened with
+psycho-analysis. When it was absolutely new and the operator had great
+confidence in it, this confidence was imparted to the patients, with
+the consequent cure or decided amelioration of their psycho-neurosis,
+just as that used to be brought about by our previous method of
+treating such cases by some strong suggestion.
+
+As I emphasize in the chapter on Dreams, the examination of the dreams
+in order to get a hint of the dominant idea, is particularly
+interesting, because it represents a return to the oldest methods of
+suggestion of which we have record. {596} The fact that sexual ideas
+seem to represent a great many of the dominant ideas in these cases is
+of interest for a similar reason. It represents the tendency
+constantly recurring to refer most nervous ailments, as indeed most
+other ailments, to something pathological in the sexual or genital
+sphere. The old idea embodied in the word hysterical exemplifies this
+very well. The "vapors" or "tantrums" or fits which were supposed to
+be due, to some extent at least, to suppressed sexuality by medical
+writers of three or four generations ago, have come back to us under
+another form and with other terms. Psycho-analysis gives occasion for
+instruction in so far as it helps the patient to get rid of old
+persuasions and exploded ideas as to disease and diet and the various
+functions of the body and the mind that have often almost
+unconsciously been acquired and secured a dominance. It is surprising
+how often it will be found that people are taking too much or too
+little water at meals, too many or too few vegetables, too much or too
+little of salt or of other condiments as the result of habits and
+notions acquired when they were young and under influences that they
+may now forget. In the same way habits of life with regard to bathing,
+clothing and the like may be the source of unfavorable conditions in
+mind and body that need only to be discovered to be corrected. Their
+correction will often bring about the relief of symptomatic conditions
+that have proved quite obstinate to treatment. We have emphasized this
+in the chapters on the Individual Patient and the necessity for
+acquiring just as much knowledge as possible about both his
+occupations and his mental attitude in order to be able successfully
+to treat chronic disease.
+
+
+{597}
+
+SECTION XVIII
+
+_DISORDERS OF MIND_
+
+
+CHAPTER I
+
+MENTAL INCAPACITY (PSYCHASTHENIA)
+
+
+In recent years we have come to realize that many of the so-called
+nervous diseases, or if they do not deserve the serious name of
+disease, nervous symptom-complexes, are really due to a deficiency of
+vital energy. Some people have a store of energy that enables them to
+accomplish many different things successfully. Some become exhausted
+from a few trivial occupations. What is noteworthy in the cases to be
+discussed in this chapter is that they show always certain symptoms of
+mental tiredness or, at least, of lack of capacity for affairs.
+Patients complain, for instance, that they cannot make up their minds
+so as to reach decisions because they doubt so much whether the
+decision they come to will be right or wrong. Others dread the outcome
+of any and every act and feel that something is hanging over them.
+Slight sources of irritation become so exaggerated by thinking about
+them and dwelling on their possibilities that they may even disturb
+sleep and appetite and, as a consequence, the general health. Fears
+come over patients lest various things should happen and they dread
+microbes, or infections, or dirt in general, or the approach of
+insanity, and all to such a degree as to incapacitate them for their
+ordinary occupations.
+
+Many of these patients become quite incapable of willing effectively.
+They not only lose initiative, the power to undertake new enterprises,
+but they find it difficult to make up their minds as to details of the
+ordinary affairs of life. As we have stated elsewhere in Professor
+Grasset's expressive formula, these patients say that they cannot do
+things, their friends say "they will not," and the physician, taking
+the middle course, which, as usual in human affairs, has much more of
+truth than either of the extremes, says "they cannot will."
+
+For these states Janet of Paris suggested the word psychasthenia. It
+is formed on the model of the word neurasthenia and unless it is used
+with discretion will have all the objections that attach to that other
+term. Above all, it shares the tendency pointed out by Sir William
+Gowers with regard to neurasthenia of being "too satisfying. Men are
+apt to rest on it as they would not on its English equivalent.
+Physicians, if they do not actually think that they have found the
+malady from which the patient is suffering, have an influence exerted
+on them of which they are often unconscious, which lessens the
+tendency to go farther in the search for the whole mental state." Much
+more can be said in defence of psychasthenia, however, than of
+neurasthenia, for the substitution for it of the translation of the
+Greek words of {598} which it is composed--"mind weakness" would be
+alarming. While it is important, then, to realize that the term may
+easily be made too general and prove, as such words as rheumatism has
+done in our time and malaria did in the past, a cloak for ignorance
+and an excuse for incomplete investigation for diagnostic purposes, it
+represents a satisfactory answer to the patient's question as to what
+is the matter without committing the physician to such definitely
+detailed opinions as to the patient's condition as would surely prove
+unfavorably suggestive.
+
+
+Psychasthenia, Natural and Acquired.--There are two forms of the
+mental incapacity that underlies many of the curious symptom-complexes
+that have been studied under the term psychasthenia. One is natural,
+that is, inherent in the special character of the individual, and the
+other acquired through disease or exhausting labor, worry, or anxiety.
+Some people are born without sufficient mental energy to do the work
+they attempt to accomplish. This is true, also, in the physical order.
+It is often pitiable to see young men who have not the physical
+strength necessary for athletic exercises, or the dexterity required
+for them, faithfully trying to accomplish by effort what others do
+with ease. When there is some natural defect in the way they will
+usually fail, no matter how much they strive. Just in the same way
+some persons are not able to accomplish certain more serious purposes
+requiring special mental ability or power which they attempt. Their
+brothers, their friends, their schoolmates, may have the ability, and
+they cannot understand why they should not have it, but the fact
+remains that they are not possessed of it and if they try to make up
+for this defect by overwork they simply break down.
+
+
+Differential Diagnosis.--Each of the two forms of mental incapacity,
+congenital and acquired, must be carefully differentiated and treated
+from a special standpoint. With regard to congenital lack of mental
+control, all that the doctor can do is to counsel against the
+assumption of duties and responsibilities that are too heavy for the
+patient. Some people have not enough nervous energy to run a business
+with many details, and some even find it difficult to try to do things
+involving much less responsibility. There is no use for a man five
+feet in height, weighing one hundred pounds, to try to be a stevedore.
+There is no use for men of delicate muscular build to try to make
+their living at heavy manual labor; they simply wear themselves out in
+a very short time. This inadaptability is recognized at once. Just the
+same thing is true with regard to many nervous systems, but the
+recognition is not so easy or immediate. Some cannot stand the strain
+of intricate business details or the burden of responsibility in
+important transactions. They must be taught to be satisfied, then,
+with quiet simple lives without what is for them, excessive
+responsibility and without strenuous business worries. A country life
+with regular hours, plenty of open air and as little responsibility as
+possible, is the ideal for them.
+
+The most difficult problem in this matter is the question of
+diagnosis. As a rule, the history is the most helpful for this. The
+patient tells of having found difficulty all his life whenever
+anything of special significance was placed on his shoulders. He is
+one of those who were born tired and remain so all their lives. It has
+been the custom to blame these people; they are rather to be pitied.
+If they are born in circumstances that allow of their {599} living
+quietly in the country, they accomplish a certain amount of work quite
+successfully and live happy, contented lives. If they are born in the
+city where the hurry and bustle around them and the insistence of
+friends that they must take up responsibilities becomes poignant, they
+get discouraged and even despondent. It is from this class of patients
+that the "ne'er-do-wells" of modern life are recruited. They form the
+under-stratum of trampdom, the scions of good families with the
+wanderlust, the willing but incapable. Certain of them become vicious
+and criminal, either because they do not want to work or because their
+mentality is perverted in some way. Such patients cannot be treated
+with any hope of their becoming successful exemplars of the strenuous
+life, but they may be directed into the less exacting occupations of
+country life and so live quiet, useful and happy lives. For the
+congenital class we can do little except to prevent them from trying
+to do things that are beyond their mental capacity and helping them to
+see just what their limitations are.
+
+
+_Mental Exhaustion_.--Many disturbances of mental energy are acquired.
+These may be either functional or organic. For the organic variety we
+cannot do much, since it is dependent on changes in organs that are
+permanent. We can, however, usually predispose the patient's mind to
+the recognition of the fact that he should no longer try to devote
+himself to occupations that constitute a special drain on his nervous
+energy. The man, for instance, who is already suffering from
+arterio-sclerosis must be warned that worry and work will surely
+hasten the process and that his nervous symptoms cannot be cured, but
+must be palliated. He must be advised to lessen his mental strain and
+to take up something which, while occupying his mind, does not make
+insistent calls on his vitality. In this matter it must be remembered
+that when a man over fifty develops nervous symptoms, as a rule there
+is no question of functional trouble but of organic change and usually
+heart or arteries or kidneys are at fault.
+
+In recent years we have come to realize that typhoid fever often makes
+serious inroads upon a patient's vitality which can only be retrieved
+by care, not alone for some months but, if possible, even for some
+years, not to put an overstrain on the vital energy. Certain other
+diseases produce an even more lasting effect. A sufferer from
+well-developed tuberculosis will probably never be able to go back to
+the strenuous city life. If he attempts to do so, not only is there
+danger of a recurrence of his tuberculosis, but there may even be a
+development of neurotic symptoms. Syphilis is another disease that
+leaves patients in a condition in which it is dangerous for them to
+assume the serious responsibilities of an exacting occupation and
+especially anything that involves excitement and worry. Syphilitic
+patients should be warned of the danger of pursuing vocations that
+make such demands upon them. It is the actor, the broker, the
+speculator, and the strenuous business man generally, who is likely to
+suffer from parasyphilitic conditions, tabes, paresis and the like,
+much more than those who follow occupations that make less demands on
+them.
+
+
+Functional Mental Incapacity.--In a large number of cases the
+incapacity to do things because of lack of mental energy is due to
+functional disturbances of the nervous system. These are the most
+important for the psycho-therapeutist because much can be accomplished
+for them. Nearly always the patient can be benefited by advice and
+suggestion, and very often some {600} unfavorable factor at work,
+using up his mental energy to no purpose, will be discovered. In order
+to do good, however, careful study of the individual patient is the
+most important element. The most frequent functional disturbance of
+the nervous system, leading to exhaustion of mental energy, is
+over-attention to one's self and to one's occupations. Men can do many
+complicated things quite naturally and easily, but when they carefully
+watch themselves doing them, accomplishment is not so ready and the
+task is double. They tire much easier, for, as a rule, what they are
+doing could be accomplished automatically and they are using up energy
+attending to it. This is probably one of the commonest causes for the
+rather frequent development of that state called nervous exhaustion in
+our time. People watch themselves too closely and by so doing they not
+only use up energy unnecessarily in the surveillance, but also they
+hamper their powers to do things and so consume additional energy in
+overcoming this inhibition.
+
+Morbidly introspective people watch almost ceaselessly everything they
+do. They not only watch themselves work and worry about it, but they
+watch themselves play and grow solicitous that it will do them good;
+they watch themselves divert themselves to see if it is giving them
+real recreation and so spoil the diversion; they watch themselves eat
+and disturb their appetite, and watch themselves digest and hamper
+digestion; they even try at least to watch themselves sleep and so
+interfere with sleep. Many of the cases of insomnia are really due to
+this over-attention. They fear they will not sleep, they worry about
+it, they keep themselves awake hoping that they will sleep, and in the
+more serious cases even during sleep itself they are so solicitous
+that their dreams become very vivid and a form of unconscious
+cerebration goes on with surveillance of themselves. They do not rest
+even in sleep. They wake feeling not rested, they get up with a
+consciousness that they are beginning a long day without being
+properly refreshed and they exhaust enough energy to complete a good
+part of the day's work in wondering whether they will be able to go on
+with their occupation for the day, whatever it may be.
+
+
+_Inhibitory Surveillance_.--People become afraid that they cannot or
+that they may not do things well and set a guard over themselves. This
+is illustrated very well in the doubts about accomplishment because of
+which they keep going back to see what they have done and how it was
+done, though usually it was accomplished quite well without any
+conscious attention. Dreads form another phase of this attitude of
+mind. For those who are affected with them they make a thing hard to
+do before it is begun, and harder to accomplish after it has been
+entered upon because of the suggestion that it may lead to some
+serious results, or they even inhibit their activities to a marked
+extent by their solicitude with regard to them. They worry about
+things before the event and thus consume energy uselessly. Worry has
+been defined as anxious solicitude about what we have to do next week
+at the same time that we occupy ourselves with what we are doing now
+and have to do in the next hour or two. The solicitude about next week
+is quite useless, as a rule, until the time comes, and it merely
+disturbs what we are doing now, making it harder to do and making
+errors in it almost inevitable, and so preparing ourselves for
+discouragement because of mistakes that have been made and still
+further adding to the difficulty of accomplishment.
+
+{601}
+
+_Inhibition of Automatism_.--These introspective people disturb
+themselves by over-attention to things that need no attention, that
+are accomplished automatically, and that are not done nearly so well
+if they are attended to. Not only is it true that it is harder to do
+work that ought to be accomplished automatically if much attention is
+given to it, but also nature resents the surveillance. Not only the
+brain does not work so well if watched to see whether perhaps it is
+working too much, or whether there are too many feelings in our head
+while we are doing things, but even the stomach resents being watched
+and does not do its work as well. The same thing is probably true for
+every one of our organic functions. In the chapters on the heart we
+call attention to the fact that surveillance makes a perfectly healthy
+though nervous heart miss beats. There is a dual waste of nervous
+energy then. We are employing our attention watching things done that
+need not be watched, and by that fact we are inhibiting natural
+processes and requiring that more energy shall be put into them for
+their accomplishment, and even then accomplishing them with
+discouraging imperfection.
+
+
+_Mental Short-Circuit_.--The reflex mental process that particularly
+affects many individuals in our time and makes it hard for them to do
+their work, has been well described under the figure of a
+short-circuit in an electrical dynamo. The short-circuit diverts the
+current so that instead of acting outside the dynamo and performing
+useful work, it is discharged within the machine, brings about
+deterioration of its elements and soon leads to a reduction in the
+amount of electrical energy that that particular dynamo can develop.
+
+
+Association Fibers Diversion.--Prof. Michael Foster in the Wilde
+Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote
+44] has many valuable suggestions with regard to the mechanism of
+mental operations on the neuron theory. He has particularly dwelt on
+the function of the association fibers in connection with mental
+operations, or with the raising of sensation to the plane of
+mentality. A portion of the brain that is originating impulses,
+instead of sending them down to the periphery, through the projection
+fibers, to lead to the accomplishment of external work, may have its
+messages diverted through the association fibers to other portions of
+the brain and thus do harm rather than good.
+
+  [Footnote 44: _Proceedings of Manchester Literary and Philosophical
+  Association_, 1898.]
+
+Occurrence of Psychasthenia.--It must not be thought that these
+curiously interesting conditions occur only among people of low
+intellectual caliber, or in those of narrow intellectual interests,
+mere specialists who may have acquired a reputation for doing one
+thing well. They are frequent among the most intellectual classes.
+Brain workers of all kinds, unless they are careful to vary the
+interests of life, unless, as suggested in the chapters on Occupation
+of Mind and Diversion of Mind, they have a hobby besides their usual
+occupations, are likely to suffer in this way. As a matter of fact,
+many intellectual people have had what are called nervous breakdowns
+of this kind. A biographical dictionary shows any number of them. Dr.
+Gould's Biographic Clinics furnish many documents for the study of
+these conditions. A typical instance, told by the sufferer himself,
+the distinguished Sir Francis Galton, is of special significance for
+the psychotherapeutist. I {602} quote because it illustrates the fact
+that such breakdowns do not portend a short or subsequently listless
+life, for Sir Francis, a most successful scientific investigator,
+lived well beyond fourscore years in the full possession of health of
+mind and body.
+
+  It was during my third year at Cambridge that I broke down entirely
+  in health and had to lose a term and go home. I suffered from
+  intermittent pulse and a variety of brain symptoms of an alarming
+  kind. A mill seemed to be working inside my head; I could not banish
+  obsessing ideas; at times I could hardly read a book, and found it
+  painful to look at even a printed page. Fortunately I did not suffer
+  from sleeplessness, and my digestion failed but little. Even a brief
+  interval of mental rest did me good, and it seemed as if a long dose
+  of it might wholly restore me. It would have been madness to
+  continue the kind of studious life that I had been leading. I had
+  been much too zealous, had worked too irregularly and in too many
+  directions, and had done myself serious harm. It was as though I had
+  tried to make a steam-engine perform more work than it was
+  constructed for, by tampering with its safety-valve and thereby
+  straining its mechanism. Happily the human body may sometimes repair
+  itself, which the steam-engine cannot.
+
+The physician with experience in such cases would be much more apt to
+say, "Happily we can learn to control our mental energy and not let it
+go to waste by foolish persistence at one set of ideas constantly, nor
+be dissipated in surveillance of functions that work automatically if
+left to themselves."
+
+
+Etiological Factors.--This form of mental incapacity develops
+particularly in people after they have gone through a prolonged period
+of hard work and then have come to a time when they are much freer
+than they were before. They are prone to think that they exhausted
+their nerve force during the preceding period of labor and that now
+they are paying for it. Almost invariably what is really happening is
+that they now have much more time to occupy themselves with themselves
+and about themselves and to worry over their ills, real and imaginary.
+This is the typical nervous breakdown, as it used to be called, of
+elderly retired merchants or bankers. They have looked forward all
+their lives to a time when they could enjoy themselves doing nothing.
+They retire from business and then their troubles begin. It is no
+wonder that the old proverb, "A machine rusts out much sooner than it
+wears out" should have been so often quoted with regard to this
+condition. A man who has been working busily at something all his life
+cannot stop all at once and do nothing. He cannot learn to occupy
+himself with trivial things. Commonly, he has few, if any, interests
+apart from his business and he very soon wears the novelty off these
+and then introspection comes to make him exaggerate the significance
+of every feeling that he has, every stiffness that occurs, every
+muscle twinge due to change in the weather, until he becomes supremely
+miserable.
+
+As a rule, these patients are simple, practical, common-sense,
+business men, and it is hard for the physician to think that there is
+nothing more than a functional neurosis present. It is even more
+difficult for the patient to be made to appreciate that his ills are
+mainly due to his own over-attention to himself in this idleness that
+he has looked forward to with so much pleasure. Ordinary medicines
+fail to relieve and the regular professional man seldom succeeds in
+doing these patients much good. They constitute the richest material
+for the quack and the charlatan. Much occupied with their ills they
+tell their friends all about them. Whenever a strong impression is
+produced {603} on their mind by a promise to cure them with some new
+wonderful remedy they are favorably influenced, often get better and
+then are walking advertisements for the particular quack who has
+happened to benefit them. It is this class of people that has given
+more trouble to legislative committees of medical societies than any
+other. Some of them appeal to legislators whenever a bill for the
+admission of some new form of practitioners of medicine comes up with
+the story of how much benefit they derived from the treatment. Since
+they have been successful business men their word carries weight. It
+is curious how little the making of money, though often presumed to be
+so, is a test of real intelligence. It is often the man of one idea
+with no intellectual breadth who is the best money-getter.
+
+These conditions develop almost entirely in predisposed individuals
+who, for some reason, are trying to overdo the energy they possess,
+and who, as a consequence, have lost a certain control over
+themselves. At times, of course, they occur in persons who have so
+little occupation of mind that thoughts of various kinds along these
+lines become insistently suggestive and cannot be thrown off because
+the patients' interests are not sufficiently deep or sufficiently
+varied to occupy their attention. The rational treatment of them,
+then, must be founded on a careful study of individual cases, the
+recognition of the special cause, and also the occasions at work in
+each case, a neutralization of unfavorable suggestion and a provision
+of such favorable suggestions and occupation of mind as will enable
+the patient to rid himself of the annoyance occasioned by these and
+the physical symptoms that so often develop as a consequence. In a
+certain number of cases a history of corresponding or equivalent
+affections in preceding generations will be found. In many patients,
+however, there is no such history, though there is usually the story
+of symptomatic mental conditions of one or other of the types
+mentioned, earlier in life. When in good health physically the patient
+has very little bother from them. When run down in weight or when
+worried or anxious about business or from the stress of important
+responsibilities these symptoms may become bothersome mentally and
+physically. Often it will be impossible to obliterate them entirely,
+but always they can be greatly improved and the patient can be made to
+realize that they are not seriously significant, that in mild form
+they are rather common and that, above all, they are not so peculiar
+to the individual as he is likely to think, with consequent increase
+of the unfavorable suggestion.
+
+
+
+CHAPTER II
+
+HALLUCINATIONS
+
+
+Hallucinations Differentiated from Illusions and
+Delusions.--Hallucinations are vivid impressions on the consciousness
+which appeal to their subject as strongly as if they were really the
+result of sensory impressions, though those who experience them know,
+either at the moment, or on investigation afterwards, that they had no
+objective reality, that is, were not due to any external physical
+cause. Illusions are deceptions of the senses, due to the imperfection
+of the senses or the conditions in which the perception occurs. {604}
+Delusions are mental states in which ideas are accepted, or
+conclusions drawn, or information assumed to be gained, though the
+whole process is mental and has no relation to reality. (For
+illustrations of illusions see chapter with that title in the
+Appendix.)
+
+Hallucinations lie in between illusions and delusions as a mode of
+deception. They are mental occurrences, but they seem to come from the
+senses and probably the best explanation for them is that a previous
+sensory impression is vaguely aroused and then finds its way into the
+consciousness as if it were coming through the senses. It has been
+suggested that they might be due to a reversal of the nervous process
+by which a sensation reaches the brain. The external object produces
+the sensation, this travels along a nerve causing a perception, this
+perception is stored in the memory, and then, when very vividly
+reawakened, causes impulses to travel backward along the nerve to the
+periphery with the production of a feeling very like sensation.
+
+
+Frequency.--While hallucinations are often supposed to be only
+incidents in the life of the insane, or at least of those who are in
+the danger zone near mental disequilibration, carefully collected
+recent observations show that many perfectly sane people have
+experienced them, and some of them have been much disturbed by them
+for fear they portended loss of mental control or some developing
+pathological condition. A certain number of men and women have seen
+things that either had no existence or existed only for them and for
+the moment, and that evidently were due to some state of mind rather
+than to their senses. They have heard things that were not said or
+that were not audible to others, or that were only reproductions of
+their memory of previous sounds and quite naturally such mysterious
+manifestations disquiet them. It was the rule in the past to dismiss
+such phenomena without serious consideration, or at most to consider
+that they were only subjective manifestations not worth discussing, or
+to go to the opposite extreme and say that they were due to mental
+disturbances.
+
+Of course, as a rule, hallucinations are an index of mental
+disturbance. No matter how apparently sane the patient, this must be
+the first thought and must be carefully excluded before proceeding
+with the case. The subject of hallucinations is larger than that,
+however, and it is a mistake to brush it aside in every case as if it
+were either very serious or of no importance and that in either case
+nothing can be done to relieve solicitude about it. Physicians can
+often do much, first to prevent hallucinations by getting at the
+physical causes of them; second, to prevent them from disturbing
+patients seriously by showing them how common are such experiences and
+by indicating their possible physical significance; third, by securing
+such mental discipline and control as will render their recurrence
+much less frequent; and, fourth, they can make the almost inevitable
+unfavorable effect upon the mind of the patient and then reflexly upon
+his body, much less than it would otherwise be, by sympathetically
+discussing and entering into the details of them enough, at least, to
+explain their significance or throw some light on their origin in
+physical conditions.
+
+Hallucinations of vision, the seeing of things and persons that have
+no real existence at the time and place they are seen, are usually
+considered to be rather uncommon and to occur only in those whose
+mentality is seriously disturbed. Careful studies of the subject,
+however, show that at least one in ten {605} of educated people
+consulted have had some hallucinations of vision. Either they have
+wakened up, or they have dreamt that they waked in the early morning,
+and have seen some one whom they knew, but knew to be at the moment at
+a distance, standing near them. Such visions have gradually faded away
+or suddenly disappeared. Occasionally these persons have in full light
+had some appearance, wraithlike or otherwise, some manifestation that
+appeals to vision, yet that they knew at the time or learned
+afterwards was non-existent.
+
+Many people are backward about confessing that they have had such
+experiences, for they fear that it will make them ridiculous or even
+cause them to be suspected of disturbed mentality. Just as soon as it
+is made clear to them that their admissions will be taken as evidence
+for a phenomenon to be discussed seriously, many more than would
+otherwise be thought confess to such hallucinations. Most of these, it
+may be said at once, are quite sensible people, a great many of them
+belong to the educated classes; all of them are trustworthy witnesses
+as far as good will goes, and the circumstances of their
+hallucinations are such in many cases that there cannot be a mere
+mistake, or error of judgment.
+
+The frequency with which hallucinations occur may be appreciated from
+the investigation made some years ago at the instance of the Congress
+of Experimental Psychology. The following question was put to 17,000
+persons, mostly residents of Great Britain, and answers received:
+"Have you ever, when believing yourself to be completely awake, had a
+vivid impression of seeing or being touched by living beings or
+inanimate objects, or of hearing a voice, which impression, so far as
+you could discover, was not due to any external physical cause?" The
+answers showed that 655 out of 8,372 men and 1,029 out of 8,628 women
+had experienced a sensory hallucination at some time in their lives.
+Some of them had had a number of them. That is, one out of ten in the
+educated classes has had some hallucination, and nearly one out of
+every eight women. An analysis of the statistics, however, brings out
+some interesting suggestions. There were nearly twice as many
+hallucinations related as having occurred during the year before the
+question was asked as in the preceding years. There was a definite
+reduction in the number that had occurred in all the preceding years,
+except the fifth and tenth, and these were evidently due to
+uncertainties of memory, so that five- and ten-year periods seemed
+about the length of time that had passed since the event.
+
+It is evident then that in spite of the fact that an hallucination
+would seem to be very important and surely startling enough to be well
+remembered, it is yet easily forgotten, since even a year's interval
+made so much difference in the number that were remembered. The
+committee, after considering this easy forgetfulness in the matter,
+considered that to arrive at the actual total of visual hallucinations
+experienced by this group of 17,000 persons during the ten-year period
+in question, the numbers in the table should be multiplied by four.
+That means that probably very nearly one in three people have had an
+hallucination of some kind within ten years. The great majority of the
+visual hallucinations consist of apparitions of human figures. Other
+forms that are seen are so few, as Mr. Podmore has insisted in his
+"Telepathic Hallucinations, The New View of Ghosts,"   [Footnote 45]
+that they are almost negligible. A frank {606} discussion of these
+details with a person who is much disturbed by having experienced an
+hallucination is the best possible remedy for the physical and mental
+disturbance that may result.
+
+  [Footnote 45: The Twentieth Century Science Series, New York, 1910.]
+
+Sir Francis Galton, well known for his investigation of many subjects
+and who may well be called the father of biometrics or statistical
+biology, in his "Memories of My Life"   [Footnote 46] tells of his own
+investigations of the visions of sane persons. The fact that he
+delivered a lecture on this subject at the Royal Institution of London
+shows how seriously his studies were made and how much value
+scientists placed on them. Galton's well-recognized training in the
+careful weighing of evidence and his ability to strip phenomena of
+everything that might divert their significance from what they really
+were, add to the worth of his conclusions. Those who care to study the
+subject further will find his discussion in the _Proceedings of the
+Royal Institution_ (London, 1882).
+
+  [Footnote 46: New York, 1909.]
+
+There are few people beyond middle age who have not had one or more
+curious experiences in the matter of visions or appearances. Mostly
+these have been vague and have not proved a disturbing element in the
+minds of the subjects. Many more than are thought, however, have seen
+visions vividly and with a detail that makes it almost impossible for
+them to believe that what they saw was merely an externation of ideas
+already in their mind. In this matter it must not be forgotten that
+the dreams of many people, especially nervous people, often present
+themselves with marvelous vividness of detail. They see people or
+places in their dreams and reason about them quite rationally.
+Occasionally a dream will bring back details that have been forgotten.
+The dreaming state seems in some people to have wonderful power over
+the subconscious. Things that are not remembered at all in the waking
+state sometimes come back in dreams, and only then are recalled by the
+individual as representing past events in his life. He is apt to
+wonder where the details could possibly come from, since he had before
+no conscious memory of them. This same thing holds for the day-dreams
+or sudden visual appearances that come when the attention has been
+wrapped in something else.
+
+A typical example of such visual hallucinations is the following
+incident told by a prominent London physician of himself:
+
+  One afternoon at tea time, before a meeting of the Royal Society,
+  Sir Risdon Bennett (1809-1891, a well-known physician. President of
+  the College of Physicians in 1876, and a fellow of the Royal
+  Society), drew me apart and told me of a strange experience he had
+  had very recently. He was writing in his study separated by a thin
+  wall from the passage, when he heard the well-known postman's knock,
+  followed by the entrance into his study of a man dressed in a
+  fantastic medieval costume, perfectly distinct in every particular,
+  buttons and all, who, after a brief time, faded and disappeared. Sir
+  Risdon says that he felt in perfect health; his pulse and breathing
+  were normal and so forth, and he was naturally alarmed at the
+  prospect of some impending brain disorder. Nothing, however, of the
+  sort had followed. The same appearance recurred; he thought the
+  postman's knock somehow originated the hallucination. ... I heard
+  the story at length, very shortly after the event, told me with
+  painstaking and scientific exactness and in tones that clearly
+  indicated the narrator's earnest desire to be minutely correct.
+
+Those who are especially interested in this subject will find any
+number of similar stories, some apparently rich with meaning, most of
+them quite {607} meaningless, in the volumes of transactions of the
+English Psychic Research Society, in F. W. H. Myers' "Human
+Personality," in Podmore's "Naturalizing the Supernatural," in
+Flammarion's "The Unknown," or many other books published in recent
+years. It is quite easy to get sufficient material to bring
+reassurance to any patient that visual hallucinations, at least, mean
+nothing serious for the mind or body of the individual having the
+experience.
+
+
+Hallucinations in the Past.--It must not be thought, however, that
+this subject of hallucinations is new. Literature is full of it and
+from the earliest times we find traces of it. Egyptian, Babylonian and
+Chaldean writers mention them. Nor indeed is the scientific
+consideration of the subject new. Aristotle speaks of them and it is
+evident that many of the old writers thought of them as psychic
+incidents on some physical basis, or at least due to some
+predisposition in the individual or in some special state of his
+senses. Two generations ago Johann Müller, the great German
+physiologist, discussed the whole subject at length in a monograph,
+and considered it of so much importance for physicians that he
+introduced a résumé of it into his great text-book of physiology. His
+explanation of the occurrence of visual hallucinations is not only a
+striking illustration of the thoroughly scientific character of his
+treatment of the subject, but it serves to show how well men
+considered these subjects long before the present fad for the study of
+abnormal psychology or mental influence came in. His discussion of the
+subject is sufficient of itself to make any patient understand his
+hallucinations and keep them from bothering him better than anything
+else I know:
+
+  The subjective images of which we are speaking have sometimes,
+  however, both color and light; different particles of the retina, of
+  the optic nerve, and of its prolongations to the brain, being
+  conceived as existing in special states of action. This happens
+  rarely in the state of health, but frequently in disease. These are
+  the true phantasms which may occur to the sense of hearing and other
+  senses as well as to that of vision. The process by which
+  "phantasms" are produced, is the reverse of that to which the vision
+  of actual external objects is due. In the latter case particles of
+  the retina thrown into an active state by external impressions, are
+  conceived in that condition by the sensorium; in the former case,
+  the idea of the sensorium excites the active state of corresponding
+  particles of the retina or optic nerve. The action of the material
+  organ of vision, which has extension in space, upon the mind, so as
+  to produce the idea of an object having extension, form and relation
+  of parts, and the action of such an idea upon the organ of vision so
+  as to produce a corresponding sensation, are both equally wonderful;
+  and hence the spectral phenomena or visions are not more
+  extraordinary than the ordinary function of sight. (Vol. II, p.
+  1393, Eng. transl., 1842.)
+
+
+Apparitions and their Explanation.--In spite of suggested explanations
+on physical grounds, some of these apparitions that appear to people
+seriously disturb them. They cannot get them out of their minds. They
+are sure that they portend evil. Hence worries, and the more nervous
+the people are and the more worried already, the more likely is such a
+thing to recur and then to be made much of. Only through their minds
+can these people be treated, and it must be made clear to them not
+only how common are hallucinations, but that there is an easy psychic
+explanation of most of them. Sir Arthur Mitchell, K. C. B., in his
+book "About Dreaming, Laughing and Blushing," [Footnote 47] tells a
+story and then gives his explanation of it in such a way as to
+illuminate many of these occurrences:
+
+  [Footnote 47: Longmans, London, 1900, page 21.]
+
+{608}
+
+  Perhaps I should illustrate how I think that apparitions may be
+  nothing more than dream hallucinations. A. B., a gentleman of
+  culture and strong character, called one hot day, after a hearty
+  lunch, on an ecclesiastic in a high position, who happened to be
+  engaged in his library at the time of the call. A. B. was shown into
+  a room opening off the library, and requested to wait. He sat down
+  beside a table, and with his elbow resting on it, he leant his head
+  on his hand. While in this position he saw a man in clerical costume
+  come through the door communicating with the library, without any
+  opening of the door. A. B. was absolutely certain that he had seen
+  an apparition, and was surprised and hurt when I expressed a doubt.
+  He called on me to explain, and I said that it was at least possible
+  that he had been asleep for some moments, that if he had slept at
+  all, however short the dream of the sleep, he must have had a dream,
+  if I am right in thinking that there is no dreamless sleep, and that
+  thus what he regarded as an apparition might be nothing more than a
+  dream hallucination. He assured me persistently that he was
+  continuously wide-awake, but I assured him that these moments of
+  sleep often occurred without any consciousness that they had
+  occurred. He refused to be deprived of his ghost, and I refused to
+  believe in the supernormal when the normal was sufficient.
+
+Such wraith-like appearances are supposed to occur especially in
+connection with the deaths of persons at a distance. Startling stories
+are told, particularly of those who are very near relatives, husbands
+and wives, mothers and sons, and, above all, twins, who have been very
+closely associated with one another during life. There are a large
+number of stories of this kind, however, that have been collected by
+the Psychic Research Society and other agents with strong evidence in
+their favor, in which the appearances have had no ulterior
+significance at all and have evidently been mere figments of the
+imagination, the externation of images from memory so vividly that
+they seem to be the reseen. Reassurances in this matter are the best
+possible source of relief from the sense of impending ill for many
+patients. The physician who wishes to relieve such symptoms must
+familiarize himself with some of the many stories that have been
+investigated and that serve to prove that these and like appearances
+must not be taken as significant of anything more than a definite
+tendency, that exists in human nature at moments of day dreaming or
+when one's attention is suddenly turned from a book in which one has
+been absorbed, to see externally what is really passing through the
+imaginative memory.
+
+
+A Disappearance.--A very interesting commentary on some of these
+appearances is to be found in Mark Twain's story of a disappearance,
+which could probably be duplicated many times if experiences in this
+line were collected and collated. Mr. Clemens, sitting on the porch of
+his residence one day, saw a stranger of rather peculiar appearance
+come up the walk toward the front door and he expected to hear him
+ring the bell and have the servant come to the door and usher him in,
+and then perhaps be called to see him. About the middle of the walk,
+however, the stranger disappeared and Mr. Clemens was quite surprised
+to come to himself, rub his eyes and conclude that he had had one of
+these curious visions or hallucinations, in which the Psychic Research
+Society would surely be interested. He had plainly seen the stranger
+enter the gate, come up the walk, and then disappear. He was so
+impressed by the disappearance that he roused himself to go into the
+house to get his notebook, so as to make notes of what had happened
+before the details escaped him. To his surprise he found the stranger
+in conversation {609} with the servant in the house. There had simply
+been a lapse in Mr. Clemen's vision of him. He had had a disappearance
+phenomenon instead of an appearance. The story will be found to amuse
+patients who complain of appearances disturbing them, though Mr.
+Clemens always told his disappearance story very seriously, and it is
+as interesting a psychic phenomenon as any told of the wraith-like
+appearances.
+
+
+Treatment.--Considering how frequent are such phenomena, the physician
+must be prepared to treat those who are disquieted by them. A
+wraith-like appearance, for instance, will disturb many people very
+seriously and often for days, sometimes for weeks, make them nervous,
+excitable, and impair their appetite, disturb their digestion and
+sleep and often such unfortunate occurrences are prone to come just
+when they are run down in weight and when they need the help of every
+factor that makes for improvement of health. Simply to dismiss such an
+appearance as if it were quite imaginary, that is, non-existent in
+some form of reality, or quite baseless and trivial, serves no good
+purpose, for, as a rule, the persons concerned are deeply impressed
+with what they have seen. The only way to remove the unfavorable
+impression produced by it is to discuss it straightforwardly on the
+basis of what we have come to know as the result of recent
+investigations and the collation of the literature which has been
+published by the various psychical research societies and authorities
+on the subject. We know now that while occasionally such wraith-like
+appearances seemed to have a definite significance, because of
+something that happened simultaneously or shortly afterwards, this is
+mere coincidence and there are literally thousands of such cases in
+which a well authenticated wraith-like appearance was followed by no
+serious consequence, was never shown to mean anything beyond a curious
+psychic phenomenon, and was evidently merely due to some personal
+subjective influence, some externation of an image in the memory,
+unusual, but not at all unique, or even very rare, and evidently due
+to a curious peculiar externalizing power with which certain
+intellects are gifted.
+
+
+Auditory Hallucinations.--Hallucinations of hearing are more common
+than those of vision. Many people have had the experience of waking up
+thinking that someone was calling them. A great many people are sure
+that they have, at some time or other, heard a voice when no one was
+near enough to them to have said anything. They have even recognized
+the voice. Some people, when thinking deeply about a person, have the
+voice of that person occur to them so clearly that they cannot quite
+make out whether they have actually heard it or whether it has only
+been very vividly reproduced in their memory. Such experiences are so
+common as to be well known, though many people hesitate to tell the
+stories of them, for hearing voices is rightly looked upon as a
+frequent preliminary symptom of insanity.
+
+Hallucinations of hearing are the most common early symptom of
+insanity. The hearing of voices must always arouse suspicion at once.
+It must not be forgotten, however, that a great many recognizedly sane
+people who have remained so for life, have thought that they heard
+voices. Of course, we have no definition for insanity, and it is
+difficult to draw the line. We have no definition for health either,
+yet we have a practical working standard for the recognition of it, as
+also for insanity. These hallucinations then, both of vision and
+hearing, deserve to be discussed seriously, and in {610} nearly every
+case, even though there is some mental disturbance, the physician can
+in this way benefit his patients and keep them from being overmuch
+distressed by their hallucinations.
+
+There is an expression in such common use that it is evidently the
+result of an almost universal experience, according to which men
+sometimes explain, after having acted in a particular way, that
+"something told them to." What they mean, of course, is that a
+conclusion formed in their minds the reasons for which they could not
+understand, but which yet had force enough to cause them to follow it
+to a practical application. When we hear of Socrates being advised in
+life by a demon, a so-called familiar spirit, we are apt to wonder
+whether by this term is meant anything more than just this curious
+feeling of aloofness from ourselves that we sometimes have when we are
+trying to make up our minds, or, indeed, not infrequently when we are
+deeply engaged in any intellectual occupation. As discussed in the
+chapter on Unconscious Cerebration, our minds seem in a certain way to
+act independently of us. Occasionally they draw us to conclusions
+quite different from those which we previously expected to reach.
+There seems to be a something within us that works quite of itself and
+beyond our will. Whether under these circumstances there may not
+occasionally come so vivid a feeling of this power within us
+impressing itself upon us, that it seems to come from without, must
+always be taken into account in the effort to get at the real
+significance of these curious hallucinations. Only thus are we able to
+come to the relief of patients who are bothered by them.
+
+
+_Explanation by Sound Reproduction_.--Auditory hallucinations are
+probably not more than reproductions of sounds heard before recalled
+vividly and apparently heard again at moments when attention is not
+attracted to actual auditory sensations and we are in receptive mood.
+Some of them are very startling because they are apparently warnings
+of future events, as is proved by their fulfillment. These, however,
+do not seem to be more than coincidences noted with regard to similar
+events connected with Premonitions, Dreads and Dreams (see chapters on
+these subjects). There is, for instance, a well authenticated story
+published by the English Psychic Research Society of a woman who was
+about to take a dose of what she thought was some ordinary home
+remedy, when she distinctly heard a voice telling her to taste it. The
+dose to be taken was a tablespoonful, and when she tasted it she found
+that by mistake she had placed her hands on a bottle containing a
+rather strong poison and a tablespoonful of it would almost inevitably
+have killed her. Unfortunately, such occurrences are so rare and the
+reason for them is so hard to find that their consideration as
+anything more than coincidences seems out of the question. Every
+medical journal almost brings the story of someone who has taken a
+dose of medicine that proves fatal, and there is no warning. If such
+warnings came with definite frequency, it would be easier to
+appreciate their significance.
+
+There are similar stories with regard to other warnings. There is the
+story of the young man who in a storm drove under a shed for
+protection. Just as he did so he heard his mother's voice--she had
+been long dead--distinctly say "Drive out!" Ho drove out at once in
+the teeth of the storm, so deeply impressed was he, and was scarcely
+beyond the entrance when the shed fell, crushing everything within it.
+Similar warnings of impending {611} accidents are rather frequent in
+certain people's minds, yet it is hard to think of them as anything
+else than premonitions. These somehow take on the character of
+auditory hallucinations in certain sensitive minds. Compared to the
+whole number of accidents, however, such incidents are extremely rare
+and follow no law, and while there are those who like to think that
+perhaps such phenomena are due to the solicitude of some being in the
+other world, this is extremely doubtful. In that case, as St.
+Augustine suggested, they would be much more frequent and have a
+clearer significance than is at present the rule. St. Augustine,
+discussing the possibility, was sure that he would have had
+communications from his mother. Most men would re-echo his feeling.
+
+
+Coincidences.--Most of these stories as they have been analyzed by
+careful investigators are indeed such trivial unmeaning things that it
+would be too bad to let people be bothered by them. They have
+occurred, however, from time immemorial. Veridical warnings are a
+commonplace in the literature of all countries. Undoubtedly some may
+suggest the action of a Higher Power, but the more one knows of the
+conditions in which they happened, the people to whom they came and
+their ultimate effects, the less will they seem providential. It is
+evident that under certain conditions they may be produced even at
+moments when men are not particularly excited and when they think that
+they are perfectly calm and self-possessed. Each story must be
+discussed in its own merits. The only thing to do, then, is not to
+make too light of them and, above all, not to treat them as merely
+imaginary or as utterly illusory; for they are often natural
+phenomena, the reasons for which and the conditions of their
+production we do not as yet fully understand. If patients can be
+brought to this viewpoint, they may even become interested in
+searching out just what it was that caused each particular
+hallucination. Over and over again it has been found that a moonbeam
+or a peculiar unexpected reflection of the sun, or the light shining
+through an unnoted aperture, or any or several of these in connection
+with a mirror has been the main cause of the wraith-like appearance.
+When they happen during the day it is sometimes at the moment of
+passing from very bright light to a darker hall that the occurrence
+takes place and evidently there is some physical occasion for the
+appearances in the eye itself. Unusual noises of various kinds are
+responsible for the auditory hallucinations.
+
+
+Dangers of Serious Considerations.--There is one serious aspect of
+these hallucinations and supposed warnings--they tend to paralyze
+action. If a person allows himself to become firmly persuaded that
+doubts and premonitory possibilities must be weighed and solved before
+he may dare to act with assurance, then action becomes almost
+impossible. Premonitions may serve to bring people into danger, or at
+least keep people from having such presence of mind as will enable
+them to get out of it, as they otherwise would. Doubts lead to
+inaction and make a state of mind that is eminently miserable. The
+patient's one hope is to put aside resolutely such hallucinations if
+they rise to the level of a disturbing doubt or a paralyzing
+premonition and to discipline himself against being influenced by
+them. In many persons this is a difficult matter, but it represents
+the only efficient path to the regaining of mental health and
+strength.
+
+{612}
+
+
+CHAPTER III
+
+DREADS
+
+
+In any discussion of the influence of mind over body, favorable and
+unfavorable, too much emphasis cannot be placed on the hold that
+dreads have over a great many people and how much they mean, not alone
+for the mental state, but also for the physical sense of well-being or
+of ill-feeling in the individual. The expression attributed to the old
+hermit who had lived to the age of one hundred and had spent some
+sixty years of existence in the solitude of the desert, with all the
+opportunities for introspection that this afforded, is the best
+illustration even in our day of what dreads signify in life: "I am an
+old man," he said to the young solitary who came to him for advice,
+"and I have had many troubles, but most of them never happened." We
+are nearly all of us, or at least those of us who spend most of our
+time in sedentary mental occupations, prone to fear that something
+untoward is preparing for us and in many cases to dread lest some
+serious ailment or other is just ahead of us. We are afraid that
+certain feelings, though we like to call them symptoms, due to some
+trivial cause or other as a rule that deserves no notice, may mean the
+insidious inroads of a constitutional disease destined to shorten
+existence. A little fatigue, over-tiredness of particular muscles, the
+straining of joints, the discomforts due to overeating and
+undersleeping, that are meant as passing warnings of nature for the
+necessity of a little more care in life, are exaggerated into symptoms
+that have a more or less serious significance.
+
+
+DEFINITE DREADS
+
+Besides these rather vague dreads, however, there are certain special
+disquietudes peculiar to individuals, even more groundless, if
+possible, than the generic apprehension just spoken of and that have
+been dignified in recent years by the name of phobias. Phobia means
+only "fear" in Greek, but the term is much more satisfying to nervous
+people than the shorter but too definite English term, dread, or fear.
+There is acrophobia, or the fear of looking down from a height;
+claustrophobia, or the fear of narrow places, as the dread of walking
+through a narrow street because of the sense of oppression that comes
+with the shut-inness of it. Then there is agoraphobia, market-place
+dread, or the fear to cross an open space because one has, as it were,
+grown accustomed to be near buildings and misses their presence. There
+are many others, indeed as many as there are dislikes in human nature,
+for any dislike apparently may be exaggerated into a dread. I mention
+a few at the beginning of the alphabet and some of special
+significance. There is aerophobia, dread of the air, a symptom
+sometimes mentioned in connection with hydrophobia; aichmophobia, the
+dread of pointed tools; ailurophobia, the dread of cats; anthrophobia
+or the dread of men; pathophobia or the fear of disease, microbophobia
+or bacillophobia; kenophobia or the dread of emptiness; phthisiophobia
+or the dread of consumption; zoophobia or the dread of animals;
+sitophobia or the dread of food, and even phobophobia, the dread of
+{613} dreading. Neuropsychologists seem to take a special pleasure in
+inventing some new phobia or at least giving us a fine long Greek name
+for a set of symptoms by no means new and that might well be explained
+in simpler terms. The most familiar examples are: the fear of
+lightning, which is more frequently brontophobia, the fear of thunder.
+
+These learned words are all formed on the same etymological principle
+as hydrophobia, but they are entirely psychic in origin, while
+hydrophobia, as it is well to explain to patients who think of the
+word phobia in connection with their symptoms, is, of course, a
+misnomer for an infectious disease--rabies--which develops as the
+consequence of a bite of a rabid animal, and the principal symptom of
+which is not fear of water, but the impossibility of swallowing any
+liquid because of spasm of the esophageal muscles.
+
+Almost any function of the body may become the subject of a dread or
+phobia that may interfere even seriously with it. Any disturbance of
+any function is likely to be emphasized by such dreads. The French
+have described the basophobia, which makes the patients suffering from
+beginning tabes dread so much walking that it becomes a much greater
+effort than it would otherwise be and often interferes with walking
+rather seriously. Then there is the fear of tremor which exaggerates a
+tremor due to some organic cause, but yet not necessarily of grave
+import, nor likely to increase rapidly. Many of the hysterical palsies
+are really due to dreads, consequent upon some incident, motor or
+sensory, which produced a profound effect upon the patient's mind. A
+patient who has been surprised by a digestive vertigo while descending
+a stairs, even though nothing more happened than the dizziness which
+required him to grasp the balustrade, will sometimes develop a fear of
+vertigo that will actually make it difficult for him to go down stairs
+without such an effort of will as is very exhausting. Even the
+slightest functions may be thus disturbed. Pitres and Regis described
+some ten years ago what they called the obsession of blushing, or
+erythrophobia, the fear of turning red. Patients make themselves
+extremely miserable in this way. Only training and self-control will
+help them.
+
+These names are long and mouth-filling and consequently satisfying,
+and most people who are suffering from a particular phobia are almost
+sure to think that they have a very special affliction. When the word
+dread is used instead of the word phobia they are less likely to
+misunderstand the character of their affection and to realize that it
+is not a disease but only an unfortunate mental peculiarity that needs
+control and discipline, and not fostering care. Neurasthenia only
+means nervous weakness, as we have pointed out, but most people are
+rather rejoiced when informed that they have so high-sounding a
+disease as neurasthenia, while to be told that they are nervously weak
+or suffer from nervous weakness seems quite a come-down from their
+interesting Greek-designated affection. Most psychiatrists feel that
+it is better not to give the long Greek term, but to state in simple
+short Saxon words just what is the matter with the patient. They are
+suffering from the dread of a height, or the dread of a narrow street,
+or the dread of open spaces, or the dread of dirt, or of cats, or of
+whatever else it may be. This makes it easier for them to begin to
+discipline themselves against the state of mind into which they allow
+themselves to fall with regard to these various objects, and mental
+discipline is the only therapeutic adjuvant that is of any avail in
+{614} lessening these conditions. With reasonable perseverance most
+people can, if not cure themselves of these affections, at least
+greatly lessen the discomfort due to them. A consideration of
+particular dreads brings out the specific suggestions that may be made
+with regard to each and the directions that may be helpful to the
+patients. Probably the commonest is acrophobia, so that the detailed
+consideration of it shows the indications for other dreads.
+
+
+Dread of Heights.--Almost without exception men have a sort of
+instinctive dread of looking down from a height. In most people this
+can be conquered to such a degree that almost anyone, if compelled by
+necessity, can learn to work on a skyscraper and continue to do good
+work without much bother about the height, though he may have to go up
+ten to twenty stories, or even more. When he takes up the work at
+first every workman finds it difficult. It gives most of us a trembly
+feeling even to sit in our chair and think of looking down from such a
+height. To see pictures of men standing on the iron frames of
+skyscrapers twenty or thirty stories up in the air looking down 300 to
+500 feet below them gives one a series of little chilly feelings in
+the back and in many people a goneness or sense of constriction around
+the abdomen that is almost a girdle feeling. To sit at a window
+opposite where a skyscraper is going up and to see the men lean over
+the edge of a beam calling directions of various kinds to workmen
+below will give most people, even those who are not nervous or
+especially sensitive, creepy feelings with sometimes a little catch in
+the breath and an iciness in the hypochondria. It would seem
+absolutely impossible that we should ever be able to perform these
+feats of looking from a height, yet experience shows that most of us,
+after a little training, learn to do it without difficulty.
+
+Even the men who work most confidently have some creepy feelings
+return to them whenever they stop and think about this and let their
+eyes wander to the distance below them. It is not difficult for us to
+walk across a plank raised a foot or two from the ground, though to
+walk across the same plank at a height of ten feet may be quite a
+trial and at thirty feet may become quite impossible. This is all due
+to lack of confidence on our part and there is no reason in the world
+why, if the plank is amply wide for us at two feet from the ground, it
+should not be just as wide and safe at 30 or 60 or even 100 feet. This
+is what the men who have learned to work on skyscrapers have
+disciplined themselves to. They have learned to disregard the wide
+vacant space around them and the yawning chasm beneath their feet;
+they keep their eyes fixed on something in the immediate vicinity,
+excluding thoughts of all that might happen if they should lose their
+balance.
+
+
+_Physical Basis_.--There is a physical basis in many of these cases
+that constitutes the underlying occasion, at least, for the
+development of the psychic dread. Our eyes have grown accustomed to
+being fixed on near objects. Whenever they are not so fixed we get a
+feeling of trepidation. Even those who have done a little day-dreaming
+know that sometimes when they have been looking into space, objects
+around them have suddenly seemed to be transferred to a long distance
+and at the same time a curious sense of insecurity came over them.
+Anyone can get this feeling experimentally by making two large dots on
+a piece of paper about two inches apart and then gazing between the
+dots into vacancy beyond the paper as it were, until the dots have a
+tendency to become four because of the fact that each eye sees {615}
+each of the dots on a part of the retina not corresponding to that on
+which the other eye sees it (see Fig. 25).
+
+
+  [Illustration: Fig. 25. (Two solid black dots about 1/2 inch
+  diameter and 4 inches apart.)]
+
+
+When the experiment is successfully performed the dots begin to float
+before the eyes, then they may coalesce into one or become three, but
+any number up to four may readily be seen. This will give the sense of
+insecurity that comes from the eyes not having any fixed object to
+look at and illustrates the discipline of the eyes that must be
+learned in order that looking down from a height may not be productive
+of the usual dread.
+
+
+_Dread of Small Heights_.--It is often thought that acrophobia, or the
+fear of a height, concerns only great heights and that ordinary
+elevations produce no discomfort. I have had patients, however, who,
+when compelled by circumstances over which they had no control or at
+least by social obligations that were hard to break, to sit on the
+front row of even a low balcony, have been extremely uncomfortable.
+There was a sense of tightness and oppression about the chest that
+made it difficult for them to breathe, that disturbed their heart
+action and gave them a general sense of ill-feeling. I have had a
+curiously interesting series of cases in clergymen who found it trying
+to say Mass or conduct services or to preach from the step of a high
+altar. One would be inclined at first to make little of their
+description of their utter discomfort. There is no doubt at all,
+however, of their real torture of mind and of the extreme effort
+required to enable them to support themselves in the trying ordeal.
+They are often so exhausted because of the effort required that only
+with difficulty can they do anything else during the day.
+
+To most people such a state of mind is inexplicable. There are deeply
+intellectual men who, in my experience, are quite disturbed by
+apparently so simple a thing as having to say Mass on an altar that
+has three or four steps to it and is elevated five or six feet above
+the surrounding floor. As for higher altars, like the main altar of a
+cathedral, they usually find it quite impossible to conduct services
+unless they are in company with others, when their feelings are much
+relieved. This same thing is true of agoraphobia in some people. To go
+alone across an open place or square is agony, but even the company of
+a little child is sufficient to relieve them to a great degree. I told
+a distinguished American prelate of this curious dread in priests so
+often called to the physician's attention, and he said that he had
+never heard of it. To his surprise some of his clergymen present at
+the table told him that there were two examples of it in brothers in
+his own diocese.
+
+
+_Mental Discipline_.--The lesson of the many men who, by discipline,
+have succeeded in conquering the aversion and the dread of heights
+that everyone has to some extent at least, shows the possibility there
+is for even those who are extremely sensitive in this matter to so
+lessen their timidity and the uncomfortable oppression that comes over
+them, as to make it possible to accomplish whatever is in their line
+of duty. It is no more difficult for the sensitive clergyman to learn
+by practice and discipline to walk with confidence on a reasonably
+high altar or platform, than it is for the workman to learn to {616}
+walk a beam on the top of a twenty-story building without a thought of
+the dangers of his position, or at least putting the thought away from
+him so that it does not interfere with his work. At the beginning he
+cannot do it, but he disciplines himself to form a habit that makes it
+easy. Yielding to his feelings makes it difficult to withstand the
+discomforts that come to him. After an accident on a high building, as
+a rule, men have to be sent home for the day to get their nerves
+settled by the night's sleep before they can work with sufficient
+confidence, and yet accomplish their usual amount of work.
+
+
+So-called Misophobia--Dread of Dirt.--Misophobia, or the fear of dirt,
+has grown much more common in recent years, and the spread of the
+knowledge of the wide diffusion of bacteria has added to the
+unreasoning dread that possesses these people. Some of them wash their
+hands forty to fifty times a day, and one young man who was brought to
+me with the worst looking hands, because of irritation from soap and
+water, that I have ever seen, seemed to be always either just plunging
+his hands into water or wiping them dry. These people make themselves
+supremely miserable. They do not care to shake hands with friends and,
+above all, with physicians, and they invent all sorts of excuses so as
+to wait outside of doors till someone else opens them so as to avoid
+touching the knob or door pull, "which" with a poignant expression of
+repugnance they tell you "is handled by so many people." When the
+patients are women, getting on and off cars becomes a nightmare to
+them, because they do not want to touch the handle bars and unless
+they do they find it difficult to ascend and descend. The curious
+excuses they offer for their peculiar actions in avoiding the touch of
+objects around them are interesting.
+
+
+Claustrophobia.--This sort of dread seems quite irrational to most
+people and many would probably conclude that individuals thus affected
+could not possibly be quite in their right minds, or must surely be
+rather weak-minded. On the contrary, many of the people who are
+affected by these curious dreads are above the average in intelligence
+and sometimes also in their power to do intellectual work. A typical
+example, for instance, of claustrophobia, or the fear of closed
+spaces, is found in the life of Philip Gilbert Hamerton. He was a
+distinguished painter and essayist, editor and novelist. Few men of
+his generation were able to do better intellectual work than he. His
+book on "The Intellectual Life" was more read perhaps than any work of
+its kind in the last generation. He was not a profound thinker, but he
+was a very talented practical man. The fact that besides being a
+writer whose books sold he was a painter whose works were in demand,
+shows a breadth of artistic quality that is quite unusual. His was not
+the sort of genius, however, that is so often supposed to be allied to
+insanity, for he was rather a worker who obtained his effects by
+plodding, than a brilliant genius that got his thoughts by intuition.
+
+In a word, in spite of the fact that he was just the sort of man that
+one would not think likely to be affected by a phobia, he had a series
+of attacks of claustrophobia, some of which were intensely annoying to
+him and seriously disturbing to his friends. His wife has described
+some of them in his "Life and Letters." Once after crossing the
+English Channel, he had a severe attack in the railroad carriage on
+the way up to London. He had not been nervous {617} on the voyage and
+had not been seasick. He was returning from a vacation and was in the
+best of health and spirits, yet suddenly the feeling of inordinate
+dread that he was shut in came over him and he could scarcely control
+himself or keep from plunging out of the window in order to get into
+the open. His wife says that "His hands became cold, his eyes took on
+a far-reaching look, his expression became hard and set and his face
+flushed." He seemed "as if ready to overthrow any obstacle in his way;
+and indeed it was the case, for, unable to control himself any longer,
+he got up and told me hoarsely that he was going to jump out of the
+train. I took hold of his hand and said I would follow him, only I
+entreated him to wait a short time, as we were near the station. I
+placed myself quite close to the door of the railway carriage and
+stood between him and it. Happily the railway station was soon
+reached, when he rushed from the train and into the fields." His wife
+followed him like one dazed, and almost heart-broken. After half an
+hour he lessened his pace, turning to her and said, "I think it is
+going." For two hours they continued to walk, at the end of which
+Gilbert said tenderly in his usual voice, "You must be terribly tired,
+poor darling. I think I could bear to rest now. We may try to sit
+down."
+
+
+Dread of Cats.--One of the most interesting of dreads, very frequently
+seen and producing much more discomfort than could possibly be
+imagined by anyone who had not seen striking cases of it, is the dread
+of cats which has been dignified and rendered more suggestively
+significant by the Greek designation ailurophobia. While the great
+majority of individuals suffering from this unreasoning dread of cats
+are women and usually of a delicate nervous organization, it must not
+be thought that it is by any means confined to them or has any
+necessary connection with hysterical symptoms. One of the most
+striking cases of this dread of which I know personally occurs in a
+large, rather masculine-looking woman, who cannot abide being in a
+room with a cat, and who is quite unable to do anything while one of
+these animals is within sight. Yet she is not at all what would be
+called timorous and she has more manly than womanly characteristics in
+every way. She once proceeded to thrash within an inch of his life a
+small burglar who entered her house and she rather prides herself on
+being able to protect herself. Nor is this dread necessarily
+associated with any other disturbances of mind or nervous system. Some
+of the patients I have seen, who confess to suffering from it, were
+thoroughly sensible, brave little women, able to stand suffering well,
+not at all hysterical in nature, and who in the midst of worries found
+time to be thoughtful of others and not to have that selfishness
+which, even more than physical symptoms, is so apt to characterize
+hysterical patients.
+
+I have had men confess to me their dread of cats, and while, as a
+rule, they were of delicate constitution and inclined to be nervous
+and did not have the phobia to an inordinate degree, there was no
+doubt that they were extremely uncomfortable whenever a cat was near
+them. On the other hand, some of them were vigorous, husky men with
+strong aversions. One of the most marked cases of ailurophobia that
+was ever brought to my attention was in an army officer who had
+exhibited bravery in battle on many occasions, and what requires much
+more strength of mind, calm fortitude in difficult campaigning, yet
+for whom a cat had many more terrors than the battery of an enemy or
+even an ambuscade of Filipinos. More cases of this particular {618}
+aversion seem to occur in clergymen than in other men, yet one of the
+worst cases I ever saw was in a priest of great moral courage, who had
+served a pest-house over and over again in smallpox epidemics.
+
+All that can be said about such a dread is that it exists, that it is
+unreasoning, that some patients have been known by discipline of mind
+to overcome the abhorrence to a great degree but never quite entirely.
+In this regard, however, it must not be forgotten that there are many
+things abhorrent to human nature that seem impossible to overcome the
+aversion for, yet discipline does much to relieve them. For instance,
+the handling of dead bodies so familiar to physicians brings with it
+an aversion that we never quite get over and which resumes most of its
+original strength with disuse, but that can be overcome to such an
+extent as to make pathological work produce very little aversion. Even
+Virchow, after all his years of occupation with pathological material,
+confessed toward the end of his life, that whenever he was away from
+his work for a few months his aversion had to be overcome anew.
+
+
+_The Spectator on Dreads_.--There might be a tendency to think that
+these curious dreads came only as the result of the individualistic
+over-occupation with self and the introspective sophistication of the
+modern time, but the dread is not confined to our time nor special to
+it in any way, for we find Shakespeare talking of those who cannot
+bear a harmless, necessary cat. A number of other writers of different
+periods refer to it. As in so many other things _The Spectator_
+reflects his time in this and so we have a letter with regard to the
+dread of cats. It would not have been a subject for discussion in one
+of these popular communications only that the writer felt that a good
+many people would realize how like it was to things that they
+themselves knew of. In number 609 the following letter, supposed to be
+from a correspondent, seems worth giving in full, because it touches
+on other subjects in which uncontrollable, unreasoning feeling plays a
+role:
+
+  I wish you would write a philosophical paper about natural
+  antipathies, with a word or two concerning the strength of
+  imagination. ... A story that relates to myself on this subject may
+  be thought not unentertaining, especially when I assure you that it
+  is literally true. I had long made love to a lady, in the possession
+  of whom I am now the happiest of mankind, whose hand I should have
+  gained with much difficulty without the assistance of a cat. You
+  must know then that my most dangerous rival had so strong an
+  aversion to this species, that he infallibly swooned away at the
+  sight of that harmless creature. My friend, Mrs. Lucy, her maid,
+  having a greater respect for me and my purse than she had for my
+  rival, always took care to pin the tail of a cat under the gown of
+  her mistress, whenever she knew of his coming; which had such an
+  effect that every time he entered the room, he looked more like one
+  of the figures in Mrs. Salmon's wax-work than a desirable lover. In
+  short, he grew sick of her company, which the young lady taking
+  notice of (who no more knew why than he did), she sent me a
+  challenge to meet her in Lincoln's Inn Chapel, which I joyfully
+  accepted; and have, amongst other pleasures, the satisfaction of
+  being praised by her for my stratagem.
+
+
+_Cat Fear and Furs_.--This dread of cats is sometimes exhibited to a
+surprising degree under rather unexpected circumstances. For instance,
+it is not unusual, since the fashion for the longer-haired furs came
+in, to find that some of these patients cannot wear certain supposedly
+elegant furs, since they are really dyed catskin. At times this is not
+suspected until other possible causes for the discomfort have been
+eliminated. Some women cannot even bear to be near catskins in muffs
+and other such furs, though the imitation {619} may be so good as to
+deceive any but an expert, and they apparently had no suspicion at the
+beginning of the presence of cat fur near them. I have been told by a
+physician the story of a man, poignantly sensitive to cats, who
+purchased a fur-lined coat and found it quite impossible to wear it
+because of the sensations it produced in him, though he had no
+suspicion of any connection between cats and the fur when he purchased
+it.
+
+
+_Recognition of Presence_.--Why this dread of cats occurs and, above
+all, the reason for the ability to know that a cat is near when the
+animal is concealed and others are not at all aware of its presence,
+or that its fur should produce a disagreeable sensation, is not easy
+to decide. Its discussion is suggestive for other forms of dreads, for
+there are probably like refinements of sensation, normal and abnormal,
+connected with them. Much has been said about this as a reversion to
+powers possessed by man in a savage state when there was necessity for
+guarding against animal attacks. Unfortunately for any such
+supposition as this, these people, who are most fearful of cats, that
+is, of the ordinary domestic animal, have no uneasiness in the
+presence of the huge cats in the menageries--the lions and the tigers.
+It is with regard to these that such a specialization of scent would
+be particularly valuable for men. There seems no doubt but that it is
+an odor or a sensation allied to an odor, though perhaps below the
+ordinary threshold of recognition as such, that enables these people
+to detect the presence of a cat. Dr. Weir Mitchell in his article on
+"Ailurophobia and The Power to Be Conscious of the Cat as Near While
+Unseen and Unheard," in the _Transactions of the Association of
+American Physicians_, 1905, discusses odor in this connections as
+follows:
+
+  To be influenced by an olfactory impression of which (as odor) the
+  subject rests unconscious, may seem an hypothesis worthy of small
+  respect and beyond power of proof. Nevertheless it seems to me
+  reasonable. There are sounds beyond the hearing of certain persons.
+  If they ever cause effects we do not know. There are rays of which
+  we are not conscious as light or heat, except through the effects to
+  which they give rise. There may be olfactory emanations
+  distinguished by some as odors and by others felt, not as odors, but
+  only in their influential results on nervous systems unusually and
+  abnormally susceptible. No other explanation seems to me available,
+  and this gains value from certain contributory facts.
+
+  We must admit that all animals and human beings emit emanations
+  which are recognizable by many animals and are in wild creatures
+  protectively valuable.
+
+  This delicate recognition is commonly lost in mankind, but some
+  abnormal beings like Laura Bridgeman and a perfectly normal lad I
+  once saw, have possessed the power of distinguishing by smell the
+  handkerchiefs of a family after they had been washed and ironed. In
+  this lad I made a personal test of his power to pick out by their
+  odor from a heap of clean handkerchiefs mine and those of others,
+  the latter two belonging to his father and mother.
+
+  I have seen a woman, well known to me, who can distinguish by mere
+  odor the gloves worn by relatives or friends. This lady, who likes
+  cats as pets, is able to detect by its odor the presence of a cat
+  when I and others cannot.
+
+  Two French observers believe that they have proved the sense of
+  olfaction to be nine times more acute in women than in men.
+
+  So far as the present paper might serve in evidence, I should be
+  inclined to say that the sense of smell was keener in women than in
+  men, but as to this there is extreme diversity of opinion and the
+  whole question awaits further investigation.    [Footnote 48]
+
+    [Footnote 48: This question of the varying acuteness of smell in
+    different people is very interesting to the psychotherapeutist for
+    diagnosis and therapy. We have a number of striking cases of very
+    acute olfactory power. This is what might be expected since
+    animals whose respiratory and smell apparatuses are very like our
+    own show extreme differences. The extent to which human power to
+    recognize odors can go is marvelous. In his "Thinking, Feeling,
+    Doing," Prof. Scripture says: "I have a case--reported by a
+    perfectly competent witness who lived for years with the person
+    mentioned--of a woman in charge of a boarding school who always
+    sorted the boys' linen after the wash by the odor alone."
+    Personally, I have sometimes wondered whether this power, like
+    that of feeling in the blind, could not be developed. The blind
+    are supposed actually to bring about an evolution in their nerves
+    of feeling. No such thing happens, however. An examination of them
+    by means of an esthesiometer shows that their nerves are no better
+    developed than those of other people, though they may be able to
+    recognize much minuter differences between the "feel" of things
+    and may be able to read raised type, which the seeing cannot. This
+    is all due to a training of their attention to note slight
+    differences in sensation, however, and not to improvement in the
+    nervous apparatus. ]
+
+{620}
+
+Dread of the Dark.--The discipline suggested with regard to overcoming
+the dread of heights must be applied to any of these dreads if
+patients are to be made comfortable. They can form the opposite habit
+and by refusing to yield to their fears can do much to lessen them.
+Nearly everyone who is unaccustomed to sleeping in a dark house alone
+has dreads that come over him when he first tries to do it. Every
+noise is exaggerated in significance and the creaking of stairs and
+rattling windows and doors and the wind through the trees are all made
+significant of something quite other than what they are. Nearly
+everyone knows, however, that this can be overcome simply by refusing
+to pay any attention to the idle fears that come over us as a
+consequence of the tension due to loneliness, and after a time,
+sleeping in a strange room and a strange house in the dark is not a
+difficult matter. It is harder for some people to accomplish than
+others, but it is impossible for none. Here is the lesson that all the
+sufferers from dreads must learn. Gradually, quietly, persistently,
+they must resist the dreads that come over them, must deliberately,
+without excitement, do the opposite to that suggested by their
+apprehension, until habits are formed that enable them to accomplish
+without discomfort what was before a source of even serious
+ill-feeling.
+
+The dread of darkness that so many people have is usually supposed to
+be cowardice. It is not, however, in most cases, but is due to
+idiosyncrasy or to certain special physical factors in the
+environment. If children have been brought up so that when they were
+small a light has been constantly shining in their eyes, even though
+only a dim light, it will often be difficult to accustom them to be
+quite comfortable in the dark. Much depends on habit in this matter. I
+have known men, who, when they came from Ireland, feared the darkness
+of the coal mines very much and their dread was increased by the awful
+horror of possible ghostly appearances, since so many accidents had
+taken place where they worked. After some years, however, they were
+quite placid about it and would calmly go into the mine as fire bosses
+at three and four in the morning, long before others were to go in,
+examining absolutely dark passages by the mile, with no human being
+near them and with the creaking of the pillars, the dripping of water,
+the rumbling of the sides and the occasional fall of a small particle
+from the roof, besides the noises of rats to add to the disturbing
+factors. Like going up on a high building, one may get entirely
+accustomed to it so as scarcely to notice it at all.
+
+When the fear is allowed to take hold of one, however, and no effort
+is made to overcome it, it may prove quite seriously disturbing. The
+unaccustomed, however, means more than anything else in this matter.
+Sometimes, {621} indeed, people have a dread of the dark that seems to
+be inborn and that apparently cannot be overcome, that, like the fear
+of cats or of lightning, may be quite beyond rational control. Hobbes,
+the English philosopher, was so perturbed by darkness that he kept a
+light in his bedroom all night. I know this to be the case in a
+clergyman who had been quite undisturbed about darkness until he was
+awakened one night by a burglar. He demanded "who's there?" and
+received as answer without further parley a bullet that fortunately
+struck only the head of the bed, but so close that it singed him. The
+burglar escaped, but the clergyman was never afterwards able to sleep
+without a light. Rousseau, the French philosopher, was also much
+afraid of darkness. Ordinarily it is presumed that superstition has
+something to do with this fear and that the victim of it has ghosts in
+mind or at least dreads spirit manifestations. Neither Hobbes nor
+Rousseau, however, was likely to be timorous about ghostly visitants.
+It was with them a physical idiosyncrasy.
+
+Associated with dread of darkness is the fear of finding some one in a
+dark room whose presence may startle us. Sir Samuel Romilly, famous
+for his labors for the reform of the English criminal law, and who
+must be considered one of the great humanitarians of the nineteenth
+century, had this dread to an acute degree. It went so far that
+whenever he slept in a strange place he carefully examined all the
+possible hiding-places in the room and in wardrobes or closets
+connected with it and, as a last precaution, never failed to look
+under the bed. He did this even when he was in his own house.
+[Footnote 49] This, however, is not so unusual, even among men, as
+might be thought. Most women who sleep alone want to investigate under
+the bed and in a hotel closets and wardrobes and even bureau drawers
+are likely to be examined. Habit in this regard may make one quite
+miserable and over-solicitous. I have had patients whose sleep was
+seriously disturbed by the remembrance that they had not looked under
+the bed and who feared to get up and light a light to do so lest there
+should be someone there. Indeed, the idea of putting their feet on the
+floor before the light had come to reassure them seemed quite out of
+the question.
+
+  [Footnote 49:  Curiously enough. Sir Samuel Romilly, in spite of his
+  dread of the dark, committed suicide and went prematurely into the
+  darkness of the beyond, apparently without his usual tendency to
+  precaution.]
+
+
+Dreads Connected with Water.--Strange as it may seem, water
+constitutes a source of dread for some people. We have the records of
+it in the peculiarities of great men and it is not unusual to meet it
+in common life. Dropping water is a source of disturbance for most
+people. It is quite impossible for the majority of men and women to go
+on writing or reading with any comfort if water is dropping near them.
+Dropping water, when one is trying to go to sleep, is one of the worst
+of awakeners. The Chinese are said to put people to death in horrible
+torture by having a drop of water fall at regular intervals on their
+heads. Robert Boyle, the great father of chemistry and a very sensible
+man in many ways, is said to have been thrown into convulsions by the
+sound of water dropping from a faucet. The splashing of water on some
+people is a poignant source of torture. I have had a woman patient who
+could not go to services where there was a sprinkling of water, for it
+seriously disturbed her and gave her a sense of depression that would
+not be overcome for some time. Peter the Great, though the father of
+the {622} Russian navy, and though he passed many years of his life in
+Holland, used to shudder at the sight of water, and if, when out
+driving, his carriage passed near a stream or over a bridge, he would
+close the windows and be overtaken with terror that brought the
+perspiration out all over him.
+
+
+Dread of Death.--The fear of death is one of the dreads that bothers
+young as well as old, and, curiously enough, as its inevitable
+approach becomes more certain, men are prone to dread it more. Long
+ago Sophocles said:
+
+  None cleave to life so fondly as the old,
+
+-- and this has remained true for all the centuries since. A young man
+is quite ready to throw his life away, but the old man hesitates and
+even in the midst of suffering, if it is not absolutely continuous,
+craves that death shall not come. Sophocles' great rival, the elder
+Greek dramatic poet AEschylus, had said:
+
+  How far from just the hate men bear to death
+  Which comes as safeguard against many ills,
+
+-- but his message was only for those with the character to face the
+worst. One may reason with the dread of death, however, and patients
+can be given motives from philosophy, literature, religion and
+experience that will help to relieve, though it will not entirely cure
+them. Shakespeare said in "Julius Caesar":
+
+  Cowards die many times before their deaths.
+  The valiant never taste of death but once,
+
+-- and people may be aroused to appreciate this.
+
+
+_Fear of Early Death_.--Many fear that if they have shown symptoms of
+delicacy of constitution at some time in life or suffered severely
+from some serious disease, that they are not likely to live long and,
+above all, that they are almost sure not to be able to accomplish
+anything worth while in life. The old proverb is "a healthy mind in a
+healthy body." This is, however, the ideal. There are very few ideals
+realized in life. Just because a man has a weak body is no argument at
+all that his mind may be weak and some of the world's finest work has
+been accomplished by men whose bodies were always delicate.
+Metchnikoff is the apostle of old age to our generation, but it is he,
+also, who has pointed out that many distinguished workers in science,
+in poetry, in art, men who have left a precious heritage in succeeding
+generations, were delicate all their lives. He cites such typical
+examples as Fresnel, the great French physicist; Giacomo Leopardi, the
+distinguished Italian poet; Weber and Schumann, the great German
+musicians, and Chopin, the Polish composer and pianist, all of whom
+did work that the world would not willingly miss, in spite of delicacy
+of health and weakness of body which shortened their lives.
+Intellectual power is not dependent on bodily energy and
+accomplishment is not a question of years of work, but intensity of
+work.
+
+It would not be difficult to add many other names to those mentioned
+by Metchnikoff. Naturally his thoughts recurred to men of distinction
+on {623} the Continent, but in English-speaking countries we have a
+number of typical examples of strong minds doing fine work in weak
+bodies. Robert Louis Stevenson is the best remembered by our
+generation. Elizabeth Barrett Browning, delicate all of her life, a
+neurasthenic during the precious adolescent years that are supposed to
+mean so much for future accomplishment, always an invalid to some
+degree at least, did some of the best work that was given to any woman
+to do during the nineteenth century. J. Addington Symonds, the
+historian of the Renaissance and of Italian literature, is another
+striking example of a man who had to do his work under great physical
+difficulties, yet who left a long bookshelf of large volumes after him
+as the product of the hours that he could cheat from caring for his
+health. Henry Harland, whose recent death all too young was a blow to
+the English-speaking world, is another striking example. The names of
+such men and women and their stories must be made familiar to people
+who are themselves delicate in health and who fear for their future
+and, above all, are despondent about the possibility of ever doing
+anything worth while.
+
+
+Dread of Insanity.--People who have relatives who are already
+sufferers from such severe forms of insanity as require asylum
+treatment are often likely to be much disturbed over the possibility
+that they themselves should become insane. Of course, there is no
+doubt but that these people are much more liable to suffer from
+insanity than others, but their worrying over the matter is sure to do
+them harm rather than good. There are quite enough sources of worry in
+life without the additional one of dread of a future event that may
+not occur, and this must be made as clear to them as possible. The
+people who have no obligations on them, who have nothing to do that
+they feel they have to do, are especially likely to suffer from such
+obsessions. The best possible relief for them is afforded, not by the
+effort not to worry about their dread, which usually has exactly the
+opposite effect and emphasizes their fear by the constant effort which
+they make to put it aside, but by getting something else to interest
+them. This must not be merely a passing interest, if possible, but a
+serious attraction of some kind that fully occupies the mind. A hobby
+is an excellent thing for this, but alas! a hobby must be cultivated
+for many years, as a rule, to become powerful enough to bring relief
+in such serious matters.
+
+Occasionally the thought of the insane asylum or the sight of an
+institution of this kind passed even at a distance in the train is
+enough to give some people a fit of depression that may last for some
+time. The thought of going to visit their ailing relatives is enough
+to make them even more depressed. I have sometimes found that in
+chosen cases, especially among women and those of sympathetic
+disposition, the apparently heroic remedy of making them visit their
+relatives in the asylum was excellent for them. It is the usual rule
+for people who are themselves sane to consider that it is the greatest
+hardship of asylum confinement for the patients to be associated with
+those whom they recognize to be insane. Exactly the opposite effect is
+the usual result. To be among people, many of whom are more irrational
+than themselves and some of whom are quite beside themselves, proves a
+stimulus and an encouragement. Contentment has been defined by a cynic
+as the feeling that things might be worse.
+
+
+{624}
+
+DREADS OF MEN OF GENIUS
+
+
+The insane are particularly prone to suffer from dreads, so that some
+people argue from their dreads to the thought of insanity. It is quite
+a mistake, however, to think of dreads as necessarily connected with
+insanity in any way. They are irrational though they will commonly be
+found to be dependent on some special physical condition. This is
+usually some exaggeration of attention to a sensation natural enough
+in itself but disturbing when dwelt on to such a degree that it
+produces a much greater reaction in these individuals than in other
+people. These dreads have existed in all sorts of people. It is said
+that they are more frequent in the highly intellectual, especially in
+the class known as geniuses, and they are often said to represent the
+definite evidence of a relationship between genius and insanity. I
+have always felt, however, that they are quite as common among
+ordinary people who have no genius and no signs of it as among the
+so-called geniuses. They are not so much spoken of by ordinary people,
+however, because they are rather ashamed of them. Genius, on the
+contrary, is quite willing, as a rule, to exploit its peculiarities
+for the benefit of the public, or what is even more true, its
+peculiarities are remembered and commented on as details of history.
+
+With this in mind the following paragraph from Dr. Dorland's book on
+"The Ages of Mental Virility"   [Footnote 50] deserves to be
+recalled. He has gathered a number of examples that are very
+interesting:
+
+    [Footnote 50: The Century Co., New York, 1908]
+
+  Fear has played an important rôle in the development of the
+  antipathies of the great--fear that was often groundless in its
+  origin and inexplicable in its manifestation. The unaccountable fear
+  of dogs is not so common as ailurophobia, although it is said that
+  De Musset cordially detested them, and Goethe despised them,
+  notwithstanding, forsooth, he kept a tame snake. Much more frequent
+  is the fear of spiders, centipedes, and other insects. Charles
+  Kingsley, thorough naturalist though he was, entertained an
+  unconquerable horror of spiders, even the common house spider;
+  Turenne became weak when he saw a spider; while the author of the
+  "Turkish Spy" once asserted that he would far prefer, with sword in
+  hand, "to face a lion in his desert lair than to have a spider crawl
+  over him in the dark." Lord Lauderdale, on the contrary, while
+  declaring that the mewing of a cat was "sweeter to him than any
+  music," had a most intense dislike for the flute and the bag-pipe;
+  and Dr. Johnson was so fond of his cats that he would personally buy
+  oysters for them, his servants being too proud to do so.
+
+There are curious contradictions to be found in these matters.
+Montaigne confesses that he did his best writing and was in the best
+humor for keeping at his Essays while stroking his favorite cat with
+his left hand, his other being occupied with his writing. This would
+be seriously disturbing to many people, but apparently occupied
+certain distracting sensory tendencies and enabled him to concentrate
+his mental energies. To many people the very thought of doing anything
+like this would put all ideas for writing out of their mind. Other of
+Montaigne's peculiarities are quite as interesting. He always refused
+to sit down with thirteen at table, his liking for odd numbers was so
+great that he made all sorts of excuses in order not to use {625} even
+numbers and his aversion for Friday made the quota of work that he
+could do on that day much less than any other day of the week.
+
+
+OBSESSIONS
+
+There are many curious obsessions that disturb people and that are
+often extremely difficult of explanation even by themselves. Dr.
+Johnson, one of the most sensible men in many ways in his time in
+England, could not, it is said, pass a post on the street without
+touching it. At least if he did so he felt that somehow he had omitted
+to do something that he ought to have done and it would make him
+uncomfortable. There are many people who have some idea that it is
+lucky to touch posts as they pass along and the number of people who
+do things like this is larger than might be imagined. Many people put
+themselves out of the way in order to avoid letting a post come
+between the person with whom they are walking and themselves because
+it is said to be unlucky. Most of them will laugh at it, but still
+they continue the practice in spite of the bother it may occasion
+them. Occasionally there is some incident in their past life which
+accounts for such obsessions, though the patients themselves are
+occasionally not quite conscious of them. Dr. Boris Sidis tells the
+story of a man who could not take a car with an odd number.
+Psycho-analysis showed that he had once seen a child run down by an
+odd-numbered car.
+
+In such cases there has been a long series of suggestions that have
+created a dominant state of mind. The only way to overcome this when
+it becomes a serious annoyance is to undo the influence of the
+suggestions by a continued series of counter-suggestions, and by such
+discipline of mind as will prevent the former suggestion from exerting
+itself. The cure can be accomplished in this way, though, as a rule,
+the patient will need the help of someone else.
+
+
+FORGOTTEN FRIGHTS AND DREADS
+
+Dreads founded on terrifying or seriously disturbing incidents of the
+past, the details of which at times have gone out of the patient's
+mind, are not infrequent. It is probable that many of the unreasoning
+dreads have some such foundation and occasionally, if patients'
+memories are carefully searched, the whole story can be reconstructed.
+All that is needed, as a rule, is to get the patients interested in
+conjunction with the physician in tracing the origin of their
+affliction and not infrequently an interesting story will turn up.
+Hypnosis used to be considered of great value for such
+reconstructions, but unfortunately patients then become so suggestible
+that it is often difficult to decide how much of what is brought out
+by questioning is due to the suggestive quality that cannot well be
+kept out of questions, and how much to a true redintegration of
+memory.
+
+Frights in children may for a time be forgotten and yet the memory of
+them may come back, or a dread connected with them develop, that will
+make the patient profoundly miserable. One of my patients slipped and
+fell on a smooth steel plate at the head of a coal breaker and was
+only saved by good fortune from falling a long distance. This happened
+when he was a {626} boy of ten. There were times when the memory of
+this recurred so vividly as to set him all atremble and he could not
+look down from a height without something of the feeling of goneness
+coming over him that he felt at the time of the accident. The calling
+of his attention to the fact that his memory probably exaggerated the
+danger he had been in as a boy led him to go back and have another
+look at the conditions in which he had fallen some thirty years
+before. He found that they were not so dangerous as he thought and
+that while he would have been scratched and his clothes would probably
+have been soiled and torn, he would not have been seriously injured.
+This has greatly diminished his dread of heights.
+
+Various physical manifestations may be due to dreads which are often
+supposed to be the result of some physical process in the nervous
+system. Occasional fits of trembling, for instance, are, in sensitive
+people, due to more or less forgotten memories of dangers or frights.
+Occasionally even slight convulsive seizures may follow such recurrent
+dreads. Not a few of the cases of so-called hystero-epilepsy in the
+borderland between hysteria and epilepsy but always one or the other,
+are due to such mental states rather than to any physical conditions.
+Such incomplete memories are sometimes spoken of as subconscious. The
+word subconscious has been so much abused, however, that I prefer not
+to use it. The reminiscences have been obscured by an accumulation of
+other facts but may with an effort of attention and concentration of
+mind be recalled. Hypnosis, or the milder form of it spoken of as the
+hypnoidal state, may enable the patient to recall them more vividly by
+enabling him to concentrate his attention, but there are always risks
+that suggestion will vitiate the old story in these cases. With care
+all the details can usually be recalled and the patient is thus given
+renewed confidence in himself and his own powers and does not learn to
+lean on someone else in the process.
+
+
+TREATMENT
+
+The most important psychotherapeutic factor for the relief of the
+discomfort due to dreads is the knowledge that there are so many and
+such different varieties of them and that so many people suffer from
+them. Many of those afflicted are inclined to think that their cases
+are almost unique. To have them know that there are all forms and
+phases of these curious aversions is to make them laugh a little at
+their own because they laugh so readily at others, and it gives them
+new courage for the attempt to conquer them. The aversion cannot be
+entirely overcome, but it can be prevented from seriously influencing
+sleep or appetite or occupation. This is after all the important
+feature of the case from the standpoint of psychotherapy. Besides,
+patients are encouraged not only to take up, but, above all, to
+continue, the practice of that mental discipline and self-control
+which will enable them to lessen their natural aversion, if not to
+remove it entirely. I have many cases in which patients' aversions
+have been entirely overcome. Curiously enough, there are rather often
+relapses when the patients are run down in weight, or are in an
+irritable condition from worry or emotional stress, and then something
+of the former mental discipline has to be reinstituted to make them
+once more free from disturbance.
+
+{627}
+
+I have sometimes found that the recommendation to patients suffering
+from dreads to read Mary Wollstonecraft Shelley's "Frankenstein" has
+proved an excellent therapeutic agent. This is particularly true when
+the patients are women, for it is likely to bring them close to the
+sad lives of the Shelleys. The circumstances in which the book was
+written add to the appeal. "Frankenstein" itself is interesting, so
+that the mood created by this combination of interests is excellently
+therapeutic. It will be recalled that in "Frankenstein" the inventor
+seeking to make a man does make an automaton that is able to move and
+to talk, but that then haunts its inventor, demanding of him a soul.
+It proves a plague to him, but he cannot escape from it. Fly where he
+will his creation follows him and bothers the life out of him, killing
+a friend, strangling his bride, and making existence intolerable. The
+symbol is complete and to the point. The things that bother us in life
+are to a great extent of our own invention. The dreads that make so
+many people miserable are practically always without any groundwork in
+reality, figments of our imagination without the soul of real life,
+but capable, as was Frankenstein's monster, of making their creators
+intensely miserable and with them, to an even greater degree, their
+friends.
+
+
+
+CHAPTER IV
+
+HEREDITY
+
+
+There are so many false and, indeed, from a scientific standpoint,
+utterly groundless notions with regard to heredity which, as a result
+of the popularization of science, have become widely diffused, that
+notions about inheritance are a most copious source of dreads and
+discouragement and even produce inhibition of resistive vitality
+against disease on the part of many patients. At first it seemed to me
+as though the subject should be treated in the chapter on Dreads. It
+is so much more important than the other dreads, however, and there
+are so many people with so many different notions as to the evil
+influence of heredity that it seems advisable to devote a special
+chapter to it in which to provide contrary suggestion. Many patients
+are constantly suggesting to themselves that, because they are
+suffering from certain symptoms due to real or supposed hereditary
+conditions, there is little or no hope of their recovery or of any
+effective relief. In the old days, when tuberculosis was considered to
+be hereditary, it was almost hopeless to try to rouse patients into a
+state of vital resistance to their disease because of this overhanging
+dread. Such a prepossession of mind must be overcome.
+
+In spite of all that has been said about the power for evil of
+heredity, and in this as in every other phase of pseudo-science, the
+reason why there are false popular notions is because the medical
+profession first cherished them and then they spread popularly, we now
+know that it means comparatively little in pathology. The false
+notions will continue, however, to be popularly diffused probably for
+another generation, at least, and will have to be combated. Their
+force must be lessened, for they are a heavy incubus on the patient's
+mind, imposing a burden on vitality that inhibits normal, vital
+reaction. This can only be done by a frank and complete statement of
+{628} our present knowledge of heredity, which is even yet not nearly
+so definite as we would like to have it, but which contradicts
+entirely most of the older impressions. In the matter of disease what
+we know of heredity, instead of being a source of distress and
+discouragement for patients, provides rather new incentives for
+vigorous reaction, since nature helps rather than hampers the effort
+of the individual to throw off disease from generation to generation.
+
+
+False Impressions and Expression.--Probably the commonest expressions
+that the physician hears from his patients, though we hear many
+stereotyped phrases in our time when patients so freely discuss their
+ills and their physicians' opinions among themselves, are such as: "My
+father suffered from rheumatism, and I suppose I must expect to be
+bothered by the same ailment." "My mother died of heart disease and I
+think I have a weak heart; I suppose that we have weak hearts in the
+family." "I have had three relatives die of cancer in the last three
+generations, so I presume that cancer is in the family, or at least we
+are much more liable to cancer than the generality of people." And,
+finally, what used to be the commonest of all, but fortunately we have
+changed that at least, though we sometimes hear it still:
+"Tuberculosis runs in our family, my mother and an uncle died of it
+and one of my brothers is suffering from it, so I suppose I must just
+make up my mind that I, too, am sure to get it." Even the rarer
+affections, like kidney disease, liver disease, various nervous
+troubles, stomach and intestinal disturbances of many kinds,
+flatulence, constipation or diarrhea, are all supposed to be
+hereditary and patients explain their ill feelings by an appeal to the
+supposed principle of heredity and its application to themselves and
+their families.
+
+In many chapters in this book the subject of heredity has been
+considered with regard to specific affections. We have no evidence at
+all, or the evidence is so trivial as to be quite negligible, that
+anything acquired by the individual, be it for good or evil, is ever
+transmitted to the next generation. That acquired characters are not
+transmitted is now almost a universally accepted principle among
+biologists. The more a biologist knows of recent biological research
+and investigation the more will he be likely to consider this
+principle of the non-transmission of acquirements as definitely
+settled. According to this, then, no disease is ever transmitted to
+the next generation. This is such a complete reversal of former
+opinions, such an open contradiction of popular beliefs, that the
+subject merits thorough discussion from this newer standpoint for
+medical applications. We must not forget that popular medicine, even
+when egregiously wrong, is founded on opinions held by the medical
+profession aforetime and, indeed, on this subject of heredity many of
+the medical profession still cling to the former opinion.
+
+Tuberculosis, which used to furnish the most serious argument in this
+matter, has now come to be the best possible explanation that we have
+for the fallacy of the transmission of anything acquired. The disease
+followed families so constantly that it seemed impossible to explain
+it unless the principle of its heredity was conceded. Now that we know
+its contagiousness, however, it is comparatively easy to explain its
+occurrence in families. When we recall how carelessly people coughed
+and even expectorated around the house, while children crept on the
+floors and carried the germs of the disease to their mouths on their
+hands, the wonder is, not that so many members of the family acquired
+the disease seeing the manifold opportunities for contagion, but that
+{629} any of them ever escaped. We know now that practically every
+adult above the age of thirty either has or has had tuberculosis.
+Careful autopsies show us remains of the disease even in the bodies of
+those who, without any history of tuberculosis, die from other
+diseases. One out of eight of the population dies of tuberculosis, but
+the remaining seven are quite capable of resisting the disease and so
+we find healed lesions at autopsies in this proportion of cases.
+
+
+Family History Favorable.--It is certain, then, that tuberculosis is
+not hereditary. On the contrary, as we have learned more about the
+disease in recent years, it has been recognized by specialists that
+patients who have a family history of tuberculosis are notably less
+likely to succumb to the disease early than those who have no such
+history. An acute case of tuberculosis with considerable loss of
+weight has a very unfavorable prognosis unless there is a history of
+the disease in the preceding generation, when at once the outlook
+becomes more hopeful. This newer view is confirmed by what we have
+learned from the ethnological pathology of the disease. Peoples
+exposed to the disease for the first time rapidly succumb to it. This
+is practically true for all the infectious diseases. Our American
+Indians succumbed in large numbers not only to tuberculosis but also
+to smallpox and even to measles when each was first introduced among
+them. The same thing was true in the South Sea Islands. Where nations
+have been exposed to the disease for some time they have acquired not
+an immunity, but at least they possess a greater resistive vitality to
+its ravages and while they still may be susceptible they are not so
+subject to the fatal forms of the disease, and even if they acquire it
+they live on for many years.
+
+Many people may insist that this immunity or comparative immunity to
+tuberculosis and increased resistive vitality against the disease is
+transmitted and illustrates the principle of heredity. The reaction of
+the system to the disease increases in each generation and this
+increase is an acquired character which passes down with the family
+strain. This immunity should be viewed from another standpoint,
+however. Certain families possess a resistive vitality to the disease;
+others lack it. The resistant families do not succumb to it, and
+propagate themselves. The others gradually die out. What caused the
+resistant families originally to possess this quality we do not know.
+We have no trace of its being acquired. Like so many other characters
+by which men differ from one another, we do not know the beginning of
+it. Once it comes in as a family trait it is transmitted. In
+successive generations we have no evidence that it is stronger, only
+the danger is recognized from experience and better precautions are
+taken; the consequence is that the original resistive vitality has a
+better chance to make itself felt and so the family is preserved. This
+is as true with regard to the conquest of the tendency to excess in
+the taking of toxic substances, as alcohol and opium, as with regard
+to disease. It is not the transmission of an acquired character, but
+the descent of a family trait the origin of which we do not know.
+
+
+Hereditary Syphilis.--Many physicians will protest that, at least, we
+have ample evidence for the transmission of syphilis by heredity. We
+have for many years talked of hereditary syphilis as if it were
+absolutely sure that its transmission by inheritance took place. There
+is no doubt, of course, that the disease is conveyed from mother to
+child. If a mother is actively syphilitic, {630} then her child will
+surely have syphilis when it is born. This, however, is no argument
+for the hereditary transmission of syphilis. We know now that if a
+mother is tuberculous, in an active stage of that disease, her child
+will almost surely have the disease, but this is a question of
+contagion not of inheritance. If a mother with active tuberculosis
+nurses her child she is likely to give it tuberculosis. Usually the
+idea is that the milk is not infective unless there are tuberculous
+lesions in the breasts, and in cattle it is well known that such
+lesions in the milk apparatus inevitably bring tubercle bacilli into
+the milk. The demonstration of tubercle bacilli in the blood of
+patients in the active stage of the disease is now much more frequent
+than used to be the case and there seems no doubt that the bacillus
+can pass through glandular structures into the secretions.
+
+In the same way syphilitic nurses are likely to infect nurslings,
+though, of course, in this case there are usually syphilitic sores on
+the nipples which directly communicate the disease. It is almost
+impossible for a syphilitic woman to nurse a child, if she is in an
+active stage of the disease, without the production of such infective
+sores on her nipples. When children are born with syphilis it means
+only that in the process of feeding the child through the placental
+tissues, a mother has infected her child quite as she might infect it
+by nursing afterwards, in case she acquired syphilis after the birth.
+Lesions corresponding to those on the nipple occur in placental
+tissues and can be demonstrated without much difficulty. Congenital
+syphilis, however, can always be traced to contagion and the being
+born with the disease or having the manifestations of it occur shortly
+after birth is no argument for heredity at all. It merely emphasizes
+the danger of contagion.
+
+
+_Mothers of Syphilitic Children_.--But there are some cases in which
+the child who shows symptoms of syphilis after birth is born from a
+mother who never had any manifestations of syphilis and therefore it
+has been supposed that the infection must have come from the sperm,
+and that in these cases, at least, there is a true heredity. It is
+perfectly possible, however, that syphilitic infective material may
+accompany the spermatozoon and so bring about the occurrence of
+syphilis in the offspring. Even this would be infection, however, and
+not heredity. Much more frequently it would seem that the disease in
+the infant was contracted from the mother while suffering from a
+latent form of syphilis, rather than from the paternal contributory
+particle to its existence. The mother gives no sign of the disease,
+but Colles' Law is that the mother of a syphilitic child may, without
+danger to herself, be allowed to nurse her own infant even though she
+herself has never had any symptoms. This can only mean that she is
+thoroughly protected against the disease. We would not think for a
+moment of allowing an ordinarily healthy women to nurse a syphilitic
+child. Such immunity in the mother of the syphilitic child can only
+come, so far as the present state of our knowledge goes, from her
+having had the disease. It has been said that as the result of the
+intimate communication with her child in utero she has acquired an
+immunity by the passage across the placental membrane which separates
+maternal and fetal blood of protective substances of various kinds due
+to the reaction against the disease already beginning in the child. As
+a matter of fact, however, there is no evidence of any such reactive
+substances in the blood of the child which after birth proceeds to
+have a series of acute lesions that are, as a rule, indicative {631}
+of almost complete lack of resistive vitality. Maternal immunity is
+evidently due to the occurrence of the disease in some form within the
+maternal tissues which produces the usual protection against the
+disease in a briefer time than usual. This certainly seems to be a
+more satisfactory explanation than that of a transmission of an
+immunity from the child to the mother which the child itself does not
+possess. It is easier to understand the transmission of an infection
+that does not manifest itself externally than of an immunity which
+there has been no time to acquire. Both explanations leave a mystery,
+but the mystery in the second case can be explained more in consonance
+with what we know about syphilitic transmission and immunity than in
+the other case. It does away with the transmission directly from the
+father almost completely, of course, leaves practically no ground for
+the heredity of syphilis, but it accords much better than older
+explanations with biological principles.
+
+
+_Late Lesions and Heredity_.--Many physicians will be likely to insist
+that the late developments of syphilis in children, in which not only
+three or five years afterwards, but even fifteen or twenty years after
+birth, there are syphilitic manifestations, are beyond all doubt
+examples of heredity. In the last twenty-five years, however, our
+ideas with regard to the after-effects of syphilis have been entirely
+modified by what we have learned of such diseases as locomotor ataxia,
+paresis and the like. These are undoubtedly parasyphilitic diseases in
+most cases, yet they not infrequently develop from ten to twenty years
+after any manifestation of syphilis and they seem to occur, by
+preference almost, in cases where the preliminary symptoms have been
+very mild. In not a few cases, indeed, the symptoms of syphilis have
+been so transient in these patients that the true significance of them
+was missed until the later developments showed their real character.
+Krafft-Ebing, at the International Medical Congress at Moscow in 1897,
+detailed some experiments that he had made on paretics in Vienna. They
+were patients in whom no history of syphilis could be found, yet they
+were suffering from typical paresis. As they were in the ultimate
+stage of the disease it did not seem unjustifiable to inoculate them
+with syphilis, and in most cases it was found that they would not take
+the disease, showing that they were probably protected by a previous
+attack, though there was no history of it.
+
+The development of the late symptoms of syphilis in the second
+generation can then be much more satisfactorily explained on the basis
+of a mild infection with very few primary symptoms, almost lacking in
+secondary symptoms, yet followed by subsequent symptoms of great
+severity consequent upon the deterioration of vitality produced by the
+disease. As for the manifestations in the third generation, they are
+not directly syphilitic, but are, whenever they occur, due to
+conditions consequent upon the degeneration that had been effected in
+the preceding generation and which directly weakened the offspring--on
+the same principle that weak parents give birth to weak children, and
+starving parents cannot have strong, healthy children--but not because
+of any direct influence of the disease. It is worth while to discuss
+this subject from this standpoint, since it disposes of the only
+supposed evidence left for the hereditary transmission of disease that
+we now have, though only a few years ago most diseases were supposed
+to be hereditary.
+
+
+Heredity in Cancer.--With regard to other diseases, the evidence for
+any inheritance has been founded entirely on coincidence. All the
+human race {632} dies and must die some way, and so in families a
+certain number will die of the same disease. The argument for heredity
+in cancer is extremely weak. When all the relatives of a person
+afflicted with cancer as far out as the third generation are taken
+into account, only about one in five of them are found to have
+suffered from cancer. When we remember, however, that more than one in
+thirty of all those who die, die of cancer and that the death-rate of
+this disease is greater than that of typhoid fever, smallpox, scarlet
+fever, measles, and all other infectious diseases put together, it is
+easy to understand how large a role coincidence plays in any such set
+of statistics, and how little the significance of the occurrence of
+cancer in different members of the same family means, unless possibly
+there is an occasional element of contagiousness which must not be
+left out of the reckoning.
+
+
+Heredity in Other Affections.--Other ailments present much less
+possibility or probability of any element of heredity. For instance,
+over-indulgence in meat or drink may readily bring about various
+ailments of the gastro-intestinal tract. These are, of course,
+definitely acquired conditions, some of them temporary and some
+persistent, that will continue to give trouble so long as the patient
+continues to produce irritation of them. They may, of course, lead to
+permanent pathological conditions. To say that any of these are likely
+to be inherited would be quite as absurd as to say that a corn could
+be inherited, or the permanent deformities produced in toes by wearing
+badly-fitting shoes could be transmitted to the next generation. We do
+not think for a moment that because a man has lost a finger his
+children are likely to be born without a finger, and still less if by
+some accident or abuse he has been deprived of the use of an arm or
+leg, that that is likely to be transmitted to the next generation. Yet
+people calmly talk of the heredity of similarly produced conditions
+within the body, and even physicians are not entirely free from the
+superstition, for such it is, of the influence of heredity in
+producing pathological conditions.
+
+Habits of various kinds, physical and mental, are calmly accepted by
+many people as influenced by or having their origin in heredity. Under
+Alcoholism and Drug Addictions we have discussed this phase of the
+subject, but a word or two more may make it clearer. A tendency to
+form the same habits may be a family trait and descend from one
+generation to another. That a specific habit should be the subject of
+heredity or transmission is as much out of the question as that a
+facility for doing anything should be transmitted. The son of an
+acrobat must practice quite as faithfully as did his father in order
+to secure his father's skill. He may inherit from his father that
+particular constitution of body, that specific combination of muscle
+and sinew and bone that enables him to become an acrobat by practice,
+though with a different kind of body it would be impossible, but his
+father's acquired facility influences in no way the son's ability. We
+often hear of a man being the descendant of a series of generations
+each of whom has gone to the university, as if that somehow assured
+him a readier and better facility for education, but we know very well
+that this is not true and that the boys straight from the soil are
+often the best students and far ahead of the scions of long-time
+academic families.
+
+
+Inheritance of Defects.--Acquired characters are not transmitted,
+though family traits are the subject of inheritance. Disease is not
+hereditary, but {633} defect is. Crossed eyes occur very commonly in
+families and are evidently a subject of transmission. Family noses are
+often very peculiar and may be traced for many generations. The
+Hapsburg lip has been noted in sixty per cent. of the Hapsburgs since
+the family came into prominence in the thirteenth century. Features of
+all kinds are inherited, as anyone who has ever spent some time in a
+family portrait gallery where the ancestors were genuine and the
+paintings reasonably true to life, knows very well. Certain features
+of European families can be traced for many generations. The tendency
+to have six toes or to have an extra finger runs in certain families.
+So small a thing as a patch of white hair in a particular part of the
+head may be the subject of hereditary transmission. Moles on a
+particular part of the body are inherited. All these, however, are
+characters with regard to the acquisition of which we know nothing,
+but that have somehow found their way into the family strain and have
+become subjects of transmission from generation to generation. They
+provide no evidence, however, as to the transmission of acquired
+characters.
+
+
+Variation.--What is even more surprising in biology, however, is that
+there is another marvelous force at work quite as incomprehensible in
+its way, perhaps even more so, than that of heredity. This is
+variation. All creatures have a tendency to vary from their parents. A
+very small proportion of the offspring resemble parents so closely as
+to be quite similar. The great majority of them, however, have
+noteworthy, individual, distinctive qualities. Occasionally these
+qualities may be traced to the less immediate ancestors and then we
+talk about reversion. Occasionally there appears in a child some trait
+or anomaly supposed to be remotely ancestral and it is spoken of as
+atavism. Whenever there is a tendency of the offspring of exceptional
+parents to regress toward the racial average, we talk of regression.
+Tall parents often have tall children, some of them may, by a special
+tendency of heredity, be taller even than themselves. Most of them
+will be shorter, however, and tend to regress toward the racial
+average.
+
+Few people understand what a wonderful power among living things is
+exerted by this very opposite of heredity--variation. All the
+possibility of improvement not only in humanity but among all living
+things is dependent on variation. It does not seem difficult to
+understand how offspring resemble parents. They are of them, therefore
+they are like them. When we analyze the problem of heredity, however,
+and find that the connecting link between offspring and parents is
+always only a single cell of less than one one-hundredth of an inch in
+diameter, the mystery of heredity looms up in all its immensity. This
+minute bit of protoplasm, so small that it requires a rather strong
+power of the microscope to see it, somehow contains compressed within
+itself all the qualities that characterize the parent and are to be
+transmitted to the offspring. Among animals, the color of the eyes and
+hairy covering, the form and height of the animal, its generic
+characteristics, and its individual characters--all are contained
+within this minute spherule. The white blaze on the horse's hind leg,
+the black blotch on the puppy's face, the white lock on a human head,
+are all carried over from one generation to another with all the other
+qualities in this small package. That is the mystery of heredity.
+
+To this must be added another mystery quite as great and even more
+{634} difficult to understand--variation. This tendency to vary is the
+basis for whatever evolution there is in the world. Some living things
+vary in such a way as to be better suited to their environment than
+they were before and then these outlive others because more favorably
+situated, and natural selection brings about a maintenance of the
+favorable variation. Instead, then, of patients being impressed with
+the unfavorable influence of heredity, they should rather be made to
+feel the weight of the idea that whatever evil tendencies the parent
+has the child is more likely to have less of them than more, so that
+variation tends to make the race better. We have had too much stress
+laid on the heredity of unfortunate qualities and entirely too little
+made of the variation tendency, which is constantly lifting the race
+up. It is, of course, only what happens in everything else,
+unfavorable are likely to have more weight than favorable suggestions,
+and unless these latter are emphasized their influence becomes
+swamped. This has happened with regard to variation. It is quite as
+important a biological element as heredity and it makes for the
+removal of unfortunate qualities, yet it has never become a popular
+idea and is little appreciated even by physicians.
+
+Patients who are worried about their heredity will, after a frank
+discussion of our present knowledge of heredity and its co-ordinate
+factor of variation, lose most of their dread of this specter of
+supposed evil influence which so often proves the source of
+discouragement and failure to react properly against pathological
+conditions. There is probably no phase of modern biology in which the
+so-called popularization of science has done more harm by providing an
+abundant source ol unfortunate suggestions. Whatever influence
+heredity has in relation to disease is favorable to the human race. It
+is true that this is exerted by the elimination of the unfit, yet the
+very consequence of this is that the children of parents who have
+suffered from a particular disease are likely to have greater average
+resistance to it than the generality of mankind, since their parents
+passed the age up to reproductive activity without succumbing to it.
+For cancer, tuberculosis and syphilis this teaching is of special
+value and is probably more effective than any other single means could
+be to prevent the ravages of the disease if it should occur, since it
+keeps the patient from interfering with his own resistive vitality by
+the discouraging conviction that there is no possible hope for him
+because his parents also suffered from the disease.
+
+
+
+CHAPTER V
+
+PREMONITIONS
+
+
+A state of mind that disturbs many people seriously, sometimes even
+producing physical results, because of the burden of dread that hangs
+over them, is that in which attention is paid to premonitions of evil.
+There are two of these general conditions to be considered. In the one
+there is a definite feeling that some special evil, occasionally very
+particularly outlined in the mind, as a railroad accident, fire, or a
+street accident of some kind, is to occur. In another mental condition
+there is a generic premonition of evil, {635} as if the worst were
+sure to happen and the patients must be constantly preparing for it.
+Occasionally this takes on some such form as an assurance of early
+breakdown in health, or of death at an untimely age, or of some
+crippling infirmity. This represents, of course, only one form of lack
+of control over the mind, but it is surprising how much physical
+suffering it may occasion. Only those who have had much to do with
+patients who suffer from this state of mind realize it. Sympathetic
+knowledge of the conditions that bring it about and of the real
+significance of premonitions will do more to help patients than
+anything else.
+
+Every now and then newspapers tell the story of someone who had an
+impending sense of danger, perhaps of a particular form of accident or
+misfortune, which he could not shake off and which finally came true.
+Sometimes it is a fire that was anticipated, though without any reason
+except the dread, and precautions that eventually proved life-saving
+to the patient were taken, or at least friends were told of it so that
+the person seemed actually to have had some warning beforehand of the
+danger that was to come. Sometimes it is the story of a railroad
+accident, which some particularly fortunate individual escaped,
+because of a premonition that made him take another train or make a
+happy change of cars. Nothing is said of the times when premonitions
+failed, nor of the disappointments of such dreads. Most people laugh
+at the stories, but a few individuals become seriously impressed with
+the possibility of such warnings and then make themselves miserable by
+having frequent premonitions.
+
+
+Etiology.--As to the origin of these premonitions it is hard to say.
+They occur more frequently on dark days than in bright weather and are
+complained of much more in spring and fall than during the cold brisk
+winter or during the summer time. A succession of very hot days,
+however, brings a series of premonitions, especially with regard to
+accidents by heat, that is not surprising since the newspapers have
+many accounts of sunstrokes and there is every suggestion of the
+possibility of danger of this kind. How large a role suggestion plays
+in the matter can be realized from the fact that after some
+particularly serious railroad accident many people have premonitions
+that they may be hurt and occasionally they put themselves to
+considerable inconvenience in choosing the car in which they will sit,
+if the last serious preceding accident of which they have heard
+happens to have brought death mainly in a particular car of a train.
+It is always suggestible people who are likely to have premonitions.
+The thought comes very simply at first, they dwell on it a little
+unwillingly, then they find it impossible to banish it and finally it
+may become a positive obsession. The soil and the seed for suggestion
+are both needed to produce premonitions.
+
+Royce suggests that many of the supposedly fulfilled premonitions are
+really only pseudo-presentiments and represent an instantaneous and
+irresistible hallucination of memory, which may give rise to the
+impression that there has been a previous dream or other warning
+presaging the facts, though no such phenomenon actually took place. In
+other words, there would be an auto-suggestion consequent upon the
+hearing of other fulfilled presentiments that sometime some such thing
+must also occur to us, and then when a happening that reminds us of
+something in the previous stories of {636} presentiments comes there
+is the sudden responsive feeling "why, this is what I saw or must have
+seen in my dream."
+
+Podmore suggests an illusion of memory magnifying or rearranging the
+details of a recent dream or premonitory impression, so as to make it
+fit into the happenings. Dreams are so vague that unless they have
+been written down we are not quite sure of them an hour after they
+occurred and a day or two later we have only the merest hint of what
+they were. If this can be made to have any connection with a casualty
+of any kind that happens subsequently we may very readily recreate the
+dream with its details concordant to the event. Certainly no reliance
+can be placed on a story of a dream fulfilled unless the dream was
+told before the happening.
+
+
+Premonitions of Death.--Certain premonitions are common and are
+frequently brought to the physician's notice. Among old people it is
+not unusual to find that a premonition of death will hang over them
+for days, seriously disturbing them and their friends, hampering often
+a healthy reaction against disease and always lowering resistive
+vitality. Many of them have heard stories which make them credit the
+belief that such premonitions are likely to come true and therefore
+they cannot shake them off. They have heard stories of people who have
+become convinced that they were going to die at a particular time on a
+particular day and whose conviction has been proven by the event. Like
+all the other premonitions, whatever truth there may appear to be in
+them, is due entirely to the fact that nearly everybody has
+premonitions and occasionally, therefore, one of them must come true.
+Those that are fulfilled create such an impression that they are
+remembered, while those that fail are forgotten, until, though it is
+not realized, it becomes true that fulfilled premonitions represent
+exactly that much misunderstood principle that the exception proves
+the rule. The rule is that premonitions fail. Exceptionally, however,
+a premonition comes true. Instead of proving that premonitions mean
+anything, the rarity of their fulfillment proves the rule of their
+non-significance and demonstrates that they are merely coincidences.
+
+
+Persuasion of Short Life.--Much mental suffering occurs in nervous
+people as a consequence of a premonition or persuasion which comes to
+them in middle life that they are destined not to live very long. This
+is a commoner impression than is usually thought and comes to nearly
+everyone at some time in life. Especially is it likely to come to
+those who have suffered some severe illness and who know how weak they
+were during their convalescence and, in spite of their thorough
+recovery of strength, cannot quite persuade themselves but that an
+ailment which made them so weak must surely have sapped their vitality
+so as to make long life for them impossible. It is, of course, one of
+the vague dreads that men always seem to be harboring, but there are
+times that it becomes so prominent and so influential in the
+production of depressive feelings that it is worth while to have the
+means at hand to counteract it as far as possible. In the last ten
+years I have made it a practice to ask, not only all my patients but
+most of my acquaintances above 70 years of age whether they had ever
+experienced such a premonition. I have particularly asked what were
+their feelings with regard to the hope of long life for them when they
+were in their forties and fifties. Without exception I have been told
+by all those who had the education and leisure to {637} be at all
+introspective, that they had felt sure that they would not have long
+life.
+
+Most of the men consulted took out life insurance in such a way as to
+benefit their families after their death rather than themselves during
+life. Indeed it seems not an unusual thing for men to have some
+experience with an ailment between 40 and 55 which makes them realize
+their mortality much more than the deaths of their friends around them
+had succeeded in doing. Premonitions and impressions, then, of this
+kind evidently mean nothing, so far as the prospect of long life is
+concerned. Practically everyone has them, and since, of course, the
+great majority of men do not live to die of old age, it would seem
+that their premonition of comparatively short life was fulfilled.
+Occasionally a man will be found at the age of fifty unwilling to take
+up further work or develop his business because of the dread that has
+come over him that he may not live long enough to make it worth the
+while. Where there is serious kidney or heart trouble such an
+abstention from business is commendable, but in many cases it leaves a
+man without occupation or with insufficient occupation and he becomes
+short-circuited on himself with more serious results from worry than
+would have come from work.
+
+
+Publication of Fulfilled Premonitions.--The publication of fulfilled
+premonitions has always seemed to me to be an especially fertile
+source of premonitions for other people. Every now and then someone
+goes to bed in a hotel having communicated to friends the idea that he
+fears there may be fire before morning. I do not suppose that one out
+of ten people who sleep in a strange hotel fail to have some such
+thought, they do not consider it a premonition, however, but only a
+suggestion for the taking of proper precautions so as to know where
+exits and fire escapes and other means of escape are situated, so that
+in the excitement of the fire they may not have to do any thinking,
+but may have already made up their minds what they shall do. This sort
+of premonition, if we call it by that name, has a definite useful
+purpose. Occasionally it seems marvelously provident. The other makes
+its possessor toss sleepless a portion of the night, does no good and
+much harm. If, however, the premonition has been communicated to
+someone else and then a fire should occur, the reporting of the
+fulfilled premonition comes to a lot of weak-minded people as a
+confirmation of their worst fears. It is, of course, only a question
+of coincidence in a succession of events by no means connected in any
+causal relation, yet by the unthinking set down as showing the
+possibility of such premonitions being supremely significant. If we
+had all the stories of unfulfilled premonitions also published then
+the true significance of the others would be clear.
+
+
+An Unfulfilled Premonition.--There is an excellent story of a strong
+but unfulfilled premonition told by Carl Schurz in his
+"Recollections," which seems to me such a good antidote to the
+influence of supposed premonitions, that every physician should know
+its details for their psychotherapeutic value with patients prone to
+be troubled in this way. The ease with which the depression consequent
+upon the premonition was relieved as soon as another forcible
+suggestion that the danger was past took possession of him, shows how
+such states of mind can be altered with no more real reason for the
+alteration than there was for the original depression.
+
+{638}
+
+On the morning of the battle of Chancellorsville General Schurz awoke
+with the absolute persuasion that at last his time had come and he was
+to be killed that day. He had never had such a premonition before. He
+had heard of many cases in which such premonitions proved the
+forerunner of death. He realized how ridiculous was the idea that he
+should know anything about what the future held for him, even vaguely,
+and he tried to shake it off. He found it impossible to do so. He
+thought that after he took up the routine work of the day the force of
+the premonition would be lost. It was not, but, on the contrary,
+seemed to increase in power over him. Finally the idea became so
+imperative that he sat down and wrote letters of farewell to his wife
+and friends, telling them that he had been tempted to do so because of
+this premonition of danger. When he went into battle--and it may be
+recalled that the Eleventh Corps did some fighting at Chancellorsville
+that day--he was sure that now the end was not far off. It did not
+take away his courage, however, and though he was well in the zone of
+danger, he issued his orders and kept his troops well in hand as we
+know from the history of the battle.
+
+Finally his aide-de-camp, riding toward the front of the line beside
+him, was killed by a cannon ball. All in an instant the thought came
+over him that this was the only danger that was likely to be near him
+for the day. The burden of premonition lifted from him as if the fact
+that a friend had been killed beside him gave him an assurance that he
+himself was not to be taken. There was absolutely no reason for his
+thinking so, but his feelings of solicitude with regard to himself and
+his fate faded completely and at once. He continued in the thick of
+the fight and of danger and was untouched. He himself called attention
+to the fact that if his premonition had come true, as well it might in
+the midst of the very serious danger which he faced, it would have
+seemed a strong confirmation of the impression that premonitions have
+a meaning other than that of coincidence. It was, however, a
+magnificent example of a failed premonition quite as striking as any
+of the stories that are told about premonitions that came true.
+
+
+Rôle of Coincidence.--This must be remembered in many of our arguments
+in medical and other scientific matters. Most diseases are
+self-limited, therefore anything that is given as a remedy for them
+just about the time that nature has succeeded in conquering the
+virulence of the disease and bringing about the cure of the patient,
+seems to be curative. Such cures, often remedies of supposed wonderful
+potency, come and go in medicine by the hundred every ten years. Such
+curious doctrines as that of the influence of maternal impressions in
+producing deformities and defects in the unborn child are founded on
+nothing better than these coincidences. They are often very startling,
+but the rule by which they must be judged is the number of times in
+which in spite of similar conditions no premonition takes place.
+Literally thousands of people go to bed every night who are to be
+waked by the danger of fire before morning and yet have no premonition
+of it. Literally millions of people have gone to bed in recent years
+without any premonition of earthquake, yet have been wakened before
+morning with their houses tumbling around them. If a few people have
+premonitions in these cases it is easy to understand that it is
+coincidence and not anything else, for these are exceptions, and this
+again is a case of the exception proving the rule.
+
+{639}
+
+
+Premonitions and Superstitions--Thirteen.--Occasionally premonitions
+are connected with certain events that are themselves, even though
+happening quite accidentally, supposed to be portentous. How many
+people, for instance, feel quite uncomfortable if they sit down
+thirteen at a table. The very fact of the gathering of thirteen is
+supposed to be a spontaneous or automatic premonition that is a
+forewarning of evil that has to come to some of them. Unfortunately,
+this superstition continues to have a vogue and an influence over
+people's minds because stories are told that are supposed to confirm
+it. Needless to say, when these stories are true, they are merely
+coincidences. Out of any baker's dozen of people who sit down to
+dinner it is not surprising if one should die or be killed during the
+year. Some of the stories, however, are merely sensational inventions
+worked up to be given to the public because a number of people are
+interested in this sort of thing. Probably one of the stories that has
+gone the rounds most and that has served to confirm many people in
+their uneasiness over the number 13 is that which is told as happening
+to Matthew Arnold and some friends, supposedly the year the great
+English litterateur died.
+
+The story runs that just as Mr. Arnold and his friends were about to
+sit down to the table it was discovered that there were thirteen
+present. According to the old tradition in the matter it is the one
+who first gets up from table under these circumstances that is likely
+to be affected by the malignant influence. When the end of the dinner
+had arrived, by previous arrangement Mr. Arnold and two very healthy
+friends, brothers, arose simultaneously. According to the widely
+diffused newspaper account of years afterward, Mr. Arnold himself died
+within the year and one of the brothers was lost in the wreck of an
+English passenger vessel off the coast of Australia in six months,
+while the other brother committed suicide before the end of the year.
+Careful investigation of the details has shown, however, that the
+story was made out of whole cloth. Mr. Arnold himself, who was
+suffering from heart trouble towards the end of his life, was not
+likely to take part in any such arrangement because of the constant
+danger, well-known to himself, of sudden death in his case. This might
+happen at any time and might seem to confirm the superstition. The
+dates of the story, moreover, are all wrong. Matthew Arnold's death
+and the loss of the English passenger vessel in Australian waters,
+referred to, do not occur within five years of each other. The story
+has gone round the world. The correction will never reach so far. The
+story is startling; the explanation commonplace. Many people will
+continue to believe that here, at least, was one striking confirmation
+of their superstition.
+
+It is curious how the force of this "13" superstition has continued in
+spite of education and enlightenment. Most passenger vessels now built
+have no staterooms numbered thirteen. On certain streets in large
+cities one finds the number 12-1/2 (until this year it was so on my
+own) substituted for thirteen. Sometimes one finds "twelve a" or
+something similar. In the large hotels, where they have immense
+banquet halls with the tables numbered so that guests may be able to
+find their places, I have often noted that there was no table number
+thirteen. It is said that in some of the new skyscraper buildings
+twenty stories and more in height there has been question of skipping
+the thirteenth floor as a designation, because while most {640} people
+would be quite undisturbed about it, some do not care to have an
+office on the thirteenth floor, giving as an excuse that clients or
+patrons do not care to come to the thirteenth floor. In automobile
+races men are willing to risk their lives by going a hundred miles an
+hour on roads never intended for such performances, but they refuse to
+race behind the fell number thirteen. This, after all, can be readily
+understood. The slightest thing that takes away a man's complete
+confidence in himself may be serious in an automobile going as fast as
+these. Men must not think of fear or they lose some of their power and
+control over themselves and their machine. They must simply forget
+everything except the task before them.
+
+The belief in the thirteen superstition is one form of acceptance of
+premonitions. That of itself should be enough to enable sensible
+people to throw them off. Above all, it must be remembered that such
+supposed malignant influence, when allowed to affect people, impairs
+their presence of mind and may thus lead up to the accident or mishap
+which it is supposed to foreshadow. This is the serious feature of
+such premonitions and dreads. Unless people can be persuaded sensibly
+to be rid of them they handicap themselves whenever they are placed in
+danger that causes them to recur to the thought of the premonition or
+dread. While there is absolutely nothing but coincidence in even the
+supposed true stories, and many of the stories are merely sensational
+inventions, yet people need to be persuaded to rid themselves of the
+incubus that settles over them because of such ideas.
+
+
+Premonitions and Telepathy.--There are many people who think that
+premonitions have something to do with telepathy. Somehow the future
+event is supposed to be able to send some message to specially
+susceptible minds. Either that, of course, or there is some being in
+another world whose interest is sufficient to convey some inkling of
+the future. A little consideration of this subject, however, shows the
+utter lack of rationality in any such opinion. Future events, having
+as yet no existence, cannot in any way influence intelligence. Such
+future events, when dependent on human free will, are quite impossible
+of being foretold and, as has been said, no being except the Creator
+Himself knows anything about them. It would be only from Him, then,
+that information might be supposed to come and it would be hard to
+think such information would be so vague and indefinite as to leave
+room for doubt and, besides, often defeat its purpose of protection by
+seriously disturbing patients and lessening their presence of mind.
+There is no reasonable explanation by which a human being can be
+supposed to obtain knowledge of a future event unless there is a
+complete overturning of the ordinary laws of nature and then it would
+be reasonably supposed that no doubt of the significance of the event
+would be left.
+
+Nearly all of us have premonitions that fail. Only a few especially
+introspective people who are constantly afraid of what will happen to
+them, and who are sure that the worst is always preparing for them,
+have their premonitions come true more than once or twice in life. The
+striking fulfillments of a few premonitions could be paralleled by an
+endless number of just as striking failures, only that most people
+dismiss the idea completely from their minds as too foolish to be
+further talked about. It is quite the same with dreams. All the world
+dreams and there would be a serious violation of the theory of
+probabilities if some dreams did not come true. The great {641}
+majority of mankind, especially after the age of thirty, is fearful
+lest something ill is going to happen to them and their premonitions
+are rather frequent. If some of these did not come true then the
+mathematics of coincidences as based on the theory of probabilities
+would prove false.
+
+
+
+CHAPTER VI
+
+PERIODICAL DEPRESSION
+
+
+Fits of periodical depression, familiarly known as "the blues," occur
+in the experience of practically everyone. In some people they are
+only slight and passing. In others they last for hours and make the
+individual quite miserable. In still others, without actually running
+into melancholia, they produce serious discouragement and continuous
+discomfort which persists even for days and makes life intolerable.
+They come and go quite unaccountably. During their occurrence all
+vitality is lowered, appetite lessened, aches and pains are
+emphasized, sleep may be disturbed, exercise becomes distasteful, and
+they usually present an interval when health is at a low ebb.
+Ordinarily when described as "the blues" they have no definite
+connection with any known physical cause. They are passing incidents
+which seem to recur at irregular intervals. When connected with
+physical ills they are thought of directly as symptoms of these ills.
+All forms of disease may be associated with such fits of depression
+and many physical symptoms seem to be due to the fact that during
+these periods there is a distinct lowering of physical vitality so
+that the nerve impulses which ordinarily enable functions to be
+performed without interference are interrupted, or at least are
+inhibited, to a noteworthy degree. While to a certain extent the
+condition is a mental disease, it may be modified by the correction of
+physical derangements, by stimulation and, above all, by suggestion
+and a change in the point of view.
+
+
+Serious Pathological Conditions.--Of course, such periodical fits of
+depression are associated with various serious progressive ailments
+and then are primarily physical, and are only secondarily psychic.
+From the standpoint of psychotherapy it is important to remember that
+certain serious organic lesions may show their first signs in the
+patient's mental state. It is not unusual, for instance, for the
+disposition of a patient suffering from kidney disease to change so
+materially that the attention of friends is called to the change
+before any physical symptom of the nephritis has been noted. Sometimes
+for a year there will be a progressive clouding of what had previously
+been a rather happy disposition. Decisions will be made more slowly
+than before. The judgment will be impaired. There are some striking
+examples of this in history, of which the unfortunate Athenian
+general, Nicias, put to death for incapacity that was undoubtedly
+pathological, is one. Pleasures will be taken half-heartedly; men who
+have been bright and jovial will now become saturnine. Men who have
+been the life of parties will try to hold the place they acquired
+before, though all around them will perceive how difficult it is for
+them to maintain the role they have set for themselves. Whenever there
+is a notable change in disposition, it is well not to attribute it to
+some passing mental condition and, above all, not to dismiss {642} it
+as a peculiarity unamenable to treatment, but to look for the
+underlying pathological basis of the new condition.
+
+In this way physical disease will sometimes be discovered long before
+it otherwise would be. This must be particularly noted when there have
+been a series of worries. Occasionally it seems enough to many people
+to ascribe a change of disposition to the troubles that have come over
+a patient. If a business man fails or passes through a crisis in his
+affairs in which failure is very near, or he has many business worries
+over a prolonged period, these are sometimes thought to be quite
+enough to explain a change of disposition. They are, but not to the
+degree that is often noted, for, in excess, melancholic tendencies are
+always pathological, that is, they have some basis in a serious mental
+or physical change. If there is an insidious nephritis already at
+work, its symptoms will be much exaggerated and its progress
+accelerated by the worries and disquietude of such a time. If a wife
+loses her husband, or an only son, or a favorite child, the occurrence
+of a prolonged period of depression should lead to a careful
+investigation of physical conditions and of the underlying mental
+state in the hope of guarding against serious developments.
+
+
+_Heart Disease_.--Periods of depression are also common in heart
+disease and are often the first symptom of the beginning of a break in
+compensation. This effect is not so simple and direct, however, as in
+the case of the kidneys. Probably the first physical symptom of a
+break in compensation, where there is real valvular heart disease, is
+a decrease in the amount of urine. This points to an insufficient
+elimination of the products of metabolism and to the retention in the
+circulation of toxic substances. The reason for this is the lessened
+circulation through the kidneys because of the diseased heart. There
+is also a lessened circulation through the brain. This impairs the
+function of the brain and quite naturally leads to mental depression,
+slowness of decision, and unwillingness to occupy one's self with many
+things. Besides, because of the lessened function of the kidney the
+circulating blood not only does not nourish so well but it tends still
+further to depress the brain cells by the toxic substances that are in
+it. Depression in such cases is rather to be expected and at the
+beginning is not continuous but comes in ever longer periods with
+shortening intervals as the disturbance of the circulation progresses.
+At first, like other diminutions of function, it is conservative in
+order to spare the heart work.
+
+
+_Respiratory Affections_.--Very curiously an affection of the lungs
+has exactly the opposite effect and is likely to create in the patient
+an artificial sense of well-being. _Spes phthisica_, the
+characteristic hope of consumptive patients, is well known, and has
+been described by many a careful observer from Hippocrates and Galen
+to our own time. A lessened amount of oxygen in the blood produces a
+certain sleepiness, but this seems to be preceded by a period of
+slight excitation. The most familiar example of this occurs at the
+beginning of the inhalation of laughing gas. Practically the only
+direct physical effect of the inhalation of nitrous-dioxide is to shut
+off our oxygen and it is a slight period of deoxygenation that
+produces the anesthesia by this agent. Whether we have not in this the
+explanation of the feeling of the consumptive, so that often on the
+day before his death he plans a number of things that he is going to
+do next year, may require more careful {643} investigation, but the
+suggestion may serve to show how much disposition, both lively and
+serious, depends on physical factors as well as on the natural state
+of mind.
+
+
+MENTAL STATES OF DISAPPOINTMENT
+
+
+Quite apart from these serious ailments, however, there are passing
+phases of depression that come to nearly everyone after adult life is
+reached that are likely to be somewhat more frequent as years go on,
+but that are not entirely unknown even in early years. They are more
+likely to come to those who feel that life has been somewhat of a
+failure and that they have accomplished very little in spite of all
+that they have tried to do. Not infrequently they come, however, to
+those who in the estimation of other people have made a magnificent
+success of life. The rich man, after he has made his fortune, unless
+he continues to engross himself with some time-taking and
+interest-claiming work, may be the subject of repeated attacks of
+mental depression. Social leaders among women who begin to feel
+something of the emptiness of social striving, after they have made
+what is called a success in society and at the time when they are the
+envy of many on the social ladder below them, are particularly likely
+to be subject to attacks of "the blues." The only men and women who
+are free from them to a great extent, and even they not absolutely,
+are those who are busily engaged with some occupation not entirely
+selfish in which they can see that what they are doing is
+accomplishing something for the people around them.
+
+Very often an attack of depression is ushered in by some small
+disappointment. As a rule, however, this is not the causative factor
+but is only an occasion which makes manifest the depressed state that
+has existed for some time and that now declares itself openly. In the
+same way only a slight occasion is necessary apparently to dispel
+clouds that hang over a person in the milder attacks of depression,
+because, for some time before, relief has been preparing itself and a
+livelier phase of existence has been gradually coming on. Relief can
+be promised with absolute assurance, but freedom from relapse cannot
+be assured and the only true source of consolation that is helpful is
+the frank recognition of the fact that these are successive phases of
+existence quite as likely to be periodic as certain physical facts in
+life. Depression is likely to be a little more manifest in the morning
+than at other times, partly because the interests of the day have not
+yet come to occupy the mind, but mainly because the physical life as
+indicated by the pulse and the temperature is lower during the morning
+hours than in the afternoon and evening. Just as soon as people
+realize the physical nature of certain dispositional changes they give
+much less depressive significance to them.
+
+
+Occupation of Mind.--The most important feature of the treatment of
+depression of mind is to secure somehow such occupation as will catch
+the attention and arouse the interest. This is not always an easy
+matter. How effective it is, however, can be best judged from what one
+notes of the effect of such things as physical pain or great
+solicitude for someone else besides themselves. I have known a mother,
+whose fits of "the blues" were getting deeper and the intervals
+growing shorter to be roused from her condition when all means had
+failed by the elopement of a daughter who had been partly pushed into
+leaving because things had become so unpleasant around home {644}
+during her mother's depression, and any change seemed welcome. On the
+other hand, I had a doctor friend who felt quite alarmed about his
+growing depression and who even had some fears lest, if it continued
+to deepen, he might commit suicide. He was completely lifted out of
+his increasing depression by the occurrence of pneumonia in his boy of
+sixteen. The pneumonia did not end by crisis but by lysis and for
+weeks he had very little sleep. He confessed that the intense
+preoccupation of mind had completely driven away his blues and had
+even done much to relieve him of various digestive symptoms to which
+he had previously attributed his depression.
+
+Again and again I have known men who, in the midst of prosperity,
+found life dull and rather hard to bear, and who just as soon as a
+crisis in their affairs compelled them to pay attention to other
+things than themselves and the state of their feelings, grew better
+mentally and physically. It seems almost a contradiction in terms to
+say that it is the man of little occupation, as a rule, or at least of
+occupations that are not insistent, who is likely to be troubled with
+insomnia, while the very busy man, especially the man busy not about
+one or two narrow interests, but about a number, is seldom so
+bothered. Nothing contributes more to the depression of mind than loss
+of sleep or supposed loss of sleep. Even women who, while living in
+ease and comfort, had much to complain of as regards depression, often
+lose entirely their tendencies to "the blues" or have fits of them at
+much longer intervals, when necessity compels them either to earn
+their own living or, at least, to occupy themselves much more with
+absolutely necessary duties.
+
+
+_Provision of Occupation_.--It is a hard matter to create such
+occupation of mind as will be satisfactory. Patients have to be tried
+by various suggestions. The tendency to periodic fits of depression
+deep enough to be called to the physician's attention is much more
+noticeable in recent years than it used to be, and seems to me at
+least to bear a corresponding ratio to the decrease of home life. Home
+duties usually mean joys and of late there has been a neglect of the
+joys of life while seeking its pleasures. Certain phases of city life
+are responsible for much dissatisfaction with existence and depression
+of spirits. Most of the women who live in apartment hotels have
+practically no serious occupation of mind. They need not get up if
+they do not feel quite right or quite rested--and who after the age of
+forty ever does feel quite all right in the morning hours unless sleep
+has been in the open air? Nothing is so likely to start a day of
+depression than failure to get up promptly, lounging around with forty
+winks here and there, reading in bed, and the like. If breakfast is
+taken in bed, then some reading indulged in, and then some sleeping,
+and only an hour or two of dawdling around comes before lunch, that
+meal is not properly enjoyed and the afternoon is started badly;
+unless there is some special diversion of mind depression is almost
+sure to get the upper hand.
+
+
+_Place of Children in Psychotherapy_.--Where there are children the
+interests are much more urgent and there is little time for such
+preoccupation with self as gives one "that tired feeling." We are very
+interesting to ourselves, but just as soon as we have no other subject
+to occupy us than ourselves we soon grow very tired of the subject.
+Children are the best interest that one can think of, for women
+particularly. When they have none of their own an interest in orphan
+asylums, in day nurseries, in various children's {645} institutions,
+and, above all, in the adoption of a child, will do more than anything
+else to relieve the tendency to blues. Of late years the adoption of
+children has been much less frequent than used to be the case in
+childless families, and doctors see the result in mental depression.
+Children are a great care, but they are a great blessing to women, and
+while the present trend of social life eliminates them as far as
+possible, this elimination, beginning with their relegation to nurses
+when they are infants, to nursemaids as they grow a little older, and
+then to the kindergarten up to six years of age, far from adding to
+comfort rather increases the discomfort of many mothers. Nature takes
+her revenge. The reason why the mothers of past generations could
+stand the suffering that they must have borne with patience before
+gynecology developed to relieve them, was that they had their children
+around them, and their minds and their hearts and their hands were so
+full that they had no time to think of themselves, to brood over their
+ills, and consequently these troubled them much less than would
+otherwise have been the case.
+
+Delicate mothers really interested in their children undoubtedly
+suffer very little compared to delicate women who are alone in life,
+and what is thus true of the mother is true also of those who have the
+care of children. It is not alone a satisfaction of the maternal
+instinct, but it is an occupation of mind and heart with cares for
+little ones. Other people's children serve just as good a therapeutic
+purpose, if only their necessities are imposed on the attendant. The
+reason why women in religious orders have such happy peaceful lives
+and are happier in spite of a routine of life that would seem to be
+fatal to happiness, is that their minds are filled with the interests
+of others, every moment of their time is occupied, and, above all,
+they have to care for children, the ailing, the poor, sometimes the
+vicious, who make many demands on them, many calls on their sympathies
+and keep them from thinking about themselves.
+
+
+_Occupation with Living Things_.--After occupation with human beings
+the most important therapeutic factor against periods of depression is
+occupation with living things of various kinds. Horseback riding is an
+excellent remedy for the blues and the outside of a horse in the old
+axiom is literally very good for the inside of man or woman. There is
+a sympathy between man and animal that in itself means much, but the
+most important element is the absolute impossibility of preoccupation
+with oneself and one's little troubles and worries while one is trying
+to manage a somewhat restive animal. If the horse, however, is old and
+very quiet--so that one can throw the reins on his neck and allow him
+to jog on for himself, then horseback riding may mean very little.
+Where the care of the animal is entirely taken off the rider's
+shoulders by a groom who brings him to a particular place and takes
+him afterwards, then, also, much of the benefit of horseback riding is
+lost. Care for other animals as well as the horse is of great service
+and especially is this true if the owners feel the duty of exercising
+the animals. Many a downhearted person finds that to take an animal
+out for a stroll will do much to lift the clouds of depression.
+
+With the disappearance of children from the families of the
+better-to-do classes, pet dogs have grown in favor mainly because of
+this influence. They awaken sympathies and so keep people from
+thinking too much about themselves, For many an elderly woman who is
+alone in the world her dogs or her {646} cats or a combination of both
+are the best possible remedies for depression. At times it will be
+found necessary to prescribe them. There is no better way to get an
+elderly person to go out at certain times than to have them feel that
+their pets need exercise.
+
+
+_Garden Cures_.--After animals the next best thing is the care of a
+garden. Here once more human sympathies with living things are aroused
+and it is easier to cultivate a forgetfulness of self while
+cultivating flowers and plants. Growing plants do not arouse the
+interest that growing animals do, but still they have advantages over
+things that do not vary, and their growth is a subject of day-to-day
+interest and the effect on them of vicissitudes of the weather arouses
+feelings of solicitude which help to dissipate the little insistent
+cares for self that depress. The care of a garden is the very best
+thing for the "pottering old." Younger people are too impatient to get
+much benefit out of a garden, but after middle life many an hour of
+depression will be saved in the care of plants.
+
+
+_Intellectual Occupations_.--It might be expected that intellectual
+occupations would serve to brush away "the blues" for educated people.
+They are perfectly capable of doing so, but they must be of the kind
+that grip attention and must be undertaken seriously, usually with an
+appeal quite apart from mere cultural interests. Hobbies of various
+kinds, especially the making of collections, even of such trivial
+things as stamps, will often serve the purpose of distraction from
+gloomier thoughts. Unfortunately, a hobby cannot be created all at
+once and usually does not take a strong enough hold to be available
+for mental therapeutic purposes unless it was acquired when the person
+was comparatively young and has been indulged in for many years.
+Reading and study utterly fail unless there is some end in view apart
+from the reading and study itself. The reading of novels and
+newspapers is particularly likely to be a failure. The gloomier
+thoughts obtrude themselves in the midst of the reading and very often
+what is read proves suggestive of melancholic thoughts and all the
+time the mind and the person are not occupied seriously enough to push
+away the state of depression which exists. The mind must be
+interested, not merely occupied superficially, or the depression will
+continue.
+
+It might be thought that the reading of books that concerned human
+suffering might have a similar appeal to that to be obtained from real
+touch with human suffering. This is true to a certain extent when the
+books concern real and not fictitious suffering. For this reason the
+trials and hardships of travelers at the North and South poles or in
+the heart of tropical Africa--Nansen and Peary and Stanley and
+Livingston--have all been excellent therapeutic agents. The stories of
+mountain climbers have something of the same effect. Adventures in
+Alaska and in the Far North, especially, come in the same category.
+Novels, however, even though they use the same material, soon fail to
+have a corresponding effect. Even when the novel does touch the
+emotions deeply it is prone to make the reader forget the suffering
+around him and does not prove a good diversion from his own feelings.
+In his play, "The Night Asylum," Maxim Gorky, the Russian novelist and
+playwright, brings this out very well. One of his characters, a young
+scrubwoman, wears her fingers to the bone during the day for a
+miserable pittance and sleeps in a squalid night lodging house, yet
+this comparatively young creature, {647} crouched near the only light
+in the room, sheds tears over the imaginary sufferings of the
+fictitious people that she reads about, while the real human suffering
+around her fails entirely to arouse her sympathy or affect her
+emotions, except to anger her if lodgers come in between her and the
+light or when the complaints made by some of those who are suffering
+around her annoy and distract her from her reading.
+
+In younger folks, study, provided there is some definite object to be
+attained by it, is often helpful. Correspondence schools are of value
+by setting a definite purpose before the mind. In a number of cases I
+have found that the suggestion to make translations from a foreign
+language when the patient knew that language even tolerably well,
+afforded excellent relief from that over-occupation with self which
+was the real cause of the depression. There are many people who know
+enough French to be able to translate fairly well and there are many
+articles and books a translation of which may at least be submitted to
+editors and often proves available for publication. To have some such
+end as this in view is of itself one of the best means that can be
+provided for these people to relieve their tendency to depression.
+Occasionally even the suggestion to write stories may prove helpful.
+One hesitates to add to the number of story-writers in this country,
+but it may be remembered as a last resort. I know at least two people
+saved from themselves by even a very moderate success as writers of
+short stories.
+
+
+_Consolation from History_.--Perhaps the most serious thing about
+depression is the feeling of those afflicted by it that they are
+singular in this respect and that other people who seem gay never have
+depressed states. There is probably no one who has not periods of
+depression. They may not be very deep and "the blues" may be only of
+a light tinge, but they are there. The higher the intelligence, as a
+rule, the more tendency there is to feelings of discouragement and
+depression at intervals when one is not occupied. Those who have the
+artistic temperament and the striving after the expression of the
+beautiful as they see it, whether it be in art or in letters or in the
+betterment of humanity, usually suffer more than others because they
+realize poignantly their failure to reach their ideals. This is well
+illustrated by the experience of writers and artists. As a rule, most
+men and women look forward to the completion of any intellectual work
+with confidence that after it is finished they will have a period of
+rest and peace. Commonly just the opposite is true. The completion of
+any work leaves one with a sense of dissatisfaction with what has been
+done, for no man of real intelligence ever thinks that he has so
+realized his ideals as to be satisfied, and only the foolishly
+conceited fail to feel the many defects that there are in their work.
+
+There is abundance of evidence, however, that it is not alone artists
+and writers who thus feel the hollowness of life and the tears there
+are in things. Many of the men who have accomplished great things in
+science and in politics have been prone to times of depression.
+Virchow told me there were moments when life seemed very empty to him
+and that he had to shake off feelings of depression in order to be
+able to go on with his work. At one time in the sixth decade of his
+life he suffered considerably from what we would now call neurasthenic
+symptoms, gave up his medical work and spent a long time with
+Schliemann in the Troad. His presence was valuable to the excavator in
+his work at Troy, and the change gave Virchow back his health.
+
+{648}
+
+Even more striking is what we know of Von Moltke, who seemed in many
+ways to have an ideally happy life. He had had the fulfillment of all
+his desires or, at least, the fruition of all his hopes, and the
+successful accomplishment of what he worked for beyond what is usually
+given to man. He had come to be one of the most highly respected men
+of Europe and was the subject of veneration on the part of his own
+German people and of intimate affection from his sovereign, who loaded
+him with honors. He was a man who had probably no enemies and many,
+many firm friends. It was said that "he could keep silence in eleven
+languages" and so he had avoided most of the pitfalls of life. His
+domestic life was ideally happy and his letters to his wife for over
+fifty years read like those of a lover, before all his great battles
+his last thought and written word was for her, after them his first
+thought and message was for her. In spite of this, towards the end of
+his life, when the question of reincarnation was a subject of
+discussion in Berlin and it was brought particularly to his attention,
+he declared that looking back on his career, in spite of all its good
+fortune, there seemed to him to be so many chances in life, so many
+possible sources of failure, so many springs of discouragement, that
+he would prefer not to have to live again. Surely, if anyone, he might
+be expected to be ready to take the chances of re-incarnation after
+such happy experiences of life, yet he was not. Such an expression
+could only come from a man who had looked depression often in the
+face, who had shaken off the blue devils and who knew that even the
+joy of success was followed by the gloom of uncertainty as to the
+future and solicitude as to the real significance of accomplishment.
+
+
+_Literature and Life_.--We have many examples of this tendency to
+depression that come to the literary man in the lives and letters of
+distinguished writers that have been published so frequently in recent
+years. Perhaps one of the most striking is to be found in the life of
+Robert Bulwer Lytton, the second Lord Lytton, so well known as a
+diplomatist in European circles and throughout the English-speaking
+world as a poet, under the pen name of "Owen Meredith."   [Footnote
+51] It might be thought that Lytton would be one of the men safely
+harbored from storms of depression and discouragement, for his life
+seemed ideally situated to enable him to get the best out of himself
+without worry or dissipation of energy in occupation with mere
+personal matters. His father had made a distinguished success as a
+literary man and a politician, had been raised to the peerage and the
+son began life with every possible advantage. He made a distinguished
+success in literature so that he even converted his father to praise
+him and as a diplomatist he occupied nearly every important post in
+English diplomacy and had hosts of friends all over the world.
+
+  [Footnote 51: Personal and Literary Letters of Lord Lytton,
+  edited by Lady Betty Balfour. New York, 1909.]
+
+It is all the more surprising, then, to have many passages in his
+letters refer to periodic attacks of depression. He says, for
+instance, "My physical temperament has a great tendency to beget blue
+devils and when those imps lay siege to my soul they recall those
+words of Schopenhauer's and say to me 'thou art the man.'" Perhaps the
+price that the artistic temperament pays for the satisfaction that it
+gets out of life in other directions is this occasional tendency {649}
+to depression because achievement does not equal aspiration. Certainly
+the price often seems excessive to those who have to pay it. In the
+same letter to his daughter, Lytton continues:
+
+  When my blue devils are cast out, and I recover sanity of spirits,
+  then I say to myself just what you say to me in your letter--that
+  the main thing is not to do but to be; that the work of a man is
+  rather in what he is than in what he does; that one may be a very
+  fine poet yet a very poor creature; that my life has at least been a
+  very full one, rich in varied experiences, touching the world at
+  many points; that had I devoted it exclusively to the cultivation of
+  one gift, though that the best, I might have become a poet as great
+  at least as any of my contemporaries, but that this is by no means
+  certain to me for my natural inclination to, and unfitness for, all
+  the practical side of life are so great that I might just as likely
+  have lapsed into a mere dreamer; that the discipline of active life
+  and forced contact with the world has been specially good for me,
+  perhaps providential, and that what I have gained from it as a man
+  may be more than compensation for whatever I may have lost by it as
+  an artist.
+
+It is surprising to think of a man of this kind becoming so depressed
+by the death of a son that all the world and the meaning of life took
+on a somber hue for him. In 1871 Lord Lytton lost a young boy by a
+very painful illness which had probably been more painful for
+sympathetic onlookers than for the patient himself. The incident
+proved sufficient, however, to make the father think that there could
+not be a beneficent Providence ruling over the world. He felt sure
+that somehow God's power must be shortened, if such suffering, for
+which he could see no reason, had to be permitted. He was much
+depressed after this and never was quite the same in his outlook upon
+the world and the significance of life. It was easy to understand that
+this was due rather to his character than his intellect, but it
+illustrates forcibly how much a deeply intelligent man may be affected
+by something that seems after all, only the course of nature.
+
+It is sometimes surprising to find from the life stories of men how
+often those who would be thought least likely to suffer from
+periodical depression were victims of it. Few Americans in our time
+have apparently had a more satisfying career than that of James
+Russell Lowell, a successful author as a young man, then a successful
+editor, a teacher whom his students appreciated very much, and in
+later life the subject of many honors and such honors as provided him
+with splendid opportunities for the exhibition of his special genius.
+He would seem to be the last who should suffer from depression. His
+post as Minister to Spain gave him an opportunity which he took
+magnificently to study the great Spanish authors and to store up
+material for writing about them. As Minister to England few men were
+so popular. He was constantly in demand for occasional addresses and
+his special style enabled him to respond to these demands with
+brilliant success. Here in America no great occasion was complete
+without Lowell. In spite of all this that would surely seem ample to
+satisfy the aspirations of any man, Lowell was often depressed and
+sometimes even talked about the possibility of suicide. Life seemed at
+times very empty to him. The story of the lives of such men, if made
+familiar to patients, proves a source of consolation, for it makes
+them realize that they are not alone in their experiences, that
+depression at some times is the lot of man, and that very few people
+are without the sphere of its influence.
+
+{650}
+
+Depression an Incident, not a State.--This suggestion may, in the case
+of some of those inclined to longer periods of depression, lead to
+indulgence in the luxury of being depressed and so putting off the
+doing of things. It must be pointed out, however, that just inasmuch
+as depression has this effect it is pathological. It seems to be
+natural to man to suffer from periods of discouragement and depression
+which keep him from devoting himself too persistently to lines of work
+that may be insignificant and make him take cognizance of the real
+values of what he is doing. Depression, however, that continues after
+the recognition of this takes place is morbid and must be actively
+resisted. Just inasmuch as depression precedes and prepares patients
+for a reaction, it is an incident in practically all lives. Indulged
+in as a luxury, it is abnormal.
+
+
+Suggestive Treatment--The most important thing for patients who suffer
+from periodic depression is to make them understand that this state of
+mind, far from being personal to them or very rare, or even uncommon,
+is an extremely frequent experience of men and women. There are
+certain men and a few women eminently occupied with the external life,
+busy with many things, though often they are trivial enough, and even
+when they are important, significant only in a financial or a social
+way, but meaning nothing for the great realities of life, who seem
+during their younger active years to escape the periodical attacks of
+depression that come to most people and come almost without exception
+to people who think seriously. Some of the best thoughts and
+inspirations of men come to them as the result of the serious mood
+that follows an attack of depression. A butterfly existence lacks
+these sources of inspiration. Far from being objectionable then,
+attacks of depression, if not allowed to proceed too far, and if kept
+from paralyzing activity, prove to be intervals when life values are
+seriously weighed and when a proper estimation of such values is come
+to. Men are prone without such interruptions to get too interested in
+trivial concerns that seem to them important because they are occupied
+with them to the exclusion of other ideas, but that prove to be of no
+real import when seen on the background of a certain hollowness that
+there is in human life, if lived merely for its own sake.
+
+The occurrence of periodical depression is a part of the mystery of
+life and it affords us a better opportunity to get a little closer to
+the heart of the mystery than almost anything else. It is out of such
+periods that men have risen "on stepping-stones of their dead selves
+to higher things" and have even risen to the highest that there is in
+life. Geniuses have nearly always had deep periods of depression, but
+in the midst of them have read new meanings into life and have read
+the lessons of humanity in their own souls better than at any other
+time. Depression throws a man back on himself and makes him think
+deeper than in his mind--in what has been called his heart. "The
+fascination of trifles obscures the good things in life" are words of
+old-time wisdom and men are weaned from this by fits of depression
+that are really moods of precious dissatisfaction with their work
+inasmuch as it falls short of the best accomplishment. Without
+periodic depression, apparently, a man never gets as close to the
+heart of life as he otherwise would. Far from being an unwelcome
+visitant, it should be rather welcome as a stimulus to the possibility
+of further study of self and the realities of life.
+
+
+{651}
+
+
+CHAPTER VII
+
+INSOMNIA
+
+
+To the minds of many people insomnia is one of the most serious ills
+to which human nature is heir. Most of this quite false impression is
+due to the sensational cultivation of dreads with regard to insomnia
+by newspapers and in general conversation. If we were to credit such
+impressions, there is a certain number of unfortunates who, for some
+unknown reason, find it impossible to sleep and who, night after
+night, drag out the weary hours wooing sleep that does not come, until
+when daylight dawns they are in despair, distracted by lack of rest.
+This is presumed to occur night after night, until finally the
+worn-out mind succumbs to the intolerable anguish of being kept
+constantly on the rack of wakefulness and the patient becomes insane
+or saves himself from that by suicide. No wonder, then, that many a
+one of these patients takes to the use of habit-forming drugs to
+produce sleep. These, though effective only to a small degree, soothe
+him for the time, but finally render him such a wreck that there is
+not even will power enough for him to take his own life and end his
+intolerable suffering.
+
+Such gruesome pictures of the awful effects of insomnia run rife and
+produce dreads in the community until just as soon as the ordinary
+nervous supersensitive person loses an hour or two of sleep two or
+three nights in a month, he begins to conjure up the specter of
+insomnia with its awful terrors and still more awful possibilities,
+and begins to bewail the fate that has chosen him as an unfortunate
+victim. This exaggerated dread that slight losses of sleep, for which
+there are often excellent reasons, will develop into an incurable
+condition of persistent wakefulness has more to do than any other
+single factor with the production of the state called insomnia which
+is, however, never half as bad as it is pictured.
+
+
+Absolute Sleeplessness.--A certain number of patients insist that they
+sleep very little at night and some tell their friends and even their
+physicians quite ingenuously that they sleep none at all, and that
+this has been the case with them for a prolonged period. Practically
+every physician has heard such stories, and at the beginning of his
+professional career has usually wondered how the patients continued to
+live and enjoy reasonably good health in spite of the lack of
+absolutely necessary brain cell rest. After the physician has the
+opportunity to investigate some of these stories he understands them
+better. Patients in hospital, who insist that they are wakeful all the
+night, prove usually when faithfully watched by a nurse to be wakeful
+for an hour or two at the beginning of the night and then to sleep for
+hours at a time, and all of them sleep for intervals more or less
+prolonged, though they may wake a number of times during the night and
+may think that they have not been asleep because they hear the clock
+regularly or some other recurring noise. It is improbable that
+patients ever spend several nights in succession without sleep and
+their story is only an index of the persuasion that they are under
+that they do not sleep, though they are having so many thoroughly
+restful intervals that their brain cells suffer but little from {652}
+the need of sleep. _Indeed, the principle source of nervous wear and
+tear for them consists in their persuasion that they do not sleep and
+the resultant impelling suggestion that a breakdown must before long
+be inevitable._
+
+
+Individual Differences.--There are too many safeguards in nature's
+ordinary dealings with human beings for us to think that people can
+pass many nights absolutely without rest. Brain cells may apparently
+be very wakeful, they may be quite ready to take up at once and
+seemingly without a break trains of thought interrupted sometime
+before, yet somehow they succeed in obtaining their needed rest. In
+this matter, as is well known, though it needs to be emphasized again
+for the benefit of nervous individuals, different people have very
+different needs. Some require many continuous hours of sleep or they
+soon begin to have symptoms of nervous exhaustion. Others live on only
+with snatches of sleep at intervals, or with interrupted sleep during
+a limited portion of the twenty-four hours, yet enjoy good health for
+many years. A few seem to be able to live in health and strength with
+but a few hours of sleep. It may possibly be thought that those who
+are living their lives with a small amount of sleep are drawing drafts
+on their future vital powers, and that what they make up in intensity
+of activity now by shortening sleep, they will discount by shortness
+of life. How utterly untrue this impression is, however, will be best
+understood from the fact that many of the men who have worked hardest
+and slept the least number of hours in the day, have lived to be
+eighty or even ninety years of age and some of them have even been
+centenarians.
+
+
+Cell Rest.--The great differences in the brain cells of different
+individuals in what concerns sleep becomes more readily intelligible
+when we recall the extreme differences as regards the need of rest of
+the various cells in the same individual. While the brain cells seem
+to require for healthy life, as a rule, nearly one-third of the time,
+and a man who is constantly taking much less than eight hours of sleep
+is probably hindering rather than helping his productiveness,
+especially if his work is intellectual, there are cells in the body
+that need no such amount of rest as this. Peristaltic movements occur
+in the digestive tract almost constantly, with only short intervals,
+and these cells get their rest between their movements. Pulmonary
+cells and tissues must do the same thing, and are able to do it
+without any special strain being put on them. The extreme example of
+the lack of need for prolonged rest is found in the heart. Two-fifths
+of every second the cells of this organ have a rest during the
+diastole, but during the remaining three-fifths of every second for
+all of life they must not only be ready to work but actually engaged
+in it or serious symptoms ensue. The cells in the brain that subtend
+cardiac and respiratory activity must be even more able to do without
+rest, since their action is ceaseless during life. By analogy with
+these it is not difficult to understand that the brain cells which are
+involved in consciousness should on occasion be able to stand
+prolonged periods of activity, or at least of wakefulness. Persistent
+wakefulness does not appeal to us as so surely destructive after this
+consideration.
+
+
+Solicitude Over Sleep.--For those who are much disturbed by the loss
+of even slight amounts of sleep and who are prone to complain rather
+bitterly if they are not able to get more than five or six hours a
+night, I find it a useful preliminary to any more formal treatment of
+their so-called insomnia {653} to recall the examples of some of the
+great workers who succeeded in accomplishing marvelously good work
+though they took much less sleep than the amount the patient secures,
+yet seems to think inadequate. In spite of such lack of sleep, these
+workers lived to advanced old age. There are many well-authenticated
+illustrations of this in recent times. Perhaps the most striking
+testimony to the power of the human mind to continue work without
+requiring the refreshment of sleep, except for very short periods, is
+that of Humboldt, the great traveller, scientist writer and diplomat.
+Max Müller, in his autobiography tells the story. It was when he
+himself was about forty. Humboldt said to him: "Ah! Max, when I was
+your age I had time to accomplish something, now I find that I must
+take at least five hours of sleep every night." At the moment
+Humboldt was over eighty. Müller said to him: "But, Your Excellency,
+how much sleep, then, did you take when you were my age?" "Oh!" he
+said, "I used to turn the light down, throw myself on the lounge for a
+couple of hours, and then get up and go on with my work again."
+Humboldt, after a life full of the hardest kind of work of many kinds,
+lived well past ninety in the full vigor of his intellectual powers.
+
+There are many other examples that might readily be quoted. The
+traditions of the University of Berlin contain many illustrations of
+men who did very little sleeping, yet succeeded in accomplishing an
+immense amount of work and lived far beyond the Psalmist's limit.
+Virchow, whom I knew very well, did not take more than four or five
+hours of sleep on most nights in the year. He would be in the Lower
+House of the Prussian Legislature, which, like the House of Commons,
+holds its meetings late at night, until one A. M. or later and would
+be at his laboratory shortly after seven. There was a tradition at the
+University of Berlin in my time there of one of the older professors
+in the theological department who went to bed only every alternate
+night. He had a forty-eight-hour day for work with a seven-hour break.
+He lived to the age of eighty-five. I know one of our most
+distinguished workers in medicine here in America who was so busy and
+so tired at the end of his day that he could not write his book. He
+would fall asleep on his chair at his desk to wake up only when the
+milkman came in the morning. He had constructed for himself a special
+stool without back or sides, shaped like a bench, so that whenever he
+fell asleep on it he fell off. The fall would wake him up and he would
+then go on with his work for some hours. He did this sort of thing for
+many years, and yet he is alive and in the full possession of
+intellectual health at the age of eighty-three. He learned this
+expedient from a German professor of medicine who told him of it and
+at the same time told him that it was no uncommon practice among
+German professors. Indeed, most of the famous long-livers of the
+nineteenth century were also well known for the small amount of sleep
+they required, and apparently there is no need of being anxious lest
+loss of sleep should prove serious, unless one is adding to whatever
+detriment to health it may be by worrying about it find so setting two
+damaging factors at work.
+
+
+TREATMENT
+
+Probably the most important immediate assurance that can be given to
+those who come complaining of insomnia is that practically no one has
+ever {654} been seriously hurt by the wakefulness called insomnia.
+Patients suffering from brain tumors, from serious disturbance's of
+cerebral circulation that give objective signs, from various organic
+diseases, as of the heart or liver, or certain constitutional
+diseases, have been made worse by the wakefulness induced by their
+affections. In the cases where there were no definite objective signs
+and wakefulness was the only symptom we have no cases on record of
+serious injury resulting. Men have come complaining of wakefulness for
+days or weeks and sometimes, though it is strange to understand it,
+for months or even years, and yet have lived their lives without
+serious developments and have neither gone into insanity nor into any
+premature loss of vitality, much less a fatal termination. It is not
+subjective symptoms but objective signs that are of value for the
+diagnosis of the serious organic conditions. This reassurance lifts a
+load from patients' minds at once and does more than anything else to
+relieve them of the burden of solicitude which is the main factor in
+the continuance of their insomnia.
+
+
+Suggestive Treatment.--The psychotherapy of sleep consists in changing
+the patient's attitude of mind toward his sleep. It is quite
+impossible for him to sleep normally and regularly if he worries much
+about it and if the afternoon and evening hours are mainly spent in
+wondering whether he will sleep, anxious as to when he is going to
+sleep like other people, marvelling how long he will last in health
+and sanity if his tendency to wakefulness continues. There is no
+factor so strong in insomnia as getting one's self on one's mind. It
+weighs as an intolerable burden, an incubus that is sure to keep its
+subject awake. Insomnia is a mental and not a physical ailment in much
+more than nine out of every ten cases. It is not the brain but the
+mind that is at fault. Patients must be made to realize that if they
+go quietly to bed, confident that if they do not sleep the early part
+of the night they will sleep later, and that in case they should lose
+considerable sleep, so long as they lie quietly for eight hours in
+bed, their physical organism is not likely to come to any serious
+trouble. They must be quiet, peaceful and unworried. They must not
+begin to toss at the first sign of not going promptly to sleep for by
+so doing they may put off completely the possibility of falling to
+sleep. Finally they must prepare for sleep by passing a quiet evening,
+as a rule, occupied with diversions of various kinds.
+
+There are many factors which inhibit sleep that must be removed or at
+least obviated. These are very different in different individuals and
+the suggestion of getting them out of the way helps a great deal in
+making people realize that they are better prepared for sleep than
+before. They have been keeping themselves awake by contrary
+unfavorable suggestions. They must be taught to aid themselves in
+going to sleep by a series of favorable suggestions attached to the
+doing of certain things that are helpful and, above all, avoiding acts
+of various kinds that have an unfavorable suggestive influence. In
+this way an accumulation of suggestions can be secured that will prove
+helpful.
+
+
+Drugs.--Of course, patients must be warned with regard to the taking
+of drugs. Certain drugs may be taken for an occasional loss of a
+night's sleep, where the loss of sleep is regular and frequent,
+however, drugs are sure to do more harm than good. Opium leads to a
+serious habit, chloral is dangerous because it must be increased, most
+of the coal-tar somnifacients produce {655} serious after results and
+their physical effect is in the end probably more deleterious than
+would be the loss of the sleep which they are supposed to counteract.
+This is true for even the vauntedly least harmful of them, and it is
+important to make patients understand it.
+
+
+External Conditions to be Inhibited.--In the treatment of insomnia two
+sets of inhibitory conditions are particularly to be looked to, those
+external to the patient, and those internal. Unless every possible
+obstacle is removed there can be no assurance of the relief of
+sleeplessness, while very often the careful regulation of a few
+conditions that are disturbing the patient will bring sleep fully and
+promptly. It is curious what small annoyances will sometimes prove
+disturbing.
+
+
+_No Pillow_.--I have found patients who had heard somewhere the idea
+that it was natural for man to sleep without a pillow. The pillow in
+this theory was supposed to be an added refinement of men in a state
+of luxury, but a real degeneration opposed to nature, and the many
+presumed benefits of sleeping on a perfectly level mattress with the
+head no higher than the rest of the body was emphasized. While in
+ordinary health these patients had found that after the preliminary
+discomfort of getting used to sleeping without a pillow, they were
+apparently the better for it. People will feel better for almost
+anything if they are only persuaded that they ought to. After a
+certain length of time, however, worry or work had a tendency to keep
+them more or less wakeful and then insomnia came on, that is, for
+several hours at the beginning of the night they did not go to sleep
+and became very much worried about it.
+
+In several of these cases I have found one of the most helpful
+adjuncts to more direct treatment of their wakefulness was the
+restoration of the pillow. Just how the hygienic theory of pillowless
+sleep originated, or on what it is supposed to be founded, I do not
+know. The only theory of sleep that seems to have many adherents at
+present is that it is due to brain anemia. With the head a little
+higher than the rest of the body the force of gravity tends to help in
+the production of this brain anemia. The experience of mankind seems
+to confirm this. Certainly, from the earliest records of history men
+have slept with something under their head, even though they could
+find nothing better than a log or a stone. To sleep without a pillow
+is, owing to the conformation of the head and neck and shoulders,
+almost inevitably to sleep mainly on the back. From the anatomical
+relations of the internal organs it is easy to understand that
+sleeping on the side is more comfortable and healthy than sleeping on
+the back and hence most people naturally take this position.
+Relaxation is much more complete and comfort is greater. What the
+majority of men do is almost surely dictated by instinct, and instinct
+is the most precious guide we have in the natural functions of life.
+We are not so differently formed from the animals that the analogy
+from their habits should not have some weight for us. Patients should
+then be advised always to sleep with a reasonably firm pillow, not too
+low, so that the head is a little higher than the body and the lateral
+position perfectly comfortable.
+
+
+_Too high Pillow_.--There is an abuse in the other direction of too
+high a pillow that deserves to be noted. Occasionally the physician
+hears complaints of waking up with tired feelings in the large muscles
+of the back of the neck near their insertion into the occiput. This is
+sometimes complained of {656} as an occipital headache. Not
+infrequently it will be found that these people are sleeping on
+pillows that are too large, or that they pile up several of them. Most
+physicians have found in their experience that having the head quite a
+little higher than the rest of the body materially aided sleep,
+especially in elderly people. This is true even when there is no
+distinct heart lesion, but this favorable position is best secured not
+by means of one or more high pillows, but by raising the head of the
+bed, or by the insertion of bolsters beneath the mattress, so that
+there is a gentle slope upward from the hips to the head. High pillows
+should, as a rule, be discouraged, especially in young folks where the
+assumption of the strained positions which they cause, may encourage
+various deformities in the anatomy of the head and shoulders so that
+stoop shoulders or a craned neck result. On the other hand, before
+attempting to give drugs to elderly people, the arrangement of the
+mattress so as to put the head a foot, or even more, higher than the
+body should be tried and will often be found to give relief where
+other things fail.
+
+
+_Discomfort Due to Cold_.--In order to sleep well patients must be
+thoroughly comfortable in bed. In recent years as the very hygienic
+practice of having a window in the sleeping apartment open has become
+a rule among intelligent people, sleeping rooms have been much colder
+than they used to be. Care must be taken lest the active factor in
+causing wakefulness should be cold. Over and over again I have found
+that patients who complain of wakefulness, in the latter part of the
+night particularly, that is, in the early morning, were awakened by
+the increasing cold because they were insufficiently clothed. Whenever
+the sleeping room becomes very cold, then, the patient should not
+sleep between cotton or linen sheets which are likely to induce
+sensations of chilliness, but in a light woolen nightgown. It is
+curious what a difference in the patient's feelings is produced by the
+touch of wool to the skin in cold weather as compared with cotton.
+Thin, anemic patients are especially likely to suffer from chilliness.
+It must not be forgotten, however, that some stout people, in spite of
+an accumulation of fat, are really anemic. Their red blood corpuscles
+and hemoglobin are distinctly below normal. These constitute some of
+that large class of stout women in whom reduction cures fail because
+of the anemic tendency. They must be as carefully protected from cold
+as thinner persons, yet they need fresh air for their comfort and
+health almost as much as tuberculosis patients. The experience of
+sanatoria in the Adirondacks and at altitudes generally shows that for
+quiet, undisturbed sleep, if the room becomes distinctly cold during
+the night because of an open window, a hood or night-cap and gloves,
+as well as the wearing of woolen underclothing, even to stockings, is
+almost indispensable. In older times, when houses were not well
+heated, many persons very sensibly wore night caps. Now that a return
+to cold fresh air in the sleeping room has come many will have to
+resume the old night-cap habit in spite of cosmetic objections to it.
+These may seem little things, but they count very much in relieving
+disturbed sleep. The curious thing about them is that patients
+themselves seldom realize that certain common-sense regulations are
+more important for sleep than formal remedies. They want to be "cured"
+of their insomnia, not relieved by suggestion.
+
+
+_Cold Feet_.--A large number of people have their sleep at the
+beginning of the night seriously disturbed by cold feet. Some cannot
+get to sleep for {657} an hour or more, because their feet are cold.
+If the patients become worried over this loss of sleep, a real
+insomnia may develop. It is for these people that the old-fashioned
+warming-pan was invented and it should not be forgotten that the
+symptom can be relieved very promptly by means of a hot-water bag or a
+hot brick wrapped in flannel at the foot of the bed. An excellent
+practice for very sensitive persons, is to have the sheets warmed
+thoroughly for a couple of hours before bedtime. This is especially
+important in damp weather.
+
+The distinguished English surgeon. Sir Henry Thompson, who lived well
+beyond eighty years of age (when surely he would seem to have some
+right to do so), wrote a little book on how to be well and grow old
+and describes a habit which he had acquired and that I have often
+recommended to patients and friends as well as used myself with
+advantage when there is a tendency to cold feet, either habitually or
+occasionally. It is, moreover, useful whenever there is a tendency to
+insomnia because some exciting occupation has preceded going to bed.
+Before retiring Sir Henry used to sit beside his bath tub and let the
+hot water flow into it over his feet, gradually becoming warmer and
+warmer, until he could no longer stand the heat. A temperature well
+above 120 degrees may be borne with comfort after a while, though at
+the beginning it would seem entirely too hot. The feet are kept in the
+hot water at least five minutes. When taken out they should be
+thoroughly red and show evidence of a good deal of blood having been
+attracted to them. If they are now carefully wiped and rubbed
+vigorously there will usually be no further tendency to cold feet that
+night and sleep will come naturally. Sir Henry said that when he had
+been out at meetings where he had to make an address or had to take
+part in business of any kind that inclined to make him wakeful, he
+found this an excellent method of preparing himself for immediate
+sleep.
+
+It must not be forgotten that the worst forms of cold feet are found
+among those suffering from flatfoot. The dropping of the arch
+interferes with the return circulation and also with lymphatic
+circulation. These individuals feel very tired because of their foot
+condition, yet their cold feet often disturbs their sleep at the
+beginning of the night. The only effective relief for this is afforded
+by proper treatment of the feet. (See the chapter on Foot Troubles.)
+
+
+_Lack of Air_.--On the other hand, occasionally it happens in spite of
+all that has been said in recent years about fresh air in sleeping
+rooms, windows are hermetically sealed and even then people cover
+themselves with many thicknesses of bed clothing and are too warm. I
+have found over and over again that where people could not be
+persuaded to leave a window open all night (and when they are old and
+deeply prejudiced in the matter I do not insist, for the suggestion of
+possibly catching cold would almost surely keep them awake), the
+thorough airing of rooms before retiring made a great difference in
+the sleep of elderly people. When patients are young, I simply insist
+on the window being wide open for some time before they go to bed and
+slightly during the night, except in extreme cold weather. Many a
+patient who complains of waking several times during the night and
+being awake for some time on each occasion will begin to have longer
+periods of sleep without a break if such a change in the ventilation
+of the room is effected. {658} Anyone who has seen fever patients who
+had been restless, disturbed and wakeful, sink into a quiet slumber
+after the room has been thoroughly aired and the temperature of it
+reduced ten or fifteen degrees, will realize how helpful this same
+method of treatment will be in nervous, wakeful irritability.
+
+How important air is for the obtaining of the power to sleep for many
+hours every day can be best understood and appreciated from the habits
+insisted on for patients in tuberculosis sanatoria as a result of
+experience. When there is any tendency to a rise in temperature in
+these patients they are kept absolutely without exercise. They are
+either in bed or on a lounging chair all day, but they are out in the
+air or at least close to an open window. As a rule, they sleep some in
+the morning and then they sleep again in the afternoon. This would
+ordinarily be fatal to sleep at night in even healthy people taking
+considerable exercise and therefore presumably tired and more likely
+to sleep than these patients who had made no exertion during the
+twenty-four hours; but it is not often, after patients have been for
+ten days or two weeks at the sanatorium, that there is any complaint
+of lack of sleep at night. This is true in spite of the fact that
+patients are often wakened by coughing during the night, yet after a
+comparatively short interval they go to sleep again and sleep until
+morning. This is not true when patients do not pass most of their time
+in the open air and when their rooms are not well aired.
+
+
+Sleep at Sea.--I know nothing that is more effective in doing away
+with insomnia than a sea voyage. The passengers sit on their lounging
+chairs all the morning in the open air, usually sleeping for some
+time, often for several hours. During the afternoon this is repeated.
+In spite of this extra sleep they turn in, not long after ten, and
+sleep well until morning. There is practically no exercise and the air
+usually excites such an appetite that five and even six meals a day
+are consumed. There is no disturbance of digestion unless some special
+excess is indulged in, and, above all, sleep is rather favored than
+impaired by the large amount of food taken. This experience which is
+so common, is very valuable as indicating just what is the best
+pre-requisite for sleep. It is not exercise and tiredness to such a
+degree that one fairly drops from fatigue, but such an oxidation of
+all tissues by the breathing of pure air that there are no toxic waste
+products left in the system to act as excitants for disturbance of
+sleep.
+
+
+Cold Water.--In summer, when wakefulness is due to heat, a cool bath,
+or at least a rub down with cold water and going to bed without drying
+is an excellent method of inviting sleep. Under these circumstances
+the sheet acts as a soothing cool pack and people who have been
+wakeful for hours before, or at least have found considerable
+difficulty in getting to sleep, sleep promptly. The mechanism of
+sleep-production is easy to understand. There is less blood to go to
+the brain when the little capillaries at the surface are pretty well
+extended and after the application of cool water the reaction which
+follows the closing of the capillaries in response to cold leaves them
+of sufficient size to accommodate a large amount of the blood of the
+body. Of course, in both cases there is the suggestive value of a
+proceeding of this kind so well calculated to predispose the patient's
+mind to go to sleep without solicitude.
+
+{659}
+
+Diet.--As has already been outlined in the hints that precede, the
+first thing in the treatment of insomnia is to remove any causes that
+may be at work in producing wakefulness. Among the most common of
+these in our modern life is the taking of coffee or tea, important in
+the order mentioned. Every physician has frequent experiences of
+people who complain of insomnia, yet who take a cup of coffee late at
+night. A large proportion of humanity cannot do this with impunity and
+expect to go to sleep promptly. Occasionally one finds that patients
+complaining of sleeplessness are taking three to five cups of coffee a
+day. This must be stopped. A physician may be told by such patients
+that they cannot get along without their coffee. I have only one
+answer for this and it is meant to show patients that if they want to
+sleep they must take the means to secure it and, above all, must
+remove all disturbing factors. I tell them that if they cannot do
+without coffee they may continue to do without sleep. If they want to
+sleep they must give up coffee or at least must limit the amount. I
+have found it comparatively easy to get people to limit coffee-taking
+by the suggestion that there should be one tablespoonful of strong
+coffee taken to a cup of hot milk. This gives the taste, or rather the
+aroma of coffee, for coffee has properly no taste to speak of, and
+while, at first, patients crave the stimulation they have been
+accustomed to, it takes but a few days to overcome this craving
+entirely.
+
+Usually it is easy to get people to confess that they are taking too
+much coffee. For some reason not easy to understand it is harder to
+get them to acknowledge that they are taking too much tea. Coffee is
+taken with a certain amount of deliberation. Tea may be and often is
+taken at odd intervals for friendliness' sake and sometimes patients
+do not know how much they are taking. Six or seven cups a day may be
+their usual quota, yet they do not realize it and at first are
+inclined to answer that they take it only two or three times a day,
+forgetting the little potations between meals. Tea is not so prone to
+cause wakefulness as coffee, yet the toxic irritant principle in both
+is the same and when the amount of tea and its strength are
+sufficient, the same results follow. The tea habit must always be
+given up if there is complaint of lack of sleep, especially early in
+the night.
+
+There is a very common persuasion that the eating of food in any
+quantity shortly before going to bed, and especially the eating of
+certain materials, will keep people awake. It is well known, however,
+that there are a great many people who can eat anything and sleep well
+after it and young children sleep best when their stomachs are full.
+There are undoubtedly idiosyncrasies in this matter that must be
+respected, but many patients are deceiving themselves. They are eating
+too little and their wakefulness is more due to the mental state than
+to anything else. As this contradicts a very prevalent impression, I
+may say that it is said deliberately and only after much experience
+with people inclined to be over-solicitous about their diet and their
+health generally and who were actually producing wakefulness or at
+least very light dreamful sleep, by their elimination from their diet,
+and especially from their evening meal, of many nutritious substances.
+I make it a rule to insist with patients that if it is more than five
+hours since their last meal they must take a glass of milk and some
+crackers or a cup of cocoa and something to eat before going to bed.
+This is particularly important if they have been out in the air much
+between their last meal and bedtime.
+
+{660}
+
+The Evening Hours.--The use of the hours after the evening meal is an
+extremely important factor with regard to insomnia. If the patient
+tries to read the paper or some conventionally interesting magazine or
+book, thoughts of the possibility of his not sleeping will surely
+obtrude themselves and he will fail to get to sleep when he lies down.
+As a matter of fact, he will have so disturbed himself as to
+predispose to insomnia. Some quiet occupation, interesting yet not too
+interesting, that diverts the mind from the thoughts about itself and
+about sleep possibilities, yet does not excite it, is the best
+possible auxiliary and preparation for sleep. Prof. Oppenheim has, as
+usual, said this very well in his "Letters to Nervous Patients," to
+which we have turned so often:
+
+  A great deal depends upon the right use of the evening hours. On no
+  account let yourself occupy them with anxious forebodings about the
+  night. But, on the other hand. It is not at present wise to take up
+  your mind with too exciting thoughts, as the strong after-impression
+  of feeling and fancy may counteract the tendency to sleep. You must
+  find out for yourself whether a quiet game (cards, halma, chess, or
+  patience), the reading of a serious or an amusing book, the perusal
+  of an illustrated paper, or a chat with a friend will be most
+  certain to give you that tranquillity of mind through the vestibule
+  of which you will pass into the temple of sleep.
+
+
+Direct Sleep Suggestions.--Many plans are suggested by which people
+are supposed to be able to get to sleep. A favorite and very old
+suggestion is that of counting sheep go over a fence or something of
+that kind that is merely mechanical, yet takes the mind from other
+thoughts. As a rule, any plan involving mental occupation that is
+meant to produce sleep is likely to react and do harm rather than
+good. Sleep must not be wooed deliberately but must be allowed to come
+of its own sweet will. It is extremely important that exciting
+thoughts and bothering interests be put aside, not at the moment when
+we want to go to sleep, but some considerable time before. This is not
+always an easy matter and often requires careful planning. It is worth
+while doing it, however, in order to secure sleep promptly and not
+allow a prolonged period to pass while one is lying awake, for if
+nervous irritability ensues wakefulness is still further prolonged and
+the patient may begin to toss and so disarrange the bedclothing and
+disturb himself as to prepare for several hours of sleeplessness which
+would not have occurred if there had been an appropriate interval
+given to preparing the mind for sleep.
+
+
+Diminishing Solicitude.--Patients must not be too anxious for sleep.
+If they worry themselves over the possibility of not sleeping then
+they will almost surely disturb their sleep, or at least delay its
+coming. The ideal state of mind is not to bother one's head about it,
+to lie down habitually at a given hour, compose one's self to sleep
+with assurance and then wait its coming without solicitude. Many
+people will say this is not easy to do, but habit makes it easy. Most
+of our animal life is lived by habit. We are hungry at certain times
+by habit. Our bowels move at a particular time by habit. We can sleep
+by habit. If we try to use our intellect solicitously with regard to
+any of these habitual functions we do much more harm than good. The
+more anxiety there is about sleep the more likely it is to be
+disturbed. When the habit of sleep at a particular hour has been
+broken the best way to regain it is to lie down at that particular
+hour and then wait patiently for {661} the advent of sleep. If
+impatience gets the better of us sleep is kept off and will not come
+for hours. If the patient can lie down feeling "Well, if I do not
+sleep now I will to-morrow morning" then there is usually little
+difficulty about sleep.
+
+
+_Dread of Consequences_.--Many people who suffer from insomnia fear
+that their loss of sleep will injure their intellectual capacity or
+make them prematurely aged, or drain their vitality so that they will
+not have health and strength of mind and body when they grow old. This
+adds to their solicitude about themselves and inveterates their
+condition. There is only one answer to this dread, which has no
+foundation in what we know of actualities, and that is, to tell them
+the experience of certain persons which absolutely contradicts such a
+notion. One distinguished physician who, at the age of seventy-five,
+is writing books that are attracting widespread attention and is doing
+an amount of work that many a younger man might envy, has told me of
+all that he suffered from insomnia between the ages of thirty and
+fifty-five. His mental productivity was much hampered at that time by
+his wakefulness and anxiety with regard to it. He feared the worst as
+regards advancing years, yet he is in the full possession of mental
+and bodily strength well beyond the Psalmist's limit. His is not an
+exceptional case, for there are many others in my own personal
+knowledge. Virchow once told me of years when he suffered from
+insomnia, yet he lived to be well past eighty and then died, not from
+natural causes, but from an injury. A man who accomplished an immense
+amount of work in his day in the organization of a great university
+suffered from insomnia in his younger years to such a degree that his
+friends and even he himself feared for his mental stability,
+eventually overcame this symptom completely and went on to years of
+great active work, dying in the end, not from his head, but his heart.
+We have records of a number of such cases. Few of the hard students of
+the world went through life without having some bother from insomnia.
+It is well-known, however, that many of the great thinkers,
+investigators and discoverers in philosophy and in science have lived
+long lives well beyond the age of the generality of mankind.
+
+
+Mental Diversion.--The main thing is to banish the thoughts of one's
+ordinary occupation as far as that can be accomplished without
+laboring so intently at this as to give the mind another bothersome
+occupation. Many people find that a game of cards just before going to
+bed takes their thoughts off business and worry almost better than
+anything else. Something like this is needed in many people. Most
+people must not write for some time before retiring, because writing
+proves so absorbing an occupation, as a rule, that the mind becomes
+thoroughly awake and then remains so for some time afterwards. Reading
+is better, but the reading must be chosen with proper care. An
+exciting story, for instance, may serve to keep one awake for hours,
+as everyone knows who has tried and found himself still reading at
+three in the morning after having begun an interesting book. The
+reading of works of general information, of travels, of description of
+places, where it is comparatively easy to stop at any place, of short
+stories which do not hold the interest beyond a brief period, is much
+better. Osler's recommendation to have a classic author beside one's
+bed to be read for a few minutes every night after retiring as a
+preparation for sleep is an excellent remedy for the milder forms of
+insomnia, as well as a stepping-stone to scholarship.
+
+{662}
+
+William Black in one of his books has a description of an old man who
+had suffered from insomnia very severely until he discovered a plan of
+his own to enable him to get to sleep. This consisted in reading the
+Encyclopedia Britannica. He began at the beginning and read straight
+ahead, article after article, and volume after volume. He never even
+by any chance departed from this routine either to look up cross
+references, or read anything further about men who were mentioned in
+the article he was going through at the moment and whose names
+occurred in another volume. He read straight on until his eyes got
+heavy and then he went to sleep. At the time he was introduced into
+the story he had already read the whole work through twice and was, I
+think, at "D" on the third reading. He had had considerable bother
+about getting to sleep before he adopted this plan, but it proved an
+always efficient somnifacients. There is a story about an old American
+farmer who said that he read the dictionary over and over again for
+the same purpose. The stories were short and disconnected, but they
+never bothered his sleep, while his wife and daughters were sometimes
+kept up more than he thought was good for them by their interest in
+the story paper.
+
+
+Treatment of Early Morning Wakefulness.--With regard to the
+disturbance of sleep in the early morning hours there are certain
+instructions to patients that have always seemed to me extremely
+important. Most of the patients who complain of wakefulness in the
+early morning hours are really suffering from hunger at that time.
+This is especially true with regard to those who stay up rather late
+at night. They have their last regular meal about seven or a little
+earlier, they get to bed at eleven or even later, and some of them,
+following the old maxim that eating before sleep is likely to disturb
+it, go to bed on an empty stomach. Whenever more than four hours have
+passed since the last meal the stomach is quite empty, and after the
+preliminary fatigue has worn off and the sleep has become lighter and
+the lack of nourishment more pronounced a vague sense of discomfort in
+the abdominal region wakes them, though most of them do not realize
+that they are disturbed by a craving for food. In a large number of
+these cases I have found that the recommendation of a glass of milk
+and some crackers, or some simple cake, just before retiring does more
+than anything else to lengthen sleep and prevent what has been
+learnedly called matutinal vigilance.
+
+After emptiness of the digestive tract, the most prominent cause of
+wakefulness in the early morning is anxiety about the hour of rising
+or about some engagement that has to be kept in the early morning. I
+have known patients who worked themselves up so much thinking over the
+necessity for rising at a particular hour to catch a train, that they
+were awake for several hours before they needed to be. Some are much
+more inclined to this over-anxiety than others. If they move to the
+country where trains have to be caught regularly, their sleep may be
+seriously disturbed by this circumstance. If the trouble becomes acute
+they must simply change their residence. If it is absolutely necessary
+that they stay, then they must have someone to wake them at a definite
+time. This must be someone on whom they can absolutely depend,
+otherwise the old solicitude will reassert itself. This seems a small
+matter, yet I have known serious cases of neurasthenia with annoying
+digestive symptoms due to nothing else than this morning wakefulness
+consequent upon overanxiety with regard to trains and other morning
+engagements.
+
+{663}
+
+Habits.--In the correction of troubles of sleep one of the
+difficulties that the physician has to contend with when patients have
+grown accustomed to staying up late and finally have so disturbed
+their sleep mechanism that symptoms of insomnia develop, is the
+declaration that there is no use for them going to bed early since
+they cannot sleep. If a man has been accustomed for a long period to
+go to bed between midnight and 2 a. m. and his habits are suddenly
+changed so that he goes to bed at ten or even eleven, it is very
+likely that for some time after retiring he will not sleep. If he
+grows over-anxious he may toss and become somewhat feverish and then,
+even when the accustomed time for sleep comes, he may not secure it.
+Besides, the depression consequent upon failure to sleep when he has
+fulfilled his physician's directions and when he knows that this is
+considered an important adjuvant in his treatment, acts as a
+distinctly discouraging factor. Under these circumstances it is
+important to recall to him that one habit can only be removed by the
+making of another. It may be necessary to send him to bed for awhile
+only an hour earlier than before until he has grown accustomed to
+going to sleep somewhat sooner, and then this habit, in turn, be
+changed to an earlier hour so as to secure all the sleep that is
+necessary.
+
+In a word, insomnia is not a definite affection to be treated by
+giving one or the other of one's favorite drugs, or if these should
+fail trying still others, but it is a condition of mind very often
+predisposed to by certain conditions of body. If this condition of
+mind can be adjusted by careful attention to the correction of
+whatever may be physically out of order, then there is every reason to
+look for definite improvement very soon and complete cure without any
+delay. Insomnia is not the awful ailment that it is sometimes
+pictured, nor all that it appears to the excited imagination of the
+young person who loses a few hours' sleep; but a manifold condition to
+be dealt with very differently in different individuals, according to
+the indications of the case. If the patient's confidence can be
+secured that means more than almost anything else that can be done. If
+a little patience is exercised in obtaining such definite details of
+the mental state and of certain physical factors as may seem quite
+trivial to the patient yet are really predisposing elements for his
+affection, the therapeutics become comparatively simple. It is the use
+of tact and judgment in this matter that means most, however, and then
+very few drugs will be required. Between the habits consequent upon
+the opiates and certain of the serious hemolytic conditions due to the
+abuse of coal-tar products, this is a consummation that may well be
+worked for assiduously.
+
+
+
+CHAPTER VIII
+
+SOME TROUBLES OF SLEEP
+
+
+Certain annoying incidents in connection with sleep annoy those
+affected by them so much as to arouse them very completely from sleep
+and make them wakeful for a time. Nothing disturbs most people so much
+as the thought that some passing incident, a little out of the common,
+is quite individual and peculiar to them. If they are at all nervous
+they are likely to think that it portends some serious ailment, either
+present or about to {664} develop. Nothing reassures them more than to
+learn that these incidents are not so uncommon as they imagine, indeed
+that many of them are quite frequent, and, above all, that many people
+who have had them are still alive and well beyond threescore and ten,
+and laughing at the fears of their earlier years.
+
+
+Starting.--Perhaps one of the most annoying of these incidental
+troubles is starting in sleep. It occasionally happens that just about
+the time a person is dozing off he suddenly starts and, almost before
+he realizes it, is fully awake, his heart beating emphatically and
+there may even be a little feeling of oppression on the chest. The
+cause is not the same in all cases and individual differences are
+worth investigating. In most people this starting means that there is,
+for the moment, some mechanical interference with the action of the
+heart and that a systole has been delayed and has been pushed through
+with more force than usual because of this delay. A full stomach will
+occasionally cause this, especially if patients lie on their left
+sides. In some people even a drink of water taken just before retiring
+will be sufficient weight to cause this interference with heart
+action. An accumulation of gas in the stomach will do it by pushing up
+against the diaphragm. Where there is a distinct tendency to the
+accumulation of gas in the stomach I have sometimes been sure that the
+expansion of the gas consequent upon the cozy warmth of the patient in
+bed, or its greater effect upon the stomach because the relaxation of
+sleep affected even the stomach walls slightly, was the cause of it.
+It happens more frequently in the old than it does in the young, but
+it is observed at all ages and patients are usually quite disturbed
+about it, as, indeed, they are likely to be with regard to anything
+that affects their hearts.
+
+The thought that this forcible beat must mean some serious
+pathological condition will obtrude itself on many people, and if it
+does sleep is sure to be disturbed. Even though there may be no
+discoverable lesion of the heart, these patients often, though they
+are physicians, will worry lest some underlying condition should be
+developing. The first patient who ever described this symptom to me
+told me of it while I was a medical student and he is still alive and
+in good health, though he is past seventy. At the time I went over him
+rather carefully with the idea that there might be an organic heart
+lesion, but found none. The prognosis of these cases is always
+favorable, for there are many who suffer yet live long. I have found
+if to occur particularly in elderly people when they were a little
+overtired on going to bed, or in anemic young people when they had had
+somewhat more exertion than usual during the day. Unless there is
+really some demonstrable heart lesion the start does not mean anything
+and patients can be reassured at once. They should be counselled
+against lying on the left side, though in some of them it will occur
+even while lying on the right side and then the mechanism of its
+production seems to be the gaseous over-distention of the stomach.
+Patients may be told at once that it occurs in a large number of
+people and then, instead of lying awake and worrying about it as they
+often do, they learn simply to place themselves in a more comfortable
+position and go to sleep again without solicitude. They would learn
+this for themselves in the course of time, but the physician's
+reassurance will enable them to anticipate the lessons of experience
+and they will thus be saved worrying.
+
+At times this starting from sleep seems due to some unusual noise. In
+{665} certain nervous states even slight noises produce an exaggerated
+reaction and there seems to be a surprising, almost hypnotic, acuity
+of hearing just at the moment when all the other senses are going to
+sleep. Any of the small noises that sound so loud in the stillness of
+the night may serve to wake the patient so thoroughly after a
+preliminary doze that sleep is disturbed for some time. As a rule,
+however, such noises would not disturb people if they were in normal
+healthy condition, or at least the disturbance would be only
+momentary. The solicitous effort that some people make to get away
+from every possible noise is an attempt in the wrong direction. We
+have heard of people building special houses, or noise-proof rooms in
+the center of houses where they hoped it would be impossible to be
+disturbed. What is needed is not so much an effort to secure
+absolutely noiseless surroundings, which is almost impossible in any
+circumstances, be it city or country, but to change the patient's
+physical condition so that slight noises are not reacted to so
+explosively. There are many general directions for this and certain
+drugs, as the bromides, are of distinct service. On the other hand,
+the taking of cinchona products seems often to emphasize it.
+
+I have found that two classes of nervous patients particularly were
+likely to be disturbed by these starts in their sleep. The first class
+is perhaps the larger. They are the patients who do not eat enough.
+They will usually be found to be underweight and to be nursing some
+thought with regard to their digestion, or some supposed idiosyncrasy
+towards food that is keeping them below the normal weight for their
+height. Nothing makes sleep lighter than a certain amount of hunger.
+This hunger may be disguised so completely, or so covered up by the
+patient's persuasion that more food cannot be taken without serious
+gastric disturbance, that it may pass utterly unnoticed. When such
+patients are disturbed early in the night, it usually means that
+besides taking a not quite sufficient amount of food they are taking
+more tea or coffee or some stimulant than is good for them. I say some
+stimulant because in several cases that I investigated rather
+carefully the cause seemed to be the alcohol taken with one of the
+largely advertised patent medicines, a supposed digestive tonic,
+consisting mainly of dilute alcohol, and really about as strong as
+whiskey. When the tendency to be startled occurs in the early
+mornings, then people need to eat something simple just before they go
+to bed.
+
+The other class of cases who are likely to start at night in their
+sleep are those who do not get out into the air enough during the day
+or who sleep in rooms insufficiently ventilated. At the beginning of
+the night the lack of ventilation makes the sleep light and easily
+disturbed. After a certain number of hours have been spent in a badly
+ventilated room the patient sinks into a rather deep sleep, which is
+likely to be dreamy, however, and then he is rather hard to waken, but
+wakes not feeling rested, but on the contrary often heavier and more
+tired than on retiring. In these cases an investigation of the amount
+of air the patient is allowing to enter his sleeping room or that his
+circumstances provide him with is extremely important. As for those
+who do not get out enough during the day, it is easy to understand
+that their sleep may be light. To them, as a rule, it will be a
+surprise to find how much depth is added to their sleep by an
+additional hour or two in the air. Commonly, people who do not get out
+much during the day are shivery and {666} suffer from cold, especially
+in the winter time, and so they are likely to keep their rooms rather
+tightly closed. In this case they have two reasons for a tendency to
+be wakeful, which is emphasized if there are noises near them or if
+there is anything that disturbs their sleep.
+
+In young children, of course, it must not be forgotten that starting
+in sleep may be due to the twitching pains of a beginning tuberculous
+joint disease. At times the children are so young, or the symptoms so
+vague and the tenderness, if there is any, so deep, that the real
+significance of this may not be recognized. The most successful
+treatment for these starting pains in children that has thus far been
+found, forms a striking commentary on what we have just been saying
+with regard to fitful sleep when ventilation is insufficient or when
+the patient has not been out of doors enough during the day. The
+children from the New York hospitals who in recent years were taken
+down to Sea Breeze during the autumn and winter and made to live in
+wards, the windows of which were constantly open so that the
+temperature was often below fifty, so that doctors and nurses had to
+wrap themselves up warmly and sometimes cover their heads and their
+hands, had all been sufferers from these starting pains before this
+experience, but gradually they lessened in frequency until after a few
+months the crying of a child at night because of these pains was
+extremely rare. The lesson is evident, and abundance of air not only
+cures tuberculous conditions, but also makes the nervous system so
+much less irritable that starting pains do not so easily affect it.
+
+
+Noise.--Slight noises often make it impossible for nervous people to
+sleep. This is much more a question of personal sensitiveness and
+anxious expectancy and over-irritability than anything else. One
+distinguished physician whom I knew was extremely sensitive to noise
+and would be awake for hours if wakened up early in the night by the
+slamming of a door or a call in the street or anything of the kind. He
+suffered from insomnia to a noteworthy degree and found to his
+surprise that he could sleep better on a train than anywhere else.
+After he had lost two or three nights of sleep he actually used to
+make arrangements to take a berth on an express train going out of his
+city, ride until the morning and then come back. He usually slept well
+amidst all the noise and jar of the train, though he would be quite
+sleepless at home as the result of even slight noises. I have known
+people suffering from insomnia who took a long ocean trip on a slow
+vessel and who slept well amidst all the noises of shipboard, but were
+light sleepers after landing, and felt that they missed the noise and
+bustle. Of course, in these cases the rocking movements sometimes
+predispose to sleep. It is not the custom now to rock infants to sleep
+and a very definite agreement seems to have been come to among
+pediatrists to forbid the practice as harmful. It is probable,
+however, that the instinct of the race in the matter was not at fault.
+Rocking seems to relax a certain tension of muscles that of itself
+prevents the brain anemia which is the physiological basis of sleep.
+It is extremely difficult for nervous people to relax themselves
+completely, and the rocking movements, by tending to help them in this
+matter, are excellent predisposing factors. A rocking chair or a
+hammock furnish abundant proof of this.
+
+Noise in general, as regards its relation to sleep, is an extremely
+individual matter. Habit plays the largest role in the matter. We all
+know the {667} stories of men who have gone to great expense in order
+to build noise-proof rooms and yet have found afterwards that they did
+not sleep well. The rustle of the bedclothes as their thoraxes rose
+and fell in respiration was enough to disturb them when they allowed
+themselves to become over-sensitive about noise. We all know how
+impossible sleep becomes with a rustle of a mouse in the wastepaper
+basket, or the scratching of one on the wainscoting. On the other
+hand, anyone who has lived in a large city where past hundreds of
+thousands of homes the elevated trains thunder every few minutes all
+during the night, or the trolley goes rolling by within a few feet of
+the bed, knows, too, that a great many people become accustomed to
+noises so as to be utterly undisturbed by them, though at the
+beginning any such insensitiveness to noise seemed out of the
+question.
+
+I remember having a patient who insisted that he could not sleep so
+near the elevated. At the end of a week he had lost so many nights of
+sleep that he was almost in despair. If he did get sound asleep he
+said he used to hear the thunder of the elevated train coming toward
+him in his dreams and he would begin to pull his feet up so as to get
+them out of the way of the train, yet always with the feeling that he
+could not get them quite far enough, until his knees were almost to
+his chin. Under the influence of a little bromides, two hours more of
+outdoor air than he had been accustomed to before, and some
+reassurance that noise need not disturb sleep at all if taken
+philosophically, he learned in the course of two weeks to sleep quite
+peacefully and now has lived for ten years where the elevated passes
+within ten feet of his window, which is wide open for seven months in
+the year and always at least slightly open, except in the most stormy
+weather. It is a question, then, of the individual much more than his
+surroundings. The problem is to predispose the mind to sleep and then
+the senses will not disturb it except under special circumstances.
+
+As a matter of fact, noises usually disturb people very little at
+night. The most surprising things can happen between 12 and 3 o'clock
+and attract no attention. Burglars calmly blow up a safe in a hotel
+confident that if there is no one awake when the explosion occurs
+there will be no investigation, because even though people wake up at
+the noise, they will wait for its repetition in order to see what it
+means, will not get up to investigate, especially in cold weather, and
+usually promptly go to sleep again.
+
+
+Lying Awake.--There are many people to whom lying awake carries with
+it a sense of discouragement and dread. They seem to forget that lying
+awake and occupation with pleasant thoughts may be made a very
+agreeable pastime by those who are not over-anxious to sleep and who
+let the pleasant thoughts that may be suggested by the environment or
+the noises that are heard flow through consciousness. Everyone knows
+how pleasant it is or may be to listen to the rain patter on the roof
+of a country house, or to hear the murmur of the ocean or of the wind
+through the trees when there is not too much anxiety about to-morrow
+and to-morrow's occupations and the necessity for sleep to be ready
+for them. Stewart Edward White, in his series of essays on "The
+Forest," has a chapter on Lying Awake at Night that can well be
+recommended to the attention of those who complain bitterly of an hour
+of sleeplessness. Of course, in his case the lying awake is in the
+midst of the forest with all the witchery of wind in the trees and the
+{668} unusual sounds of forest life, while ordinary lying awake is in
+the rather monotonous environment at home, but still there is much
+that can be said for his insistence that in peaceful brooding,
+faculties revive while soft velvet fingers are laid on the drowsy
+imagination and you feel that in their caressing vaster spaces of
+thought are opened up. The impatience that comes to so many almost at
+once if they fail to go to sleep promptly only serves to keep them
+awake just that much more surely.
+
+Very often, as suggested by Mr. White, this wakefulness occurs just
+when a good night's rest is surely expected. There is sometimes even a
+preliminary period of drowsiness. Then some little noise that
+ordinarily would not be noticed at all floats into the consciousness
+with a vigor that indicates that one sense is thoroughly awake. The
+very surprise of it wakes up the other senses with a start and then
+comes the thought that there is to be no sleep for some time. If this
+is resented, the period of wakefulness will be all the longer. If,
+when it has proved to be inevitable, one sits up quietly, reads a book
+for a time, plays a quiet game of solitaire, it may be on a board kept
+beside the bed for such purposes, or in some quiet way succeeds in
+bothering away the thought of insomnia, then almost surely sleep will
+come after a time, quietly and restfully, and the lost period will not
+prove harmful. If nature does not want to sleep she must not be forced
+into it, but gently led and after a time the wakefulness will
+disappear.
+
+
+Night Terrors.--One of the troubles of sleep that is more often called
+to the attention of the physician than almost any other, is the
+so-called "night terrors" of children. Little ones wake with a scream,
+sit up in bed, evidently terrified, usually trembling, and ready to
+seek refuge from something that has seriously disturbed them. Under
+Dreams we have called attention to the fact that usually these terrors
+are due to a dream. Sometimes the dreams are the ordinary experience
+of supposed falling in sleep, from which the patients wake very much
+startled, or they are repetitions of exciting scenes through which
+they have passed, or of stories that they have heard, or, above all,
+plays that they have seen. Ghost stories, for instance, told shortly
+before they go to bed will often disturb children. Fairy stories and
+the ordinary myths of childhood, usually with a happy ending and
+without any serious terrors in them, are not so likely to disturb
+them. Melodramatic theatrical performances to which children lend
+themselves and their attention with great concentration of mind, have
+nearly as much effect on them as if they passed through the actual
+scenes. Every physician knows how much a fright is likely to disturb a
+child and cause it to wake many a night afterwards in a state of
+terror.
+
+
+Respiratory Interference.--It is particularly important to remember
+that any interference with breathing will almost surely wake the child
+in a seriously startled condition. Adults are often affected by this
+same sort of dream, due very often to some pathological condition in
+the throat around which a series of dream ideas collect with somewhat
+poignant results. I have known a man suffering from elongated uvula
+wake up thinking that he was suffocating because, as he thought, he
+had nearly swallowed his tongue, or at least had been trying to do so.
+The sensation was so startling that it brought him to his feet at
+once. I have known a patient traveling a long five-days' railroad
+journey and suffering severely from train catarrh, come to the {669}
+persuasion that he might suffocate during sleep because his nose was
+completely stopped up and he had not the habit of sleeping with his
+mouth open. As a result his sleep was as much disturbed by his mind as
+his breathing. If these affect adults so strongly, it is easy to
+understand why children should be so frightened by them. Children who
+are mouth-breathers from adenoids or nasal obstruction, and still more
+those whose nasal breathing apparatus is not completely stopped up,
+but who are frequent intermittent mouth-breathers, are especially
+likely to be troubled in this way. The neurosis known as nervous
+croup, due to a spasm of the vocal cords, occurs oftenest in this
+class of children and is an associated phenomenon to that of night
+terrors.
+
+
+Sleeping in the Light.--The habit of accustoming children to sleep
+with a light in the room nearly always lessens the depth of their
+sleep. They are more easily wakened and their sleep is not so
+refreshing. Besides, if they do not grow accustomed to the dark when
+they are young, they may always retain a dread of the dark and will
+require some light in the room where they sleep. Nature intended that
+the eyes and the optic nerve should have as complete a rest as
+possible and even with the lids lowered some light stimulus, if it is
+present, finds its way to the nerve fibers. Hence the desirability of
+having as far as possible an absolutely dark room. For some very
+timorous children, this may seem impossible. Many mothers will recall
+how awful the dark seemed to them and what shadowy shapes loomed up in
+it. It will usually be found on inquiry, however, that in these cases
+the children, after having been accustomed to sleep with some light
+and after having had all sorts of exciting pictures shown them and
+stories told them, were asked to sleep in the dark. From the very
+beginning they should be accustomed to sleeping in the dark and then
+it has none of the terrors thus pictured.
+
+
+
+CHAPTER IX
+
+DREAMS
+
+
+Dreams, that is, thoughts and illusions and mental phenomena of
+various kinds that occur during sleep, have always been interesting to
+the psychologist, and have usually been related to physicians by
+patients either because they were thought to have a significance
+related to disease, or because something in them disturbed the
+patient's mind. This is almost as true in the modern time as it was
+long ago. It is curiously interesting to note that the very latest
+development of psychotherapy includes the use of hints obtained from
+dreams in order to determine the origin of psycho-neurotic conditions
+and certain of the minor psychic disturbances, and also as a
+foundation for treatment. The oldest stories of therapeutics that we
+have are those of patients waited on by the priest physicians of the
+olden times in the temples, who were supposed to be greatly helped by
+information obtained from the patient's dreams. It is interesting to
+read such recent studies as that of "Incubation in the Old Temples,"
+by Miss Ingersoll, with the thought in mind that we are once more
+analyzing dreams in order to accomplish a similar purpose.
+
+{670}
+
+Dreams are so often a source of disturbance of mind for patients, lead
+to such disturbed sleep, or even so affect the bodily health that it
+is important for anyone who wants to influence patients through their
+minds to know the significance attributed to dreams by the most recent
+studies of them. This is all the more important because dreams are
+such a universal phenomenon. From our earliest years we dream. The
+night terrors of children are probably due to dreams and show that
+even as early as the age of three we dream vividly. Doubtless some of
+the terrifying dreams of childhood are similar to those that we
+experience later. Dreams of falling, dreams of being cold, of being
+out of breath, with vivid repetitions of exciting scenes through which
+they have gone during the day, or which they have seen in picture or
+been told in story, form the substance of these dreams. Children are
+likely to be much disturbed by them. They wake in a terror of anxiety,
+in cold sweat, and crying bitterly because of their dream visions.
+Older people are not so much disturbed at the moment, but often brood
+over dreams and may be seriously affected by them.
+
+It is difficult, however, to persuade many people that their dreams
+have no special significance, either of present or of future evil, and
+to many the fact that they dream much becomes a suggestion of
+wakefulness that disturbs sleep and makes them quite unequal to the
+next day's work, because they have the feeling that, as they have been
+dreaming all night, they must be quite tired. Tiredness in nervous
+people is often a matter of the mental state rather than of physical
+exhaustion or genuine mental weariness. The actual place of dreams in
+psychology, then, becomes an important consideration in
+psychotherapeutics.
+
+Our real advances in the knowledge of the significance of dreams have
+come from the study of the dreams that are common to most people.
+These show us exactly how and why dreams occur and just what their
+meaning is. Probably the most familiar dream common to all the human
+race is that of falling from a height. Everyone has been wakened with
+a startled sense of intense relief that the sensation of falling was
+illusory. The waking came just before the bottom was reached. There is
+a tradition that if one ever did strike the bottom in one's dream it
+would be the end and that death would result as surely as if the fall
+were real. So far we have had no one come back to tell us of that, and
+the tradition is reasonably safe from direct contradiction. It serves
+without any reason, however, to disturb timorous people and make them
+dread to fall asleep again. Often this dream-falling so seriously
+affects sensitive individuals that they do not get to sleep for an
+hour or more and occasionally those with an inclination to insomnia
+may even suffer for the rest of the night from the effect of it. It is
+important to explain, then, what we know about the causation of the
+dream. In nearly all cases the subject on waking finds himself on his
+back, and then the inclination is at once to turn over to the side
+with a sigh of relief. Commonly the dream occurs rather early in the
+night, when a rather heavy meal has been taken shortly before
+retiring. The weight in the stomach, particularly if considerable
+liquid has been taken, seems to press upon the abdominal aorta and
+interferes, to some extent at least, with the circulation to the legs.
+This deprives little nerves at the periphery of the body of some of
+their nutrition and causes a tingling feeling in them. This is quite
+different from pressure {671} on nerves, which gives the sensation
+termed "being asleep" to a limb. This tingling feeling resembles that
+which we experience when going down rapidly in an elevator. It is the
+falling sensation. This sensation tries to force its way into the
+consciousness and in this process does not completely wake
+consciousness up, but brings about an association of ideas connected
+with falling--hence the dream of being on a height and of falling
+therefrom out of which we wake so startled. The whole process instead
+of being injurious is really conservative. It is important that the
+aorta should not be pressed upon and this is the mode by which
+awakening is brought about and the position shifted so that further
+interference is stopped, though we ourselves are quite unconscious of
+the real purpose that has been accomplished. An explanation of this
+kind usually makes people who suffer from such dreams and have been
+disturbed by them much more tolerant of the phenomenon and more ready
+to go to sleep again, since evidently nature can be trusted to care
+for them even during sleep.
+
+After the sensation of falling probably the commonest dream that
+humanity has, at least in the civilized state, is that of being out in
+some public place without sufficient clothing. Usually we wake just to
+find that some portion of our anatomy has been exposed to the air and
+that it is cold. It is this sensation gradually forcing its way into
+consciousness that has gathered around it a group of ideas that form
+our dream.
+
+Among men, a familiar dream is that of running for a car, or away from
+something, or to catch someone, and finding that it is almost
+impossible to move. We are so out of breath that we are scarcely able
+to drag one foot after another and, indeed, sometimes we seem to be
+actually rooted to the spot. We cannot move at all. When we wake after
+this dream we find that, because of a cold in the head, our nose is
+stopped up by the secretion and that our mouths are shut and
+consequently we were getting no air. When that sensation tries to
+break into the consciousness there gather around it certain familiar
+ideas usually associated with being out of breath and hence we have
+the dream of trying to run without being able to move.
+
+
+Frequency of Dreams.--Nervous people often complain that they dream
+all night or else very frequently, and that as a consequence their
+sleep is not restful. It is probable that there are always ideas in
+the mind and that literally we dream without ceasing. These ideas,
+however, do not get into our consciousness except just during the
+process of waking. All those who have investigated the subject of
+dreams are practically agreed on this. In subsequent paragraphs we
+quote a number of good observers on this subject. Certainly this is
+what we should expect from what we all know about day-dreaming. We can
+never catch ourselves during the day without finding some thought
+wandering through our minds. If we want to understand dreaming during
+sleep this day dreaming is instructive. We jump from one idea to
+another, apparently without a connection; yet there is always some
+connecting link. We have just read in the paper of someone in Cairo,
+and we think of old Egypt, and then of old Babylonia, and the Code of
+Hammurrabi, and the laws of the Medes and the Persians, and Xenophon
+and our school days, and of an old schoolmaster now a missionary in
+Japan, and of Japanese art and of an American artist much influenced
+by it, and of one of his great windows in a church in New York and of
+social work in connection with that church, {672} and of settlement
+houses and then Hull House, Chicago, and then of the Adamses in
+Massachusetts, and so on.
+
+Thus, also, do our minds go flitting round apparently during the
+night. We remember only such things as are brought into our
+consciousness directly and emphatically during the process of
+wakening. During our day dreaming we recall only those things which
+for some reason led us to think consciously about them and then follow
+out our thoughts to definite conclusions. It is an interesting study
+to follow back our day dreams through their wanderings to the origin.
+As a rule, however, we lose track of the connections and after a time
+remember only some of the wonderful transformations and
+transmigrations of thought; and so it is in our dreams.
+
+With regard to the frequency of dreaming. Sir Arthur Mitchell in his
+book "Dreaming, Laughing, and Blushing" (London, 1905), insists on the
+great probability of the constancy of our dreaming during sleep. He
+says:
+
+  It seems to me that there is no such thing as dreamless sleep.
+  During the whole continuance of sleep, the mind, I believe, is
+  occupied with a certain kind of thinking which works round what I
+  have called hallucinations. I do not expect to be able to prove the
+  correctness of this opinion as to the persistence of dreams all
+  through sleep, but I think that it can easily be shown to be
+  possibly correct. I go further, and say that many things show that
+  it is probably correct. I may not be able to prove absolutely its
+  correctness, but it is proper to bear in mind that it is quite as
+  difficult to prove absolutely that it is not correct. My difficulty
+  is frankly avowed. Many things, however, are taught in biology as
+  being certainly true. In regard to which a like avowal could be made
+  but is not made. There is what has been called a "conjectural
+  biology."
+
+  We do not and we cannot remember much of what we have been thinking
+  about while we are awake. This is unquestionably true in a large
+  sense. But, nevertheless, we do not doubt that we have been thinking
+  continuously. We do not suppose that at any time all thinking had
+  ceased, though we may be completely unable to recall what it was
+  about.
+
+He shows further that many writers on dreams and careful students of
+the subject in the past have come to the same conclusion. Robert Dale
+Owen, for instance, deliberately endeavored to find out whether he had
+always been dreaming just before he awoke. After months of observation
+he records that in every instance he was conscious of having dreamed.
+Hazlitt, a century ago, tried the same thing for a prolonged period
+and notes that whenever he was waked, and immediately recollected
+himself as to possible dreaming, he was always aware that he had been
+dreaming. Sir Arthur Mitchell himself has tried this same experiment
+on himself and for a considerable time has scarcely ever failed to put
+to himself this question about dreaming when he awoke and always got a
+satisfying affirmative answer. Personally, for several years, I have
+been interested enough in this subject to recur frequently to it
+immediately on awaking and I cannot say that I have ever, under those
+circumstances, failed to find that there had been some vague dream
+fancies at least running through my mind before I was fully awake.
+This opinion as to the constancy of dreaming during sleep has many
+authorities in its support. Sir Arthur Mitchell has quoted a number,
+some of them distinguished physicians, who add the weight of their
+testimony to this view:
+
+  It is not a new thing to hold that there is no sleep without
+  dreaming--in other words, that dreaming goes on unceasingly all
+  through sleep. I have stated my own {673} opinion strongly, but the
+  same opinion has been nearly as strongly expressed by others. Sir
+  Benjamin Brodie, for instance, may be said to express it when he
+  writes, "I believe that I seldom if ever sleep without dreaming."
+  Sir Henry Holland expresses it still more plainly when he says: "No
+  moment of sleep is without some condition of dreaming." Goodwin says
+  much the same thing when he asserts that "sleep is not a suspension
+  of thought"--in other words, that dreaming is sleep-thinking. Dr.
+  John Reid still more clearly holds the opinion, though he does not
+  furnish me with a short apt quotation. Hazlitt, too, may be taken as
+  holding that there is no such thing as dreamless sleep.
+
+ Descartes and his followers may, perhaps, be regarded as holding that
+ the mind is unceasingly at work in sleep--even in the "profoundest
+ sleep," though "the memory retains it not," and Isaac Watts says that
+ "the soul never intermits its activity," and that we may "know of
+ sleeping thoughts at the moment they arise, and not retain them the
+ next moment."
+
+  Hippocrates, Leibnitz, and Abercrombie have also been quoted as
+  holding that there is no dreamless sleep, and so far as they express
+  themselves on the subject they appear to do so.
+
+A strong weight of opinion in all ages favors the view that during
+sleep dream-thoughts are constantly running through our mind, though
+we recollect only those which are impressed upon us at the moment of
+awaking. We do not even recall those unless, for some reason, we have
+paid special attention to them. That is just exactly what is true of
+day dreaming. After it is over we have no idea at all of the thoughts
+that occupied our minds for hours, though we are all aware that at any
+given moment, if we turned our consciousness inwards we found that
+there was something that we were thinking about.
+
+
+Short Duration of Dreams.--This view of the constant occurrence of
+dreams during sleep is confirmed by other things that we have come to
+know as to dreams and dream states. Probably the most interesting of
+these is with regard to the length of dreams. As our memory of dreams
+is only such as we have from the thoughts of sleep getting into our
+consciousness just at the moment of awaking, dreams are never as long
+as they sometimes seem to be. As a matter of fact, they occupy but a
+few moments, though in that time a long story may seem to unroll
+itself. Probably nothing gives more assurance to people who are
+persuaded that they are losing much rest because of their dreams than
+this explanation of the brevity of the phenomena. Nervous people wake
+frequently. Whenever they wake they find themselves dreaming. As a
+consequence, they acquire the persuasion that they have been dreaming
+"all the night long," and it is not hard for them to suggest to
+themselves in the early morning that they are not rested. Nervous
+people seldom feel rested in the early morning, it is their worst
+time, and with the occurrence of dreams as a suggested reason for
+this, they exaggerate the feeling of tiredness with which they get up.
+A frank discussion of this question of the duration of dreams is often
+the best possible therapeutic auxiliary for such cases. It gives them
+a new series of suggestions and, above all, relieves them of
+unfavorable suggestions.
+
+Prof. Maury of the University of Paris tells a striking story of a
+very brief dream of his own which shows how short may be the time
+occupied by what seems surely a long dream. He had been reading before
+going to bed a very striking book on the Reign of Terror. He dreamt
+that he himself was arrested during the Terror, taken to prison, that
+his name was called on the list of the condemned, that he was carried
+to the guillotine, fastened to the {674} board, pushed beneath the
+knife and that he woke just as the knife struck his neck. Of course he
+awoke with the usual sense of thankfulness and relief that comes at
+such times. When he awoke he found that a light curtain rod had fallen
+from the bed above him and had struck just across his neck. His dream
+evidently had all come to him during the extremely short time
+necessary for him to become fully awake after the rod had hit him. His
+mind was occupying itself with the history that he had read before
+going to bed. When the rod struck him the long story of his arrest and
+imprisonment, the journey to the place of the guillotine and the
+preparations for execution, all came to him as a series of rapid ideas
+during his coming to consciousness.
+
+It is probable that most of our dreams are not much longer than this.
+One of my earliest recollections is of an old gentleman coming into
+the country school during my first year as a pupil and telling us the
+story of a dream of his of the night before quite as brief as that of
+Professor Maury. He had fallen asleep after dinner in his chair and,
+having a cold that stopped up his nose and his mouth being shut, he
+had the usual dream of being out of breath from running. It took him
+back to the story of the massacre of Wyoming, near the scene of which
+the school was situated. He dreamt that for hours he had been running
+away from the Indians and seemed at last utterly unable to escape them
+because he was out of breath. He made such efforts in his chair that
+his wife awakened him and then he found that he had been asleep
+altogether only a very few minutes.
+
+
+Significance of Dreams.--Many people are quite sure that their dreams
+have a definite significance quite apart from any mere wandering of
+the mind or the suggestion of half-waking and the ideas that gather
+round sensations not fully in the consciousness. A number of people,
+for instance, have dreams of events that are happening at a distance
+at the moment that they dream. The Psychic Research Society of England
+has gathered a number of these and it is indeed difficult to
+understand many of them. There seems no doubt, however, that in many
+cases there is an illusion of memory, by which, after an event, dreams
+that might be taken to refer in some vague way to the happening, are
+clothed with a wealth of detail which appears to make them wonderful
+premonitory representations of future events or repetitions of
+simultaneous events. One of the most familiar of this form of dreams
+is what has been called a phantasm of the dying. People dying at a
+distance seem to have some wonderful power of making themselves appear
+to very near friends, especially brothers and sisters, and, above all,
+twins, and to friends with whom they have been very intimately
+associated. Occasionally such phantasms are seen during waking hours,
+or what are supposed to be waking hours, though it must not be
+forgotten that dreams may come very easily and almost unconsciously in
+short naps, but much more frequently in what are known to be dreams.
+
+Nearly always these partake of the nature of the ordinary dream, as
+can be seen by a careful analysis of their conditions, and are mere
+coincidences occupying a very brief space of time. A typical example
+of this is to be found in one of the stories told by Camille
+Flammarion, the French astronomer, in his book "The Unknown." A young
+man who had fallen in love with a young woman was deeply grieved to be
+parted from her by the injunction of parents. Separated by a long
+distance, they kept up a clandestine {675} correspondence for more
+than a year. For a considerable period, however, he had not heard from
+her, and he was beginning to be anxious lest anything had happened to
+her. One night she appeared to him in a dream in his room in white
+garments with a pale face and, placing her cold hand in his, she bade
+him good-bye. He awoke with a start. He found it difficult to sleep
+and was very anxious about her. The next day he learned that she had
+died the night before and concluded that his dream was a last message
+from her. The end of the story, however, as it is told, spoils this
+nice sentimental conclusion. When he awoke he found he had in his hand
+a glass of ice water which had been standing on the table beside him.
+The grasping of this had awakened him. During the awakening process
+the thoughts of her in his mind gathered round the cold sensation in
+his hand and gave him the dream of her and the last farewell.
+
+There are many instances in which dreams of future events seem to come
+true. Indeed, so many of these stories have been told that it is hard
+to persuade some people that dreams have no meaning and can have no
+meaning. By this we mean that they can by no possibility represent
+prophetic foresight. What patients need to be made to understand is
+that dreams represent only straggling sensations trying to get into
+our consciousness, just barely succeeding, and then arousing trains of
+ideas unconnected in themselves, but which we connect afterwards when
+we recollect our dreams. This whole subject has been studied so
+thoroughly in Maury's work on _"Le Sommeil et les Rêves"_ about the
+middle of the last century and Freud _"Ueber den Traum"_ and Sante de
+Sanctis' _"I Sogni"_ Turin, 1899, at the end of the century, that
+there can be no further doubts about the matter for those who are open
+to conviction. Most people, however, want to believe that their dreams
+mean something. They like to think that they are in some way picked
+out from the multitude and that their dreaming has a significance more
+than is accorded to other people. It is, indeed, this
+self-centeredness that makes for the belief in premonitions and
+prophetic dreams and, as in all cases, these feelings work out their
+own revenge.
+
+If they will listen to reason, however, most people may be rather
+readily convinced that their dreams cannot have any serious
+significance. In the chapter on Premonitions we have already called
+attention to the situation that exists with regard to the possibility
+of future events giving information of themselves in advance of their
+happening. Simultaneous events may perhaps in some way give warnings.
+The possibility of action on the mind at a distance, especially where
+minds are involved, has been discussed and admitted. The cases in
+which it is supposed to have happened are, to my mind, all dubious and
+are mere coincidences. For future events, however, there is no
+possible physical explanation. When we turn to explanations in the
+borderland between spirit and matter we find nothing satisfactory. The
+future event exists nowhere. No spirit even knows it; it is dependent
+on human free will. To the Creator it is known only as a contingent
+possibility dependent on free will. The information does not come from
+Him, for then there would be more design in these incidents. Such
+dreams would effect some serious purpose, while usually they have but
+minor significance in the stories as told and they often concern only
+the most trivial things.
+
+What is thus true of premonitions can readily be applied to dreams.
+{676} There is no reasonable source of information with regard to
+future events. What, then, are we to say of the dreams that come true?
+There is no doubt that dreaming is extremely common. Probably, as was
+said, we never sleep without dreams. There are a billion dreams at
+least, probably many billions of dreams every night, then, in this
+little world of ours. When these are startling they cling to us. It
+would be surprising if some of them did not come true. Indeed, it is
+inevitable, according to the theory of probabilities, that some of
+them will connect themselves directly with future events. We have a
+few thousands of such startling coincidences in the history of the
+race. Out of these have been made all the data supposed to underlie
+the teaching that dreams have a prophetic significance. It is much
+easier to understand with regard to dreams than even with regard to
+telepathy coincidence explains all the supposedly wonderful warnings
+of events that actually happen after we have had apparently
+premonitory dreams.
+
+An interesting example of a premonition that did not come true, the
+subject of which was sure that it was a waking premonition and not a
+dream, though it seems more likely that it was as suggested by the
+narrator a sleep vision, is told by Sir Arthur Mitchell in his
+"Dreaming, Laughing, Blushing" (London, 1905). A number of scientists
+who discussed the story declared that if it had only come true it
+would have been one of the most startling manifestations of
+premonition and of the clairvoyant power of dreams, or at least of
+their telepathic significance, that we have ever had. It involved so
+many distinguished scientists that there could have been no doubt
+about it. It was so detailed and those details were known to so many
+authorities in science, that it would have carried great weight and it
+would have been extremely difficult to have people accept it as a
+mere coincidence. It is easy to see now after the event that, if it
+had been fulfilled, it would have been, in spite of its startlingness,
+a mere coincidence. Since it was not fulfilled, however, it represents
+one of the best evidences that we have for the insignificance of
+premonitory or telepathic dreams.
+
+  Sir William T. Gairdner, K. C. B., whose interesting typhus delirium
+  experience appears in the paper by Professor Coates on "Sleep,
+  Dreams and Delirium" (_Glas. Med. Jour.,_ Vol. xxxviii, 1892, pp.
+  241-261), has written to me about his dreams generally, and he
+  concludes his letter with the narrative of a dream, which, as he
+  correctly says, "if it had only fulfilled itself, might have become
+  famous." He prefaces the narrative by this statement: "In all my
+  individual experience, now extending over more than the usual term
+  of life, I have never met with anything suggestive in the remotest
+  degree of telepathy or second sight, or of dream prophecies or any
+  other fact bearing on the marvellous." He then goes on to tell the
+  dream to which I have referred. "In crossing the Atlantic In 1891,"
+  he says, "in delightful weather and perfect bodily health, and
+  without a shade of anxiety on my mind so far as I was aware (in
+  waking consciousness), I was suddenly aroused in the very early
+  morning, say, three or four a. m., out of a perfectly sound, and, as
+  I should call it, dreamless sleep, by the apparition of a telegram
+  written on the usual paper, and presumably from home, in these
+  words: 'Miss Dorothea died at ----,' all the rest being blurred and
+  indistinct, but these words having a startling distinctness and a
+  vivid sense of reality. I was not, I think, in the least degree
+  alarmed at first, and certainly had no superstition about it on
+  discovering that it was only a dream; but, failing to get any more
+  sleep, I rose early, took my bath as usual, and went on deck, where
+  I had to repeat the story of my dream to each one of some three or
+  four companions who were on board, of whom I will only mention Sir.
+  John Batty Tuke, Professor Young of Owens College, and Professor
+  {677} Cunningham, then of Trinity College, Dublin. Any of these
+  gentlemen will confirm my saying that I attached no special
+  importance to this dream in the way of a scare or a superstition,
+  but in this way it got abroad to a certain extent within a small
+  circle on board in such a way as would have ensured it a widespread
+  fame had it only come true. In discussing the matter at breakfast I
+  remarked (alluding to telepathy) that the telegram was clearly,
+  judging from its terms, not from my wife or any member of my
+  immediate family, and could only have been despatched by a servant
+  or some one with whom I could not be supposed to be in telepathic
+  rapport. From this point of view it clearly refuted itself, and yet
+  the effect upon my mind was such that, upon arriving at New York, I
+  at once despatched a telegram announcing my arrival and making
+  inquiry, the reply to which showed that the family were pursuing a
+  quite undisturbed course at St. Andrews."
+
+  Sir William describes himself as aroused out of sound sleep by the
+  apparition of a telegram, but I think this only means that he became
+  suddenly awake on seeing the telegram during sleep. He does not say
+  whether he knew in his dream that he was a passenger on a great ship
+  on the mid-ocean, but he says that the telegram was written on the
+  usual paper by which I take it that he means the paper used here on
+  shore.
+
+  If it happened that the death of Miss Dorothea took place about the
+  time of the appearance of the telegram to so distinguished a man as
+  Sir William in his sleep, I scarcely think there would be any more
+  startling record of a so-called telepathic message. But most happily
+  the death did not take place, so that the story of the dream will be
+  forgotten. Tens of thousands of similar dream stories have that
+  fate.
+
+
+Children's Dreams.--There is an old tradition that to tell our dreams
+causes them to come back, or at least to recur in some other form.
+This tradition is so old and so universal that probably there is more
+in it than might at first be thought. This emphasizing of certain
+forms of unconscious cerebration probably encourages their repetition,
+or, at least, the repetition of further processes of the same kind.
+There seems to be no doubt, too, that the reading of certain kinds of
+imaginative writing and the looking at exciting pictures sometimes
+leads to dreams about them. Certainly children should not be told
+terrifying stories and the more nervous they are and the more affected
+they are by such stories, which to some people make renewed
+temptations to tell them, the more should they be avoided.
+
+Any physician who has had much experience with city children,
+especially in New York City, is likely to know how exciting, tragic
+and, above all, melodramatic scenes serve as the basis for disturbing
+dreams and night terrors. They will not, of course, in vigorous,
+healthy and strong-minded children, but these are the ones who are
+most prone to play out of doors and so are likely to be less bothered.
+Just the nervous, old-fashioned, delicate children who prefer the
+theater to sports of other kinds, are likely to be most affected in
+this unfortunate way. The scenes become so real to children that they
+impress them very deeply and are readily rehearsed in the unconscious
+cerebration of sleep. Many a child sees in its dreams someone, often a
+near relative, fastened on the carriage of a sawmill and inevitably
+approaching a buzz-saw, or fastened inextricably to the rails while an
+express train thunders down on them. That they should wake up with a
+start and a scream of terror and lose most of their night's sleep and
+disturb that of others, is not surprising. It is well known how
+witnessing actual danger, as of an automobile accident, or a railroad
+wreck, disturbs a child's imagination for long after; and its theater
+experiences are almost as actual as the reality.
+
+{678}
+
+Many of the colored supplements of Sunday newspapers seem to be
+particularly undesirable literature for children in this respect,
+though, of course, there are many other reasons why children should
+not be encouraged to look at them. It is not unusual for the
+newspapers to give lurid pictures of wonderful dreams or things that
+happen in dreams. This is undoubtedly a suggestion that acts in
+causing nearly all children, but especially those of nervous
+organization, to dream much more than would ordinarily be the case. It
+recalls the old warning about telling dreams. These sets of pictures
+certainly serve to develop the imagination of the child along
+undesirable lines. Possibly some of them which emphasize the fact that
+after eating certain very undesirable foods, dreams are much more
+likely to come than at other times may not be without their
+prophylactic sanitary value, but this is a doubtful advantage compared
+to the psychic harm that they bring. I am not of those who would limit
+the fairy stories and other pleasant essays in imagination which
+delight children so much and form a desirable part of their education,
+but artistic effort that is terrifying or deterrent, whether with pen
+or brush, should be kept away from them until after their mental
+control is well established. Children will probably dream anyhow, and,
+therefore, should have a pleasant fund of imaginative material as a
+basis for their dreams.
+
+
+
+CHAPTER X
+
+DISORDERS OF MEMORY
+
+
+Many patients suffering from various nervous symptoms insist that they
+are losing their memory or that it is becoming notably deficient in
+some ways. If they are a little on in years they are sure that their
+memory is not as good as it used to be and that they now forget many
+things that were formerly remembered without difficulty. Especially
+are they likely to assert that the names of people and certain words
+will not come to them when they want them, that they often have to
+seek for facts and dates that should be quite familiar, that they fail
+to remember acquaintances and the like. These symptoms of which they
+complain are often sources of considerable worry and serve to
+emphasize in them the idea that there is something serious the matter
+with their general health, or some pathological condition developing
+in their brain. They have heard much of loss of memory as a sign of
+degenerative nervous diseases and they are prone to think that their
+own special loss of memory, be it real or imaginary, must be a
+forerunner, or perhaps even an early symptom, of some important
+organic lesion.
+
+This idea of progressive memory disturbance as a preliminary of
+nervous breakdown often becomes so firmly fixed as to be of itself a
+profound source of anxiety to patients, and an almost unspeakable
+dread. So it is important to make them understand what the real nature
+of their condition is and what their loss of memory, supposed or real,
+is due to. As a matter of fact, what many of these patients need is
+not treatment for a diseased memory, but reassurance from what we know
+about the psychology of memory, that their troubles are only quite
+natural incidents in the life history of their particular memory {679}
+faculty. Many a man who is worrying about his supposed loss of memory
+or, at least, impairment of it in some way, is not suffering from a
+true pathological condition, but is usually the victim only of some
+functional disturbance of the nervous system with the neurotic anxiety
+and heightened introspection that accompanies such a condition.
+
+
+Reasons for Memory Difficulties.--Nervous patients particularly
+complain that they do not remember what they wish to as easily as they
+used to a few years before. They say that it is much more difficult
+for them to impress things upon their memories and, in addition, that
+it is much easier for them to forget. There are three quite natural
+reasons for these phenomena as far as they actually exist, which
+should be pointed out to these patients. The first and most important
+is that they are incapable of that concentration of mind which they
+had in earlier years and which enabled them to give themselves up so
+completely to the consideration of a particular subject that it could
+not help but be impressed on their minds. They are now so much
+occupied with many other things, and, above all, most of these
+patients are so preoccupied with themselves that they cannot hope to
+have the concentration of mind that was comparatively easy when they
+were younger and is now impaired, but which is so necessary for the
+enduring remembrance of things. Secondly, their over-anxiety to
+remember things sometimes acts as an inhibitory motive in securing
+that deep, impression that will enable them to remember details very
+well. Thirdly, their supposed impairment of memory is due to a false
+judgment with regard to themselves. They are not comparing their power
+of memory now with what they used to have, but owing to anxiety about
+themselves they have taken to comparing themselves with others and,
+after all, the faculty of memory acts very differently for different
+people and it is well known that what one man remembers with ease
+another recalls with difficulty, or only because of special attention.
+
+
+_Attention and Memory_.--The first of these causes for supposed
+impairment deserves to be discussed further. It is often said that as
+we grow older our memory is not so retentive as it used to be, and
+that while we remember the events of boyhood and the things we learned
+in the early years of school life, our recollection of recent events
+and things learned in later years is much less vivid. This is all very
+true, but the reason usually given, that in the meantime our memories
+have failed in power is inconclusive. What we learned in early
+childhood came to us with the surprise of novelty and for this reason
+we paid close attention, it was new and impressed us with its
+importance, it was dwelt upon for long periods and often, because
+there was little else to think about, has been frequently recalled
+since and, of course, is indelibly impressed upon our memories. The
+same thing is true with regard to early acquaintances. We got to know
+them so well that, of course, we cannot forget them. What we have
+learned in later life, however, has come in the midst of many other
+things, has not been dwelt on very long, has not been often recalled
+and, of course, occupies much less place in the memory than the things
+of earlier life. That is not, however, because of any defect in
+memory, but because of lack of attention and repetition that means so
+much for memory.
+
+
+_Age and Memory_.--It is often said that people do not learn so
+readily when they get older. This is, of course, a truth of common
+experience, but {680} it is not because of dullness of the faculty of
+memory, but failure to concentrate the attention sufficiently for
+memorizing. I have known old men who could learn things just as well
+as any young man and indeed better than most of them. They were men
+who had been accustomed all their lives to concentrate attention on
+the subject they had in hand and who did not allow the cares and
+worries of life to intrude on their studies. Cato learning Greek at
+eighty is often quoted as an exceptional example, but I have had some
+dear old friends who could learn things quite as readily as younger
+men and whose minds were just as bright and clear. Whenever they
+devoted as much attention to anything that they wanted to remember as
+they did when they were younger men, I am sure that they remembered
+quite as well. It is a question of attention and not of any loss of
+faculty that makes the difference between the memory of the young and
+the old until, of course, senile impairment actually comes.
+
+
+_Solicitude and Memory_.--Everyone who has had to depend much on his
+memory knows that over-anxiety with regard to the recollection of
+anything may seriously inhibit the power to recall it. Public speakers
+know that to hesitate is to be lost. If they want a particular name or
+word which they know often escapes them, they must with confidence
+begin the sentence in which it is to occur, though perhaps wondering
+all the time whether the word will be on hand or not for them to use
+it. Occasionally it will not come, but as a rule it turns up just in
+time. If they allow themselves to be disturbed by the thought that the
+word or expression may not come, then they know the hopeless vacant
+blank that stares them in the face when they want it. They have to
+make a circumlocution in the hope that it may turn up. Some let it go
+at that, but many start another sentence in the hope to tempt it to
+come and often it will eventually come, but sometimes it persistently
+refuses to come. That is not a loss of memory but a failure of neuron
+connections. There are some of us who know that certain words will
+always do that with us. Archimedes has bothered me for years and his
+name will often not come when I want it. Then there are certain words
+with regard to which transposition is likely to take place. We
+involuntarily and unconsciously substitute one word for another. We
+call one man by another's name. We have done it before and we know
+that we are likely to do it again. Somehow the connections in memory
+exist along these wrong lines and are constantly mismade. The name of
+something a man has written comes up instead of his name. This
+heterophemia is often noted in men of excellent memory.
+
+
+Peculiarities of Memory.--Memory is an illusive and elusive function
+at best. All of us have had the sensation of having a word, and
+particularly a name, on the tip of our tongues. We often know the
+first letter and sometimes the first syllable of it. What memory
+brings to us, however, may not always be the first syllable of a word
+or name, though we are prone to think it must be, and we may go
+looking for it in the dictionary of names only to discover after a
+time that we are many letters away from its beginning. Very often we
+have to give up seeking in sheer inability to get a hint of it and
+then of itself it will come a little later. Sometimes it will come
+when we no longer want it. As a rule, words that have escaped us once
+in this way are prone to do so again. Over and over again the
+experience will be that {681} a particular word or group of words
+escapes our memory, or at least fails to be at our command, as most
+other things are. Those of us who are not much given to introspection
+take no notice of these difficulties which are common-place
+experiences enough, but the man or the woman who is looking for
+symptoms, who is prone to believe for some reason or other that his or
+her memory is failing, will take these hints of the more or less
+natural fallacy of memory as confirmations, strong as direct proof of
+the fact that memory is seriously deteriorating.
+
+Such pauses and lapses of memory are much more likely to occur if we
+are nervous and over-anxious about possible loss of memory. I was once
+asked to attend for a few hours before the time fixed for his oration
+one of the greatest orators of this country, who was about to talk at
+a university commencement. What surprised me was that this practiced
+speaker, who had often appeared before very large audiences, took a
+very light meal in considerable trepidation, immediately after asked
+to have certain books brought to him and certain facts looked up for
+him, took notes in a hurried, feverish way and generally displayed all
+the over-excitement of the schoolboy about to make his first oration.
+He was a magnificent occasional speaker, often called upon, yet he
+assured me that it was always thus with him and that the reason for it
+was that in spite of previous preparation--and the finish of his
+orations made it clear that he had devoted much thought to them
+beforehand--certain of his facts and names and dates had the habit of
+slipping from him in the midst of the development of his theme, unless
+he had refreshed his memory with regard to them immediately before,
+and that he feared that sometime he would find himself in the midst of
+an address with an absolute blank before him and that he would be
+compelled to sit down in disgrace. He had never done so and never did
+in the many years that he, lived afterwards, though always with this
+dread, never trusting his memory as most people do.
+
+
+_Name Memory_.--There are certain circumstances in which memory may
+fail and yet no significance of a pathological nature can be
+attributed to the fact. All of us probably have had the disturbing
+experience of undertaking to introduce two friends whom we had known
+for many years and yet having to ask at least one of them for his name
+before we could make the introduction. It is not that we did not know
+the name, but at the moment we were utterly unable to recall it. After
+this has happened once or twice it is prone to happen again, because
+when we set about introducing people the thought of the previous
+unfortunate occurrences of this kind comes to our mind and acts as an
+inhibition of memory, making it impossible for us to recall names. Not
+infrequently if we are brought to the pass of having to ask one of the
+parties for his name we have to ask the other, though it was on the
+tip of our tongue a moment before, because in the meantime the
+disturbance of mind incident to having to ask has interfered with the
+train of recollection. Men have been known to forget their own names
+under circumstances of great excitement and such a forgetting is not
+pathological, but only a physiological disturbance of function because
+of secondary trains of association set to work in the brain which
+disturb ordinary recollection. Of course, some people have an
+excellent memory for names and never have such experiences, but they
+are very rare, though practice in recalling names does much to keep
+{682} people from such embarrassing situations. On the other hand,
+there are some people especially gifted with name memories. Napoleon
+could recall all his soldiers' names.
+
+
+Fatigue and Memory.--Occasionally it happens quite normally that when
+we are very tired certain portions of our memory at least become vague
+and indefinite and may even fail to respond to any excitation on our
+part. Under these circumstances we seem to be able only with
+considerable effort to exert the effort necessary to bring about such
+connections of brain cells as will facilitate recollection and
+reproduction and we may fail entirely. In a foreign country it is, as
+a rule, much more easy to talk the language in the morning when we are
+fresh than in the evening when we are tired. Especially is this true
+if we are asked to pass from one foreign language to another, which
+always requires a special effort. Everyone who has traveled must have
+had the experience that on crossing the frontier suddenly to be
+addressed in German after he has been talking French for weeks, may
+quite nonplus the traveler, even though he knows German as well or
+even better than French. This is especially true if much depends on
+the answers, if he has been addressed by a railway official or customs
+inspector. Apparently there must be a momentary wait until some
+shifting operation takes place in the brain before the German memory
+can get to work to establish the connections necessary to enable him
+to talk German. After a man has been talking to a number of people in
+one foreign tongue he is likely to be quite lost for words for a
+moment if he has to use another. The effects of fatigue and excitement
+and unusualness upon memory then must be remembered in order to be
+able to reassure patients who pervert the significance of the
+phenomena.
+
+Ribot gives an excellent personal illustration of this peculiarity of
+memory in his "Diseases of Memory," which is worth recalling here. He
+says:
+
+  I descended on the same day two very deep mines In the Hartz
+  Mountains, remaining some hours underground in each. While in the
+  second mine, and exhausted both from fatigue and inanition, I felt
+  the utter impossibility of talking longer with the German inspector
+  who accompanied me. Every German word and phrase deserted my
+  recollection; and it was not until I had taken food and wine, and
+  been some time at rest, that I regained them again.
+
+
+Sensations and Memory.--Just as soon as people compare their memories
+with others, as they do when they worry and begin to grow
+introspectively self-conscious, they find noteworthy differences and
+because of differences they will be prone to think that their memory
+is pathologically defective when it is only different, or, still more,
+that because they are not able to remember some things, as others do,
+their memory must be failing. It is well known that some people have a
+good memory for things seen, others for things heard, and still others
+only for things in which they have taken actual part. These are spoken
+of as visual, auditory and action memories. Memories for things seen
+are divided into special classes. Some people remember forms very
+well, while others remember colors. It is evident that our memories
+are somehow dependent on the special mode in which sensation affects
+us and that our acutest sensations are the sources of our longest and
+best memories. Color vision defectives are not affected much by colors
+and easily forget them. The tone-deaf have no memory for tunes. Every
+sense defect affects the memory. Sense defects are often unconscious.
+Their effect on memory may {683} only be noted when introspection
+begins to bring out the special sensation and memory qualities of the
+individual. Nature, not disease, may be the basis of some memory
+troubles thus brought to recognition. All these curious phenomena with
+regard to memory need to be recalled whenever there is question of a
+supposed deterioration of it, for it is not easy to decide such a
+question.
+
+
+Limits of Normal Forgetfulness.--Curious instances of forgetfulness
+may occur in the experience of men with excellent memories, which,
+when they happen to persons morbidly inclined to test their every act,
+are interpreted to signify something much more serious than they
+really mean. Nearly everyone has had more than once the experience of
+telling a story to a particular group of people and then forgetting
+all about having told it and coming back a few days later to tell it
+over again. Occasionally a teacher hears the same lesson a week apart
+and yet does not remember that he went over it before, though the
+class is almost sure to do so. A man may repeat a lecture that he has
+given before to the same audience without realizing it. The story has
+been told more than once of a clergyman delivering the same sermon on
+two Sundays in succession and, though such lapses are very rare, they
+do not necessarily indicate a failing memory, but may only mean a lack
+of concentration of attention on the part of the human mind. Prof.
+Ribot in his "Diseases of Memory" tells the story of one such case in
+which the subject was quite alarmed lest it should indicate that he
+was beginning to suffer from some serious memory disturbance due to
+brain disease, though there was no ground for his fears:
+
+  A dissenting minister, apparently in good health, went through the
+  entire pulpit service one Sunday morning with perfect
+  consistency--his choice of hymns and lessons and extempore prayer
+  being all related to the subject of the sermon. On the Sunday
+  following he went through the service in precisely the same manner,
+  selecting the same hymns and lessons, offering the same prayer,
+  giving out the same text, and preaching the same sermon. On
+  descending from the pulpit he had not the slightest remembrance of
+  having gone through precisely the same service on the preceding
+  Sunday. He was much alarmed and feared an attack of brain disease,
+  but nothing of the kind supervened.
+
+
+Attention not Memory.--When patients come with complaints of the loss
+of memory, the most important thing is to analyze their symptoms
+carefully. This will usually enable us to give patients ample
+reassurance. I have known men who were convinced that they were losing
+their memories because of their failure to recall important details in
+their business affairs in the midst of much hurry and bustle in the
+winter time, find that when they were living a simpler life in the
+course of travel or life in the country during the summer time under
+conditions different from the ordinary, their memory could be
+absolutely depended on for trains and travel details and all important
+matters to which they were now devoting attention.
+
+
+Cultivating Looseness of Memory.--Many people complain of loss of
+memory in the sense that they do not now remember when things took
+place as well as they used to. For instance, I have had men of fifty
+tell me that they were sure that their memories were growing weaker
+than they used to be because a number of times within a year they had
+found that events which they thought had taken place only a year or
+two ago really dated four or {684} five or even more years in the
+past. Some are considerably disturbed by this. As a matter of fact it
+is only another instance of lack of attention. Most of what we read in
+newspapers attracts so little of our serious attention that it is no
+wonder that we do not recall with exactness when events took place.
+Events crowd each other out of memory. Newspaper reading is, indeed,
+the best possible cultivation of looseness of memory that we could
+have. We do not expect to remember what we read. We would probably
+grow distracted if we did. At the end of the day if you ask a man what
+he read in the morning paper he will have no idea at all, unless
+something especially startling or particularly interesting to him has
+turned up. After a week we could no more separate Monday's from
+Tuesday's news of the week before than we could recall a random list
+of events, having heard it but once. We cultivate looseness of memory
+with great assiduity. Let us not be surprised if, to some extent, we
+succeed.
+
+
+Memories Individual.--People are often much worried over children's
+memories and may communicate this worry and anxiety to the children
+themselves, making them solicitous. It is probable that our memories
+are like our stature. They are what they are. By thinking we cannot
+add a cubit to the one nor facility to the other. The training of the
+memory is a very small element compared to the natural faculty. It
+must not be forgotten, however, that many distinguished men have been
+noted for rather bad memories when they were young and yet these
+faculties have developed quite enough to enable them to accomplish
+good work afterwards. The memory is, after all, a comparatively
+unimportant faculty in itself and other intellectual faculties surpass
+it in significance. It is the faculty that first develops, however,
+and so a child is often thought to be intellectually slow when it has
+not so bright a memory as its companions, though a little later its
+other faculties may develop so as to put it on a plane above its
+fellows. Memories, too, are very individual and may not retain any of
+the ordinary subjects, while they may be very attentive for certain
+special lines of thought. This form of the faculty is better, for the
+encyclopedic memory is usually of little use and, except in high
+degrees, encourages superficiality rather than real knowledge.
+
+As a matter of fact, few of our greatest thinkers have had what would
+be called brilliant memories and it would almost seem as though the
+diversion of mental energy to this faculty rather disturbed the
+development of the others. Many a distinguished man has been rather
+notorious as a child for bad memory, so that in the early days when
+memory was the only faculty called upon at school he was set down as a
+dunce. Perhaps the most striking example of this was Sir Isaac Newton,
+who was actually called a dunce, and yet the world would welcome a few
+other such dunces. Thomas of Aquin, the great medieval writer on
+philosophy and theology, who still influences philosophy so much, was
+so slow as a young man that he was called by his fellow pupils "the
+dumb ox." His great teacher, Albertus Magnus, recognized the depth of
+mind that his fellow students could not see and declared that the
+bellowings of that "ox" would be heard throughout the world. Sir
+Walter Scott was spoken of as a very backward child. This is all the
+more surprising to those who know and appreciate the wealth of
+information that he put into his Waverley Novels. Goldsmith, than whom
+we have no more brilliant writer in English, seemed not only a dunce
+as a child, but all his {685} life, so far as outward appearance went,
+was a numbsknll. This was due to a lack of readiness rather than any
+lack of wit.
+
+
+Tricks of Memory.--Some tricks of memory may be very disturbing to
+those who are over-occupied with themselves and with the possibility
+of losing their memory. For their consolation it is well for the
+physician who hears their complaints to have at hand some stories that
+illustrate certain of these curious tricks of memory. I had been
+trying to persuade a literary woman for some time that it was not her
+memory that was playing her false, but merely her habit of attention
+and lack of concentration of mind on things because she is occupied
+with a great many interests, when one day she came to me with what she
+thought was absolutely convincing proof that her memory was going. She
+had read a passage in a newspaper the day before which she liked very
+much, but after reflection it sounded strangely like some of the
+things that she had thought along these lines herself. It was a
+quotation, but there was no indication to tell whence it came. A
+little inquiry, however, showed that the quotation was from an article
+of her own written only two years before. Here was definite proof of a
+failure of memory. Strange as it may seem, however, this experience is
+quite common. I feel sure that there is not a single writer for
+periodical literature who has not had similar experiences. Anyone who
+writes much editorially, where the articles are unsigned, finds it
+rather difficult two or three years later, as a rule, to be absolutely
+sure which editorials are his. Occasionally it happens that even by
+the time the proof comes back for monthly periodicals, say six weeks
+or two months, some at least of what was written may seem quite
+unfamiliar. This will be particularly true if phases of the same
+subjects have been treated in successive articles and thus repetitions
+are caused.
+
+There is plenty of good warrant for such occurrences in the lives of
+distinguished writers. Scott once heard a song in a drawing-room that
+he did not care for very much and he said rather contemptuously, "Oh!
+that's some of Byron's stuff." His attention was called to the fact
+that he was the author of the stuff himself. Carlyle confessed to
+Froude when Froude went over some of the passages of Carlyle's own
+autobiography with him, that he had quite forgotten some of the things
+written down there. Manzoni, the distinguished Italian writer, whose
+"I Promessi Sposi" has probably been more read throughout Europe than
+any novel written during the nineteenth century, except possibly some
+of Scott's, tells some stories of his own lapses of memory and, above
+all, of having once quoted a sentence of his own to confirm something
+that he was saying, though he confessed that he did not know by whom
+the quotation had been written.
+
+
+Memory and Low Grade Intelligence.--There are many people who complain
+of their memory and of their inability to recall many things which
+others recall without difficulty. They are prone to think that this is
+some defect in them and not infrequently, as a consequence of
+comparisons, they persuade themselves that their memory was better and
+that it has lost some of its qualities. Until they became familiar
+with some of the feats of memory possible of performance by others,
+they were quite satisfied, but now they find in every instance of
+forgetting a new symptom of an increasingly deficient memory. I have
+found in these cases, that setting before such people some of the
+curiosities of memory, and especially the fact that memory is by no
+{686} means necessarily connected with profound intelligence, so that,
+indeed, its presence is quite compatible with a low grade of
+intelligence or even with what is practically idiocy, will do much to
+rob these gloomy forebodings of their terrors with regard to their own
+supposed deterioration of intellect. Ribot, in his "Diseases of
+Memory"   [Footnote 52] has an excellent passage in which he sums up a
+number of these peculiarities of memory that are likely to be
+especially consolatory to people of ordinary memory who are worrying
+about themselves.
+
+    [Footnote 52: International Scientific Series,
+    D. Appleton & Co., New York.]
+
+  It has long been observed that in many idiots and imbeciles the
+  senses are very unequally developed; thus, the hearing may be of
+  extreme delicacy and precision, while the other senses are blunted.
+  The arrest of development is not uniform in all respects. It is not
+  surprising, then, that general weakness of memory should co-exist in
+  the same subject with evolution and even hypertrophy of a particular
+  memory. Thus certain idiots, insensible to all other impressions,
+  have an extraordinary taste for music, and are able to retain an air
+  which they have once heard. In rare instances there is a memory for
+  forms and colors, and an aptitude for drawing. Cases of memory of
+  figures, dates, proper names, and words in general, are more common.
+  An idiot "could remember the day when every person in the parish had
+  been buried for thirty-five years, and could repeat with unvarying
+  accuracy the name and age of the deceased, and the mourners at the
+  funeral. Out of the line of burials he had not one idea, could not
+  give an intelligible reply to a single question, nor be trusted even
+  to feed himself." Certain idiots, unable to make the most elementary
+  arithmetical calculations, repeat the whole of the multiplication
+  table without an error. Others recite, word for word, passages that
+  have been read to them, and cannot learn the letters of the
+  alphabet. Drobisch reports the following case of which he was an
+  observer: A boy of fourteen, almost an idiot, experienced great
+  trouble in learning to read. He had, nevertheless, a marvelous
+  facility for remembering the order in which words and letters
+  succeeded one another. When allowed two or three minutes in which to
+  glance over the page of a book printed in a language which he did
+  not know, or treating of subjects of which he was ignorant, he
+  could, in the brief time mentioned, repeat every word from memory
+  exactly as if the book remained open before him. The existence of
+  this partial memory is so common that it has been utilized in the
+  education of idiots and imbeciles. It is worth noting that idiots
+  attacked by mania or some other acute disease frequently display a
+  temporary memory. Thus, an idiot in a fit of anger told of a
+  complicated incident of which he had been a witness long before, and
+  which at the time seemed to have made no impression upon him.
+
+
+Training Memory.--In recent years in many departments of therapeutics
+training has been found to be of value. This is especially true with
+regard to nervous defects. Probably one of the greatest surprises that
+nervous specialists have had in the last twenty-five years in the
+domain of therapeutics came from the introduction of Frenkel's methods
+of retraining the muscles in locomotor ataxia. This idea of retraining
+has been found useful in such distinct departments as the use of the
+eye muscles, the co-ordination of the muscles of speech, so as to get
+rid of stuttering and stammering, and the muscles of the hand for
+writing. We are only just beginning to realize that retraining can be
+of great value in psychic affections also. Patients may be disciplined
+against their dreads and tremulousness due to over-apprehension and
+against even certain defective uses of their intellect. Urbantschitsch
+of Vienna showed that by training defective hearing it might in many
+cases be very much improved. What he accomplished, however, was not
+{687} any better use of the external auditory apparatus, but a more
+intense attention of mind which enabled the patient to catch and
+understand sounds which had hitherto been so vague that their
+significance was lost.
+
+In a number of cases of complaint of loss of memory I have
+deliberately set patients to retrain their memories and have at least
+relieved their apprehensions if I have not always succeeded in
+increasing their actual memory power. It has even seemed, however,
+that in old people some actual improvement of the memory faculties was
+thus brought about. Under the head of Occupation of Mind I have
+referred to the exercise of memory in younger people as representing
+an excellent form of mental diversion. When the idea first suggested
+itself it seemed as though patients would not take to it at all, and
+yet I have found that with a little persuasion they become much
+interested and find a great deal of pleasure in their gradually
+increasing power to recall the great thoughts of great authors in the
+literal original words. A reference to that chapter will tell more of
+my experience. This made me more confident of the possibilities there
+were of making people understand that if they were losing their
+memories they could bring them back by proper exercise. In this way
+many of the modern evils of lack of attention and of failure of
+concentration of mind can be corrected.
+
+My rule now is to tell patients who come complaining of loss of memory
+that if there is any real loss of memory it is due to their improper
+use of the faculty, or perhaps to their failure to exercise it
+sufficiently, for the proper performance of function depends on
+adequate exercise. They are then instructed to take certain simple
+classical bits of literature and commit them to memory. At the
+beginning such short poems with frequently repeated rhymes of the
+modern poets as are comparatively easy to learn are set as memory
+exercises. Later Goldsmith's "Traveler" and "Deserted Village" are
+suggested. Then passages from Shakeaspeare are given. Just as soon as
+the patient finds that he can commit to memory as he used to, if he
+only gives himself to the task, a change comes over his ideas with
+regard to the loss of memory. For many of these people the occupation
+of mind is an excellent therapeutic measure. Besides selections can be
+made in such a way as to keep before their minds the thoughts they
+most need in the shape of memory lessons. It is a discipline of memory
+that revives it and also a constant exercise in favorable suggestion.
+
+Gregor in the _Monattschrift für Psychiatrie und Neurologie_, Band
+XXI, has detailed some of his experiences with the retraining of the
+memory of patients suffering from Korsakoff's Psychosis--alcoholic
+neuritis with psychic disturbances, especially of memory. The patient
+was required to learn words and then after a certain length of time
+was tested to see if he could learn a similar series with fewer
+repetitions than at first. The memory increased in capacity with the
+exercises and there was evidently a definite gain in the faculty. In
+this disease patients have also lost the power to some degree at least
+of recognizing objects. After exercises in recognition they are much
+more capable in this matter, however, and it is evident that in every
+way the memory can be improved. This experience, with a serious form
+of disease that gravely impairs the memory, shows how much can be
+accomplished in circumstances far more unfavorable than are those
+which usually bring patients to the physician complaining of
+deficiencies of memory.
+
+
+
+{688}
+
+
+
+CHAPTER XI
+
+PSYCHIC CONTAGION
+
+
+The term psychic contagion is often thought of as merely figurative.
+It is, however, quite literal. Many minds are influenced by what they
+see happening round them and induced to imitate the activities of
+others. The term psychic contagion is so thoroughly descriptive of
+what happens that it deserves the place that it has secured.
+
+Everywhere and at all times we find historical traces of psychic
+contagion compelling people to perform in crowds or groups the most
+curious and inexplicable and sometimes the most horrible things. Even
+in the old myths before the times of the Trojan War, we have the story
+of hysteria spreading among the daughters of King Proteus, so that the
+famous old physician, Pelampus, had to administer white hellebore in
+goat's milk in order to relieve them. It is probable that this rather
+heroic remedy with its definite effect upon the bowels produced such a
+revulsion of feeling as to cure the hysteria. Anyone who has read the
+awful tragedy that Euripides has written in the _Bacchae_ will have
+had brought home to him a typical example of psychic contagion. The
+queen mother in the midst of one of the Bacchic orgies kills her own
+son in the frenzy that has come from the religious excitement
+exaggerated by the association of a number of women in the religious
+rites of the god Bacchus. It is well understood that this was not a
+case of drunkenness, but of psychic intoxication.
+
+Phrygian Bacchantes are described as overcome from time to time by
+paroxysms of curious uncontrollable automatic movements with or
+without disturbance of consciousness. This represents the earliest
+form of what came to be known afterwards as St. Vitus Dance when it
+spread among a number of people. Such manifestations were not at all
+uncommon in the East in the earlier days and they have continued
+during all history. In Hindustan epidemics of automatic movements,
+evidently choreic in character, have been known for many centuries
+under the name of _lapax_. Outbreaks of this kind were common in the
+Middle Ages and Paracelsus has described them as happening early in
+the sixteenth century. At any time the occurrence of an hysterical
+seizure in a crowded hall, and especially in a schoolroom, will lead
+to other hysterical manifestations. A case of chorea will induce
+imitative movements in susceptible bystanders that may be quite
+uncontrollable. Tics of various kinds are readily picked up by
+children and special care must be exercised to prevent their spread.
+In general the state of mind is extremely important in all these
+conditions and they can be influenced favorably only through the mind.
+
+
+Contagions Trifles.--Perhaps the extent to which psychic contagion
+influences us can be seen better in little things than anywhere else.
+Everyone knows how contagious yawning is. Again and again observations
+have been made while actors were yawning upon the stage. Nearly
+everyone in the theater begins to yawn in a few minutes and, in spite
+of the most determined {689} efforts, every now and then even the most
+serious-minded elderly gentleman in the audience finds himself
+unconsciously joining in. It seems foolish and to an onlooker appears
+almost prearranged. It is only necessary, however, to yawn a few times
+in a street car, especially at night, to have many imitators. Nearly
+the same thing is true of all respiratory phenomena. Sighing, for
+instance, is quite contagious. Coughing is often as much the result of
+imitation as anything else. At certain pauses in church services a
+preliminary cough is heard and then some scattering coughs here and
+there, like the musketry of scouts, and then a whole battery of coughs
+is let off, especially if it is in the winter time, because nearly
+everybody within hearing is tempted to cough. To talk about yawning or
+coughing or sighing before some people is almost sure to produce a
+tendency to these manifestations. These apparently trivial happenings
+help to explain many phenomena of human imitation in more serious
+things.
+
+Most of the phenomena associated with expression are liable to be
+initiated as the result of imitation. Laughing, for instance, is
+particularly contagious among young folks and is especially likely to
+be insuppressible when they wish to be particularly solemn. At
+religious services it takes but little to make people laugh and
+giggle, no matter how much they may wish to be dignified and
+reverential. A few giggling girls will sometimes disturb a serious
+service. Extremes are particularly prone to meet in this matter and
+the sublime easily becomes the ridiculous. A titter will set off even
+the best intentioned of young folks in spite of resolutions to the
+contrary. Crying has something of the same contagious nature, though
+it is not quite so strong, but among women tears are particularly
+likely to evoke tears. The epidemic of curious manifestations of
+expression, usually of an hysterical nature, that we know by tradition
+to have spread in communities in the Middle Ages and much later, are
+only typical examples of this tendency for modes of expression to be
+contagious to an exaggerated degree.
+
+Expectoration is largely dependent on imitation, sometimes conscious,
+of course, but often quite unconscious. In the recent crusade
+organized to prevent the spread of tuberculosis the question of
+expectoration as a diffusing agent of the bacilli has given a new
+importance to observations on this subject. It is recognized that we
+have "a spitting sex" and that men spit from force of habit, boys
+imitate them, while women and girls almost never spit. There is no
+reason in the world why when men and women are engaged in the same
+occupations there should be any difference in this regard between
+them, yet employers know how hard it is to keep corners and by-places
+in the rooms where men work free from expectoration, while no such
+difficulty is found where women work. We have a spitting sex because
+of psychic contagion, and in spite of the fact that there are serious
+dangers connected with the habit. What is true of spitting may also be
+true of other habits relating to the respiratory passages. Hawking and
+blowing the nose more frequently than is needed are spread by psychic
+contagion and certain habits in these matters that are injurious to
+the respiratory apparatus often require considerable effort to break.
+
+
+Fads and Health.--Enlightened as we think ourselves, we have many more
+examples of psychic contagion in the present than we would perhaps
+care to admit, unless the facts were called to our special attention.
+{690} At a particular period in the modern time it becomes the fad to
+do things in a special way. We write alike, we build our houses after
+a common type. We take our recreation in a particular fashion.
+Bicycling comes in and goes out; roller skating attacks nearly every
+one of the young folks and then is abandoned. There are fashions in
+everything and fashions, after all, are recurring instances of psychic
+contagion. The mental influence spreads from one to another. It may be
+that a particular fashion, as in houses or in clothes, is especially
+ugly. That makes no difference. After a time taste revolts against it,
+but in the meantime the psychic contagion is enough to overturn the
+canons of taste. There are fashions in literature, or at least what is
+called literature. The nature novel comes and goes, then the novel of
+adventure has its place, then the detective novel, after a time the
+little-country prince or princess and their romance comes into
+fashion. After a time we realize that these are passing fancies, but
+in the meantime they have influenced many people.
+
+Some of these fashions bring conditions that are deleterious to
+health. The moving-picture show in places that almost never have a
+stime of sunlight in them and are, in their way, quite as bad,
+especially for respiratory troubles, as the dust-laden atmosphere of
+the roller-skating rink, become the fad of the moment in spite of
+knowledge or ignorance of hygiene. Just now we are in the midst of a
+fad for fresh air, that, unfortunately, goes and comes with the
+centuries and we have no guarantee that people will not learn again to
+live in closely sealed houses. High heels come and go, as do corsets
+of various kinds, more or less injurious, in spite of the admonition
+of the physician. In fact, one of the most interesting studies in
+psychic contagion is the history of the fashions. A particular
+fashion, especially in its exaggerated forms, will probably look well
+on about one-fifth of the women at a given time. About four-fifths of
+them, however, adopt it in spite of the fact that on three-fifths it
+emphasizes certain qualities that it would be well to keep in the
+background. It is woman's principal desire to please, yet this is
+completely perverted by the psychic epidemic of fashion which causes
+people to follow after others quite as much as did the medieval people
+in various fads that attracted attention and have come down to us.
+
+Our enlightenment, at least in as far as that word means general
+diffusion of the ability to read, has rather added to the power of
+psychic contagion. People accept ideas from others almost as
+unconsciously as they catch disease from those suffering from it. The
+psychology of advertising shows how easy it is to make people accept
+things just by insisting on them and by frequent repetitions of
+statements. The psychology of the proprietary medicine business in
+modern times is about as typical an example of psychic contagion
+induced deliberately as one could well imagine. Those who stop to
+reason do not fall victims. Most people, however, do not stop to
+reason. They have not the mental resistive vitality to render them
+immune to the influence of certain irrationalities and so literally
+hundreds of millions of dollars have been spent on perfectly useless,
+oftentimes harmful drugs, which people had become persuaded through
+the psychic contagium of printer's ink were sure to do them good. The
+psychology of the mob has been studied somewhat in recent years and it
+shows how clear it is that men follow after one another in doing
+foolish things even more than in doing wise ones. Psychic contagion is
+a prominent factor in life, it always has been, is now, and evidently
+always {691} will be, and must be reckoned with by anyone who wishes
+to recognize the principles that underlie psychotherapy.
+
+
+Suicide Contagions.--It is with regard to much more serious things
+than fashions, however, that psychic contagion is most manifest. For
+instance, there is no doubt that suicide is frequently the result of
+such psychic influence. Seldom does it happen that a very queer
+suicide is reported without there being certain imitations of it more
+or less complete in various parts of the country afterwards. There is
+no doubt that the reporting of suicides has a serious effect in this
+matter. Perhaps the most striking example of this that we have ever
+had in America was the well-known suicidal epidemic at Emporia,
+Kansas, which reached its height just about the middle of June, 1901.
+Two or three well-known people in town committed suicide at the end of
+May and the beginning of June. A veritable epidemic of suicide broke
+out as a consequence. Nothing seemed to stop it and the authorities
+were much disturbed. Finally it was agreed that the most potent
+influence in bringing about the imitation of the epidemic was the
+publication of the details of the suicides in the papers. The Mayor of
+the city, after consulting with the Board of Health, decided to issue
+the following proclamation:
+
+  I have consulted the Board of Health, and if the Emporia papers do
+  not comply with my request I shall have a right to stop, and I will
+  stop summarily, the publication of these suicide details, under the
+  law providing for the suppression of epidemics. There is clearly an
+  epidemic in this city, and although it is mental, it is none the
+  less deadly. Its contagion may be clearly shown to come from what is
+  known in medicine as the psychic suggestion found in the publication
+  of the details of suicides. If the paper on which the local Journals
+  are printed had been kept in a place infected with smallpox, I could
+  demand that the Journals stop using that paper, or stop publication.
+  If they spread another contagion--the contagious suggestion of
+  suicide--I believe the liberty of the press is not to be considered
+  before the public welfare, and that the courts would sustain me in
+  using force to prevent the publication of newspapers containing
+  matter clearly deleterious to the public health.
+
+
+Murder.--In almost the same way murders prove contagious. Especially
+is this true of murder and suicide together. These occur notably in
+groups. A man who is downhearted and for whom the future looks blank,
+will, out of a sense of pity for those who are dependent on him,
+murder them and himself; then the brutal story is reported and another
+tottering intellect gives way and a similar story has to be told
+within a few days. A mother who is melancholic about her health and
+includes her children in her gloomy outlook makes away with them and
+herself. Within a few days a similar story is reported because of the
+influence of psychic contagion. Very often there are distinct
+imitations of the methods employed in the first case. Often, however,
+it is only the idea itself that has proved contagious. There is no
+doubt that this suggestion brings about subsequent cases when
+otherwise such an awful thought might not occur. The connection is too
+clear for us to doubt the reality of it or to think that it is mere
+coincidence. As in Emporia, doubtless the suppression of the
+description of such events would have a beneficial effect. There are
+many disequilibrated minds, apparently just tottering on the verge of
+an insane act of this kind, that are pushed over by the suggestion
+furnished by the details of another story.
+
+{692}
+
+Place of Psychic Contagion.--The physician who would treat nervous
+patients successfully and use psychotherapeutics to advantage must
+recognize the place that psychic contagion has in influencing the
+generality of mankind. We know that direct suggestions are profoundly
+influential. It must be constantly kept in mind, however, that
+indirect suggestion, suggestion that does not come by any formal
+method, but that is represented by the examples of those around, also
+has great weight.
+
+
+Favorable Influence.--Fortunately it is not alone for evil that
+psychic contagion is manifest. People in a crowd stand fatigue better
+than when alone. Soldiers marching in step do not notice their
+tiredness to such a degree and even forget their sore feet. People
+suffering from hunger, so long as there is a good spirit among them,
+will help each other to bear it. The accidents in coal mines in recent
+years in which men have been imprisoned for considerable periods have
+shown that in groups they stand the hardships of confinement and of
+lack of food and water better than they do when alone, men live
+longer, they do not suffer so much or at least their suffering is not
+so insistent, and they bear up better.
+
+This has been particularly noticed in the cures at various watering
+places. The very air of the place takes on a favorable suggestion that
+is helpful to patients. The routine, the hopefulness of those who are
+completing the cure, the stories of improvement, the evident
+betterment, all these things combine to give a psychic contagion of
+health. Health is, in this sense, quite as contagious as disease. This
+must be taken advantage of just as far as possible for the advantage
+of patients. On the other hand, ideas are contagious for ill and
+patients may derive from their environment notions that prove
+auto-suggestive and against which it is extremely difficult to work.
+Ideas derived from the general feelings of those around, without any
+direct suggestion, may become obsessions. The physician, therefore,
+must be ready to secure prophylaxis against psychic contagion and then
+by counter-suggestion relieve the patient, who has become afflicted by
+it, of the resulting disturbance of mind. It must not be forgotten
+that, instead of being less susceptible as education and civilization
+progress, people really become more susceptible.
+
+
+Psychology of the Mob.--The most interesting instance of psychic
+contagion is the tendency just hinted at for crowds to run away with
+the sober judgment of serious sensible people that happen to be among
+them and do things that may be extremely regrettable. A mob always
+follows the suggestions of the worst elements in it unless perchance
+there is some extremely strong character who asserts himself and
+imposes his views on the rest. The tendencies to panic, to cowardly
+flight, sometimes to destructiveness, that come over crowds represent
+the power of psychic contagion to override reason. An alarm of fire
+will, if a few persons lose their heads, lead to the most serious
+consequences. Persons trample over one another, pull and maul one
+another, sometimes even pulling out hair or pulling off ears in their
+insane efforts to escape what is often an imaginary danger, though a
+few moments before they were rational beings and they will be quite
+reasonable a short time after. It is possible, however, to overcome
+even the worst tendencies in human nature by the suggestive power of
+discipline. Fire drills in schools enable children to get out in a few
+minutes without confusion when without them the most serious results
+could be looked for. Discipline and training, {693} following commands
+and observing tactics, helps an army almost more than the individual
+courage of soldiers. The suggestive influence of the thought that now
+is the time to do something that has often been done before at the
+word of command is enough to enable the soldier to control his panicky
+feelings. The difference between the trained soldier and the raw
+recruit is great, but it consists only in this mental discipline and
+self-control.
+
+
+Prevention.--Evidently, then, in the many circumstances in life in
+which psychic contagion manifests itself it is perfectly possible to
+overcome its influence by such discipline and mental training as gives
+the individual control over himself. In children corporal punishment
+is often not effective in breaking up habits and tendencies and the
+motive of fear often lessens self-control and makes conditions worse.
+In older people the fear of punishment is likely to be forgotten,
+whereas the suggestion of discipline will assert itself powerfully.
+Psychic contagion can be neutralized by psychotherapy, but its force
+in life must be recognized and its unfavorable influence guarded
+against. While it concerns mainly the less serious things of life, it
+may affect the most serious and imitation leads even to such serious
+criminal acts as suicide and murder. The modes of psychic contagion,
+then, must be constantly under surveillance.
+
+With this before us it is extremely interesting to realize how
+unfavorably suggestive for human health and happiness are our
+newspapers. They are constantly suggesting disease and suicide and
+murder and sex crimes and crimes against property, by giving all the
+details available with regard to these subjects. Such news can do no
+good, only excites morbid curiosity which requires still further
+satisfaction in the same line, and keeps thoughts with regard to these
+things constantly before the mind. We have had many burglaries and
+holdups and stealings of various kinds as a consequence of boys and
+even girls seeing the pictures of crimes in the moving-picture show.
+The saturation of mind with disease and crime produced by daily
+reading of unsavory and sensational newspaper accounts is sure to
+produce evil effects. There seems to be consolation for some people in
+reading of the crimes and punishments of others because they feel
+that, bad as is their own state, there are others who are worse. This
+_schadenfreude_, "harm-joy" as the Germans call it, is not satisfying
+to think of for human nature and it has an inevitable reaction through
+the unfavorable suggestion of these crimes.
+
+I have found over and over again that the prohibition of reading the
+newspapers for a time did many nervous people much good. This is
+particularly true for sufferers from such forms of psychasthenia as
+bring down on them dreads and premonitions of evil in fears for the
+development of disease and in general a sense of instability with
+regard to the future, lest dreadful things should happen to them. At
+first patients object strenuously and seem to be deprived of a great
+satisfaction. After a time, however, they are invariably persuaded of
+the fact that the absence of mental contact with human misfortune, in
+this morbid way, is doing them good and that their dreads and
+premonitory feelings of evil drop from them.
+
+{694}
+
+SECTION XIX
+
+_DISORDERS OF WILL_
+
+
+CHAPTER I
+
+ALCOHOLISM
+
+
+In recent years so much has been said about addiction to alcohol as a
+disease rather than as a habit that the treatment of it frankly as a
+disease in psychotherapeutics, even though there be not entire
+readiness to agree with those who emphasize exclusively the
+pathological interest of these cases, will not seem surprising. It is
+with regard to the various habits, drug and alcoholic, occurring in
+neurotic subjects that psychotherapy proves most effective and has
+secured some of its real triumphs. As a matter of fact, it has long
+been conceded that all of the so-called cures for alcoholism are
+dependent for their success upon the mental effect produced upon the
+patient. Most of them emphasize the necessity for building up the
+physical condition of the patient as a necessary preliminary to any
+lasting cure. There is no doubt that the powers of resistance of a man
+whose physical health has been seriously impaired by over-indulgence
+in alcohol and the lack of food and irregular sleep and exposure to
+the elements that so frequently accompany it, will not be sufficient
+to enable him to break off the alcohol habit, nor afford him the
+ability to inhibit the craving for stimulants, that he would have in a
+state of health. On the other hand, even in good health, unless his
+moral character is braced up, there will surely be a return to his old
+habit.
+
+
+Historical Résumé of Cures.--We have had many different cures for
+alcoholism exploited during the last half century. The older method of
+the first inebriate asylums founded in this country was to give a man
+a disgust for liquor, as it was then called, by putting a small amount
+of alcohol into practically everything that he consumed. This did not
+give him enough to satisfy his craving, but it did create in him an
+intense distaste for it by constantly keeping the flavor before him.
+There was a drop or two of whiskey in his tea, there was some whiskey
+in his milk, there was a taste of it in the water that he drank, there
+was some of it mixed even in the gravy of his meat, and he always had
+weak brandy sauce on his dessert. The consequence was, in most cases,
+such a complete disgust for liquor that men were sure that they would
+never touch it again. Of course, in the meantime they were fed well
+and heartily, they were kept in an environment free from temptations
+to excessive indulgence in alcoholic drinks, they had brought home to
+them what a mess they were making of their lives and their health,
+they had time to reflect what ruin they were bringing on themselves
+and their families and usually they {695} recognized that they were
+the kind of men who must stay away from alcohol absolutely, for whom
+there could be no such thing as a moderate indulgence in stimulants.
+This, with the intense distaste for alcohol, amounting almost to
+nausea at the sight of it, acquired from the system in vogue, started
+them well on the road to reform.
+
+
+_Moral Cures_.--It was the moral elements in the cure, however, that
+were the most important, though its inventors were sure that the
+physical elements played the largest role. The physical disgust for
+alcohol consequent upon having its taste constantly recur in
+everything at table passed off in a few weeks or at the most a few
+months. It was then that the moral uplift came in and had to be
+effective if the patient was to be preserved for the future from his
+old habit. If he was of a weak and flabby character, if,
+unfortunately, he was placed in circumstances where temptations were
+frequent, if, owing to the enforced absence in the inebriate asylum
+his business affairs had become involved and he was subject to many
+worries, then almost surely he dropped back. As a result his case was
+even more hopeless than before and, indeed, second cures were seldom
+of much benefit, for the man's confidence in himself was gone.
+
+All in all, however, this old-time, simple method probably produced as
+large a proportion of "real cures" as any other method, even the much
+advertised and discussed scientific discoveries of modern times. All
+of us have heard stories of men who had seemed to be hopeless
+drunkards, who were thus reformed and hundreds of men who appeared to
+be drifting into hopeless inebriety were reformed to such an extent
+that they became not only useful members of society and supports to
+their families where they had before been a drain, but even became
+leaders in the work of uplifting the character of others to resist the
+temptation of over-indulgence in stimulants.
+
+
+_Modern Cures_.--Of late we have had a number of "cures" for
+alcoholism widely exploited by well-directed advertising in the hands
+of men who realized what a fortune there was in this sort of thing and
+who actually have made immense sums of money out of them. Needless to
+say these "cures," though supposed to be secret, did not long remain
+so. Perhaps the most famous of them, the one whose institutes were
+found all over the country, was said to have used only two drugs,
+strychnin and apomorphin. The strychnin was given as a needed and
+well-chosen tonic for the physical condition of the patients who came
+to the institution usually in a rather seriously broken down
+condition. When patients began the treatment they were distinctly told
+that if they wanted whiskey at any time they could have it, but that
+the next injection of the "cure" after they took the whiskey would
+show how directly opposed to alcohol the ingredients of it were, by
+producing vomiting and prostration.
+
+As a rule, the patients came in perfectly confident of the effect of
+the remedy they had heard so much of. The strychnin injections made an
+excellent tonic for these nervous wrecks, bracing them up at once so
+that they felt better from the very beginning and this betterment was
+confirmed by the growing assurance from the physician and the patients
+around them that now, at last, they were to be relieved of their
+degrading habit. To those whose craving for alcohol returned in spite
+of the favorable condition in which they were placed and the
+stimulation of the strychnin, which made up so well, as a {696} rule,
+for the absence of their accustomed alcohol, whiskey was actually
+allowed. When the next time for their injection came, however, these
+patients who had been given whiskey on their request did not now
+receive an injection of strychnin but instead a small injection of
+apomorphin. The apomorphin acted promptly in making the stomach
+relieve itself and produced a complete and immediate sense of
+prostration. The limpness and discomfort of seasickness is as nothing
+compared to the state that, as a rule, develops after such treatment.
+Anyone who has ever had to handle, in a hospital, a wildly drunk,
+long-shoreman, whose brute strength in his irrational condition made
+him a dangerous object for patients and physicians, who has seen even
+large doses of morphin fail to produce quiet, and then has felt bound
+for the patient's sake as well as those around him, to administer a
+tenth of a grain of apomorphin with the result of having an eminently
+tractable patient in a few minutes, will have a good idea of what
+happened to the poor alcoholic who got apomorphin instead of
+strychnin.
+
+After that the inebriate knew that any further indulgence in liquor
+would be followed by this extremely unpleasant result and so he had a
+new argument for avoiding it. After a month or six weeks of careful
+treatment, the preliminary rest that would restore physical health and
+strength being followed by a course of exercise in the open air with
+plenty of good food, pleasant surroundings, and hope constantly held
+out to them, it is no wonder that these patients went out of the
+sanitariums as a rule confident that their habit was conquered for
+good. In many cases this proved to be true. It was soon found,
+however, that there were many relapses. This hurt the prestige of the
+"cure" and the gradual diffusion of this idea spoiled its
+effectiveness. It still continued to do good, however, and though it
+has been modified in various ways, and, indeed, in various parts of
+the country is said to be applied quite differently, there are still
+many reformations worked by these cures every year and they
+undoubtedly do good. The secret of its success, however, is not any
+marvelous drug or other mode of treatment that is employed, but is
+because the victims of alcoholism are given an opportunity to retrieve
+their physical condition and then to brace up their moral characters
+so as to resist their craving for alcohol.
+
+
+_Mental Influence_.--Other so-called cures and treatments have
+followed almost exactly similar lines. The main element in the cure
+has been the producing in the mind of the patient a definite idea that
+he can stay away from liquor if he really wishes to and then helping
+his run-down physical condition so that he craves stimulants less than
+before. Whenever such "sure cures" are used on the worst forms of
+alcoholic patients as we see them in the large general hospitals of
+our greater cities, the bums of the streets, the drunkards of a score
+of years or more, they have practically no effect. The man must have
+moral stamina, he must have some character left, besides, as a rule,
+he must have some good reasons in worldly interest to help him to
+brace up and then he may get away from alcoholism if he sincerely
+wills to reform. The important element, however, is the will to do so.
+If he is firmly convinced that he cannot stay away from liquor, if he
+feels in spite of all that has been done for him that he cannot resist
+his craving, then, of course, he will not reform. Men, however, who
+have sunk to the lowest depths, who, according to their own and
+others' testimony, have scarcely drawn a {697} sober breath for ten or
+even twenty years, sometimes have something happen to them, often it
+seems very trivial to everyone but themselves, that stiffens their
+relaxed moral fiber, that wakens their sense of manhood, that serves
+quite beyond expectation to give them a new purpose in life, and they
+reform and never drink again.
+
+It is this successful phase of the cure of alcoholism, however it may
+be explained, that is most interesting. It represents the most
+encouraging aspect of the whole question. Probably nothing more
+harmful has ever been done than the public proclamation that
+alcoholism is often an hereditary disease against which it is hopeless
+to struggle, and that the poor victims of it are to be pitied and not
+blamed. Except in those of low mentality, whether of intellect or
+will, or in the actually insane, there never was a case of alcoholism
+that did not deserve at least as much blame as is usually accorded to
+it. This is said after making due allowances for temperament. It is
+quite clear that for one man alcohol has no attractions at all, while
+for another the craving for it is almost an insuperable temptation. It
+is idle to say that these two contrasted men are equally free as to
+whether they shall take alcohol or not. Of course they are not equally
+free. If the man who has no craving for alcohol prides himself on his
+power of resistance against the vile habit, he is simply fooling
+himself. He probably knows nothing about the real nature of the
+temptation of alcohol. The Spaniards have a proverb: "He who doesn't
+drink wine and doesn't smoke, the devil gets by some other way." There
+is probably something else with regard to which the non-alcoholic has
+quite as little freedom as the poor victim of alcoholism and the great
+law of compensation comes in to make up to both of them, for their
+failings. Man has the defects of his virtues.
+
+
+Supposed Inheritance.--No man is such a slave to the habit, however,
+that he cannot correct it if he will. We have heard much about the
+inheritance of this disease. We have heard even more about its
+essentially morbid character, though people used to think it a moral
+defect. It must still be considered a moral defect, however, even
+though we all concede that there is an element of the pathological in
+it. We are getting away entirely from the ordinary idea of inheritance
+of disease. There is no inheritance of acquired characters. The fact
+that a man's father acquired the drinking habit because he was placed
+in circumstances where it was easy for him to indulge himself and
+because he did not have the moral stamina to resist, is no reason why
+his son should have an unconquerable or even a very strong craving for
+alcohol. One might as well say that because a father lost a finger
+when he was young his son would be born without that finger. Alcohol
+destroyed certain cells in the father's body and injured certain
+others, but produced no change deep enough to lead to hereditary
+influences.
+
+
+_Contagion More than Heredity_.--Perhaps some tendency to take alcohol
+runs in a family, that is, perhaps there is lessened resistance to the
+craving for stimulants that awakens in every human being if it is once
+aroused. This is what is true in tuberculosis. Some people have less
+resistive vitality to it than others. Careful autopsies show that
+practically every man who lives to be over thirty has or has had
+living tubercle bacilli in his tissues. Seven-eighths of us are
+thoroughly able to resist them. The other eighth succumbs. Their lack
+of resistive vitality may in some degree be due to hereditary taint,
+{698} but that is doubtful and we know that they acquire the disease
+by contact with others who have it already and, as a rule, it is able
+to work its ravages because they are not living in conditions that
+would help them to resist it. If they live in the free open air and
+have plenty of good, simple food, the disease will not run its fatal
+course, but nature will cure it. If the craving for alcohol is lighted
+up by association, aroused by indulgence, rendered strong by
+environment and by exposure to temptations of all kinds with regard to
+it, then the resistive power of the individual is so lowered that the
+alcoholic habit rules him instead of his being able to command it.
+
+
+_Inherited Resistance_.--The most curious fact that has come out in
+our studies of heredity in recent years has been that far from
+heredity working its will in causing degeneration and deterioration of
+mankind, immunity, for the race at least, is acquired in the course of
+subjection to disease and to various morbid habits. Nations, for
+instance, that have been subjected to diseases for long periods no
+longer display the susceptibility to them which they formerly
+possessed. After a disease has been endemic among a people for many
+generations that people gradually becomes quite insusceptible to its
+effects and suffers much less from it than before.
+
+Just this same thing is true of alcoholism. Nations that have been the
+longest in a position to be subject to the temptation to use alcohol
+in its stronger forms suffer least from the ravages of alcoholism. The
+southern nations of Europe using wine daily and knowing well the
+process of distillation to help them to make stronger drink for many
+hundreds of years, now exhibit much less tendency to over-indulgence
+in strong drink than the northern nations whose ancestors have only in
+comparatively recent times been subjected to the temptation of craving
+for strong alcoholic liquors. The attitude of any nation toward
+alcohol is a function of the length of time that nation has had a
+chance to procure strong drink easily. Our American Indians
+discovered, as has every people at some time, that intoxicating liquor
+could be made by allowing solutions of starch and sugar to ferment. It
+was only with the coming of the European, however, that they were
+provided with "fire water"--strong drink--in quantities. Its effect on
+them is a matter of history. Two things the white man brought his
+Indian brother to which the Indians were unaccustomed and that
+gradually obliterated the original inhabitants of this
+country--infectious diseases and strong alcoholic liquors. They proved
+equally fatal because of Indian susceptibility to them.
+
+From these considerations it is clear that just such an immunity to
+the effect of alcohol is produced in a people exposed to its effects
+in concentrated form for a long time as with regard to an infectious
+disease when they have been correspondingly exposed to it. Heredity,
+then, instead of playing a role that brings about deterioration in the
+race, on the contrary, carries on the higher qualities and gives us,
+as might be expected in the course of evolution, a better, that is, a
+more resistant, race. Most of what is commonly said as to alcoholism,
+and unfortunately most of the recent so-called popular scientific
+articles on this subject, seem to point to just the opposite
+conclusion to this. Men are supposed to be condemned by heredity to an
+inevitable craving to take alcoholic drinks that, in certain of them
+at least, cannot be overcome by any natural power of resistance. At
+this stage of our western civilization this is not true for anyone, as
+the more susceptible families have been long {699} since eliminated
+and it is a personal weakness and not a family characteristic that
+leads people to indulge this appetite to their own destruction.
+
+
+_Unfavorable Suggestion of Heredity Idea_.--An alcoholic patient, or
+even a man with only a moderately strong tendency to take alcohol to
+excess, who harbors any such notion as this, has a serious impediment
+to the full exercise of his will in overcoming the difficulties that
+he encounters in any attempt at reform. In going counter to so much
+that has been written and still more that has been said and generally
+accepted on this subject I feel it necessary to quote a good recent
+authority on the matter and so here insert these passages from "The
+Principles of Heredity" by Dr. Archdall Reid.   [Footnote 53] He says
+(p. 157):
+
+  [Footnote 53: Author of "The Present Evolution of Man," "Alcoholism,"
+  "A Study in Heredity," etc. Chapman and Hall, London, 1905. ]
+
+  Formerly all the world believed in the transmission of acquirements,
+  and consequently all the world was constantly finding conclusive
+  evidence of its constant occurrence. To-day there is hardly a rag of
+  that evidence left, and, with rare exceptions, only certain French
+  medical observers are able to discover fresh evidence. It is a
+  remarkable fact, however, that the problem of evolution--of
+  adaptation--has excited singularly little interest in France, and
+  it is equally curious that these French observations relate almost
+  entirely to laboratory work which it is not easy to repeat. In Great
+  Britain or Germany, you may cut off the tails of a thousand dogs, or
+  amputate the limbs of a thousand men, or observe the non-infected
+  offspring of a thousand tuberculous patients, and get no evidence of
+  transmission.
+
+With regard to alcohol Dr. Reid in the same volume insists on the
+proposition that alcohol does not cause degeneration of a race,
+creating, as is claimed, ever more and more a tendency for people to
+take it because their immediate ancestors have taken it, but, on the
+contrary, there is a distinct evolution against it, and that what is
+hereditary, not by acquisition, but by family trait, is an immunity
+against the disease which eventually protects the nations that have
+been longest exposed to the effects of alcohol from the evil
+consequences of the substance. He says (p. 196):
+
+  How, then, has alcohol affected the races that have used it? Are the
+  Jews and the races inhabiting the South of Europe the most
+  degenerate on earth? Are North Europeans only less degenerate? Are
+  the races that have never used alcohol, the Terra del Fuegians, the
+  Esquimaux, and the Australian blacks, for instance, mentally and
+  physically the finest in the world? We have only to state the
+  proposition to see its absurdity. There is no evidence that the
+  hereditary tendencies of any race have been altered by alcohol
+  circulating in the blood and acting directly on the germ plasm. Once
+  again the sufferings of the peoples have produced no effect, but the
+  deaths among the peoples have produced an immense effect. Every race
+  that has had experience of alcohol is temperate in the presence of
+  an abundant supply in proportion to the length and severity of its
+  past experience of the poison. The South Europeans and the Jews are
+  the most temperate peoples in the world. West Africans also are very
+  temperate. North Europeans are not drunken. Those savages, and those
+  only, who have had little or no experience of alcohol--Esquimaux,
+  Red Indians, Patagonians, Terra del Fuegians, Australian blacks--are
+  beyond all the peoples the most drunken on earth.
+
+Lest it should be thought that this discussion of the subject is only
+of significance with regard to nations and does not touch the
+individual, and, therefore, has but little significance for the
+problem that we are treating here. Dr. Reid's succeeding paragraph
+deserves attention:
+
+{700}
+
+  Stated in this brief and direct way, the thesis is apt to excite
+  incredulity. It is sharply opposed to popular beliefs, though that
+  need not trouble us. Popular notions on abstruse points of science
+  are occasionally erroneous. Of more importance is the fact that a
+  mass of statistics purporting to prove that the children of
+  drunkards tend to be degenerate has been compiled, especially by
+  medical men in charge of lunatic asylums. But no "control"
+  observations appear to have been made. We know that many drunken
+  parents have normal children; certainly, therefore, parental
+  drunkenness is not invariably a cause of filial degeneration. We
+  know also that many temperate parents have defective children. There
+  is nothing to show that the proportion is greater in the one case
+  than in the other. Even were it established that the proportion of
+  defective children is higher in the case of drunken parents, it
+  would still have to be proved that the relation is one of cause and
+  effect. People who have an inborn tendency to mental defect, who are
+  abnormally depressed, nervous, restless or irritable, are often so
+  constituted as to find solace in drink. Their children are liable to
+  inherit their inborn mental defects with spontaneous
+  variations--that is, to inherit the defect to a greater or lesser
+  extent. The unborn child of a drunken and pregnant mother is
+  practically another drunken person, as liable, or more liable to
+  suffer from the effects of drink; but in such a case the resulting
+  defect, though a mere acquirement, is tolerably certain to be
+  regarded as a congenital (i. e. inborn) defect by the medical man
+  who sees it. Mere acquirements, also, are the defects due to the
+  ill-treatment, want and neglect to which the children of drunken
+  parents are particularly exposed. Indeed, were it fully established
+  that drunken parents, other than pregnant mothers, tend to have an
+  excessive number of their children "congenitally defective," it
+  would still be a question whether the filial defects were not mere
+  acquirements. Prof. Cossar Ewart's observations on diseased pigeons
+  renders this not unlikely. All these sources of error render the
+  success of a statistical inquiry peculiarly difficult, if not
+  impossible, but there is no indication that they ever occurred to
+  the minds of the compilers.
+
+
+Warnings as Suggestions.--I have a case in my notes in which a rather
+prominent professional man insists that he is quite sure that the
+alcoholism from which he suffered during the ten years between
+twenty-five and thirty-five was entirely due to suggestion. As a boy
+of sixteen he had gone off to boarding school, but not until his
+mother had taken him aside, told him that his father had drunk himself
+to death, had done it by secret tippling, and that they had found that
+for many years he had been accustomed to have whiskey near him in his
+office and take it rather frequently. He had never tasted spirituous
+liquor at this time and his mother begged him not to, for she felt
+sure that if he did his father's craving would awaken in him and would
+become uncontrollable. The day that he went away his father's eldest
+brother took him aside and said practically the same thing to him. A
+maiden aunt was not quite so emphatic, but she, too, pleaded with him
+to understand all the dangers. For his first year at school he did not
+touch liquor, but in his second year he tasted it once or twice but
+had no particular craving aroused in him. By chance when he was home
+at Christmas time some college mates who were visiting him gave his
+mother the impression that he belonged to a rather jovial set. Once
+more he was warned by mother and uncle. Above all they told him never
+to keep strong drink near him because that was what his father used to
+do. During his college years the fear of this hung over him. He
+resented it and probably took more liquor than he would have so far as
+actual craving went. After getting out into active life once more he
+suggested himself into the habit of taking an occasional glass of
+whiskey by himself. After a time he was constantly taking too much.
+For {701} ten years he hurt all of his prospects, broke his mothers
+heart, and was looked upon as a hopeless alcoholic. Then one day the
+thought came to him that it was not that he craved alcohol so much,
+but that his thoughts turned on it constantly and at first he dreaded
+it overmuch, then wondered what attraction there could be and then
+acquired a habit by suggestion. Once this train of thought worked
+itself out in his mind, he quit spirituous liquors for good. For ten
+years he has not touched them, he does not care for them, they do not
+constitute a temptation.
+
+It must not be forgotten that many warnings may so preoccupy the mind
+with regard to a danger as to constitute temptations by suggestion.
+This is eminently true of alcoholism, the drug habits, sex habits and
+the like, in spite of the foolish present-day notion that information
+and warning must necessarily be helpful. In all these, teaching may be
+suggestively harmful.
+
+
+Prophylaxis.--The most important part of the treatment of alcoholism
+through mental influence is by prophylaxis, and that, to be effective,
+must begin very early. Just as with regard to overeating, as I have
+pointed out in the chapter on Obesity, it is extremely important not
+to permit children to acquire habits with regard to alcohol when they
+are young. During the growing years the system, indeed one may say all
+the systems of the body--the nervous, the muscular, the digestive and
+the mental systems--are all more or less unstable. Deep impressions
+may be produced on them then, and if children are allowed, much less
+encouraged, during their growing years (and this includes practically
+all the years up to twenty-five) to indulge in alcohol, then one can
+look for the development of a craving very hard to eradicate later in
+life. Many of them will be able to conquer the desire thus awakened,
+but a great many of them will not. We have some very definite evidence
+on this point and some of it collected here in America is very
+valuable. Dr. Alexander Lambert of New York made a study of over 250
+cases of alcoholism seen in the wards at Bellevue Hospital, paying
+special attention to the age at which the patients remembered they had
+begun the use of alcoholic liquors. If anyone doubts the influence of
+youth in this matter, then his statistics should be read:
+
+  Of 259 instances where the age of beginning to drink was known, four
+  began before six years of age; thirteen between 6 and 12 years;
+  sixty between 12 and 16; one hundred and two between 16 and 21;
+  seventy-one between 21 and 30; and eight only after 30 years of age.
+  Thus nearly seven per cent. began before 12 years of age, or the
+  seventh school year; thirty per cent. began before the age of 16;
+  and over two-thirds--that is, sixty-eight per cent.--began before 21
+  years of age.
+
+Dr. Henry Smith Williams, commenting on Dr. Lambert's study of this
+subject in his article on "The Scientific Solution of the Liquor
+Problem,"  [Footnote 54] states emphatically the conclusion so
+inevitable from these statistics that more than anything else
+alcoholism is the result of habits and occasions created in early
+years. He adds some remarks that are worth noting for those who are
+interested in the prevention and cure of alcoholism, not only in
+particular cases, but also for the community:
+
+    [Footnote 54: _McClure's Magazine_, February. 1909.]
+
+{702}
+
+  In the light of such facts, it is clear that the drink problem is
+  essentially a problem of adolescence. The cumulative effects of
+  alcoholic poisoning frequently fail to declare themselves fully
+  until later in life; but the youth who does not taste liquor till
+  his majority minimizes the danger of acquiring the habit in its most
+  insistent form; and the man who does not drink until he is thirty is
+  in no great danger of ever becoming a drunkard. As to the man who
+  has passed forty--well, according to the old saw, he must be either
+  a fool or his own physician. His habits of mind and body are formed,
+  and if he becomes a drinker now he can at most curtail by a few
+  years a life that is already entering upon the reminiscent stage. As
+  factors in racial evolution, the youth of each successive
+  generation, not its quadragenarians, are of interest and importance.
+
+
+Treatment.--The conclusions that naturally flow from the historical
+introduction to this chapter which show mental influence as the basis
+of all cures, simplify very much the treatment of alcoholism on
+psychotherapeutic principles. There is no doubt that moral means are
+the only really effective remedies in this matter. They fail often,
+not because of any lack of power, but because of lack of co-operation
+on the part of the patient. There are men whose mentality and
+responsibility is breaking down, and who are on the way to the insane
+asylum for various causes, who cannot be thus influenced. They are,
+however, not alcoholics, but incipient insane patients likely to go to
+excess in any line. There is no pretense that psychotherapy will cure
+mental disorder that rises to the height of real insanity. On the
+other hand, just as after several relapses of tuberculosis due to the
+foolishness of the patient, further improvement by sanatorium
+treatment is usually out of the question, so each relapse of the
+alcoholic patient makes it increasingly difficult to bring about
+noteworthy improvement. There are examples, however, which demonstrate
+that even after seventy times seven relapses men may still encounter
+something that rouses their dormant wills to real activity and then
+their alcoholism is a thing of the past, for good and all.
+
+
+_Sanitarium Question_.--There always comes the question whether these
+cases need to be sent to a sanitarium or can be treated at home. The
+answer to this question is the same for alcoholism as it is for
+tuberculosis or, indeed, for any of the exhaustive diseases. It all
+depends on the individual's physical condition and his circumstances.
+If tuberculosis is discovered, as it should be, at a very early stage
+in the disease--not when the patient is coughing up bacilli in large
+numbers and already has many physical signs in his lungs, but when he
+has a slight unproductive cough and over-rapid pulse and some
+prolongation of expiration at one apex--then he may be cared for at
+home, if the physician is confident that he can make his patient feel
+the absolute necessity for following instructions and can make him
+realize the seriousness of his condition in spite of the few symptoms
+that are present. If his environment is unfavorable, in a crowded
+tenement house or where an abundance of fresh air cannot be readily
+obtained, the patient may have to go to a sanitarium for proper
+treatment even at this early stage, or at least he will have to change
+his living conditions.
+
+This question has received a very different answer in recent years
+from what used to be given to it. Formerly the physician hesitated to
+say "tuberculosis" to his patient until the disease was well advanced
+and then he advised the distant West or some other change of climate,
+though, as a rule, this brought only a palliation of symptoms, the
+case being too far advanced, and {703} the fatal termination came in
+the course of two or three years. Now the careful physician diagnoses
+tuberculosis much earlier, detects the disease in its incipiency, and
+is able to treat the patient at home quite successfully, if conditions
+are at all favorable. It is true he has to make him give up fatiguing
+occupations, and especially those in dusty places; he has to insist on
+his living out of doors a good part of the day, even though there
+should be no better means of securing this than the roof or a
+fire-escape, and on keeping his windows open all night. He has to
+watch his nutrition carefully and see that he gains in weight. If all
+this can be accomplished, however, there is no reason why a
+tuberculosis patient in the incipient state should not get better at
+home almost as well as he would at a sanitarium. The only difference
+between the two methods of treatment is that in a sanitarium the
+patient realizes that his one duty in life is to care for his health
+and he does not bother about other things, as he is likely to do if he
+remains at home.
+
+If this precious development of teaching with regard to tuberculosis,
+which is founded on such thorough-going common sense and the
+application of good therapeutic principles to the treatment of the
+disease, be transferred to the sphere of alcoholism, then the answer
+to the question whether there shall be sanitarium treatment or not is
+practically arrived at. If the patient is in an early stage of his
+alcoholism, if the pathological character of his tendency to take
+intoxicants has been recognized and made clear to him early, then
+there is little difficulty in treating him at home. The crux of the
+problem is just that which occurred with regard to tuberculosis years
+ago. The physician does not take the early symptoms of the affection
+seriously enough. He does not want to disturb his patient's equanimity
+by the suggestion that he is in the incipient stage of alcoholism any
+more than a few years ago the family physician cared to suggest the
+awful thought of tuberculosis until the condition had reached a
+serious stage. But this is the essential preliminary to the successful
+treatment of alcoholism just as it is to the successful treatment of
+tuberculosis.
+
+It is almost useless to send advanced cases of tuberculosis, in which
+cavity formation has already occurred, to a sanitarium. The course of
+their disease may be delayed for a while, but scarcely more than that.
+Their resistive vitality has been so overcome by the ravages of the
+disease that their ultimate cure seems beyond hope, yet not
+infrequently wonderful results are obtained even in these cases. Just
+this same thing is true with advanced cases of alcoholism. No one can
+do anything with them, though careful treatment in a sanitarium may,
+on a number of occasions, afford them opportunity to brace up and be
+themselves, i.e., their better selves, for several months. Just as
+with tuberculosis, however, even the quite advanced cases will
+sometimes be so much bettered by sanitarium treatment that, though
+their prognosis seemed absolutely hopeless and was so pronounced by
+good authorities, all the symptoms are relieved and the patients get a
+new lease of life that may last for many years.
+
+In the same way some apparently hopeless cases of alcoholism will
+brace up after sanitarium treatment and have many years of useful
+sober life without a break. In alcoholism, as in tuberculosis, the
+will of the individual is the all-important consideration. Someone has
+said that tuberculosis takes away mainly the quitters. Those who have
+the courage to insist that they {704} _will live_ in spite of
+everything being apparently against them, pull through crises that
+seem absolutely hopeless and survive for years. Robert Louis Stevenson
+bravely doing his work, living on in spite of fate and disease, is the
+typical example. Alcoholism completely overcomes only the quitters. If
+a man wants to give up drinking even when he seems practically a
+hopeless wreck from the effects of alcohol, he can do so if he has a
+physician in whom he has confidence, who will relieve him from
+depressing symptoms due to previous excess, who will lift him up and
+strengthen him by food and stimulation, and, above all, by faithful,
+unending, never discouraged assurance that he can conquer the craving
+which has such a hold of him, if he only persists a little and does
+not give up the struggle. The victory is worth while and it is not
+hard to lift a man up if he has any remnants of character left.
+
+
+_Confidence_.--In the treatment of alcoholism, then, just two things
+are necessary. One of these is that the patient has confidence in
+himself, the other that he has confidence that his physician can help
+him over the hard spots on the road. There is no doubt that many drugs
+can be used that will lessen the patient's irritability, increase his
+nerve force, stimulate organs which are depressed by the reaction
+against over-stimulation, arouse appetite and correct disturbed
+functions. All these things must be done. It is no use laying down any
+set of rules as to how they shall be done, for they must be done
+differently in individual patients. It is not alcoholism that is
+treated nor the effects of alcoholism, but an individual alcoholic
+patient, and a set of symptoms that are very different in every
+individual. The more physiological disturbance can be relieved by
+proper drug, dietetic, hydropathic and remedial measures, the more
+chance is there for the patient to get over his habit without trouble.
+Every ill feeling that he has tempts him to think of alcohol. Above
+all, he must be made to sleep, his bowels must be thoroughly
+regulated, and he must be made to eat heartily. For stimulation full
+doses of nux vomica, not less than thirty drops three or four times a
+day or even oftener, are probably best.
+
+For cases of alcoholism in the earlier stages there is but little
+difficulty. Those who try the effect of favorable suggestion, of
+confident assurance, of constantly repeated encouragement on
+individuals who have begun to be afraid that they cannot break the
+habit, will frequently have the most gratifying results. The important
+point to remember is that men are suffering from alcoholism who are
+indulging in alcohol every day and to whom it has become more or less
+of a necessity, though even as yet its effect upon their business is
+not marked and they are not known, even among their acquaintances, as
+drunkards. Whenever a man must have three or four whiskeys a day or he
+cannot do his business and his appetite fails him and he does not
+sleep well, he is an alcoholist. He has the cellular craving that
+later may become an absolute tyrant. If we can educate the community
+generally to realize this as we are gradually educating them to the
+knowledge that tuberculosis must be caught in its incipient stage and
+that pulmonary consumption begins in very mild symptoms after a person
+has been exposed to it, we shall have little difficulty in curing
+tuberculosis or in treating alcoholism successfully by suggestion.
+
+For alcoholism, as for the drug habits and also the sex habits, moral
+influences are all-important. Hence the necessity for exercising them
+{705} frequently. It is probable that the best way to break any of
+these habits is to have the patient come regularly to the physician's
+office, at least once, and at the beginning twice a day. In cases of
+alcoholism the method of giving for the first week, at least, the dose
+of the stimulant drug which replaces the alcoholic stimulation
+directly to the patient is often of great service. It seems a good
+deal to ask the patient to come three times a day just to get a drug
+(tonic), but it is comparatively easy to resist the craving for liquor
+for four or five hours, that is, until the doctor is seen again, while
+sometimes twenty-four hours will seem a long while. The personal
+element in this matter is extremely valuable. It is this that has made
+the efficiency of all forms of cures, and it is only this that can be
+successfully used.
+
+How much can be accomplished for even the worst forms of drunkenness
+and under extremely unfavorable circumstances once a really strong
+impression is made on the individual's mind and his will is aroused to
+help himself seriously may be readily learned from the lives of any of
+the great temperance advocates. Their experience is illuminating. It
+shows clearly that strong personal influence will do more than
+anything else for these sufferers. Sometimes their efforts are
+supposed to affect only certain classes of individuals who have
+character but who, for some reason, have fallen into an unfortunate
+habit. A little investigation will show, however, that they affect all
+classes and kinds of individuals and, indeed, may reform a whole
+community. The story of Father Matthew is very interesting in this
+regard because there is some striking testimony as to his reformation
+of whole neighborhoods that had been given over to drink before and
+that among a people especially emotional and susceptible. The movement
+that he initiated still lives in the temperance societies of the
+English-speaking peoples everywhere which help by prophylaxis in youth
+and the moral force of association in later life.
+
+
+After-Treatment.--In alcoholism the most important feature of the
+treatment is what has come to be known in our time as the
+after-treatment. This department of therapeutics has taken on great
+importance in recent years in every form of disease. For early and
+middle life most diseases have a definite tendency to get better,
+though many of them leave distinct pathological tendencies. The
+after-treatment, then, has become much more important than the cure
+for the patient during the existence of the acute or sub-acute stage.
+Even in children's diseases it is now generally recognized that while
+measles and whooping cough are not dangerous affections as a rule,
+they may prove the forerunners of tuberculosis, because of the
+weakened pulmonary resistance consequent upon their invasion. For
+scarlet fever, the possibilities of injury to the kidneys after the
+great irritation to which they have been subjected, is now recognized
+and convalescence is prolonged. In typhoid fever we realize that not
+weeks but many months of convalescence are needed to put the patient
+beyond the risk of various degenerative processes that may be serious.
+There is even question in the minds of many observant physicians
+whether the weakness incident to typhoid fever may not, if a premature
+return to work is allowed, prove a potent cause of precocious
+arterio-sclerosis.
+
+In a word, after-treatment has become one of the most interesting
+subjects of modern therapeutics. It will not be surprising, then, if
+we insist that the after-treatment of the alcoholic is the most
+important part of the remedial methods to be employed. If a man who
+has suffered from tuberculosis because {706} he was working in one of
+the many dusty trades and living in a badly ventilated tenement house
+is restored to health or at least has all his symptoms disappear as a
+consequence of sanitarium treatment, it is almost needless to say that
+he must not be allowed to return to the conditions in which his
+disease originally developed. If he does, he is absolutely certain to
+have a relapse. This phase of tuberculosis has been much discussed in
+recent years. It is often said that it is impossible to keep working
+people from a return to their occupations. Just so far as that is
+impossible, so far will any real hope of keeping their tuberculosis in
+abeyance be reduced. They are much more likely to suffer from the
+disease, as a rule, after their return from the sanitarium than they
+were before they originally contracted it, because apparently some of
+their immunity has been destroyed by the invasion of the bacillus.
+
+It is only recently that we have thus planned for the after-treatment
+of tuberculosis. If we are to be successful in the after-treatment of
+alcoholism, at least some of this same thoughtfulness must be
+exercised. The victims must be discouraged from going back into the
+conditions in which their habit developed. It is comparatively easy,
+especially at the beginning of his alcoholism, to stimulate a man back
+to normal physical condition, to reduce his craving for intoxicants,
+give him back his appetite and set him on his feet again. The
+affection is quite curable. If a man returns to the conditions in
+which it originally developed, however, it will develop again quite as
+inevitably as tuberculosis does under similar conditions. We do not
+blame the sanitarium if, after having given a man a new lease of life
+in spite of tuberculosis, he resumes the unsanitary life in which his
+disease originally developed and has a relapse. It is not the fault of
+the system of treatment for alcoholism if men relapse, but the blame
+is upon them that they do not take their danger of relapse seriously
+enough, permit themselves to get into an unfavorable environment, and,
+as a consequence, suffer once again from their affection.
+
+
+_Religious Motives_.--More and more we are realizing the place of the
+higher motives of life in the reform of alcoholic patients. Religious
+motives probably form the best possible source of suggestions that
+enable a patient to lift himself out of the slough of despond of
+chronic alcoholism. Many of the best workers for the reform of the
+drunkard were themselves drunkards for many years. The motive of
+helping others is particularly important in its effects upon any
+alcoholic. Some motive apart from himself is more helpful than any
+appeal to his selfishness or even to what he can do for his children
+and his wife. It is the newer motive that appeals most strikingly. In
+recent years certain church movements have done much for alcoholic
+patients. In this they are only repeating the effect of other great
+church movements and the effect of the lives of apostles of temperance
+in recent generations. Without these higher motives cure is probably
+impossible in many cases. With them it not only becomes possible but
+even comparatively easy in the most hopeless-looking cases.
+
+In the light of what we have heard recently of the success of the
+Emanuel movement in the treatment of alcoholism, it is interesting to
+recur to what was said in this relation by Prof. Forel of Zurich on
+the treatment of alcoholism, in a communication read to the South
+German Neurologists and Psychiatrists at its meeting in Freiburg over
+twenty years ago. Prof. Forel, who is not what {707} would be called a
+particularly religious-minded man, insisted that "an inebriate asylum
+can only with great difficulty be successful without religious
+auxiliaries, since most inebriates, and especially at the beginning of
+their reformation, are entirely too weak to get along without
+religious consolation. To secure this, however, the nicest tact is
+required in order to permit the practice of all the different nuances
+of faith that men have, in peace and comfort. This can only be secured
+if in practice faith is subjected to charity for one's neighbor as the
+basis for religion."
+
+Many such expressions have been used before and since in practically
+every country in Europe. The assertion that physicians have failed to
+recognize the part that religion plays in such cases is entirely
+without foundation and can only be made by those who are quite
+ignorant of our medical literature.
+
+
+
+CHAPTER II
+
+DRUG ADDICTIONS
+
+
+Much of what has been said with regard to alcoholism finds ready
+application to the treatment of drug addictions. At the very beginning
+it must be realized that there is no specific remedy that will enable
+the patient to overcome his craving for a drag to which he has become
+habituated. There is no method of treatment that will infallibly and
+without serious and prolonged and determined effort on his part enable
+him to overcome his craving. The first and most important thing in any
+system of treatment is the patient's good will. If the patient is not
+ready to give up the drug, then nothing that a physician can do for
+him will make him do so, or will turn him against it; above all,
+nothing will make the process of cure so easy that there will be no
+trouble involved or only a passing period of struggle required to
+accomplish it. There have been many claims made in this matter. We
+have wanted such remedies and methods of treatment so much that it has
+been rather easy to persuade us sometimes that they have been
+discovered. It is like the question of specifics in medicine. For
+centuries men devoted themselves to trying to find a specific remedy
+for each disease. It was thought they must exist in nature. Now we
+know that they probably do not exist, though those who claim to
+discover them find an easy livelihood exploiting the credulity of
+those who still cherish the belief in them. Scientific students of
+medicine have practically given over the search for them in order to
+devote themselves to strengthen the patient to resist the disease
+rather than spend more time trying to find something to give him that
+cures it.
+
+
+Treating the Patient rather than the Habit--This principle holds with
+special force with regard to drug addictions. We do not treat the
+patient's habit, but we treat the patient. He must be braced up, must
+be made to understand that if he wants to quit the habit, no matter
+how slavishly he is addicted to it, he can do so. He must be told of
+men who had habits like his, often of longer duration and to a greater
+degree, yet gave them up when firmly resolved and properly stimulated.
+It is not hard to find such examples, since medical and even ordinary
+literature abound with them and every physician's experience furnishes
+him with instances. The first and {708} most absolutely necessary
+preliminary of the treatment is to lift up the patient in his own eyes
+and make him understand that, low as he has sunk, his case is not
+hopeless, that his degradation is not at all uncommon nor so rare as
+he might think, and that men and women have succeeded in lifting
+themselves out of conditions worse than his. The psychotherapeutist
+must, above all, not be of those who insist that human nature is
+degenerating and that people are much weaker physically and morally
+than they used to be, though of course he must be thoroughly aware
+that drug habits are more frequent than they were and are quite
+alarmingly on the increase. This is not due to any deterioration in
+human nature, however, but mainly to the excitement of modern life and
+its inevitable reaction, the strenuousness with which men now take
+existence and the consequent craving for artificial relief from
+over-activity, and then, above all, the facility with which the
+habit-forming drugs can be obtained.
+
+
+Prophylaxis.--This last point accounts for the frequency of drug
+habits in our time more than anything else. Men have always been ready
+to do something for the sake of novelty and excitement. Everyone is
+curious to experience for himself the effects produced by drugs that
+can make people such slaves to them. We hear too often of the intense
+pleasure that the drug habitué gets from his use of drugs. The
+curiosity thus aroused constitutes the suggestion that has led many to
+try the effect, confident that he or she would be able to resist any
+craving just before it became seriously tyrannous. Psychiatrists agree
+that one of the worst elements in modern social conditions is the
+impression generally maintained that there is such intense pleasure in
+the taking of drugs. A clear statement of the reality of the case is
+eminently desirable. It is not positive pleasure that the drug habitué
+has, but mere negative pleasure, as a rule. His "dope" does not so
+much add to his good feeling as take away the bad feelings that he has
+because of depression or ennui at the beginning and later because of
+the craving for the drug.
+
+Physicians to whom many drug habitués have told their experience
+frankly are not at all inclined to think that the usually accepted
+opinion of pleasure in drug taking is true. It is not that it is
+heaven to have the drug so much as it is hell to be without it. The
+patient's system has learned to crave it so much because of the
+surcease of painful consciousness of self it gives and this it is that
+compels these unfortunates to go back to ever-increasing doses. The
+pleasant side is a very dubious affair at all times, accompanies only
+the earliest steps of the formation of the habit at most, and usually
+whatever agreeable feelings there are are accompanied by such a
+nightmare of solicitude and anxiety as a background that the pleasure
+is more poignant than agreeable. As a prophylactic against the
+formation of drug habits this aspect of the experience of drug
+habitués deserves to be emphasized and knowledge of it widely
+diffused. Of course, the morphin fiend brightens up after his dose of
+morphin, his eye lightens, his expression becomes happy, and his
+nerves get steadier, but that is only because the depression in which
+he was sunk before has now been stimulated away, the struggle with his
+worst feelings is over and the consequent reaction has developed. Of
+course, the cocain-taker is pitiably helpless and downcast without his
+"dope," but it is only by contrast with this previous state that his
+succeeding condition can be said to be pleasant or agreeable, even to
+himself.
+
+{709}
+
+_Favorable Suggestion_.--One of the most helpful sources of favorable
+suggestion for these patients is to be found in the stories of cured
+drug habitués. These may be used tactfully to bring confidence to
+patients that they, too, can be broken of their habit if they are
+willing to take the pains to do so. De Quincey, taking his thousand
+drops of laudanum a day, represents one of the most encouraging
+examples of this since he succeeded eventually in breaking away from
+his habit. Coleridge succeeded, also, in breaking his habit more than
+once, but unfortunately returned again and again, and illustrates the
+danger of the almost inevitable tendency to relapse, if the patient
+permits himself to think that now that he has once conquered the habit
+he is too strong ever to let it get hold of him again. If he ventures
+to think complacently of his self-control and that consequently he may
+with impunity--always for some good reason--take a dose or two of his
+favorite drug in order to tide him over some crisis of mental worry or
+some spell of physical pain, relapse is certain. The tendency of
+patients to fool themselves in this way is too well known to need
+special emphasis, but it is as well to say that there is scarcely a
+single cured case that does not relapse. The relapse is due not so
+much to craving for the drug, as to the memory of its previous effects
+in relieving discomfort and the unfortunate confidence that the
+patient has developed that now, knowing the dangers, he will be able
+to resist the formation of the habit before it gets a strong hold of
+him.
+
+It is curious how even highly intelligent patients will slip back into
+their old habits, sometimes deeper than before, on this reasoning, in
+spite of the lessons of experience, even their own as well as others.
+Like the drunkard, they persuade themselves that just this once will
+not count, and when it would have been comparatively easy for them to
+say no they yield once or twice and make self-denial for the future
+increasingly difficult. This is especially true if patients have the
+drug near them, so that it is not difficult for them to have recourse
+to it. Hence doctors and nurses are not hard to cure of such habits,
+as a rule, provided they are away from their professional duties, but
+they almost inevitably relapse when they go back to work. Every time
+the relapse is due to the fact that tired feelings, because of
+irregular hours or some physical pain, prompt them to seek relief and
+they yield to the temptation of taking the old drug, sure that they
+need it, only for the moment. They will all assert that they could
+just as well resist as not, that, indeed, had not the drug been so
+handy, they would not have taken it, and that if anyone had been near
+to help them by a word in the matter even then they would not have
+indulged in it.
+
+If patients are to be kept from relapsing, all this must be set before
+them frankly. After they have been told once or perhaps twice or
+perhaps many times and yet relapse into their habits, they must simply
+be told it again a little more emphatically, more encouragingly, up to
+seventy times seven, if necessary. Patience is needed more than
+anything else in taking care of these cases. Over and over again their
+confidence in their power to overcome their habit, if they really wish
+to do so, must be reawakened. Without this confidence in themselves
+success is hopeless. It matters not how often they have relapsed, they
+can still break off the habit, and if they will not fool themselves
+into over-confidence in their power to keep away, they need never be
+slaves to the habit again. There will be quite as many disappointments
+in {710} treating drug addiction as in the treatment of alcoholism.
+Those who have most experience insist that there are even more, but
+there are some wonderfully encouraging examples of men and women who
+have broken from their habit, even after a number of bad relapses, and
+have for many years lived absolutely without any of their drug and,
+though still not over-confident in their power to resist if once they
+should yield (such confidence, it cannot be repeated too often, is
+always fatal), do actually keep away from the drug without any other
+bother than the necessity of living a regular hygienic life and
+exercising a little self-control.
+
+In drug addictions as in alcoholisms, the question of sanitarium
+treatment comes up in every case. Much more rarely than in the case of
+the alcohol habit is it necessary to send a drug habitué to a
+sanitarium. Here once more, however, the patient's circumstances and
+the possibility of diversion of mind with reasonable freedom from
+temptations to take the drug and from ready access to it, are the most
+important considerations. If a patient really wants to break off the
+use of a drug, it can be done gently and without much bother in the
+course of three or four weeks. I have seen cocain fiends who have
+tried many remedies and many physicians completely cured in five or
+six weeks without serious trouble. The important thing is perseverance
+in the effort and in the treatment and the definite persuasion of the
+patient that it is not only perfectly possible to get rid of the
+habit, but that it is even easy with good will on his part. If certain
+other milder stimulants are supplied for a time so that all the
+symptoms due to the physiological effects of the excessive use of the
+drug are minimized, the physical trial need not be severe. The
+patient's mind, however, must be occupied. Time must not be allowed to
+hang heavy on his hands and all physical symptoms must be treated
+promptly. Drug addictions are indeed more curable than alcoholism and
+the danger of relapse is not quite so imminent. The social temptations
+do not exist for drug habitués as they do for alcoholics. As I have
+said, however, in the cases of nurses and physicians almost a
+corresponding state of affairs obtains and in them the danger of
+relapse is great.
+
+
+Early Treatment.--It is quite as important for drug victims as it is
+for alcoholics that the case should be taken under treatment early.
+Every physician knows how curiously easy it is for some people, indeed
+for most people, to acquire a drug habit. I have seen one of the
+solidest men I ever knew, with plenty of character that had been tried
+by many a crisis in life, recommended cocain for a toothache when he
+was past fifty years of age and in the course of ten days acquire a
+thorough beginning of the cocain habit, so that he was taking several
+grains a day. He had no idea that he was unconsciously slipping into a
+drug habit. When the druggist refused any longer to supply the cocain
+solution without a prescription he was quite indignant. It was not
+until he had forty-eight hours of nervous symptoms and craving that he
+realized that he had created a need for stimulation of his nervous
+system by the mere taking of cocain by application on his gums. This
+habit was broken up at once and there has never been any tendency to
+its recurrence. He had his warning, fortunately, without evil effects.
+
+If the cocain habit can be formed as unconsciously as this, there
+should be little difficulty in treating it. It is not a profound
+change in the organism, but only a habit. It is not the habit itself
+that is hard to break, but the effects {711} upon the nervous system
+of the patient are such as to create a series of symptoms that can
+only be soothed by the drug. It is these symptoms of depression,
+irritation, sleeplessness, lack of appetite, constipation and the rest
+that it is the physician's duty to treat in order to help the patient.
+The patient breaks the habit by his will-power when properly persuaded
+and when it is made clear to him that it is neither so difficult as he
+thought, nor is he so likely to fail in the matter as he has imagined,
+and as has perhaps been suggested to him even by physicians. The
+mental treatment consists in making him realize that he can do it and
+that if he wants to get rid of his habit he must do it for himself.
+With this must come the assurance that every annoying symptom will be
+met, that he need not recur to his favorite drug for this purpose,
+that his appetite will be gradually restored and that, though perhaps
+for a week he will have considerable inconvenience to bear, after that
+it will be plain sailing. Usually three days can be set as the term at
+which his craving ceases to be so disturbing as to make the
+possibility of his relapsing into the habit a positive danger. As in
+alcoholic and sex habits, the patient to be helped in breaking the
+habit should be seen once a day at least, usually oftener. If he can
+be made to understand that whenever the old tendency seems about to
+get the upper hand is the time to see his physician, and if something
+physical as well as moral is done for him, the breaking of the habit
+is comparatively simple.
+
+This method of treatment looks too simple to be quite credible to
+those who have so often tried and failed in the cure of drug habits.
+It is not the doctor, however, who fails, but the patient. We cannot
+put new wills into a patient, but we can so brace up even an old and
+tottering will as to make it possible for the worst victims of drug
+habits to reform. The doctor, too, easily becomes discouraged. He has
+not confidence enough in his own methods to make assurance doubly sure
+for the patient as to his cure. This is what many of the pretended
+specific purveyors of drug habit cures have as their principal stock
+in trade. They assure patients with absolute confidence, while the
+physician only too often says the same thing, but half-heartedly. A
+half-hearted physician makes a hesitant patient, and success is then
+very dubious from the beginning. Every patient can be cured. They may
+relapse, but then they can be cured again. This is the essence of the
+psychotherapy of drug habits, but it is also the only successful
+element in any treatment of the drug habit that is really effective.
+Specifics come and go. Sure cures cease to have their effect. The only
+really effective element in any cure is the absolute trust of the
+patient.
+
+In his "Drugs and the Drug Habit" (Methuen, London) Dr. Harrington
+Sainsbury, Senior Physician to the Royal Free Hospital of London, has
+emphasized all these points that can only be touched on very briefly
+here. He has called particular attention to the fact that the victim
+of one drug habit is rather prone to acquire another if by any chance
+he should once begin to take another habit-forming drug. The original
+drug habit has broken down the will. It is not so much the craving for
+a particular drug as the lack of will power that proves unfortunate
+for the patient. He suggests "incidentally, if this explanation hold
+good, it proves the solidarity of the will that it works as a whole
+and not by compartments." He has dwelt on recoveries from the most
+discouraging depths and insists "we must teach that {712} no one is
+ever so enslaved by a habit as to be incapable of relief--this alone
+is _right_ teaching, justifiable moreover by records well
+substantiated of recoveries from desperate plights."
+
+
+Heredity and Unfavorable Suggestion.--As to the suggestion, sometimes
+encountered, of the influence of heredity and its all-powerful effect
+in making it practically impossible for the son of a man who has taken
+drugs to keep from doing the same thing, we must recall very
+emphatically here the principles discussed elsewhere. So far as
+concerns heredity, opium and the other drugs are exactly in the same
+position as alcohol in their effect upon the human race. Instead of
+being justified in saying that by heredity individuals of succeeding
+generations are rendered more susceptible to them, just the opposite
+is true and, if anything, an immunity is produced. This is not only
+racial and general but is personal and actual. In recent years we have
+come to realize that individuals born of tuberculous parents who care
+for themselves properly are much better able to resist the invasion of
+the tubercle bacilli than those who come from stocks that were never
+affected by the disease. They are the patients who, in spite of the
+fact that their disease reaches an advanced stage, sometimes live on
+for years with proper care. Just this is true for drug addictions so
+far as we know anything about it. The whole subject is as yet obscure,
+but heredity rather favors than hurts the patient in these cases.
+
+
+Hereditary Resistance.--Instead of being discouraged by the fact that
+his father took a drug to excess and that therefore he is weaker
+against this than other people, a man should rather be encouraged by
+the thought that a certain amount of resistance to the craving has
+probably been acquired by the particular line of cells through which
+his personality is manifested. Dr. Archdall Reid has said that "the
+facts concerning opium are very similar" (to those that concern
+alcohol). Then he continues:
+
+  That narcotic has been used extensively in India for several
+  centuries. It was introduced by the English into China about two
+  centuries ago. Quite recently the Chinese have taken it to Burma, to
+  various Polynesian Islands, and to Australia. There is no evidence
+  that the use of opium has caused any race to deteriorate. Indeed it
+  happens that the finest races in India are most addicted to its use.
+  According to the evidence given before the late Royal Commission on
+  Opium, the natives of India never or very rarely take it to excess.
+  When first introduced into China it was the cause of a large
+  mortality; but to-day most Chinamen, especially in the littoral
+  provinces, take it in great moderation. On the other hand. Burmans,
+  Polynesians and Australian natives take opium in such excess and
+  perish of it in such numbers that their European governors are
+  obliged to forbid the drug to them, though the use of it is
+  permitted to foreign immigrants to their countries. In exactly the
+  same way alcohol is forbidden to Australians and Red Indians in
+  places where It is permitted to white men.
+
+
+After-Cures.--I have said so much about the after-cure of alcoholism
+that applies directly to drug addictions also, that it does not seem
+necessary to repeat it here. Patients must be warned that if they
+become overtired, if they lose sleep, if they are subject to much
+excitement, if they put themselves in conditions of anxiety and worry,
+if any form of recurrent pain develops--headache, toothache,
+stomach-ache--they are likely to be tempted to take up their old
+habit. If they are in a position where they can easily get the drug it
+is almost inevitable that something will happen to make them feel that
+{713} they are justified in taking one or two doses and from this to
+the reestablishment of the habit is only a small step. Often these
+patients need a change of occupation. Some of them are over-occupied,
+some of them have not enough to do. In either case it is the doctor's
+duty to know enough about his patient to be able to give directions.
+We do not treat a drug addiction with the hope of curing it, but we
+treat a patient suffering from a particular drug habit and we try so
+to modify that patient's life that after we have succeeded in getting
+him away from his habit, which is never difficult, he will not relapse
+into it. The after-cure is the more important of the two.
+
+
+
+CHAPTER III
+
+SUICIDE
+
+
+In spite of the gradual increase of comfort in life and its wide
+diffusion--far beyond what people enjoyed in the past--there has been
+a steady progressive increase in the number of suicides in recent
+years. It is as if people found life less worth living the more of
+ease and convenience there was in it. This increase in suicide is much
+greater (over three times in the last twenty years) than the increase
+in the population. Surprising as it may seem, prosperity always brings
+an addition to the number of suicides. Stranger still, during hard
+times the number of suicides decreases to a noteworthy degree. It is
+not those who are suffering most from physical conditions who most
+frequently commit suicide. Our suicides come, as a rule, from among
+the better-to-do classes of people. While suicide might seem to be
+quite beyond the province of the physician, it is a duty of the
+psychotherapeutist to prevent not only the further increase of
+suicides in general but to save particular patients from themselves in
+this matter. A careful study of the conditions as they exist,
+moreover, will show that he can accomplish much--more than is usually
+thought--and that it is as much a professional obligation to do so as,
+by the application of hygienic precautions and regulations, to lessen
+disease and suffering of all kinds and prevent death.
+
+The same two modes of preventive influence that we have over disease
+in general can be applied to suicide. The physician can modify the
+mental attitude in individual cases and thus save people from
+themselves and then he can, by his influence in various ways upon
+public opinion, lessen the death rate from suicide. For this purpose,
+just as with regard to infectious disease, it is important for him to
+appreciate the social and individual conditions that predispose to
+suicide, as well as the factors that are more directly causative. The
+more he studies the more will he be convinced that what we have to do
+with in suicide is a mental affliction not necessarily inevitable in
+its results and that may be much influenced by suggestion. Indeed,
+unfavorable suggestion is largely responsible for the increase in
+suicide that has been seen in recent years. Favorable suggestion might
+be made not only to stop the increase, but actually to reduce the
+suicide rate. For this purpose it is important to know just what are
+the conditions and motives that predispose to suicide and, above all,
+to realize that it is not the result of insufferable pain {714} or
+anguish, but rather of the concentration of mind on some comparatively
+trivial ailment, or exaggeration of dread with regard to the
+consequences of physical or moral ills.
+
+Suicides are often said to be irrational; in a certain sense they are.
+No one who weighs reasonably all the consequences of his act will take
+his own life. This irrationality, however, is nearly always functional
+and passing, not of the kind that makes the commission of suicide
+inevitable, but only produces a tendency to it. This tendency is
+emphasized by many conditions of mind and body that the physician can
+modify very materially if he sets about it. Many of the supposed
+reasons for suicide are founded on the complete misunderstanding of
+the significance of symptoms and dread of the future of his ailments,
+often quite unjustified by what the individual is actually suffering.
+Indeed, the desperation that leads to suicide is practically always
+the result of a state of mind and not of a state of body. It is
+exactly the same sort of state of mind which sometimes proves so
+discouraging in the midst of diseases of various kinds as to make it
+impossible for patients to get over their affections until a change is
+brought about in their ideas. This makes clear the role of
+psychotherapy with regard to suicide, and there is no doubt that many
+people on the verge of self-murder can be brought to a more rational
+view and then live happy, useful lives afterwards. For this purpose,
+however, it is important that the physician should come to be looked
+upon as a refuge by those to whom the thought of suicide has become an
+obsession.
+
+A well-known social religious organization not long since established
+a suicide bureau, that is, a department to which those contemplating
+suicide may apply with the idea that they would there find consolation
+and perhaps some relief for their troubles and thus the idea of
+suicide might be dissipated. Many a suicide would be avoided if the
+reasons that impelled to it had been known to one or two other people
+beforehand, so that some relief might have been afforded to what
+seemed an intolerable condition. This suicide bureau is said to have
+done much good. There is no doubt that the mere act of giving one's
+confidence to another is quite sufficient of itself to diminish to a
+marked degree a burden of grief and trial. If anything in the world is
+true, it is that sorrows are halved by sharing them with another,
+while joys are correspondingly increased. The fact that there is
+someone to whom they might go, who would look sympathetically at their
+state of mind, who would appreciate the conditions, who had been
+accustomed to dealing with such cases, would be enough to tempt many
+people from that awful introspection and concentration of mind on
+themselves which, more than their genuine sufferings and trials,
+whatever they may be, make their situation intolerable.
+
+There has always been a suicide bureau, however, in the office of
+every physician who really appreciates the genuine responsibilities of
+his profession. More than any others we have the opportunity to
+alleviate physical sufferings, to lessen mental anguish and to make
+what seemed unbearable ill at least more or less tolerable.
+Unfortunately in recent years the change in the position of the
+physician in his relations to the family has somewhat obscured this
+fact in the minds of the public. The old family physician occupied to
+no slight extent the position of a father confessor, to whom all the
+family secrets were told, from whom indeed, as a rule, it was felt
+that they should not be kept; to whom father went with regard to
+himself and mother, to whom mother {715} went with regard to all the
+family as well as herself, to whom the boy confided some of his sex
+trials and the girl some of the secrets that she hid from almost
+everyone else, so that to go to him for anything disturbing became the
+first thought. We must restore something of this old-fashioned idea of
+the doctor's place in life if all our professional duties are to be
+properly fulfilled. If those contemplating suicide learn to think of
+us as persons to be appealed to when all looks so black that life is
+no longer tolerable, we shall soon be in a position to confer
+increased benefits on this generation that needs them so much.
+
+
+Physical Factors.--As a rule there is a physical element as the basis
+for nearly all suicides. With the unfortunate, unfavorable suggestion
+that has come from the supplying of details of pathological
+information--the half-knowledge of popular medical science--without
+the proper antidote of the wonderful compensatory powers of the human
+body for even serious ailments, a great many nervous people are
+harboring the idea that they have or soon will have an incurable
+disease. Physicians have abundant evidence of this. All sorts of
+educated people come to us to be reassured that some trivial digestive
+disturbance does not mean cancer of the stomach, or, when they are
+between forty and fifty, come to make sure that some slight
+disturbance of urination is not an enlarged prostate. Brain workers of
+all classes come over and over again to be reassured that they are not
+breaking down because of organic brain disease, of which they show
+absolutely no sign. Sometimes they have been making themselves quite
+miserable for a long period by such thoughts. It is easy to
+understand, then, how many less informed people, yet provided with the
+opportunities of quasi-information that modern life affords, are apt
+to think the worst about themselves.
+
+
+_So-called Insomnia_.--The correction of such preconceived notions
+will always greatly alleviate the mental sufferings of these patients.
+For this purpose there are many chapters of this book which point out
+how various symptoms and syndromes that are often amongst the factors
+in the production of suicide may be managed. Perhaps one of the most
+frequent of these is so-called insomnia. Most people are insomniac,
+mainly because they are overanxious about their sleep. A few of them
+are wakeful because of bad habits in the matter of work and the taking
+of air and exercise. Essential insomnia is extremely rare and
+symptomatic; insomnia is not mental, but is usually due to some
+definite physical condition that can be found out and, as a rule,
+treated successfully. There is always some other symptom besides loss
+of sleep. If men will live properly and rationally there is no reason
+why insomnia should be a bane of existence, nor even any reason why
+the morphin or other drug habit should be formed which is so likely to
+come if inability to sleep is treated as if it were an independent
+ailment. In the forms in which it incites to suicide it owes its
+origin to a nervous superexcitement with regard to sleep in people
+whose daily life in some way does not properly predispose them for the
+greatest of blessings on which there is no patent right. Additional
+suggestions as to these insomniac conditions are made in the chapters
+on Insomnia and Some Troubles of Sleep which make it clear that
+suicide, because of insomnia is due to a delusion.
+
+
+_Headache_.--Persistent supposedly incurable headache is another
+prominent feature of the stories of suicides and here once more we
+have to deal rather {716} with a delusion of over-attention of mind
+and concentration of self on a particular part than a real physical
+ailment. Most of the so-called headaches that are supposed to be so
+intractable are really not headaches but pressure feelings and other
+queer sensations in the head originally perhaps partaking of the
+nature of an ache but continued through over-advertence. Severe pain
+within the head occurs in cases of congestion and brain tumor, and
+without the head in cases of neuralgia, but most of these are only
+temporary and long-continued headaches are rather neurotic than
+neuritic or due to any real disturbance of the nervous system. This is
+discussed in the chapter on Headaches. People commit suicide who have
+for a long time been sufferers from headache because they fear that
+they may go crazy. There is absolutely no reason in the world to think
+this probable, and in the one case of continuance of severe
+intermittent headaches for years already mentioned--that of von Bülow,
+the Austrian pianist and composer, in which we have the autopsy
+record--it was found, after a long life, that his severe intracranial
+headaches were due to the pinching of a nerve in the dura and not to
+any organic change in the brain itself.
+
+
+Mental Factors.--While physical factors enter into the suicide problem
+to a marked degree, it would be a great mistake to think that physical
+conditions or material circumstances are the main causes or occasions
+in suicide. It is supposed, as a rule, to be due to depression
+produced by incurable disease, oppressive weather, financial losses
+and the like. There is no doubt that these are contributing causes,
+but the physical conditions have very little influence compared with
+the attitude of the patient's mind toward himself. As a rule, it is
+not those who are in absolutely hopeless conditions who turn to this
+supposed refuge of a voluntary exit from life in order to get out of
+trouble, but rather those who are momentarily discouraged and who have
+not sufficient moral stamina to face the consequences of their acts.
+There was a time when it was considered brave to fight a duel and
+cowardly to refuse to do so. Looking back now, we know that they were
+the real brave men who dared to refuse when a barbarous civilization
+would force them into a false position and who, in spite of disgrace,
+ventured to be men and not fools. There are those who used to say that
+it was brave to take one's own life rather than bring disgrace on
+loved ones, but the mitigation, if there be any, of the disgrace that
+suicide brings with it, comes from that lowest of all motives, pity
+for the survivors, and the cowardly suicide leaves to others the
+thankless task of making up for his faults.
+
+
+_Suicide and the Weather_.--An investigation of suicide records shows,
+as we have said, that it is not nearly so often bodily or material
+hardships that lead men to it as mental states. These mental states
+are not mental diseases, but passing discouragements in which men are
+tempted beyond their strength and do irretrievable things for which
+there is no rational justification. It is not in dark damp weather
+that men commit suicides most, though this was supposed to be a
+commonplace in our knowledge of suicide. Recent investigations show
+that quite the contrary is true. Professor Edwin T. Dexter of the
+University of Illinois published a very important study of this
+question in a paper entitled "Suicide and the Weather."   [Footnote
+55] He followed out the records of nearly 2,000 cases of suicide
+reported to the police in the City of New York {717} and placed beside
+them the records of the weather bureau of the same city for the days
+on which these suicides occurred. According to this, which represents
+the realities of the situation, the tendency to suicide is highest in
+spring and summer and the deed is accomplished in the great majority
+of cases on the sunniest days of these seasons.
+
+  [Footnote 55: _Popular Science Monthly_, April, 1901. ]
+
+His conclusions are carefully drawn and there is no doubt that they
+must be accepted as representing the actual facts. All the world feels
+depressed on rainy days and in dark, cloudy weather, but suicides
+react well, as a rule, against this physical depression, yet allow
+their mental depression to get the better of them on the finest days
+of the year. Prof. Dexter said:
+
+  The clear, dry days show the greatest number of suicides, and the
+  wet, partly cloudy days the least; and with differences too great to
+  be attributed to accident or chance. In fact there are thirty-one
+  per cent. more suicides on dry than on wet days, and twenty-one per
+  cent. more on clear days than on days that are partly cloudy.
+
+What is thus brought out with regard to the influence of weather can
+be still more strikingly seen from the suicide statistics of various
+climates. The suicide rate is not highest in the Torrid nor in the
+Frigid zones, but in the Temperate zones. In the North Temperate zone
+it is much more marked than in the South Temperate zone. Civilization
+and culture, diffused to a much greater extent in the North Temperate
+zone than in the South, seem to be the main reason for this
+difference. We make people capable of feeling pain more poignantly,
+but do not add to their power to stand trials nor train character by
+self-control to make the best of life under reasonably severe
+conditions. With this in mind it is not surprising to find that the
+least suicides occur in the month of December, when the disagreeable
+changes so common produce a healthy vital reaction, though the many
+damp dark days that occur would usually be presumed to make this the
+most likely time for suicides. On the contrary, it is the month of
+June, the pleasantest in the North Temperate zone, that has the most
+suicides. It is important to remember this in estimating the role of
+physical influences on the tendency to suicide.
+
+
+Social Factors that Restrain Suicides.--_War_.--A most startling
+limitation of suicide is brought about by war. For instance, our
+Spanish-American war reduced the death rate from suicide in this
+country over forty per cent. throughout the country and over fifty per
+cent. in Washington itself, where there was most excitement with
+regard to the war. This was true also during the Civil War. Our
+minimum annual death rate from suicide from 1805 (when statistics on
+this subject began to be kept) was one suicide to about 24,000 people,
+which occurred in 1864 when our Civil War was in its severest phase.
+There had been constant increase in our suicide rate every year until
+the Civil War began, then there was a drop at once and this continued
+until the end of the war. In New York City the average rate of suicide
+for the five years of the Civil War was nearly forty-five per cent.
+lower than the average for the five following years. In Massachusetts,
+where the statistics were gathered very carefully, the number of
+suicides for the five-year period before 1860 was nearly twenty per
+cent. greater than for the five-year period immediately following,
+which represents the preliminary excitement over the war and the
+actual years of the war. This experience in America is only in
+accordance {718} with what happens everywhere. Mr. George Kennan in
+his article on "The Problems of Suicide" (_McClure's Magazine_, June,
+1908), has a paragraph which brings this out very well. He says:
+
+  In Europe the restraining influence of war upon the suicidal impulse
+  is equally marked. The war between Austria and Italy in 1866
+  decreased the suicide rate for each country about fourteen per cent.
+  The Franco-German War of 1870-71 lowered the suicide rate of Saxony
+  8 per cent., that of Prussia 11.4 per cent. and that of France 18.7
+  per cent. The reduction was greatest in France, because the German
+  invasion of that country made the war excitement there much more
+  general and intense than it was in Saxony or Prussia.
+
+
+_Great Cataclysms_.--Even more interesting than the fact that war
+reduces the suicide rate is the further fact that a reduction of the
+number of suicides takes place after any severe cataclysm. The
+earthquake at San Francisco, for instance, had a very marked effect in
+this way. Before the catastrophe suicides were occurring in that city
+on an average of twelve a week. After the earthquake, when, if
+physical sufferings had anything to do with suicide, it might be
+expected that the self-murder rate would go up, there was so great a
+reduction that only three suicides were reported in two months. Some
+of this reduction was due to inadequate records, but there can be no
+doubt that literally hundreds of lives were saved from suicide by the
+awful catastrophe that levelled the city. Men and women were homeless,
+destitute, and exposed to every kind of hardship, yet because all
+those around them were suffering in the same way, everyone seemed to
+be reasonably satisfied. Evidently a comparison with the conditions in
+which others are has much to do with deciding the would-be suicide not
+to make away with himself, for by dwelling too much on his own state
+he is prone to think that he is ever so much worse off than others.
+
+  If life were always vividly interesting, as it was in San Francisco
+  after the earthquake, and if all men worked and suffered together as
+  the San Franciscans did for a few weeks, suicide would not end ten
+  thousand American lives every year, as it does now.
+
+
+Individual Restraints.--_Religion_.--It seems worth while to call to
+attention certain factors that modify the tendency to suicide and
+limit it very distinctly, because it is with the limitation of it that
+the physician must be mainly occupied. There seems to be no doubt that
+certain religious beliefs, which affect the individual profoundly and
+occupy his thoughts very much, furnishing, both by tradition and
+heredity as it were, sources of consolation for evils in this life by
+the thought of a future life, notably lessen the suicide rate. All
+over the world the Jews who cling to their old-time belief have
+perhaps the lowest suicide rate of any people. This is true in spite
+of racial differences. People who retain the confidence in prayer,
+that used to characterize members of all religions a century or more
+ago, are likely to be able to resist the temptation to suicide. This
+is true particularly for the more or less rational suicide. Oppenheim
+has recalled attention to the power of prayer against depression and
+in the insane asylums of England its efficiency in this way is well
+recognized.
+
+
+It is well-known that Roman Catholics the world over have much less
+tendency to suicide than their Protestant neighbors living in the same
+{719} communities. It is true that where the national suicide rate is
+high many Catholics also commit suicide, but there is a distinct
+disproportion between them and their neighbors. The suicide rate of
+Protestants in the northern part of Ireland, as pointed by Mr. George
+Kennan, is twice that of Roman Catholics in the southern part. He
+discusses certain factors that would seem to modify the breadth of the
+conclusion that might be drawn from this, but in the end he confesses
+that their faith probably has much to do with it and that, above all,
+the practice of confession must be considered as tending to lessen the
+suicide rate materially. It is the securing of the confidence of these
+patients that seems the physician's best hope of helping them to
+combat their impulse and Mr. Kennan's opinion is worth recalling for
+therapeutic purposes:
+
+  In view of the fact that the suicide rate of the Protestant cantons
+  in Switzerland is nearly four times that of Catholic cantons, it
+  seems probable that Catholicism, as a form of religious belief, does
+  restrain the suicidal impulse. The efficient cause may be the
+  Catholic practice of confessing to priests, which probably gives
+  much encouragement and consolation to unhappy but devout believers
+  and thus induces many of them to struggle on in spite of misfortune
+  and depression.
+
+
+_Disgrace as a Restraint_.--It is curious what far-fetched motives,
+that appear quite unlikely to have any such influence, sometimes prove
+able to affect favorably would-be suicides and prevent their
+self-destruction. Plutarch tells the story, in his treatise on "The
+Virtuous Actions of Women," of the well-authenticated instance of the
+young women of Milesia. Disappointed in love, they thought life not
+worth living. Accordingly there was an epidemic of suicide among the
+young women and it even became a sort of distinction to prefer death
+to matrimony. Some perverted sense of delicacy entered into the
+feeling that prompted the suicides, as if sex and its indulgence were
+something belittling to the better part of their nature. The
+authorities in Milesia must have been psychologists. They issued a
+decree that the body of every young woman who committed suicide would
+be exposed absolutely naked in the market-place for a number of days
+after her death. This decree, once put into effect, immediately
+stopped the suicides. The young women shrank from this exposure of
+their bodies, even though it might be after death, and the suicide
+fashion came to an end.
+
+It might be thought perhaps that this incident represented ancient
+feeling and that a similar condition in the modern times would not
+have a corresponding effect. It so happens that something similar has
+been tried. In some of the cities of South Central Europe in which the
+suicide rate is almost the highest in the world, it was decided about
+a generation ago by the Church authorities of the towns that suicides
+would not thereafter be buried in the cemeteries near the bodies of
+those who died in the regular course of nature, but must be interred
+in a separate portion reserved for themselves. Strange as it may seem,
+just as in the case of the young women of Milesia, this proved a great
+deterrent to suicide. The suicide rate was reduced one-half the next
+year.
+
+As a matter of fact, it only takes some reasonably forceful
+countervailing notion to set a train of suggestions at work that will
+prevent suicide. If those contemplating suicide are made acquainted
+with some of these curious facts we know, then the notion of suicide
+loses more than half its terrible {720} attraction by being stripped
+of all of its supposed inevitableness. Almost any motive that attracts
+attention, even apparently so small a thing as disgrace after death,
+makes these people realize the littleness and the cowardice of the
+act.
+
+
+Favoring Factors.--_Psychic Contagion_.--A prominent factor in
+suicides that must constantly be borne in mind is the influence of
+example or, as we have come to call it learnedly in recent years,
+psychic contagion. It is discussed more in detail in the chapter on
+Psychic Contagion, but its place here must be emphasized. It has often
+been noted that certain peculiar suicides are followed by others of
+the same kind. If a special poison has been used, others obtain it and
+put an end to their lives in that way. Even such horrible modes of
+death as eroding the jugular vein by drawing the neck backward and
+forward across a barbed-wire fence have been imitated. If the story of
+jumping off a high building is told with lurid details, special care
+has to be taken in permitting unknown people to go up to the same
+place for some time afterwards. The imitative tendency is evidently a
+strong factor. Plutarch's story of the young women of Milesia brings
+this out, and it has been noted all down the centuries.
+
+In any discussion of the prophylaxis of suicide the effect of
+newspaper descriptions of previous suicides must be looked upon as
+very important. The influence of suggestion of this kind on people who
+have been thinking for some time of suicide is very strong. There
+comes to them the impelling thought that the suicide's miseries are
+over and they wish they were with him. From the wish to the resolve
+and then to the deed itself are only successive steps when suggestion
+is constantly prodding the unfortunate individual. If we are going to
+reduce the suicide rate materially or, indeed, keep it from increasing
+beyond all bounds, this question must be squarely faced. Accounts of
+suicides are not news in the ordinary sense of the word and while they
+might find a place for legal and other purposes in a few lines of an
+obituary column, the present exploitation of them by the papers makes
+them a constantly recurring source of strong suggestion to go and do
+likewise. These suggestions come to persons already tottering on the
+edge of disequilibration in this matter, and it is like tempting
+children to do things that they know are wrong, but that look
+irresistibly inviting when presented under certain lights. The very
+fact that their death will produce a sensation and will give them so
+much space in the newspapers attracts many morbidly sensation-loving
+people. Physicians must work as much for this prophylaxis as we have
+for the prevention of infectious diseases.
+
+
+Child Suicides.--Probably the worst feature of the suicide statistics
+of recent times in all countries is the great increase of self-murder
+among children. Arthur MacDonald in discussing the "Statistics of
+Child Suicide"   [Footnote 56] has shown that there is a special
+increase of young suicides everywhere. In France there are nearly five
+times as many suicides at the end of the nineteenth century as there
+were at the beginning of it. In England there is almost as startling
+an increase. Though the statistics are not as well kept, child suicide
+has increased not only in proportion to the increase of suicide among
+adults, but ever so much more. In Prussia the condition is even worse.
+
+  [Footnote 56: "Statistics of Child Suicide," _Transactions of American
+  Statistical Association_, Vol. X., pp. 1906-1907. ]
+
+
+{721}
+
+The French child suicide rate is especially interesting and
+disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the
+subject of suicide among young people and shows how rapid has been the
+growth of the number of such suicides in the last 100 years. The first
+statistics available for the purpose that, in his opinion, are exact
+enough to furnish a basis for scientific conclusions, are from 1836 to
+1840. Altogether during that period in France there were 92 suicides
+under the age of seventeen years, 69 of whom were boys and 23 girls.
+In 1895 this number had increased to such a degree that in a single
+year there were almost as many suicides (90) as there had been in five
+years, only fifty years before. In 1895 the proportion of suicides
+less than ten years of age was a little more than one in twenty of the
+total number of suicides in France. There are countries in Europe in
+which the suicide rate among such children is even higher than it is
+in France. In every country it has gone on increasing and the awful
+thing is that the suicide rate is increasing more rapidly among
+children than it is among adults, though among adults it doubles every
+twenty years.
+
+
+_Causes at Work_.--The causes for the increase in suicide among
+children were pointed out even by Esquirol, the great French
+psychiatrist, nearly a century ago. They are the same to-day, only
+emphasized by the conditions of our civilization. He attributed it to
+a false education which emphasizes all the vicious side of life, makes
+worldly success the one object of life, does not properly prepare the
+child for constancy in the midst of hardships, nor make it appreciate
+that suffering is a precious heritage to the race, that has its reward
+in forming character and fixing purpose. He thought that there were
+two very serious factors for the increase of suicide among children
+not usually realized. They were in his time literature and the
+theater. He said: "When the theater presents only the triumphs of
+crime, the misfortunes of virtue, when the books that are in common
+circulation because of the low price at which they are issued, contain
+only declarations against religion, against family ties and duties
+towards our neighbor and society, then they inspire a disdain of life
+and it is no wonder that suicide rapidly increases even among the very
+young." He was commenting on the case of a child of thirteen who had
+hanged himself, leaving this written message: "I bequeath my soul to
+Rousseau and my body to the earth."
+
+
+Cowardice of Suicide.--Of course, the strongest motive for dissuasion
+from suicide is the utter cowardice of the act. As a rule, the man who
+contemplates suicide is not a sufferer from inevitable natural causes,
+but one who for some foolish act has put himself into what seems to
+him an intolerable position out of which escape without disgrace is
+impossible, and he is afraid to face the consequences of his own acts.
+It is from the fear of mental worry and of the condemnation of others
+rather than from any dread of physical suffering and pain that men
+commit suicide. The suicide leaves those who are nearest and dearest
+to him to face the battle of life alone, with all the handicaps that
+have been created by their foolishness. Running away in battle is as
+nothing compared to the cowardice of the suicide. The deserter is
+deservedly held in deepest dishonor, and if there is some little pity
+for the suicide, it is because of the supreme foolishness of his act
+and the feeling that it only can have been dictated by some defect of
+mental equilibrium. A frank recognition of these conditions in their
+real significance probably will do more than anything {722} else to
+make the prospective suicide realize the true status of his act better
+than anything else.
+
+Men sometimes seem to persuade themselves that it is a brave thing
+thus to face death. The shadowy terrors of what may come after death
+are too little realized to deter a man from his act when compared with
+the real disgrace that he is so familiar with and that he has often
+witnessed in actual life. It is the man, as a rule, who has most
+condemned others when something has gone wrong, who has found no
+sympathy in his heart for the slips of his fellows, who discovers no
+courage in himself when he has to face disgrace. He does not realize
+that for most men there are so many extenuations of any evil that a
+man may do, that the large-minded man is ready to forgive and
+eventually to forget almost anything that happens. "To know all is to
+forgive all," and the more we know of men the readier we are to
+forgive them. Little men do not forgive and cannot forget the failings
+of their fellows and they think that everyone else looks upon men's
+failings in the same way. It is only the small, narrow man who
+contemplates suicide as a refuge from disgrace, and the fact that he
+can complacently plan the abandonment of others not only to the
+disgrace which he himself is not ready to face, but to all the
+suffering consequent upon it, is the best proof of his littleness of
+soul. The utter pusillanimity of suicide is the best mental antidote
+for the temptation to it.
+
+Besides, the thought that deterred Hamlet may well be urged:
+
+                                          There's the rub;
+  For in that sleep of death what dreams may come.
+  When we have shuffled off this mortal coil,
+  Must give us pause;
+       . . . who would fardels bear,
+  To grunt and sweat under a weary life;
+  Cut that the dread of something after death.--
+  The undiscovered country, from whose bourn
+  No traveller returns.--puzzles the will;
+  And makes us rather bear those ills we have.
+  Than fly to others we know not of?
+
+It is sometimes said that this is the argument of a coward, but such
+cowardice is as reasonable as the dread of touching a wire that may be
+carrying a high charge of electricity. Besides it is only such an
+argument that will properly suit the man who, in his cowardice, is
+ready to let others bear the brunt of his disgrace, flying from it
+himself.  [Footnote 57]
+
+  [Footnote 57: Is life worth living? How old this argument as to
+  suicide is can perhaps best be appreciated from the fact that it is
+  discussed very suggestively in a papyrus of the Middle Kingdom the
+  date of which is probably not later than 2500 B. C, which is now in
+  the Berlin Museum and is recognized to be the most ancient text of
+  its kind that has been preserved in the Nile Valley. I have referred
+  to this in the initial historical chapter. I think that I have more
+  than once turned men's thoughts from the serious contemplation of
+  suicide--always a dangerous thing--by discussing with them this
+  fact that men have at all times in the world's history argued just
+  the same way on these subjects. Men prefer not to resemble the dead
+  ones, and a motive is all that is needed. ]
+
+There has sometimes been an erroneous tendency to confuse suicide and
+heroism, but Chesterton, in "Orthodoxy,"   [Footnote 58]
+has well expressed the difference:
+
+  [Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John
+  Lane Co., 1909. http://www.gutenberg.org/ebooks/130]
+
+{723}
+
+  A soldier surrounded by enemies, if he is to cut his way out, needs
+  to combine a strong desire for living with a strange carelessness
+  about dying. He must not merely cling to life, for then he will be a
+  coward, and will not escape. He must not merely wait for death, for
+  then he will be a suicide, and will not escape. He must seek his
+  life in a spirit of furious indifference to it; he must desire life
+  like water and yet drink death like wine. No philosopher, I fancy,
+  has ever expressed this romantic riddle with adequate lucidity, and
+  I certainly have not done so. But Christianity has done more: it has
+  marked the limits of it in the awful graves of the suicide and the
+  hero, showing the distance between him who dies for a great cause
+  and him who dies for the sake of dying. And it has held up ever
+  since above the European lances the banner of the mystery of
+  chivalry: the Christian courage, which is a disdain of death; not
+  the Chinese courage, which is a disdain of life.
+
+The feature of incidents in life that bring with them disgrace and
+punishment which needs to be insisted on for those to whom the thought
+of suicide comes, is that the sensation which the revelation of such
+acts causes is but a passing phase of present-day publicity, and that
+after all it is not even a nine-days' wonder, but a two- or
+three-days' wonder, and then it is forgotten and replaced by something
+else. The facing of the condemnation for the moment may seem an
+extremely severe trial. The world's blame, however, is largely a
+bogey, a dread that is phantom-like and that disappears, or at least
+diminishes, to a great degree as soon as it is bravely faced. Besides,
+as practically every man who has been carrying around a guilty secret
+with him for years is free to confess, there is an immense sense of
+relief once the worst is known. At last the effort at concealment, the
+nervous tension, the fear of the moment of exposure are all past and a
+new set of thoughts can be allowed to come. Those may be unpleasant
+and yet they are not so bad as the dread of discovery that hung over
+the unfortunate. If a man can be braced up to meet exposure, usually
+he will find in a very few days that there are sources of consolation
+that make it much easier for him to live than he thought possible
+before.
+
+
+Real Suffering a Tonic.--Probably the best remedy for a man or a woman
+who talks of suicide and seems to fear lest the temptation should
+overcome them is, if possible, to give them an opportunity to see some
+real suffering. I have on a number of occasions had the opportunity to
+note the effect on a discouraged man or woman of the sight of a cancer
+patient suffering severely, yet bearing the suffering patiently,
+wishing that the end might come, yet ready to wait until it shall come
+in the appointed order of nature. Suffering, like everything else,
+becomes much more bearable with inurement to it. The old have learned
+the lesson of not only not looking for pleasure in life, but of being
+quite satisfied with their lot if no pain comes to them, and they even
+grow to consider that they have not much right to murmur if their pain
+is not too severe. It is not among those who have to suffer severe
+pain that one finds suicides as a rule. It is true that young, strong,
+healthy persons who suddenly find that pain is to be their lot for a
+prolonged period may grow so discouraged and moody over it as to take
+their lives. The patients that I have seen suffering from incurable
+diseases have expressed no desire at all that their life should be
+shortened, except during the paroxysms of their pain, unless they feel
+that they are a serious burden on others when they may express the
+wish to be no more.
+
+
+Euthanasia.--Every now and then there is a discussion in the
+newspapers {724} of the justifiableness of euthanasia, that is, the
+giving of a pleasant death to those who are known to be incurably ill
+and who are doomed to suffer pain for most of what is left of their
+existence. The question usually discussed is whether patients have the
+right to shorten their own existence and then, also, whether their
+physician might have the right or, even as some people say, the duty,
+to lessen human suffering by abbreviating existence for such incurable
+cases. The discussion has always seemed to me beside the realities of
+things, because physicians do not see many patients, I might almost
+say any patients, who really want to shorten their lives or would want
+to have them shortened. I have known many physicians die of cancer,
+but very seldom is it that one tries to shorten his own existence, or
+that even his best friend in the profession would consider that he was
+justified in doing this for him. This, it seems to me, should be the
+test of the problem. It is true that not infrequently, in the midst of
+their paroxysms of pain, patients wish they were dead, but there come
+intervals of surcease from discomfort to some degree at least that
+make life quite livable for a time again and even occasionally there
+is real happiness in these intervals, deep, human, natural happiness
+in heroic forbearance and example.
+
+We can recall AEsop's fable of the old man who, gathering wood for the
+fire in the winter that he needed so much, finds the burden of his
+labor and the wood too much for him and calls loudly for death to come
+to him. Promptly Death makes his appearance and asks what the old man
+wants. "Oh! nothing," is the reply; "only I would like you to help me
+to carry this bundle of sticks." This is the attitude of mind of
+practically all who have grown old in suffering. They have learned to
+bear with patience, and that patience gives even something of
+satisfaction. After all, it is not so often the pleasant things in
+life that we look back on and recall with most satisfaction as the
+difficulties and trials. Virgil said long ago, _"Forsan et hoc olim
+meminisse juvabit"_--perhaps at some future time we shall recall
+these, our trials and pains, with pleasure. It is the conquering of
+difficulty that means most for men and even the standing of pain is
+not without an aftermath, if not of pleasure, at least of broad human
+satisfaction. When we talk about euthanasia, then, it would be well to
+ask some of these old people whether they want it or not. Seldom will
+the answer be found to be that which is so often presumed, by those in
+good health and strength, to be inevitable under such conditions.
+
+Physicians have all seen incurable cancer patients who were
+approaching their end inevitably and with the fatal termination not
+far off, have hours and days of alleviation of suffering and even of
+enjoyment that made up for the prolongation of life almost in the
+midst of constant agony. The distinguished New York surgeon who had
+the pleasure a few years ago of listening once more to his favorite
+singer and fairly seemed to get renewed life from the inspiration of
+her voice and who for days after had the pleasant consciousness of
+smooth running life in improvement so characteristic of convalescence,
+is a typical example of what may happen under such circumstances. I
+shall not soon forget Dr. Thomas Dunn English, the well-known author
+of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the
+University of Pennsylvania, that, like Bismarck, he used to think that
+all the joys of life's existence were in the first eighty years of
+life, but of late years he had found {725} that many of them were also
+in the second eighty years of life. He was at the time 83. He made the
+most joyous and happiest speech on that occasion. He was quite blind,
+was almost deaf, had been reported dying some months before, and had
+gone through prolonged suffering, yet he was by his cheeriness and
+whole-hearted gaiety on that occasion a joy and inspiration to all the
+younger men at the table.
+
+
+Dread of Suicide.--There are patients who come to the physician worked
+up because they fear they may commit suicide. Every now and then the
+thought comes to them that some time or other they will perhaps throw
+themselves out of a window, or be tempted to drop in front of a
+passing train, or over the side of a steamboat, or impulsively take
+poison. Some nervous people become quite disturbed by these thoughts.
+Every physician is sure to have some patients who must be reassured,
+every now and then, that they are not likely to commit suicide. Their
+nervousness over the fear of this may serve to make them supremely
+miserable and it evidently becomes the doctor's duty to reassure them.
+It is not difficult to do this, as a rule, provided the physician will
+be absolutely confident and unhesitating in his declaration that there
+is no danger that they will commit suicide, since it has almost never
+been known that patients who dread it very much and, above all, those
+who dread it so much that they take others into their confidence in
+the matter, take their own lives. The very fact that the thought
+produces so much horror and disturbance in them is the best proof that
+they will not impulsively do anything irretrievable in this way.
+
+Prof. Dubois has discussed this subject in his usual thoroughly
+practical way and his words serve as an authoritative confirmation of
+what has been already said, though as a matter of fact the expressions
+and experience of nearly every nervous specialist thoroughly justify
+the position here assumed. Besides, it must be realized that this
+confident assurance is the best possible prop that doubting patients
+can have with regard to the actions they dread, and by positive
+declarations the physician will accomplish more than in any other way.
+
+  There are patients who are subject to strange obsessions. They are
+  afraid that they will throw themselves out of the door of a car, or
+  climb over the parapet of a bridge. They are afraid that they will
+  throw their relatives out of a window, or will wound somebody with a
+  knife or a gun. There are some with a strong impulse to open their
+  veins. But if there is a certain attraction in such things, it is
+  really a phobia. It tends to make one shrink back and not to act.
+
+  Nothing quiets these patients like the frequently repeated statement
+  that they will not do anything. It is necessary to show them the
+  vast distance there is between the impulse toward suicide and murder
+  and the phobia which, however distressing it may be, is a safeguard.
+  One must keep at this education of the mind with imperturbable
+  persistence and use the most forceful and convincing arguments that
+  one can think of to correct the judgment of his patient, in order to
+  make the strings of moral feeling and reason vibrate in unison.
+
+  It is through lack of courage and perseverance that we err in the
+  treatment of these psychoneuroses. We wait too long to distinguish
+  the morbid entities that bear on a certain etiology or a different
+  prognosis. We do not see clearly enough the bond which unites these
+  different affections.
+
+It may seem to some physicians as though they would be assuming too
+much responsibility in giving patients such positive assurance that
+their dreads {726} will not be fulfilled, but as a matter of fact the
+experience of physicians is quite sufficient to justify the confident
+statements here suggested. It is true that occasionally a person who
+afterwards commits suicide talks the matter over and hints at the
+possibility of taking his own life. He does not, as a rule, speak of
+it with dread, however, but as one of the alluring solutions of his
+difficulties that he sees ahead of him. He is much more likely to
+write a letter to his physician telling him that all his arrangements
+are made and that by the time this letter reaches him he will be
+already dead. The prospective suicide is usually quite secretive about
+this purpose, not only to friends, lest he should be prevented from
+accomplishing it, but even with his physician, in whom he has had
+absolute confidence and to whom he has told practically everything
+else. The patients who fear the possibility of committing suicide, who
+tell how much they dread the horror of it, and who rush to consult the
+physician to help them against themselves, show by the very fact the
+unlikelihood of action on their part.
+
+
+The Physician and Suicide.--By mental influence, then, the physician
+may lessen the tendency to suicide in the individual and in the
+community. To do this is to save suffering and to help in the solution
+of one of the most serious social problems in modern times. It can
+only be accomplished by a sympathetic attitude towards the whole
+subject and a tactful understanding of each individual case. Every
+effort in the matter, however, is well worth while, for there is no
+more hideous blot on our modern civilization than the startling
+increase of suicide. It is particularly important to bring about
+improvement in this regard among young suicides, and fortunately it is
+here that the influence of the physician for good is likely to be most
+felt. The saving of life is the noblest part of the mission of the
+physician and nowhere, perhaps, can this be accomplished more
+successfully than with regard to some of these patients whom a rash
+resolution, due to a momentary fit of depression and a sense of
+suffering exaggerated out of all proportion to their actual pain, is
+hurrying out of life.
+
+
+
+CHAPTER IV
+
+GRIEF
+
+Grieving would seem at first glance to be one of the conditions for
+which the physician, especially if the etymology of the name of his
+profession be taken strictly, should not be called upon to minister,
+nor his remedies be expected to relieve. Grief is usually supposed to
+be due to moral ills and, therefore, at most to come under the care of
+the alienist, with the feeling that even he can accomplish very little
+for what is an affective rather than a true mental disorder. There is
+no doubt at all, however, that grieving, especially in the excess that
+shows it to be pathological, is always associated with certain
+physical and mental conditions for which the physician can accomplish
+much. Indeed more often than not the physical condition of the
+grief-stricken person is a prominent factor in the production of the
+state of feeling which causes grief to be exaggerated, while, on the
+other hand, this state of mind {727} itself reacts upon the physical
+being so as to make it more sluggish in all its functions, and as a
+consequence a vicious circle of cause and effect is formed affecting
+unfavorably both the mental and physical conditions. It is when
+patients are run down in health that grief becomes extremely difficult
+or apparently impossible to bear and grief itself still further brings
+about a deterioration of health that makes the mind's reactionary
+power against its gloomy feelings still weaker than they were.
+
+Viewed in this way, grief is an ailment that should properly come to
+the physician for treatment and with regard to which that important
+principle is eminently true that the physician cannot always cure, but
+he can nearly always relieve, and he can always console his patients.
+On the one hand, an improvement in the general health always make
+grief easier to bear because it increases the resistive vitality of
+both mind and body. On the other, any diversion of mind that lifts the
+burden of grief even to some degree, releases new stimuli and physical
+powers for the restoration of bodily function to the normal and this
+brings about an immediate lessening of the depressive condition. In a
+word, for the vicious circle of unfavorable influences ever pushing
+the victim farther into depression, a virtuous circle, in the Latin
+sense of the word virtue, meaning courage, favoring strength, must be
+formed, that brings about an immediate improvement in the patient's
+mental and physical well-being. This is not a pretty bit of theory but
+is the result of the experience of every physician who has ever taken
+seriously the problems of caring for the grief-stricken.
+
+
+Natural and Pathological Grief.--It is, of course, not easy to
+distinguish between grief that may be called morbid in the sense of a
+melancholy, that is, more than natural--a true mental disease--and
+that which represents only an affective state accompanied by
+depression from which there will be complete reaction. A mother loses
+a favorite, it may be an only son, and is plunged into grief. For
+days, even weeks, she refuses to take any interest in life, she thinks
+moodily about the awful affliction that has come to her and how blank
+the future is, and she cannot be aroused to attend either to her own
+affairs or to the duties of life around her. Such a grief is, in many
+cases, not more than the normal depression incident to such a loss. If
+after months, however, the mother still continues to refuse to take
+interest in life and the things around her, especially if, besides,
+she now talks of having been visited with this punishment because of
+some unpardonable sin in her own life, or because the Deity has been
+offended beyond all hope of propitiation, then the case verges over
+into one of true melancholy in which the mental depression is not
+merely a symptom of a passing condition, but partakes of the nature of
+a mental disease, or is the consequence of a profound neurotic
+condition.
+
+It must not be forgotten that there is always the danger that
+exaggerated grief, as it seems for the moment to be, may be only the
+first symptom of a true melancholic condition. Only too often friends
+and physicians have been deceived by this. Some of the sad cases of
+self-destruction and a few cases of homicide and suicide have followed
+a condition that seemed to be only abnormal grief for the loss of a
+relative.
+
+
+Etiology.--The cause of exaggerated, prolonged grief is, in a
+considerable proportion of the cases, a melancholic tendency, that is,
+a failure on the {728} part of the mind to react against depression.
+The weakness of mind that predisposes to this may be inherent or
+acquired. Sometimes no special loss is needed to produce melancholia
+in susceptible individuals, while occasionally it is precipitated by
+some misfortune, inasmuch as this is a mental disease, very little can
+be done directly, and yet the patient can be helped and diversion of
+mind may bring a good measure of relief. More often, however, the
+reason for persistent grieving is that before the disturbing loss came
+into the life of the individual there had been a serious deterioration
+in health. This was due to the conditions preceding the unfortunate
+event. Wives sometimes have worn themselves out physically and
+mentally while nursing husbands, or mothers their children, and this
+has produced a lack of physical force which prevents them from
+reacting with healthy mentality against the subsequent shock of loss.
+
+
+Prophylaxis..--For the melancholic tendency prophylaxis cannot be
+special, but must be general. We cannot prevent people from suffering
+serious losses, but we can foresee the possibility of a loss proving
+very depressing, and can, therefore, try to keep the individual in
+reasonably good physical condition. If this is done the subsequent
+depression will be much less than it otherwise would be. Very often
+there is little or no recognition of the fact that there is a definite
+tendency in some patients to too great an inclination toward
+melancholic thoughts, and it is not until an exaggerated manifestation
+of it comes that the danger is realized. It is not easy to make
+patients realize the dangers, but where the physician talks with
+assurance and points out definite things to do in order to prevent
+serious developments, patients, or at least their friends, can be made
+to appreciate the dangers.
+
+The best demonstration that I know of the value of work as a remedy
+for grief is my experience with members of religious orders. For them,
+as a rule, there is no interruption in life no matter what the loss
+may be. Their work goes on the day after the funeral just as before.
+This is the most precious possible arrangement, time and occupation of
+mind are the two factors that will dull the edge of grief and while
+humanly we may resent the consolation that is thus brought by such
+conventional things as the passage of time and humdrum occupations,
+they represent nature's resources. Above all, patients must be given
+something to do and if that something concerns other suffering human
+beings, there is every reason to expect relief.
+
+
+Treatment.--The most important element in the treatment of grief cases
+is to prevent physical running down as far as possible and to build up
+the physical condition. Depression that comes to patients who have
+lost considerable weight, even though it may show some of the signs of
+melancholia, is always hopeful. Where patients are twenty or thirty
+pounds under weight the recovery of weight up to the normal condition
+will often mean the relief of their depressed condition. The one hope
+lies in this physical improvement. Mental treatment by diversion of
+mind must, of course, be practiced. This does not mean getting the
+patients interested once more in trivial things, but to be successful
+it means arousing the deeper feelings of their nature. Above all, the
+solace of tears will often save depressed and grieving persons from
+themselves. An interest in the sufferings of other people that awaken
+their sympathy will do the most to end exaggerated grieving over their
+own loss. The self-centeredness of their grief is the principal reason
+for its exaggeration. {729} It is because of overestimation of their
+own importance and of the importance of their loss that these people
+suffer severely.
+
+
+_Motives of Consolation_.--The main resource of the physician who
+would employ psychotherapy for the treatment of those who are grieving
+beyond the limit of what is normal, is to supply motives by which they
+can understand the real significance of their loss. Very often,
+especially in young folks, there is no proper estimation of values in
+life and no recognition of the fact that human life was evidently not
+meant for happiness since that comes to but few, while suffering and
+partings are inevitable. They come to all, and apparently will always
+continue to do so. It is the young or, at least, those under middle
+age, who are most likely to be affected by exaggerated depression over
+losses and disappointments. Older folks have grown more accustomed to
+such incidents. These patients must be made to see how many motives
+there are to take their grief philosophically and while permitting
+themselves the luxury of sorrow, not to let this interfere either with
+their physical condition or their mental state to such a degree as to
+prevent them from taking the proper interest in their duties in life.
+
+The ethical motives that may be urged to keep people from grieving
+over-much are many, but there is sometimes the feeling in the
+physician's mind that it is scarcely his business to emphasize them in
+any way. It is supposed that to the clergyman must be committed the
+task of consoling people for losses in life. This has always seemed to
+me a serious mistake. As physicians we know how much the mind
+influences the body and since it is our duty to care for the body, we
+must, above all and first of all, care for the mind as far as we can.
+_Mens sana in corpore sano_ is a very old motto and is usually taken
+only in the sense that to have a healthy mind one must have a healthy
+body. In its Latin form, however, it might very well also be taken to
+mean that to have a healthy body one must have a healthy mind. Since
+grief has an untoward influence on the body, physicians are bound to
+learn what to do for it in any and every possible way and to exercise
+every faculty they have for its relief. This is all the more true
+because in recent years many persons have no regular religious
+attendant who would come to offer them consolation or to whom they
+would go in their trouble. It is not at all with the idea of
+infringing on the rights of the clergy or invading his territory that
+I would insist not only on the right of the medical man, but even his
+duty, to afford consolation to the mind as well as relief for the
+body.
+
+
+_The Family Physician_.--In older times the family physician was a
+friend of the family to whom people turned in all troubles where he
+might possibly be of aid, with just as much confidence and as promptly
+as they did to their religious attendant. Unfortunately, in the
+progress of medicine, though still more because of the social
+vicissitudes that have taken place in recent years, this relationship
+of the family physician has been largely diminished, but that
+constitutes only one more reason why every physician, to whose
+attention the grief of a patient for any loss is presented as a cause
+of ill-health, should know all the means and be ready to employ them
+for the amelioration of the condition. As a matter of fact, there is
+often a feeling on the part of patients that it is more or less the
+business of the clergyman to afford consolation and that the
+performance of his duty in this matter is somewhat conventional, not
+{730} as if he performed it less thoroughly because of this, but as if
+the feeling of the routine practice detracted from its effectiveness.
+Some of the motives for consolation advanced by the clergyman, then,
+lose in significance, in some persons' minds at least, because of this
+feeling, while motives presented by the physician rather gain in
+weight because of the impression that he is a thoroughly practical
+man, deeply interested in life's problems from a common-sense
+standpoint, and who knows the motives for consolation because he has
+realized that losses are inevitable, suffering unavoidable, and grief
+sure to come, though somehow we must learn to bear up bravely under
+life as we find it.
+
+Physicians have always done this in the past, but in more recent years
+either they have lost the habit, or have considered it unworthy of
+their profession, or else, perhaps, only too often they themselves
+have had no motives to offer that might seem sources of consolation
+for those in suffering and especially those who are grieved for the
+loss of friends. If life were a mere chance, if there were not an
+evident purpose in it, if, as Lord Kelvin insisted, science did not
+demonstrate (not "suggest" but "demonstrate" is the word he used) the
+existence of a Creator and a Providence, Who, while caring for the
+huge concerns of the universe, can just as well employ Himself with
+the little details of human life, then there would be some reason for
+physicians thinking that their science kept them from seeking
+consolation from the ordinary motives. Even if they occupy an advanced
+agnostic position, however, they may still find sources of consolation
+that, if not so effective as those attached to the old beliefs, at
+least will provide something for the forlorn to take hold of, that
+will mitigate their grief and sense of loss and make the present and
+the future look not all too blank.
+
+Few men have been so thoroughly agnostic as Prof. Huxley, yet on the
+death of his wife he found that some of the thoughts of the old
+beliefs might prove a source of consolation. Huxley had loved his wife
+very dearly and their separation by death meant very much. The epitaph
+that he wrote for her sums up his doubts yet plucks out of them
+something to console, expressed in old Scriptural language:
+
+  And if there be no meeting past the grave.
+  If all is darkness, silence, yet 'tis rest.
+  Be not afraid, ye waiting hearts that weep.
+  For God still giveth His beloved sleep;
+  And if an endless sleep He wills, so best.
+
+
+_Attitude Toward Death_.--The ordinary attitude of people toward death
+is a very curious one. Death is the one absolutely certain thing in
+life after birth, yet most of us live our lives without much regard to
+it, and whenever it comes and under whatever circumstances, at
+whatever age, it is always a shock to us. No matter how old people are
+it always comes a little before it is expected. When death comes it is
+always a shock and all that can be said of it is what Hamlet resents
+when the commonplace consolations for the loss of his father, who also
+lost a father and so on all down the course of history, are offered to
+him. Perhaps, however, as much the reason for his resentment was the
+person who offered the consolation as the form of the consolation
+itself, which, after all, exhausts nearly all that we can say in this
+matter for grief for near and dear ones:
+
+{731}
+
+  King.
+    'Tis sweet and commendable in your nature, Hamlet,
+    To give these mourning duties to your father:
+    But, you must know, your father lost a father;
+    That father lost, lost his; and the survivor bound
+    In filial obligation, for some term
+    To do obsequious sorrow: but to persevere
+    In obstinate condolement, is a course
+    Of impious stubbornness: 'tis unmanly grief:
+        . . . Fie! 'tis a fault to heaven,
+    A fault against the dead, a fault to nature.
+    To reason most absurd, whose common theme
+    Is death of fathers, and who still hath cried,
+    From the first corse, till he that died to-day,
+    "This must be so."
+
+
+_Death and Pain_.--One of the most effective consolations in our day
+for all classes of people, quite apart from religious affiliations or
+beliefs, is the sociological import of death and suffering in the
+world. Life, without suffering and death in it, would be a riot of
+selfishness. Men, as a rule, would not care for others at all, the
+weak would go to the wall, the individuals who possess less efficiency
+than others would simply have to make out as best they could, and bad
+as social conditions are now, they would be intolerably worse. As it
+is the young and strong and vigorous have very little of true
+sympathy. Nothing makes a man feel for others like having gone through
+some suffering himself. On the other hand, nothing makes him feel the
+impotence of struggling ceaselessly for vain success and the futile
+rewards of life than to lose near and dear friends whose share in that
+success and joy over the rewards would constitute their only real
+value and justification. As a man grows older and has gone through
+some of the sufferings and has had to bear the losses of life, he
+learns more and more to feel for others, he is ready even to make
+sacrifices that others may not have to suffer as he has suffered, he
+has charity for them for the sake of his own suffering and that of
+near and dear ones, and things are much better than they could
+possibly be without suffering and death.
+
+
+_Therapy by Example_.--Many men have taken losses so seriously as to
+think that life held no more for them, and have foolishly given up
+their occupations, yet have found that Time, the great healer, could
+work his marvels in their case as well as in most others and that new
+interests and, above all, their life work, could arouse them to a
+sense of duty and bring them back to the old routine of life. Dr.
+Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how
+even that veteran surgeon gave up everything at the death of his wife
+and yet found, after a year of idleness, that he had to come back to
+the old life again. Dr. Mumford says: "Sir Astley Cooper was an
+emotional man. In 1827 his wife died, and the event prostrated him
+with grief. He felt that all the interests of life were over for him.
+He fell into an acute physical decline, sold his town house, threw up
+his practice and other professional employments, and retired to his
+country place to pass his last days. Within a year of the sad event he
+had returned to town, taken another house, resumed practice with
+increased vigor, and married again. He was then sixty years old, he
+lived on until 1841, and died in his seventy-fourth year."
+
+{732}
+
+A typical example of how much a strong man whose diplomatic ability
+had stamped him as one of the large men of his generation may yet be
+afflicted beyond measure by a loss of this kind is to be found in the
+life of the second Lord Lytton. I have told it somewhat in detail in
+the chapter on Periodic Depression. After the death of his boy Lord
+Lytton, who for more than a week of anguish had watched unceasingly at
+the death-bed of his dying son, came to the conclusion that God was
+not in His world or, at least, that the arm of Providence was
+shortened if such (as it seemed to him) needless suffering was
+permitted. The boy had probably suffered much less than the bystanders
+thought and much less than he seemed to, for in these cases nearly
+always there is a merciful deadening of the senses that to a great
+extent eliminates suffering, but Lord Lytton could not understand and
+refused ever to look at life from the same standpoint afterwards. This
+is, of course, only what happens in many cases, but it represents an
+exaggeration of grief since death and suffering have always been in
+the world and sometimes they will come to those near and dear to us,
+much as we may resent it.
+
+Neither profound intelligence nor the sympathetic genius of the poet
+or artist is sufficient to safeguard men against the severer forms of
+griefs for loss. Louis, the distinguished French physician (to whom we
+in America are indebted so much as the Master of the Boston and
+Philadelphia schools of diagnosis, and, above all, for his teaching of
+the differentiation between typhoid and typhus fever), suffered so
+much from the loss of his son that he could scarcely be consoled.
+Dante Gabriel Rossetti was so much affected by the death of his wife
+that he put into her coffin the only manuscript copy of his poems that
+he possessed. It is interesting to learn that some years later he had
+the coffin exhumed and took out his manuscript at the urging of
+friends, and published the poems. Many other examples of this kind
+might be given, for exaggeration of grief affects all classes and
+conditions in life. They are practically always pathological, usually
+on a basis of somewhat disturbed mentality, though often the real
+underlying and predisposing condition is the physical exhaustion that
+has preceded the loss and which makes patients unable to bear the
+strain of it after weeks of care, solicitude, anxiety and neglect of
+eating and sleep.
+
+
+
+CHAPTER V
+
+DOUBTING
+
+
+In recent years the attention of physicians has been called to the
+fact that many people are made profoundly miserable by an
+unconquerable tendency to doubt about nearly everything that has
+happened to them, or is happening, or is about to happen. This is not
+a new phenomenon, but introspection has emphasized it, leisure gives
+more opportunity for it, and so physicians hear more of it now than
+they did in the past. This doubting tendency sometimes makes serious
+inroads on the peace of mind of sufferers from it because they cannot
+make up their minds to do things, even to take exercise, to eat as
+{733} they should in quantity or quality, and to share the ordinary
+life around them sufficiently to get such diversion of mind as will
+keep their physical functions normal. The state used to be described
+as a neurasthenia (nervous weakness), but in recent years has come
+better to be designated as in the class of psychasthenias (lack of
+mental energy). It is always a mental trouble in the sense that it is
+difficult for these patients to make up their minds about things, yet
+it is not a mental disease in the ordinary sense of the term, and
+these people are often eminently sane and thoroughly intellectual when
+their attention has been once profoundly attracted. They may even,
+under favorable circumstances, be active and useful helpers in great
+causes, yet there is always to be observed in them a certain
+noteworthy difference in mentality from the normal. The physician can
+do more for an affection of this kind than is usually thought, and he
+is probably the only one who can thoroughly appreciate and sympathize
+and, therefore, be helpful in the condition.
+
+Sufferers are often laughed at by their friends and relatives and are
+likely to be the subjects of at least a little ridicule if they take
+their troubles to their physician. As a matter of fact, however,
+doubting is a typical case for psychotherapeutics and not only can
+much be done for its relief, but it can be kept from disturbing the
+general health, which it is prone to do if neglected, and by mental
+discipline and acquired habits of self-control, the doubting habit may
+be almost completely eradicated.
+
+
+Exaggeration of Ordinary State of Mind.--The first thing absolutely
+necessary to impress upon the minds of these victims of their own
+doubts is that their condition is by no means unique, it is not even
+very singular, but is only an exaggeration of that hesitancy and
+tendency to put off making decisions that practically every person
+finds in a lifelong experience. This frame of mind is rather
+cultivated by education and by a large accumulation of knowledge. The
+less one knows the easier it is to come to decisions about difficult
+problems and to form conclusions without hesitancy. The young man will
+decide anything under the sun, and a few other things besides, almost
+without a moment's hesitation, and after but slight consideration.
+Twenty years later he looks back and wonders how he did it, and having
+done it, how he succeeded in turning the practical conclusions to
+which he came to advantage. The scholar is eminently a doubter and a
+hesitater, and we recognize that he loses certain of the qualities
+that would make him a practical man of affairs, though he gains so
+much more that broadens and deepens life's significance that there can
+be no doubt about the value of his liberal education.
+
+"Hamlet" is just the story of one of these doubters and hesitaters. He
+saw his duty clearly and that duty was imperative. In spite of
+cumulative evidence, however, he refused to go on to the performance
+of that duty, urging to himself now one and now another reason of
+delay, until finally he wonders whether it would not be worth the
+while to take his own life, rather than try any longer to solve the
+problems that lie around him demanding solution. When he finally does
+something, his hand is forced and circumstances have so arranged
+themselves that instead of one clean-cut punishment for a great crime,
+there is the tragedy that involves six lives, including his own. The
+play seems to involve such exceptional characters and to be written
+around such an unusual set of circumstances that it might be thought
+{734} that it would prove uninteresting for men and women generally.
+As a matter of fact, however, "Hamlet" is the most popular of
+Shakespeare's plays and probably the most popular play, both for
+readers and auditors, that was ever written. There are commentaries by
+the hundred on it in nearly every modern language. Men have been more
+interested in this figment of Shakespeare's imagination than in any
+man that ever lived. Caesar and Napoleon have not attracted so much
+attention. Only Homer and Dante have been perhaps more written about
+than Hamlet.
+
+Shakespeare has emphasized the condition of Hamlet by showing us an
+eminently well educated man. His deep interest in literature, and
+especially in dramatic literature and all that relates to the stage,
+can be appreciated very readily from his speech to the players. No one
+but a man of profound critical ability and deep intellectual interests
+could have so summed up the actors' relation to the drama. Of course,
+this is Shakespeare himself talking and unthinking people have said
+that this was a purple patch fastened on the play because it gave the
+author an opportunity to express his views with regard to actors and
+their ways. Instead of that, it is of the very essence of the
+development of Hamlet's character and shows us the scholarly amateur
+who knows so much about many things that he has become quite unable to
+make up his mind about the practical problems that lie before him.
+James Russell Lowell says that Shakespeare sent Hamlet to Wittenberg,
+though Wittenberg was not founded until centuries after Hamlet
+existed--and Shakespeare probably knew that very well--because
+Wittenberg in Shakespeare's time, on account of its connection with
+Luther and the religious revolt in Germany, had the widespread repute
+of occupying men's minds with doubts about many of the things that had
+been deemed perfectly settled before, and its popular reputation
+serves to give an added hint as to the character of Hamlet as the
+dramatist saw it.
+
+Once those who are perturbed by doubts learn that the reason for the
+universal human interest in Hamlet is that there is a large capacity
+for doubt of self in every man and woman, that we all put off making
+decisions whenever possible, sometimes refuse to open letters when
+they come if we fear that they will contain some disturbing news, put
+off writing letters because we have to state ideas definitely,
+apparently hope that the day and the night will bring us counsel and
+that somehow the decision will be made for us without the trouble of
+making up our minds, then they lose their sense of discouragement over
+their condition and appreciate that they are suffering only from an
+exaggeration, probably temporary and quite eradicable, of a state of
+mind that comes to practically every human being.
+
+This is the important thing, because on it can be founded the only
+really hopeful therapy of the condition. Doubting is a habit that may
+be increased by yielding to it, but that can be diminished to a very
+great extent by constant discipline, which refuses to permit doubts
+and hesitancy and bravely makes decisions, even though there may be
+the feeling that they may prove to be wrong.
+
+
+Extent of Affection.--If such discipline is not instituted, then the
+lengths to which the doubting hesitant habit may go are almost
+incredible. I have had patients tell me that they doubted about nearly
+everything in the past. A very dear friend once confided to me that it
+was always a source of bother {735} to him that he was not quite sure
+whether he was married or not. His marriage I knew had been a public
+ceremonial, and he had led his bride down the aisle to the strains of
+the "Wedding March" in quite conventional style, but he was hesitant
+of speech, especially under excitement, and he was not sure that he
+had ever said "I will" to the question of the clergyman, for there was
+a constriction at his throat at the moment and he could utter no
+sound. The absence of any audible sound from the groom is not so
+unusual as to attract attention and, of course, his intention and his
+bodily presence and everything else gave the assent without the
+necessity for the word, but he could not get out of his mind the
+thought that possibly he was not married and at times it gave him
+poignant discomfort. He was a thoroughly intelligent man, a teacher
+and a writer, with no abnormalities that attracted attention, and his
+tendency to doubt was only known to very near friends who laughed at
+it and had no idea at all of the annoyance that it often gave its
+unfortunate victim.
+
+I have a clergyman friend who has had some serious scruples with
+regard to his ordination. He is a Catholic priest and at a certain
+part of the ceremonial of ordination it is considered necessary for
+the candidate for orders to touch at the same moment the paten, the
+small metal plate on which the Host is placed, and the chalice. This
+clergyman is not sure that he had done this simultaneously. As a rule,
+great care is exercised in seeing that all the details of the
+ordination ceremonies are carried out very exactly and as there are a
+number of attendants on the altar whose duty it is to see that the
+absolutely necessary details are properly fulfilled, it is quite
+improbable that any mistake in this matter was made. The young
+clergyman, however, had not made an act of conscious attention at the
+moment when he was supposed to do this, and consequently he could not
+be sure afterwards whether he had done it or not. He thought of it as
+the very essence of his ordination and he feared that all his
+subsequent acts as a clergyman might be impaired by this negligence.
+
+
+Trivial Doubts.--It is not alone with regard to important things,
+however, that people may doubt and are disturbed by doubts, but with
+regard to every trivial thing in life, if they permit the habit to
+grow on them. Doubting is, after all, one of the phobias, that is to
+say, it is the fear that something may happen if the decision they
+make is wrong, that causes people to hesitate so much. There is a
+tendency in all of us which, if undisciplined, may make us put off the
+doing of things until the last moment. It is easy to resolve the night
+before that we will do certain things the next day, but when the next
+day comes we find excuses to put them off. I have already suggested as
+a symptom that some people put off the opening of letters. There are
+probably more who do this than anyone has any idea of. Delay in
+answering letters is probably much more often due to hesitancy of
+decision than to actual laziness. We doubt as to what we should say
+about certain things, and we do not care to take the trouble of making
+up our minds, and we fear if we do make up our minds it may be wrong,
+so we adjourn the whole matter to another time and keep on adjourning
+it. Many people are quite ready to confess that they do not do things
+until they have to, though few are ready to acknowledge that it is due
+to hesitancy or doubting about themselves and their decisions.
+
+{736}
+
+Of course, the man who doubts whether he has locked the door of his
+house after he gets to bed can only satisfy himself by getting up and
+actually investigating the state of affairs. Then there is the man who
+doubts whether he has locked his safe at the office. He may get his
+doubts just as he reaches the foot of the elevator and then if he is
+wise he will go back and determine the matter. If he is wise with
+experience he will also deliberately determine while he is there
+whether the office window is closed and locked and will make a
+conscious act when he comes out as to the locking of the office door.
+If he does not do all this he will have further doubts on the way up
+town and at his home during the evening which will make the doing of
+anything else a matter of discomfort and he will spoil the restfulness
+of his after-dinner hours. Some men conquer their first doubt, make
+their way home only to be beset by so many doubts that at the end of
+an hour they go back to their office and determine whether the safe is
+locked or not. Finding it locked they may forget to notice other
+things about the office and then they will surely have doubts about
+these, and they may have to go back again and see about them.
+
+Then there is the man who doubts whether he posted a letter or if he
+did post it, who doubts whether it found its way down to the bottom of
+the mail box, or whether it may not have caught on a projecting screw
+or bolt or some portion of the upper part of the box and so fail of
+collection; he may go back several times to determine this. Doubts
+about even more trivial matters than this, however, annoy some people.
+I have known widows on whom the responsibility of managing the
+financial affairs of the household had been thrown for the first time
+after their husbands' death, who constantly doubted whether they could
+afford to spend this or that, though they were regularly saving money
+from their income. Over and over again they would have to go over all
+their recent expenditures to decide whether they could afford certain
+expenses. Such little things as the sort of paper to use in their
+correspondence, the wages they paid their servants, the amount of
+waste in the food in the household, all aroused in them doubts and set
+them to calculating once more just what was the relation of their
+income to expenditure, all to no purpose, for they would have the same
+doubts the next week or month.
+
+Then there are people who doubt whether their friends really think
+anything of them. They think that though they treat them courteously
+this may be only common politeness and they may really resent their
+wasting their time when they call on them. They hesitate to ask these
+people to do things for them, though over and over again the friends
+may have shown their willingness and, above all, by asking favors of
+them in turn, may have shown that they were quite willing to put
+themselves under obligations. They doubt about their charities. They
+wonder whether they may really not be doing more harm than good,
+though they have investigated the cases or have had them investigated
+and the object of their charity may have been proved to be quite
+deserving. They hesitate about the acquisition of new friends, and
+doubt whether they should give them any confidence and whether the
+confidences that they have received from them are not really baits.
+This is, of course, a verging on suspicion as well as hesitancy and
+doubt, but the stories of how these people try to conquer themselves,
+yet have to make decision after decision, each one requiring time and
+a certain resolution of mind, are quite {737} pitiable. It gets worse
+rather than better unless a definite discipline of opposition and
+control is organized.
+
+What ordinary people do habitually and easily and without any effort
+of mind, these people must waste time and mental energy over so that
+it is extremely difficult for them to accomplish anything. Training of
+mind, as of hand, consists in making certain actions so habitual that
+they are accomplished quite automatically. If we have decided that we
+are to get up at a certain hour we get up at that hour and do not have
+to make up our minds about it again, though this is one of the actions
+in which we all have the most lapses and the most need of renewal of
+resolution and habit. We make up our mind what we are going to eat and
+gradually acquire the habit of eating a certain quantity and a certain
+variety at meals and then we do not have to make up our minds about it
+every time. We go out, to do whatever must be done in our occupation
+quite automatically and there is no need of wasting mental energy over
+decisions about it. It is this that the doubter cannot do. He or she
+calls every trifling act before the supreme court of last decision,
+the bar of intellect, to decide whether it is worth while doing,
+whether it is to be done or not, how it is to be done, and then there
+is a doubt whether after it is done it may not prove to be quite the
+wrong thing to have done. This adds so much to the friction of life
+that all the surplus energy is used up in the settling of trivial
+matters, and nothing worth while is accomplished.
+
+Sir James Paget once expressed all the realities of the situation of
+many of these people in a few terse phrases. It is probably the best
+explanation of its kind that we have and it deserves to be in the
+notebook and often before the mind of physicians who treat neurotic
+patients. Sir James said: "The patient says 'She cannot'; her friends
+say 'She will not'; the truth is she cannot will."
+
+The expression, of course, applies to many other phases of so-called
+nervous disease besides doubting and especially to the psychasthenias.
+It represents, indeed, the keynote of many of these puzzling
+affections. The fact that it was uttered more than half a century ago
+shows how much better these affections were understood two generations
+before ours than we are likely to think, and how well physicians then
+got to the heart of them. From this to the re-education of will, that
+mental discipline and relearning of self-control which constitutes the
+essence of the treatment of them, is but a short step.
+
+
+Prophylaxis.--_Serious Occupation_.--Of course, the real way out of
+the trouble is to have to do certain important things that occupy the
+mind and require the doing of many other things as subsidiaries which
+must be accomplished in order to carry out the greater resolution. Men
+who have important affairs on their hands seldom are bothered by
+doubts and hesitancy. Women who have not much to do make mountains out
+of the molehills of their little occupations and every trifle must be
+adjudged. The larger interests must be cultivated, the smaller ones
+must be turned over to the automaton which every one of us can develop
+in our persons if we only set about it resolutely. Each thing that
+comes up must be settled at once and action must replace
+contemplation. The Hamlet in us all must be put down and resolution
+must not be allowed to be sicklied over with the pale cast of thought.
+We must do {738} things and not think about them too much. The
+doubters can learn this lesson. They will never be entirely without
+hesitancy, but they can remove many of their difficulties, and live to
+accomplish much in spite of their make-up.
+
+
+Physical Treatment.--The physical treatment of the doubting state
+consists, of course, in bringing the individual's physical condition
+as near as possible up to the normal. When the state occurs in people
+who are under weight its betterment is rather easy. The special
+feature of the physical condition that needs seeing to is an ample
+supply of fresh air. People who live in ill-ventilated places, or who
+do not get out into the air enough, are almost sure to suffer from the
+tendency to avoid the making of decisions. The man of decision usually
+is a vigorous outdoor-air individual. Even the perfectly healthy man
+who has been in the house for some reason for days together gets into
+a state of mind where the making of decisions becomes objectionable.
+He wants to push things away from him. In individuals who already have
+a natural tendency this way this is greatly exaggerated by
+confinement. Arrangements must be made, therefore, that will ensure
+getting out for some time, not once but twice every day. The regular
+making of decisions for this purpose is of itself a good mental
+discipline. It must not be omitted even for rain or snow, unless there
+are additional reasons of some kind. An abundance of fresh air in the
+sleeping-room is extremely important and must be secured.
+
+
+Mental Treatment.--The mental treatment consists in diversion of mind.
+Usually the doubters have no interests that appeal to them deeply and
+in which they have to make prompt regular decisions. If possible,
+these must be secured. They must form habits of doing things regularly
+and of making up their minds to do them, and then not have to repeat
+the adjudication and resolution. In recent years people realize, quite
+apart from its religious significance, the value of what older
+religious writers called examination of conscience. Regularly before
+they go to sleep these people must be told to call up what they have
+done during the day and to note their faults in the matter of putting
+off doing things and making decisions slowly. They must, however, not
+only realize their faults, but they must make up their mind to correct
+them during the following day. They must not leave the arrangement of
+what they shall do next day to chance, but must decide just how and
+when they shall do things and then, as far as possible, keep to this
+program. The program must, of course, be sensible and considerate.
+This preliminary arrangement can be made to mean much more than might
+be thought. Some people thus learn to correct entirely their tendency
+to doubt whether they should do things or not and lessen greatly the
+difficulties they have in making decisions.
+
+
+
+CHAPTER VI
+
+RESPONSIBILITY AND WILL POWER
+
+
+The development of science (meaning by that term knowledge with regard
+to physical nature in contradistinction to philosophy or the relation
+of nature to man) in modern times has brought about in some minds a
+hesitant, if {739} not frankly contradictory attitude towards the
+question of free will. There are many scientists who not only doubt
+the existence of free will, but insist that there cannot be such a
+thing. For them, man like the animals is determined to do things from
+without rather than from within. The stronger motive compels him.
+There may be a weighing in the balance of motives, but that is a
+question of intellect and not of will. It is true that the stronger
+motive may be one that is less alluring to nature or to sense than
+some of the others which clamor for a hearing, but it is eventually
+the stronger motive that compels. A man may desire something that does
+not belong to him very much, but the consciousness that it does not
+belong to him and that to take things that do not belong to him is
+unworthy of him will override his covetousness and so he remains
+honest if he has been trained to regard things that way. After all,
+the old maxim, "Honesty is the best policy," is founded on some such
+reasoning as this, since only one who is at heart dishonest would
+consider men as swayed by the thought that to be honest is the most
+profitable, instead of being the right, and therefore the only proper
+thing.
+
+The argument for free will that appeals to most men is the
+consciousness that we are free and that at any given moment we can do
+a thing or not do it, just as suits us. If two things are presented
+to us we can do that one which seems right to us to do, or we can do
+both of them, or we can permit ourselves to be led into the wrong,
+though always acknowledging to ourselves that it is the wrong and
+feeling downcast, or at least disturbed, that we should let ourselves
+be led away from higher motives. Even in this case the determinist
+insists that we are determined from without by motives due to our
+training, to our education along certain lines with the influence of
+the environment in which we live, to the special sentiment that we
+have within us as a consequence of the influences of preceding life.
+Such determination, however, does not come from without us, but from
+within. It is the result of the formation of our wills in a particular
+direction. The argument is, therefore, a begging of the question. A
+man may have formed the habit of doing evil things and then finds it
+easy to do them without compunction. On the other hand, the exercise
+of his will in doing what he considers right, in spite of the fact
+that it may not be pleasant at the moment, is a training of the will
+founded on its essential freedom. There is an essential distinction
+between right and wrong, and we have it in our power, as many a man
+has done, to follow the right even though it costs our life.
+
+
+Bad Temper.--A typical example of supposed determinism, which proves
+exactly the opposite of what is sometimes urged, may be noted with
+regard to exhibitions of temper. As Clouston declares in his
+"Unsoundness of Mind" (Methuen, London, 1911), "an uncontrollable
+temper is in many cases very like and nearly allied to an unsoundness
+of mind. It is certain that bad temper may gradually pass into
+technical insanity and that a considerable number of persons who are
+passing or have passed into insanity exhibit as the most marked
+symptom morbidness and violence of temper. 'It's just temper. Doctor,'
+is one of the most common remarks that I have heard made to me by
+patients' friends. I think that it is quite certain that in most cases
+much might be done in youth to establish a reasonable control over
+temper where it is inclined to be uncontrolled, so preventing serious
+discomforts in life both to its possessor and to others. In many cases
+I am satisfied that {740} this education would have the effect of
+preventing unsoundness of mind also, arising out of uncontrolled
+temper." There are many examples in the literature of hagiology
+particularly, from which it is clear that men have learned to control
+even violent tempers and by self-discipline and training in
+self-control have even become rather quiet, gentle individuals. The
+truth of such examples is attested too well to be discredited. This
+question of training, then, is extremely important.
+
+It has been pointed out that the consciousness of freedom to which an
+appeal is made in this argument for free will is shared with us by the
+insane even in the performance of many acts that we know are compelled
+in certain ways. Insane persons reason themselves into a peculiar
+state of mind, in which they represent to themselves that they have
+been persecuted, for instance, by a particular person and then they
+become persecutors in turn and do harm. As they see their act, it is
+often a species of self-defense. They themselves have no
+consciousness, or, at most, a very dim and hazy realization of the
+inner compulsion to which they are subjected at the time of the act
+and sometimes talk quite rationally and discuss the motives which
+impelled them to do things, just as if they were free. We recognize,
+however, the distinction between this delusion of the insane and the
+rational state of mind of the sane. We have no definition for
+insanity, that is, no formula of words, which will absolutely include
+all the insane and at the same time exclude all the sane, but we have
+a practical working knowledge that enables us to judge rather well
+between those who are compelled to do things by delusions, and those
+who do them from motives that are rationally weighed and that
+influence a will that is free to follow them as it pleases. We hold
+the rational man responsible for his acts because he knows he was free
+not to do them. We punish him partly because he should not have done
+them and partly because we want him not to do them again, and we know
+that punishment will help him to keep from committing crime, because
+it will support his free will against his inclinations, when the time
+of trial comes again.
+
+Above all, we are conscious of our own responsibility. We know that
+when we do wrong we are worthy of blame. We know that when we allow
+covetousness to lead us into the appropriation of what does not belong
+to us we are deserving of punishment, because we need not have done
+it, but we yielded to unworthy motives. We know that while anger may
+be blind we can control it, at least those of us who are fully in
+possession of our intellectual and voluntary powers, so as to keep
+from doing violence, even in the heat of it. This dealing with
+ourselves is the best proof that we have of our recognition of our
+freedom of will. We are responsible, and what we genuinely do not will
+to do is not accomplished. Our will may be bent by many attractions,
+but we know that these motives are not compelling unless we allow them
+to be. When a child tells us that he did something because he could
+not help it, we either feel sorry for him because he is not yet in
+possession of his full faculties or else we laugh at this excuse.
+There is a tendency to admit this excuse as having a meaning, but only
+by those who themselves come into court with hands assoiled in some
+way and who are looking for pardon from others for offenses, and who,
+above all, want to feel that they can pardon, or at least excuse,
+themselves.
+
+In recent years we have seriously impaired the idea of responsibility
+in {741} the minds of the general public by a foolishly sentimental
+mercifulness to criminals. If a man under indictment for murder can
+show that he has ever previously in his life acted even slightly
+irrationally, or if he has been peculiar in certain ways, provided, of
+course, he has money enough to pay for the opinions, there will be an
+abundance of expert testimony to declare that he is irresponsible and
+should not be punished. As a consequence, in many cases justice fails.
+We are reaping the harvest of this pseudo-scientific invasion of law.
+Human life is cheaper in no country in the world than it is in
+America. Our murder rate is going up by leaps and bounds, while that
+of Canada remains almost stationary, and the reason is that while nine
+out of ten of all our murderers do not receive the death penalty and
+many of them escape serious punishment of any kind, nearly as large a
+proportion of Canadian murderers are punished by death. A man may have
+his responsibility somewhat impaired and yet retain sufficient free
+will so that he deserves to be punished for serious crimes. It is hard
+to decide in certain cases, but in most cases the decision is not
+difficult if, with the right sense of justice, morbid sentimentality
+is put aside.
+
+    [Footnote 59, the following lengthy citation  is from an article on
+    "Responsibility and Punishment," in the _American Journal of
+    Medical Science_, 1909.]
+
+
+  While the doctrine of free will is so clear it is still true that
+  the question of responsibility for actions, and above all for
+  criminal actions, is not so simple as many people used to proclaim
+  it in the past. No two men are free to perform an act or not to
+  perform it in quite the same way. Familiar examples are ready to
+  hand: One man finds no difficulty at all in resisting the
+  inclination to take spirituous liquor to excess; another finds it a
+  most difficult feat, often apparently impossible for him to refrain
+  from indulging to excess almost whenever the opportunity offers, or
+  at least whenever he gets a taste of liquor. This difference between
+  the two men is founded in their very nature. It would be utterly a
+  mistake to praise the one for his abstinence or to blame the other
+  under certain circumstances for his indulgence. Between these two
+  classes there are others quite different individually. Some of them
+  have a slight tendency, and, fearing the worst, do not indulge in
+  it; some of them have a marked tendency which they are able to
+  resist under most circumstances without very much difficulty once
+  they have made up their minds; some are sorely tempted, fall
+  occasionally, yet never become habitual drunkards. For each of these
+  men there is a different responsibility, and so far as they are to
+  be punished a different punishment must be meted out, for it is our
+  effort in the modern time to make the punishment fit the criminal
+  and not the crime.
+
+  This same thing holds true for many other forms of crime. Some men
+  readily lose sight of the distinction between mine and thine, and
+  possess themselves of their neighbors' goods almost without
+  realizing that they have done wrong. They are rare, and we have been
+  accustomed to call these people kleptomaniacs. Between these and the
+  man who hesitates to steal, even when starving or for his starving
+  children, there are many degrees of inclination and disinclination
+  toward stealing. The same thing is true to a more noteworthy degree
+  with regard to anger. Anger, the old saw says, is a brief madness.
+  In America we say very frankly that a man who is very angry is mad.
+  In this brief madness he may be led to do things which he would not
+  do at all in his sober senses. Some men easily get into one of these
+  awful fits of anger in which their responsibility is lessened, while
+  others have a calm phlegmatic disposition from which they are
+  scarcely aroused even by the worst forms of abuse or injury, or even
+  physical suffering.
+
+  It is evident in all these cases that in order to measure how much
+  of punishment ought to be meted out for acts committed it is more
+  necessary to know the individual than his act. This often becomes an
+  extremely difficult matter, for {742} after the commission of crime
+  every effort is made to make out as little responsibility as
+  possible for the criminal. The easiest way to do this has been to
+  use the insanity plea. As already stated, we have no definition of
+  insanity. It is easy to understand then that there will be a
+  disagreement among physicians as to who is or is not insane, and the
+  result is almost sure to create doubt which tends to obscure the
+  principles on which are based the proper punishment of crime. Now
+  this system is founded on certain wrong principles as regards the
+  administration of Justice. While it is difficult to decide with
+  regard to a man's insanity or sanity, it is not difficult to decide
+  with regard to his punishment when the ordinary purposes of
+  punishment are kept well in view.
+
+  The old idea of punishment used to be that of revenge. A man had
+  done a wrong, and what would ordinarily be held a wrong had to be
+  done to him in order that the scales of Justice should be maintained
+  level. At the present time we have no such idea at all. Punishment
+  has two main purposes--the prevention of further disturbance of
+  social order by the particular criminal, and the deterrence of
+  others from like acts. If a man takes away the life of another we do
+  not take away his because thus Justice will be obtained, but we take
+  it away to prevent him from ever doing anything of the same kind
+  again. A man who has committed murder is more likely to do it again
+  than another. He has committed one breach of social order; we shall
+  prevent him forever from committing another of the same kind. This
+  is the very best deterrent to such crimes that there is. It will be
+  said, of course, that these men could not refrain from doing their
+  acts. It is doubtful, however, whether this contention is true in
+  the great majority of cases, and the proper punishment of such as
+  occur furnishes the best possible motive to help others from the
+  commission of like acts.
+
+  This holds true for children at a time when their sense of
+  responsibility for their acts is as yet undeveloped. They can be
+  taught, even very early in life, by properly applied punishment,
+  that need not be severe, that they must not do certain things, and
+  then they will not do them, or at least, will do them much less.
+  This is true not only for perfectly rational children, but also for
+  those that are to some degree irrational. Punishment is of great
+  importance in the training of children of low grade intelligence,
+  and there is scarcely any child, however wanting it may be in
+  intellect, that cannot be disciplined into conduct that makes it
+  much less bothersome than would ordinarily be the case. This is well
+  known and it is also well known that the attempt to manage such
+  children without punishment would be extremely difficult, not to say
+  impossible. They do not reason about the thing, they are not quite
+  responsible for their acts; but they do connect punishment with what
+  they have done, and are in many cases deterred from doing it again,
+  especially while they realize that authority is near them and that
+  punishment is inevitable. These are the principles on which the
+  adjudication of punishment for crime must be measured. There is
+  nothing else that can be done if society would preserve itself and
+  its members from those who are irresponsible even in minor degrees.
+
+  In this matter practical experience is well worth the while. The
+  lower order of creatures, the animals, we do not consider
+  responsible for their acts in the same way as human beings. We know
+  the value, however, of punishment in deterring them. A dog, for
+  instance, by being whipped a few times when he is young, can be
+  taught not to steal things to eat, and taught that there is an
+  inevitable connection between the taking of such things and the
+  infliction of such punishment. I shall not soon forget my first
+  lesson in philosophy from a dear old professor, who, talking of the
+  memory of animals, demonstrated that they had a memory, from the
+  ordinary experience of mankind with regard to them. "If a cat does
+  something naughty in your room," he said, "you rub its nose in it,
+  and it will not do it again." The cat had no idea that it was doing
+  wrong. According to its way of life it was not doing wrong. It
+  learned, however, from sensory experience that it must not do this
+  sort of thing under special circumstances, and after the lesson has
+  been once thoroughly learned there is no more trouble of this kind.
+
+  Individuals who are of less mental stability than normal require,
+  indeed, more careful discipline than average men. The rational may
+  be managed by sweet reasonableness. The defective child must be made
+  to realize that certain actions {743} will surely be followed by
+  painful punishment, though, of course, the main purpose of modern
+  care for such children is to watch over them so diligently as to
+  prevent them getting into mischief. This is after all what we do
+  with the animals, and we realize the necessity for it. Defective
+  human beings approach the animal in their lessened power to resist
+  impulses, and they must be treated in the same way. If we were to
+  save the animals in an excess of tenderness toward them, because we
+  held to the notion either that they did not know any better or else
+  could not resist their impulses, and then permitted them to do
+  things without punishment, we should either have to get rid of
+  animals entirely, or else life would be one continuous readjustment
+  of things to animal ways. Since defectives occur in the general
+  population, it must be realized that far from being less rigid with
+  them in the matter of meting out punishment for things they do that
+  are harmful to others, we must be even more strict with them.
+  Otherwise, we will have to take the bitter consequences of our own
+  foolishness.
+
+  It does not make so much difference if the thoroughly rational
+  individual occasionally escapes punishment for something done, but
+  whenever the subrational escapes, he is encouraged to do it again.
+  More than that, the example of his punishment is needed for others.
+  So far as possible, punishment must inevitably follow crime in the
+  world, in order to impress the subrational and deter them from
+  yielding to impulses. Far from being less deserving of punishment in
+  every sense in which a modern penologist cares to inflict
+  punishment, these individuals are more impressed by it, and, above
+  all, need to be more impressed by it. When the subrational know that
+  they can do things without being severely punished for them, they
+  will always abuse that state of affairs. The thoroughly rational man
+  may be depended on to do his duty as a rule without the need of
+  punishment hanging over him. This is not true for the others, and
+  hence the greater increase in crime, and above all in murder, which
+  has made human life cheaper in this than in any other country in the
+  world, as the direct consequence of recent abuses in our penal
+  system.
+
+  It has become very clear now that in recent years we have come to
+  take entirely too lenient a view in these matters, and that many
+  criminals who deserved to be punished, both because in this way they
+  would be prevented from future crime and others deterred by the
+  knowledge of their punishment, have been allowed to escape Justice.
+  The tendency is toward too great mercifulness, which spoils the
+  character of the nation, just as leniency to the developing child
+  spoils individual character. Men may very well be insane, in the
+  broad meaning of that term, in the sense that they have done
+  irrational things, but then there is almost no one who has not. The
+  responsibility of most men for a definite action is quite clear in
+  the sense that if they are punished they will not do it again, or
+  will be less likely to do it again, while if they are not punished
+  their escape becomes a suggestion to themselves and to others to
+  repeat such acts. It is for the subrational that we most need to
+  insist on punishment. The cunning of the insane is proverbial, and
+  this extends also to the subrational, and many of these folk realize
+  that their difference from others, their queerness, as their folks
+  call it, is quite enough to make a verdict of insanity in their case
+  assured with the present lax enforcement of law. If the present
+  state of affairs continues in this matter, we are simply allowing
+  ourselves to be led by the nose by these cunning people into the
+  perpetuation of a state of affairs in which they may do what they
+  like because we have become foolishly oversensitive in the matter of
+  inflicting punishment.
+
+  On the principle that punishment deters, a man who has killed
+  another man, even under conditions that seriously impaired his
+  responsibility for the act and with evidence of previous lowered
+  mentality, must never again be free to live the ordinary life of
+  men. He must be under surveillance, and should be confined for life
+  in an institution for the criminally insane. For the subrational
+  such a sentence, if known to be inevitable, would usually be more
+  deterrent than even imprisonment in an ordinary prison for life with
+  all the possibilities for freedom which are presented by executive
+  clemency, pardoning boards, and the like. It is absurd to say that a
+  man may have such an attack of mental unsoundness as will lead him
+  to do so serious an act as taking away human life, and then be
+  expected to get over his mental condition so as not to be likely to
+  do the same thing again. {744} Every alienist knows that this is not
+  true. Such acts, when really due to mental instability, occur either
+  in depressed or maniacal conditions, and these, as is now well known
+  from carefully collected statistics, inevitably recur, or in
+  weakened toxic conditions in susceptible subjects, and a return to
+  the old mode of life may at any time bring recurrences.
+
+It is in the treatment of disorders of the will of various kinds that
+the physician is brought to realize how much harm is done by the
+teaching that determinism and not free will rules life. It is true
+that we often find cases in which men and women cannot use their wills
+or at least seem not to be able to use them. They are lacking in some
+essential quality of human mentality. We find many human beings,
+however, doing things that are harmful for them and that are so
+inveterated by habit that it is extremely difficult to get away from
+them. In every case the sane person can conquer and break the habit,
+no matter how much of a hold it may have obtained.
+
+We have heard much of the born criminal and of the degenerate and his
+inevitable tendencies, but most of the theories founded on this phase
+of criminal anthropology have gradually been given up as a consequence
+of more careful and, above all, more detailed observation. Many
+criminals bear the stigmata of so-called degeneration. Many of them
+have irregular heads, uneven ears, some fastened directly to the cheek
+and some with the animal peak, many have misshapen mouths and noses,
+but, on the other hand, many people having these physical qualities
+are good men and women, perfectly capable of self-control, honest,
+efficient members of society, and it is evident that the original
+observations were founded too exclusively on the criminal classes,
+instead of on the whole population. It is important, then, to get away
+from the notion of irresponsibility in these cases.
+
+While men are free, yet each in a different way and the freedom of
+their wills is as individual as their countenances, it must not be
+forgotten that the freedom of the will is a function of the human
+being, and, like all other functions, can be increased or decreased by
+exercise or the lack of it. The old idea of "breaking the will" was as
+much of a mistake as that other old-fashioned notion contemporary with
+it of "hardening" children by exposing them to inclement weather and
+severe physical trials. The will may be strengthened, however, by the
+exercise of it and if not exercised it may not be expected, by
+analogy, at least, to be as weak and flabby as muscles would be under
+similar circumstances. The training of the will by self-denial and
+self-control is extremely important. When there is an hereditary
+influence, a family trait and not merely an acquired character, by
+which the will rather easily passes out of control, there is all the
+more need for the training of it in early youth. Without such training
+men may find it impossible to make up their minds to deny themselves
+indulgence of many kinds, but this is not because they have not free
+will, but because this function has never been exercised sufficiently
+to enable them to use it properly. A man who attempts to do gymnastic
+feats without training comes a cropper. A man who is placed in
+circumstances requiring hard muscle exertion will fail if his muscles
+have not been trained to bear it. The same thing will happen with the
+will.
+
+Unfortunately this training of the will has been neglected to a
+considerable extent in modern education, and, above all, in modern
+families, where the presence of but one or two children concentrates
+attention on them, {745} over-stimulating them when young, leading to
+self-centeredness and, above all, discouraging self-denial in any way
+and preventing that development of thorough self-control which comes
+in the well-regulated large family. Besides, unfortunately it is just
+the neurotic individuals who most need thorough training in
+self-control and whose parents suffer from the same nervous condition
+(for, while disease is not inherited, defects are inherited), that are
+deprived of such regular training in self-control because of the
+inability of their parents to regulate either themselves or others
+properly. Here is the secret of the more frequent development of
+neurotic symptoms in recent years. It is not so much the strenuous
+life as the lack of training of the will so that the faculty of free
+will can be used properly. Lacking this, hysterical symptoms,
+unethical tendencies, lack of self-control become easily manifest. The
+training that would prevent these should come early in life, and when
+it does not it is very difficult to make up for it later. Just as far
+as possible, however, it is the duty of the psychotherapeutist to
+supply by suggestions as to training and discipline for the education
+of the will that has unfortunately been missed.
+
+
+{746}
+
+SECTION XX
+
+_PSYCHOTHERAPY IN SURGERY_
+
+
+
+CHAPTER I
+
+PSYCHOTHERAPY IN OLD-TIME SURGERY
+
+
+Surgery, a name derived from chirurgy--handwork--might seem to be
+dependent almost entirely on mechanical and technical skill, yet there
+has always been the conviction that the patient's attitude of mind
+towards an operation is almost as important a factor in the success of
+surgery as the surgeon's skill.
+
+
+Astrology in Surgery.--From the earliest history of surgery we, find
+that astrology was mainly employed in order to determine what days
+were likely to be favorable, and what unfavorable, for the practice of
+such surgical procedures as were in vogue at that time. Certain
+conjunctions of the planets were declared to be particularly
+unfavorable, and some of them, indeed, were declared almost absolutely
+fatal; others were said to be especially favorable. As astronomical
+and anatomical knowledge grew, more and more details were added in
+this matter. Definite portions of the body were supposed to be under
+the occult influence of certain constellations. It was only with
+careful reference to these constellations then that surgical
+procedures or, indeed, the application of remedies of any kind, might
+be undertaken. All remember the picture in old almanacs of a man with
+the signs of the zodiac around him, and the indications that referred
+certain of these signs and the corresponding constellations to the
+different parts of the body.
+
+
+_Venesection and the Stars_.--When venesection became a frequently
+used remedy, the question of the favorable and unfavorable influence
+of the stars was an important element in it. In old Babylonia, noted
+for its knowledge of astronomy, which was then called astrology
+without any of our derogatory meaning in the word, certain positions
+of the planets were absolute contraindications for the performance of
+venesection. Indeed, astrology often furnished the best possible
+excuses for the failure of what were thought to be absolutely specific
+remedies. When the remedies did not succeed, their failure was
+attributed to their being taken at unfavorable times and not to the
+remedies themselves. These astrological ideas continued to influence
+medicine, and, above all, surgery, down almost to our own time.
+Galileo and Kepler made horoscopes, and Mesmer wrote a thesis on the
+influence of the stars on human constitutions. In fact, very few
+important patients of the seventeenth and even eighteenth centuries
+were treated medically or surgically without due reference to the
+stars at the time. All this had a profound influence on {747} the
+patient's mind. He felt that every precaution was being taken to
+preclude the possibility of failure and assure favorable results, and
+he, therefore, submitted to the operation absolutely confident that so
+far as human knowledge could go, everything was favorably disposed in
+his regard.
+
+
+Mental Influence in Old Hospitals.--It is rather interesting to
+realize how much the history of medicine illustrates the profound
+attention that was given in the old times to the question of the
+occupation of patients' minds as an eminently helpful factor in the
+treatment of disease and, above all, in convalescence. In the great
+health resorts, the temple hospitals like that at Epidaurus, or even
+the city hospital, the AEsculapeum at Athens, the question of
+recreation of mind was evidently considered very important. At Athens,
+the two city theaters, the larger one seating perhaps 50,000, and the
+smaller, Odeon, were not far from the hospital. At Epidaurus, a
+theater seating probably 12,000, in which the great Greek classic
+plays were given; a Stadium, seating nearly 10,000, in which athletic
+contests were conducted, and a Hippodrome, seating 6,000, in which
+animal performances might be witnessed, were all in connection with
+the temple hospital. Outdoor sleeping apartments were provided; that
+is, the patients slept under a colonnade, and, in general, the mental
+and physical hygiene of modern times was thoroughly anticipated. All
+of this was considered particularly important for convalescents.
+Patients were occupied, while in bed, with various interests. Just as
+soon as they could be moved, their minds were occupied with all sorts
+of interests external to themselves, and especially such as had the
+readiest appeal to humanity. (See bird's-eye view, facing p. 9.)
+
+
+Medieval Hospitals and the Mind.--It is not difficult to trace the
+development of similar conditions in the hospitals of the Middle Ages.
+While we are inclined to think of these older hospitals as surely
+lacking in everything that we have developed in our modern hospitals,
+they prove, on the contrary, to have anticipated most of our hospital
+improvements. They were of single story construction, with large
+windows high up in the wall so that there could be no drafts, with a
+balcony on which patients could sit in the sun, with arrangements for
+procuring privacy rather easily by means of sliding partitions, with
+tiled floors, and, above all, with pictures on the walls, some of them
+the products of the brush of the great artists of the old time and
+which would serve to occupy patients' minds. Probably nothing is worse
+for patients who are convalescing from illness or operation than to be
+left to their own thoughts. Often they must not be talked to overmuch,
+or permitted the exertion of conversation or of reading, yet they must
+have some occupation of mind. The frescoes painted directly on the
+walls of the old hospitals were eminently psychotherapeutic in this
+respect, and we shall probably have to imitate them. Besides, the
+patients had the opportunity every morning to hear Mass, which was
+said at an altar at an end of the ward, and certain religious
+exercises were conducted by the sister nurses each afternoon. How much
+of consolation this was to believing patients at a time when all were
+believers is rather easy to understand.
+
+
+Medieval Surgeons and Mental Influence.--Some of the insistence on
+this favorable state of mind for operations during the Middle Ages is
+extremely interesting. One of the great surgeons of the fourteenth
+century was Mondeville, whose text-book has recently been published in
+both France and {748} Germany. I have translated in "Old-time Makers
+of Medicine"   [Footnote 60] some of his emphatic expressions, which
+show how important he deemed it to keep the patient in as favorable a
+state of mind as possible before and after operations. He went so far
+as to suggest that someone should be deliberately called in to tell
+him jokes. He said, "Let the surgeon take care to regulate the whole
+regimen of the patient's life for joy and happiness by promising that
+he will soon be well, by allowing his relatives and special friends to
+cheer him, and by having someone to tell him jokes, and let him be
+solaced also by music on the viol or psaltery. The surgeon must forbid
+anger, hatred, and sadness in the patient, and remind him that the
+body grows fat from joy and thin from sadness. He must insist on the
+patient obeying him faithfully in all things." He repeats with
+approval the expression of Avicenna that "often the confidence of the
+patient in his physician does more for the cure of his disease than
+the physician with all his remedies."
+
+  [Footnote 60: Fordham University Press, 1911.]
+
+Mondeville was but one of the great surgeons of the medieval period
+who dwelt on this. It would not be hard to find corresponding
+expressions in the books of such men as Guy de Chauliac, Hugh of
+Lucca, Theodoric, or even earlier among the great Arabian physicians
+and surgeons. Rhazes, for instance, declared that "physicians ought to
+console their patients even if the signs of impending death seem to be
+present, for the bodies of men are dependent on their spirits." He
+considered that the most valuable thing for the physician to do was to
+increase the patient's natural vitality. Hence his advice: "In
+treating a patient, let your first thought be to strengthen his
+natural vitality. If you strengthen that, you remove ever so many ills
+without more ado. If you weaken it, however, by the remedies that you
+use, you always work harm." Another of his aphorisms seems worth while
+quoting: "The patient who consults a great many physicians is likely
+to have a very confused state of mind." For him a confused state of
+mind evidently meant a lessened tendency to recovery.
+
+
+Surgical Lesions Influenced.--The King's touch in England, which so
+often proved beneficial for scrofulous patients, illustrates very well
+how much strong mental influence may avail even in cases where surgery
+seems surely indicated. Many cases of epilepsy were also greatly
+benefited by the King's touch, and, indeed, in this matter there are
+probably many more cases of the cure of epilepsy, or at least relief
+of the worst symptoms of the affection, reported as following the
+King's touch than after operation in the modern time. In both sets of
+cases we are now confident that the good effects produced came through
+the minds of the patients. When, during the eighteenth century,
+Mesmerism began to attract attention, investigators and experimenters
+on the subject were able to show that many pains and aches could be
+greatly benefited by psychic treatment. The painful conditions
+following fractures and sprains proved to be particularly amenable to
+mental influence exerted in this special way. As we approach the
+modern time, there comes to be a definite recognition of the fact that
+the mind may produce many pains and aches which seem due to purely
+physical conditions that might be expected to yield only to physical
+treatment. A corresponding recognition of the power of the mind to
+lessen and even suppress actual physical pain is almost a corrollary
+of this.
+
+{749}
+
+Sir Benjamin Brodie declared, as I have quoted in the section on
+"Diseases of the Muscular and Articular System" that a large
+proportion of the painful joint conditions that he saw among his
+better-to-do patients were of the hysterical or neurotic type. Sir
+James Paget thought this expression of Brodie an exaggeration, but
+acknowledged that one-fifth to one-fourth of all his cases in both
+hospital and private practice were due to hysteria. In those days most
+of the painful conditions were considered to belong rather to surgery
+than to medicine, so that these opinions represent very well the
+practice of medicine in these cases during the early nineteenth
+century.
+
+During the nineteenth century great practical surgeons, and especially
+those who have taught us how to treat individual patients rather than
+their diseases--for it is quite as true in surgery as in medicine that
+the patient is more than his disease--have made distinct contributions
+to the department of psychotherapy in surgery. Dr. Hilton's great book
+on "Rest and Pain" is full of psychotherapy. His cases illustrate the
+fact that when patients' minds and bodies are set at rest, all sorts
+of serious conditions proceed to get better. The rest of mind, the
+cessation of worry, the presence of a feeling of confidence in
+recovery, is quite as important as the physical measures. Young
+surgeons particularly probably could not do better than follow the
+advice of the old Scotch surgical professor at Edinburgh who suggests
+to his pupils that they should read Hilton's "Rest and Pain" at least
+once a year.
+
+
+
+CHAPTER II
+
+MENTAL INFLUENCE BEFORE OPERATION
+
+
+Much may be done during the preparation for operation to put the
+patient in the most suitable condition for the manifestation of
+healthy reaction of tissue and of normal convalescence. Many patients
+do not come for operation until their health has been somewhat
+impaired at least by the condition requiring operation. Not
+infrequently a good proportion of this impairment of health is due not
+so much to the lesion that is present as to the worry over it and the
+anxiety and solicitude which its development has occasioned. If the
+lesion is in connection with the digestive tract, this is particularly
+likely to be true, and nutrition will often have been sadly interfered
+with, not so much by direct influence of the pathological condition as
+by the unfavorable mental influence developing in connection with it.
+We know now that it is perfectly possible for an indigestion which is
+entirely above the neck to make rather serious inroads upon the health
+of the patient, by producing dislike for food or at least such loss of
+appetite as leads to considerable reduction in weight. In such cases
+there are often complications, such as tendencies to constipation,
+that still further impair health or at least reduce vitality and
+therefore hamper that healthy reaction which should occur after
+operation in order to assure normal convalescence.
+
+
+Accessory Neuroses.--In many of these cases, even where there is a
+definite lesion present, the patient can be brought up to normal
+weight, or at least his condition can be greatly improved by medical
+treatment accompanied {750} by such attention to his state of mind as
+will neutralize its unfavorable influence. If he can be made to
+understand that a definite effort to increase weight and to bring back
+his strength will be of assistance in recovery from the operation, and
+that the reestablishment of certain habits of eating and caring for
+himself will do much to help in this, very desirable changes for the
+better in his general health may be brought about. This is illustrated
+very well by what happens in certain incurable cancer cases. The
+patients often have lost considerable weight, even thirty to forty
+pounds, before an operation is decided on, and then when the operation
+is performed their cancer is found to be inoperable. After the
+exploration the patient is not told this, but is mercifully spared and
+is assured that now he ought to get better, since an operation has
+been performed. Such patients have been known to gain twenty, thirty,
+and in one case I believe over forty pounds as the result of the
+mental influence of this suggestion and the resumption of former
+habits of life to some extent at least, consequent upon the
+neutralization of the unfavorable state of mind into which they had
+sunk before through over-solicitude about themselves. If even the
+depressing effect of the toxins of cancer can thus be overcome, it is
+easy to understand how much can be accomplished when there is no such
+physical factor at work.
+
+
+Dominant Ideas.--As a general rule, it must be recognized that
+patients may be, and indeed frequently are, besides their definite
+pathological conditions, under the influence of dominant ideas which
+must be recognized and as far as possible neutralized. Some of them
+have persuasions with regard to food and the amount that they can eat,
+others have removed many important nutritious articles from their diet
+and are quite sure that any attempt on their part to take such
+articles is sure to be followed by indigestion, and still others have
+habits with regard to the amount and the kind of fluids that they take
+at meals and between meals and, above all, the lack of fluids in their
+diet which need to be overcome. Unless such ideas are counteracted
+there is difficulty even in convalescence, and very often they have
+brought patients into physical conditions in which whatever
+pathological condition is present is emphasized by that over-attention
+which the nervous system is so prone to give to even slight sensations
+when the organism is in a state of lowered nutrition.
+
+In not a few of these cases the bringing of the patient up to the
+normal condition of weight and health, and the removal of the
+influence of dominant ideas, will perhaps also remove many of the
+indications for operation. There are many patients, and especially
+such as are reasonably educated and have some leisure, who get certain
+of their organs on their minds and produce symptoms or emphasize such
+symptoms as are present until it seems as though an operation is the
+only thing that can lift their burden of discomfort and permit them to
+go on again with their work. We have all known of physicians who felt
+sure that they ought to be operated on for such conditions as gastric
+ulcer or duodenal ulcer, though subsequent developments in the case,
+when they were persuaded to put off operation and made to reform
+certain ill-advised habits, proved that no such lesion as they
+suspected had ever been present. Indeed, some of these physicians and
+even surgeons have insisted so much that surgical friends occasionally
+have operated on them and have found nothing to justify the operation.
+
+{751}
+
+Some of these states in connection with discomfort of various kinds in
+the abdomen have been discussed in the chapter on Abdominal
+Discomfort, and some illustrations of useless operations given. We
+must not forget that there is a constant stream of pathological
+suggestion in the air at the present time, not only in medical
+journals, but even in the secular press, and that this concentrates
+the attention of patients on comparatively slight discomforts and
+leads to the exaggeration of them until even an operation seems a
+welcome relief for them.
+
+
+Operative Persuasions.--While surgical operations are in practically
+all cases mutilations, they are absolutely necessary under certain
+circumstances, are often, indeed, life-saving, and there is no doubt
+that they have saved mankind a great deal of discomfort. Surgeons are
+agreed, however, that they are not to be performed unless they hold
+out a definite promise of physical relief. It is extremely important,
+then, that patients must not become persuaded of the need of an
+operation in their cases unless surgical intervention is really
+necessary. This is as true for physicians and even surgeons
+themselves, as I have said, as it is for the general public. Women are
+much more susceptible than men to operation suggestions, and since it
+has become fashionable to talk about _their_ operations, not only has
+the deterrent idea of surgical mutilation been greatly lessened, but
+there has actually developed in many of them a morbid fascination for
+a similar experience with all its attraction of attention and promised
+occupation of mind for the woman of leisure.
+
+This phase of the necessity for favorable mental influence has been
+especially emphasized in the chapters on Gynecology. Unless,
+therefore, there are very definite indications, operations must not be
+performed, for they will relieve, as a rule, only for the time being,
+and further operations may have to be done to no purpose. Any
+physician of reasonably large experience has seen such cases. Patients
+get the idea of an operation as their one hope, and then nothing less
+than that will produce such diversion of mind as will bring relief of
+symptoms. It is important in these cases that such patients should not
+have operations suggested to them. Once the suggestion takes hold,
+they do not use their reserve energy in such a way as to help out
+effectively other remedies that may be given. They distrust all
+remedial measures, think that at most they can be only palliative, and
+so do not add to other forms of therapeutics the power of
+psychotherapy to cure them.
+
+Besides the abdominal conditions, there are certain tuberculous
+conditions with regard to which this seems to be particularly true. I
+have seen enlarged cervical glands disappear without discharge when
+patients have taken up the outdoor life, and, above all, when they
+have gone out of the city and have lived the regime proper for those
+in whom tubercle bacilli are growing. If such patients, however, once
+become persuaded that their glands must be operated on, they are
+likely to need, if not active intervention, at least the discharge of
+material from their tuberculous lesions before they get well.
+Operations of a radical character for tuberculosis used to be much
+more popular than they are now, when we are likely to think that
+nature can do more for tuberculous lesions in nearly all cases than
+the most skillful surgery.
+
+
+Fractures and the Mind.--In such surgical conditions as fractures and
+dislocations, a change has come about in the mode of treatment, at
+least in many hands, that seems entirely physical in its effect, yet
+has undoubtedly {752} exerted important psychic influences favorable
+to recovery which deserve to be noted. In dislocations and fractures,
+and particularly the latter, it was the custom in the past to do the
+fractured limb up in bandages and then leave it until knitting of the
+bones, or, in dislocations, healing of the soft tissues, had taken
+place. Apparently it was forgotten that this eminently artificial
+condition was not conducive to that healthy reaction of tissues for
+reparative purposes which must be expected in these cases. Circulation
+was not so good because of the constrictive effect of the bandages;
+vitality not so high because of failure of nervous activity in
+absolute immobility; the return venous circulation was somewhat
+hampered because there were no contractions of muscles; and all the
+conditions were distinctly unfavorable, though nature was expected not
+only to maintain the health of the part, but bring about the added
+functions of repair. In spite of the more or less unfavorable
+conditions, nature was able, as a rule, to do so. Prof. Lucas
+Championére reintroduced the older method of treating fractures and
+dislocations more openly and of even using certain manipulations,
+passive movements, and massage in order to encourage the circulation
+and the natural vitality of the limb.
+
+There is another phase of the influence of this mode of treatment that
+deserves to be recalled. When the fracture is hidden away for many
+days and the patient is not absolutely sure whether it is getting on
+well or not, solicitude or anxiety is awakened in some minds that
+prevents, or at least delays, normal healthy repair. It is well known
+by surgeons that fractures do not heal so well after accidents in
+which there has been considerable shock, or in which the simultaneous
+death of a friend seriously disturbs the patient's mind. Nor do
+fractures heal so well if the patient is worried about business
+affairs or seriously disturbed over family matters. Among sensitive
+patients, a state of mind not unlike that produced by worry or shock
+may develop as a consequence of the dread that the fracture may not
+heal properly, or that there may be deformity, or that when the
+surgeon removes the bandages he may find it necessary either to break
+it again or do something that would involve considerable discomfort.
+These patients need reassurance. If the surgeon sees the broken limb
+occasionally, and, by manipulation and passive movements such as may
+properly be used, assures himself as to its condition, the patient's
+mind is much better satisfied and that inhibition of trophic processes
+which otherwise sometimes occurs is prevented.
+
+
+Incisions and Suggestion.--Something of this same psychotherapeutic
+influence is noted with regard to the healing of incisions when these
+are not left without inspection too long. The newer surgical customs
+of comparatively few dressings, so that the wound may easily be
+inspected and the patient may be completely assured with regard to it,
+has undoubtedly had a good influence in bringing about more rapid
+repair. Air is the best environment for a healing as well as a healthy
+skin, and mental trust is best for the patient's power of repair. In
+vigorous individuals such repair will occur anyhow. It is in those of
+delicate health, neurotic disposition, and psychoneurotic tendencies,
+that reassurances are needed. Often their physical condition is such
+that they need every possible aid in bringing about complete repair.
+Their state of mind, then, must be noted carefully, and any inhibitory
+ideas that may be present because of over-anxiety as to how the
+incision is getting on must be removed. This does not mean that
+patients' whims should be yielded {753} to in the matter of
+over-solicitude about their condition, but that proper care should be
+taken to prevent inhibition of trophic influences through unfavorable
+mental states just as far as is possible. Most surgeons of experience
+do these things in the proper way by instinct from the beginning, or
+by a tactful habit, which develops in their surgical experience of
+adapting themselves to individual patients. It is well to realize,
+however, that such mental attitudes are extremely important and must
+be deliberately treated by the surgeon.
+
+
+Pseudo-rabies.--Certain conditions usually treated of as surgical have
+mental relations that are very interesting. There seems no doubt that
+in a certain number of cases pseudo-rabies occurs; that is, persons
+are bitten by a dog, become seriously disturbed over the possibility
+of rabies developing, and after brooding over this for a time their
+mind gives way and there is either a neurosis simulating many symptoms
+of true rabies, or a state of collapse from fright in which even death
+may take place. These cases are not frequent. Their occurrence is
+taken by some of those who are opposed to animal experimentation as a
+proof that rabies is always some such delusion, and that it is due to
+the exaggeration of the significance of dog-bites by the medical
+profession that the symptom complex known as rabies has come into
+existence. This is, of course, nonsense, and many true cases of rabies
+occur. Since, however, these other cases provide the opportunity for
+argument in the matter, it is all the more necessary that they should
+be recognized for what they are. When a patient has been bitten by a
+dog that has not died from rabies within three weeks after the bite,
+there is practical certainty that the animal did not have and could
+not communicate rabies. The cases of hydrophobia with long incubation
+periods are rather dubious, and the general impression now is that
+there has been subsequent infection. Patients who are in the midst of
+overwhelming dread of the development of rabies must be taken
+seriously and their cases treated by mental influence. Suggestion,
+instruction, and the neutralization of wrong ideas by reference to
+authorities in the matter, must be used to overcome the unfortunate
+state of mind which may, if allowed to continue and, above all, to
+develop, prove serious for the individual.
+
+Pseudo-rabies is but a type, though the most serious and perhaps most
+frequent of what may be called surgical psycho-neuroses. There are
+others. Imaginary syphilis is an affection that often causes worry and
+trouble to patient and physician. _Herpes preputialis_ with mental
+symptoms is almost as bad. These are mental infections of various
+kinds. There are many neoplastic persuasions and toxic suggestions
+that must be treated with tact and firmness.
+
+
+
+CHAPTER III
+
+MENTAL INFLUENCE IN ANESTHESIA
+
+
+Nowhere in the domain of surgery is the influence of the mind more
+important than in the production of anesthesia for surgical purposes.
+It is well known that intense preoccupation of mind will make an
+individual completely anesthetic even for very severe injuries. In
+battle men frequently are severely wounded, yet do not know it, or at
+least have no idea of the extent of the wound and of the pain that
+ordinarily would be inflicted by it. In the {754} midst of panics, as
+during fires, or when crowds are trying to get out of buildings
+rapidly, people often suffer severe injuries and know nothing about
+them. The story of the woman who lost her ear in the theater panic and
+was quite unaware of it until her attention was called to it, is only
+one of many striking examples. Men have been known to walk round even
+with a broken leg, or with a dislocation with which it proved quite
+impossible for them to move, once their mental preoccupation for
+others ceased and they had time to think about themselves. Anesthetic
+incidents under conditions in which great pain might well be expected
+are not uncommon. It is evidently possible so completely to occupy the
+mind that pain sensations cannot find their way into the
+consciousness.
+
+
+Pain and Diversion of Mind.--From very old times, attempts have been
+made to use this power of the mind to prevent pain, and often with
+some results. In preanesthetic surgery, minor operations were
+performed rapidly, beginning just after the patient's attention had
+been attracted to something else besides the thought of the operation.
+Pain is, of course, much less tolerable and seems to the sufferer at
+least to be much more severe whenever the attention is concentrated on
+it. Specialists in nervous diseases, during the process of eliciting
+complaints of pain or tenderness while employing movements or
+manipulations, usually try to attract the patient's attention as much
+as possible to something else, in order to determine just how much
+genuine pain or tenderness is present. Often it is found that, while a
+part of the body is complained of as exquisitely tender or it is
+averred that a joint cannot, be touched or a limb moved without severe
+pain, when the patient's attention is attracted strongly to something
+else, deep palpations may be practiced and rather extensive
+manipulations can be made without complaint. In these cases very often
+the pain is not imaginary, but is slight, due to some physical basis,
+and has been very much increased by the concentration of attention on
+it. This part, at least of the pain, may be removed by an appeal to
+the mind. The principle is valuable when there is question of minor
+operations.
+
+Surgeons have often taken advantage of this power of distraction of
+attention to relieve pain in surgical manipulations. The story is told
+of the French surgeon, Dupuytren, that he was called one day to see a
+lady whom he knew very well in order to determine the form of injury
+from which she was suffering. He found that she had a dislocation of
+the shoulder, and during the manipulations, in order to make his
+diagnosis, he almost inevitably inflicted considerable pain. She
+complained very bitterly and told him that she understood that he was
+very rough with his hospital patients, but he must not be rough with
+her. He had hold of her hand at the moment, and, just before grasping
+the arm in such a way as to make the manipulations necessary to reduce
+the dislocation, he slapped her face and told her that she must not
+talk to him while he was treating her. Needless to say, she was deeply
+shocked. Before her shock had passed away, Dupuytren had completed the
+reduction of the dislocation, and in her preoccupation of mind she
+felt almost no pain. She remarked afterwards, however, that she had
+suffered so much mental anguish from his unexpected roughness that she
+was not sure whether, after all, she had been really spared in her
+feelings.
+
+
+Hypnotic Anesthesia.--When, in the first half of the nineteenth
+century, {755} scientific attention was seriously attracted to
+hypnotism, it was hoped that this would prove an effective means of
+producing anesthesia during surgical operations or at least of greatly
+lessening pain. The hope was not disappointed. There was a discussion
+on the subject before the Medical Chirurgical Society of London in
+1840, and in 1843 Dr. Eliotson wrote a work with the title, "Numerous
+Cases of Surgical Operations Without Pain in the Mesmeric State." In
+1846 Sir John Forbes wrote in his Review that "the testimony as to the
+value of hypnotism as an anesthetic is now of so varied and extensive
+a kind as to require an immediate and complete trial of the practice
+in surgical cases." At the end of that same year, ether as an
+anesthetic was introduced into England, and the first case was
+reported under the caption "Animal Magnetism Superseded," which shows
+how much attention the previous attempts at hypnotic anesthesia had
+attracted. After this, hypnotism was given up for anesthetic purposes
+except by a few enthusiastic students of it. These, however, succeeded
+in accomplishing much with it. Dr. Esdaile, in India, succeeded in
+doing all sorts of operations under hypnotism. Dr. Milne Bramwell, in
+"Hypnotism, Its History, Practice and Theory" (London, 1906), lays
+down the rules for hypnosis for anesthetic purposes. They are
+eminently practical.
+
+While hypnotism can be used to produce anesthesia, it has many
+disadvantages. The length of the hypnosis cannot always be arranged so
+as to assure anesthesia during the whole of an operation, while in
+some cases it will continue after the operation for some time in spite
+of every effort on the part of the hypnotist to bring the patient to
+himself. Besides, the depth of the hypnosis cannot always be assured,
+and sometimes some sensation remains. Patients will groan and wince
+and move, though, of course, under ether or chloroform such
+manifestations may take place, yet the patient afterwards will give
+every assurance that not the slightest pain was felt. In some cases,
+however, even where the pain sensation is not severe during an
+operation under hypnosis, it may, nevertheless, prove sufficient, when
+continued for some time, to bring the patient out of the hypnotic
+state.
+
+For short operations of minor character, undoubtedly hypnosis can be
+employed successfully. As we explain in the chapter on Hypnotism,
+anyone can produce hypnosis who has confidence in his own power and in
+whom the patient has trust. There is no need of a special hypnotist,
+and there is no special faculty required. There should be some
+familiarity with procedures, but any man has just as much hypnotic
+power as another. The influence does not pass from the operator to the
+subject, but is due to the subject's concentration of his attention so
+that there is a short circuiting of association tracts within the
+brain very probably, which does not permit the entrance into
+consciousness of sensations through any path except one or two,
+usually that of hearing, and sometimes of sight, less frequently of
+other sensations.
+
+
+Concentration of Attention.--In a great many cases of minor
+operations, such as the opening of a boil of a small abscess, the
+pulling of a tooth, the lancing of a gum, or other such procedures, a
+surgeon who is confident in his own mental power over his patient can
+rather easily produce a state of mind in which the discomfort of the
+surgical procedure is greatly minimized. There are certain physical
+helps for this. For instance, if patients are asked to breathe rapidly
+and deeply for a few minutes, there is a hyperoxygenation {756} of the
+blood which seems to obtund sensibility. If patients are told of this,
+and then made to breathe rapidly for a half a minute in order that
+they may continue consciously their deep, rapid breathing even when
+pain is noted, a state of mind is produced from concentration of
+attention on their breathing in which painful sensations are greatly
+obtunded. The effect is probably more mental than physical, and is
+well worth while trying because of the amount of pain it often saves.
+
+
+Waking Suggestion.--Without resort to hypnotism, much can be
+accomplished by mental suggestion in the waking state to lessen the
+pain of surgical operations and maneuvers. This is particularly true
+as regards nervous persons, who will otherwise emphasize their
+discomfort, and for those of lesser intelligence, children, and the
+like. Esdaile's experiences in India show how much can be done in this
+way. Often the hypnosis was so slight that the patients were perfectly
+cognizant of everything that went on around them, yet under the
+compelling influence of the assurance of Dr. Esdaile, whom they
+trusted completely, they did not complain of pain nor wince even when
+considerable surgical intervention was practiced, and they always
+assured their friends afterwards that they had felt nothing. I know an
+American physician who has an almost similar power over negroes.
+Ordinarily it requires more of an anesthetic to produce
+insensitiveness to pain in the negro than in a white person. By
+personal assurance, by the absolute securing of their confidence, and
+through their trust in him, this man is able to produce anesthesia
+without the use of more than a minimum quantity of the anesthetic. He
+is able to do the same thing with children, and, of course, it is well
+known that mental influence over them is extremely important in
+limiting the amount of anesthetic that will be necessary.
+
+
+Personality of Anesthetist.--Some anesthetists by their personal
+influence are able to bring patients under the influence of an
+anesthetic with much less excitement and, as a consequence, with the
+use of much less of the anesthetic than others. It is the same
+question of personal influence that extends through all medicine. Some
+men seem to have it naturally, and others not, though to some extent,
+at least, it may be cultivated. Of course, it is now well understood
+that, under no circumstances, should a patient be forced to take an
+anesthetic. This is as true for a child as for any other patient. Only
+a little management is required to secure the cooperation of even a
+young child. Above all, there must be no struggling, and while there
+may be a passing stage of excitement, which cannot be entirely
+controlled, this can be eliminated by those who are skillful. It may
+be necessary, especially in the case of children, for the little
+patients to become familiar with the anesthetist. They should see him
+on several occasions and should be made to feel that they know him.
+The presence of a stranger is enough of itself to excite children and
+make them suspicious and resentful of any manipulations. It may be
+well for them to have breathed through the cone on several occasions
+and to play a sort of game with it. In this way children will often go
+under an anesthetic without any struggle or excitement.
+
+It seems a little childish to suggest similar procedures with grown
+patients, but even surgeons of long experience with the older methods
+who have insisted on the trial being made on their patients have found
+much benefit from it. Familiarity with the anesthetist and even with
+the inhaler {757} and the breathing through it on several occasions
+beforehand, when no anesthetic is being administered, helps many
+patients not a little. This preliminary is particularly of help with
+regard to nervous patients and especially women. It is very seldom
+necessary to use nitrous oxide as a preliminary to ether if this mode
+of procedure is practiced.
+
+
+Mental Diversion.--It is well to concentrate the mind of the patient
+on something else besides his sensations. One element that is
+extremely important for anesthesia is deep breathing. The patient must
+then have his attention called to the necessity for deep breathing and
+should frequently have the suggestion to this effect repeated in his
+ear as he comes under the anesthetic. There should be some practice in
+deep breathing deliberately beforehand, with the idea of accustoming
+the respiratory mechanism to take deep breaths by habit even when not
+entirely under the control of the will. This may be done with the
+inhaler on a few occasions at least. The occupation of attention
+necessary for deep breathing during the taking of the anesthetic
+lessens the concentration of mind on the feelings, and actually makes
+the discomfort much less. Besides, deep breathing distributes the
+anesthetic over the lungs, leads to its absorption more rapidly, and
+makes the irritation of the anesthetic less by diffusing it over a
+larger surface. On the contrary, short, rapid breaths lead to an
+intensity of irritation and much slower absorption.
+
+Skilled anesthetists have found it of decided advantage to keep the
+patient's mind fixed on something else besides the breathing. Perhaps
+the easiest recommendation is that of locking the hands over the
+abdomen just above the umbilicus and asking the patient to hold tight.
+This gives something very definite to think about and to occupy the
+mind with. I have seen patients of rather nervous organizations go
+under the influence of even a very small quantity of an anesthetic
+when required to hold their hands thus and when the command was
+constantly repeated, "Hold your hands tight," whenever there was the
+slightest sign of struggle or excitement. Where this was done
+tactfully and regularly, I have seen patient after patient go into
+anaesthesia without struggle or excitement and usually without any
+noise or even a loud word. I realize how much the personality of the
+anaesthetist means in such cases, and I feel sure that anyone who is
+confident in his own power in the matter will produce a corresponding
+feeling of confidence in the patients.
+
+
+Fright in Anesthesia.--There seems good reason to think that
+occasionally the deaths reported from anesthesia have really occurred
+from fright or at least have been greatly influenced by emotional
+factors. It has often been noted that these deaths occurred
+particularly at the beginning of the administration of an anesthetic
+and before anything like a sufficient quantity to produce a toxic
+effect had been administered. In other cases it has been noted that
+patients were allowed to come out partially from under the anesthetic,
+and as they recovered consciousness were disturbed by some incident.
+Sometimes the pain seems to act as an inhibitory agent on the heart.
+In more than one reported case the patient told afterwards of hearing
+very distinctly some remark that seemed to be of bad omen. In one case
+in my own experience the breathing and heart stopped (though the
+patient fortunately was resuscitated) as a consequence of hearing a
+series of rather loud goodbyes said at the door of the elevator
+leading to the operating room during the {758} course of an operation
+just at a moment when the anaesthetic influence was very much lessened
+for a while. In some cases where there has been great fear of the
+anesthetic which has been talked over beforehand by the patient, even
+a few whiffs of the ether or chloroform have given rise to serious
+symptoms from stoppage of the heart. It is evident that it is
+extremely important properly to predispose such patients.
+
+The well-known surgical warning not to make remarks during the course
+of an operation that might prove disturbing to the patient, needs to
+be emphasized. By a very curious psychological anomaly some patients,
+though thoroughly anesthetic as regards pain, are able to hear and
+understand very well remarks that are made near them. Fortunately,
+such patients are few in number, but they are sometimes rather
+seriously disturbed by chance observations that for the moment at
+least seem to have an unfavorable bearing on their case. Besides,
+certain patients sometimes have their special senses come out from
+under the influence of the anesthetic before their sense of pain. They
+may also hear and be disturbed. These cases illustrate very well the
+place of mental influence and how much deliberate attention should be
+given to this phase of the treatment of surgical cases coming out of
+anesthesia, as well as while more or less under its influence.
+
+
+Local Anesthesia.--In local anesthesia it has come to be generally
+recognized in recent years that the personality of the operator is one
+of the most important factors for success. A number of local
+anesthetics have been introduced, and in some hands only comparatively
+small quantities of them are needed in order to produce complete
+absence of pain during operations. In other hands, however,
+considerable and even toxic quantities may have to be employed and
+sometimes without entire satisfaction. Infiltration anesthesia depends
+for its success largely on the personal influence of the administrator
+over the patient. It is extremely important that the patient should
+have complete confidence and not have that confidence disturbed in any
+way. For instance, he needs to be warned that he will feel the slight
+prick of the needle when it is first introduced, for otherwise he will
+be disturbed by even so slight a pain at the very beginning and will
+magnify subsequent feelings until satisfactory local anesthesia
+becomes impossible. Without thorough command over the patient and
+complete trust, local anesthesia never succeeds except in very minor
+operations. There are some men, however, who can do even severe and
+extensive operations with comparatively small amounts of local
+anesthesia. Others cannot perform satisfactorily even minor operations
+with large amounts. It is the operator, his personality, and mental
+influence over the patient that counts.
+
+
+Vomiting After Anesthesia.--The vomiting that comes after anesthesia,
+especially with ether, often constitutes not only an annoying but
+sometimes a seriously disturbing complication. It must not be
+forgotten that vomiting in neurotic individuals, and especially women,
+may be largely due to a neurosis. In the section on Psychotherapy in
+Obstetrics we discuss the vomiting that occurs in connection with
+pregnancy and suggest that it is nearly always neurotic in character.
+The best-known European obstetricians are now agreed in this. While
+ether produces a tendency to vomit in everyone, in some the actual
+vomiting is very slight or completely absent. If patients expect that
+there is to be vomiting, if they are of the neurotic temperament that
+not only {759} vomits easily but has a tendency to secure sympathy by
+fostering this symptom unconsciously perhaps, then the vomiting may
+become even a dangerous complication. If there is no expectancy in the
+matter, however, but if, on the contrary, it is made clear to these
+patients before the anesthetic is administered that, while there may
+be some nausea, there need be no vomiting unless they yield too
+readily to their feelings, much can be done to lessen the vomiting. A
+single suggestion may not mean much in this matter, but a series of
+suggestions properly given beforehand, especially if the patient has
+seen others vomiting after operations and is worrying about it, may
+prove of excellent contrary suggestive value.
+
+If there is no expectancy, the physician must be careful not to arouse
+it by over-solicitous anxiety in the matter. A plain statement should
+be made on several occasions, however, so that the patient will have
+in mind a good basis for contrary suggestion when coming out of the
+anesthetic. Many remedies have been suggested for this post-anesthetic
+vomiting, but, just as with regard to the vomiting of pregnancy, the
+most important element in all the cures that have been reported has
+been the influence upon the patient's mind. Whenever we have a number
+of remedies for an affection, it is almost sure that it is not their
+physical but their psychic effect that is of most importance.
+
+
+
+CHAPTER IV
+
+MENTAL INFLUENCE AFTER OPERATION
+
+
+Every surgeon feels the necessity of having his patients as quiet and
+restful as possible after operation. Any unfavorable mental influence
+will surely hamper the curative reaction of tissues and delay
+convalescence. We all know how fear blanches tissues, and anxiety
+causes hyperemia, and how solicitude with regard to any part of the
+body interferes with the normal control of the sympathetic nervous
+system and sets up vasomotor disturbances. Either a lessening or
+surplus of blood in a particular part interferes with the normal and
+healthy curative reaction of tissues. The patient's mind should
+therefore be as much as possible diverted from attention to the part
+that has been operated on in order to leave nature to pursue its
+purposes without disturbance. For this, of course, pain must be
+relieved and every possible measure taken that will add to the comfort
+of the patient. In spite of the fact that opium may interfere with
+certain natural processes, it is always useful after severe
+operations, because it represents the lesser of two evils. The pain of
+itself would produce more detriment than does the opium which relieves
+the pain. There are, of course, other anodynes which may be used and
+that have less disturbing sequelae. In this matter, routine is
+unfortunate, for individual patients react very differently to opium
+and its derivatives, the disturbing effect upon the mind being greater
+than the quieting effect on the body. Many patients stand the coal-tar
+derivatives much better because of their lack of effect on the mind.
+
+
+Removal of Worries.--Worries of all kinds not associated with the
+operation must have been thoroughly removed beforehand and must not be
+allowed {760} to obtrude themselves afterwards until convalescence is
+well established. Business is quite another matter. Whenever it does
+not imply worry but only means occupation of mind and distraction of
+the attention of the patient from himself, it may very well be
+permitted, after only a comparatively brief interval after operation.
+Within a few days a business man may certainly be allowed to dictate
+letters for an hour or so, and an author may even be allowed to
+dictate notes of some of the fancies that came to him during
+anesthesia. When a man has the opportunity to look forward to even a
+short interval during the day when he can do something that is useful,
+it serves as an excellent distraction for many hours beforehand and as
+a satisfactory memory for hours afterwards.
+
+
+Pleasant Visits.--It used to be the custom to keep visitors from
+patients after operation much longer than is at present the custom.
+There has come the realization, however, that short visits from
+pleasant friends may mean much for the patient. It is hard to make the
+selection, for certain friends and especially relatives disturb and
+annoy rather than help the patient. Anyone who shows much solicitude
+and, above all, fussy over-anxiety, must be excluded, no matter how
+nearly related he or she may be.
+
+
+Psychic Conditions of Hospitals.--The atmosphere of the hospital must
+all conduce to peace and quiet of mind. It is surprising the
+differences that may be noted in this respect. I have been in a
+hospital where only a dozen of operations were done a week and have
+scarcely ever been there without hearing complaints of pain and
+discomfort that were surely disturbing to others. On the other hand, I
+have been in a hospital where twenty capital operations a day were
+done, and have heard no complaint, and at nine o'clock at night have
+found in it the peace of a religious community. I knew that it was all
+due to the personality of the surgeons and their lack of power in one
+case to impress their patients' minds and a very marvelous power in
+the other of impressing patients favorably. The success of many a
+surgeon in a material way depends on this power to impress his
+patients. It is they who send others to him, and in general there is a
+feeling that if he cannot cure them no one can.
+
+Of course, it is extremely important that circumspection should be
+employed as regards chance remarks that may be seriously
+misinterpreted and prove unfavorably suggestive. Patients should not,
+as a rule, be allowed to see their own charts whenever there are
+disturbing developments in pulse and temperature. During dressings the
+conversation should be cheerful, distracting to the patient, and
+should not contain remarks that may be disturbing. The surgeon and his
+assistants must know how to control their expressions so as not to
+reveal any solicitude that may be occasioned by the patient's progress
+or by the state of his wound when these are not satisfactory.
+
+
+Surgeon's Visits.--Practically every time that a surgeon visits a
+patient after operation there is something that the patient has to ask
+or have explained. A good deal depends, as far as regards the comfort
+and peace of mind during the interval until the coming of the surgeon
+again, on the satisfaction derived from the surgeon's explanation. He
+should be prepared, therefore, to answer in such a way as will leave
+no haunting doubts in the patient's mind. Some patients are very prone
+to find unfavorable suggestions in even simple expressions of the
+physician. He must be prepared for {761} this, therefore, and be sure
+to say nothing that can possibly be misunderstood. In spite of this,
+at times patients will draw unfavorable inferences and then the nurse
+should have the confidence of the patient sufficiently to set the
+matter right or at least to give reassurance that will keep the
+patient's anxiety from disturbing until the next visit of the surgeon.
+All of this seems trivial from a certain standpoint, but even surgery
+is as yet an art and not a science. Art depends on personality and the
+influence of it and the power to express itself. The personality of
+the surgeon must be felt in the patient, and the more he can make it
+felt the better the convalescence and the less discomfort even though
+there should be more of pain. The amount of pain actually felt depends
+on how much of it gets above the threshold of consciousness.
+
+Almost any surgical patient, especially if he has gone through a
+serious convalescence, will tell you how much good the visits of his
+physician used to do him, though a glum and over-serious surgeon may
+have exactly the opposite effect. Sometimes busy surgeons neglect to
+visit their patients daily, and nearly always this has an unfortunate
+effect. In serious cases, the seeing of the surgeon several times a
+day, when it is well understood that his visits are not due to
+over-anxiety with regard to the patient, may hasten convalescence
+materially.
+
+
+Comfort, Mental and Physical.--Everything must be done to make the
+patients as physically comfortable as possible. It must be well
+understood, however, that comfort lies much more in variety and
+response to feeling than in any continuous condition. Patients will
+have little complaints and there must be always something novel to do
+for them. This does not necessarily imply medicine or even troublesome
+external applications, but the rearranging of bed clothing, the use of
+a hot-water bag or of an ice bag, the relief of pressure, sometimes
+mild applications of pressure, the lifting of the head, slight
+turning, even small changes of position and the like. Whenever a
+patient can be relieved by some means so simple as these external
+trifling remedial measures, confidence is awakened that the discomfort
+they feel is not due to any serious condition, but is only such achy
+tiredness as comes from confinement to bed. Without relief afforded in
+this way, they are likely to let unfavorable suggestion accumulate
+until their dread of something serious may inhibit convalescence or at
+least interfere with sleep and greatly enhance their discomfort
+generally. It is the state of mind that develops as a consequence of
+continued trifling discomforts and not the physical results of those
+discomforts that must be carefully looked to in post-operative
+patients.
+
+
+Nursing.--In the general management of patients after operations it
+would be eminently helpful to the surgeon if surgical nurses were
+supposed to read at least once a year, Florence Nightingale's "Notes
+on Nursing,"   [Footnote 61] written half a century ago, and if the
+surgeon himself should have read it through once at least and dip into
+it occasionally afterwards. In her chapter on Noise there are many
+remarks that I should like to quote, but the whole chapter is so
+valuable that it is hard to know where it stops, and so only a few
+expressions may be given here. For instance, "Never to allow a patient
+to be waked intentionally or accidentally, is a _sine qua non_ of all
+good nursing. If he is aroused out of his first sleep he is almost
+certain to have no more sleep." "The more sleep patients get the
+better will they be able to sleep." "I have often {762} been surprised
+at the thoughtlessness (resulting in cruelty, quite unintentionally)
+of friends or of doctors who will hold a long conversation just in the
+room or passage adjoining the room of the patient, who is either every
+moment expecting them to come in, or who has just seen them, and knows
+they are talking about him." "Everything you do in a patient's room
+after he is 'put up' for the night increases tenfold the risk of his
+having a bad night. Remember, never to lean against, sit upon, or
+unnecessarily shake or even touch the bed in which a patient lies."
+
+  [Footnote 61: American edition, Appleton, N. Y.. 1860.]
+
+Miss Nightingale, as might be expected, insists emphatically on the
+state of the room, the arrangement of the furniture and the
+cheerfulness of surroundings as important factors for the cure of
+patients. One of the most important elements is, of course, the nurse.
+She must be gentle, patient, quick to understand, often ready to
+anticipate wishes, and always as noiseless as possible. Slowness may
+be neither gentle nor noiseless. Patients, particularly men, often
+grow impatient at the slowness with which things are done for them.
+
+
+Chattering Hopes.--There is scarcely an element of mind in the
+patient's environment that Miss Nightingale has not thought of and
+touched with very practical wisdom. She deprecates, as does anyone who
+knows anything about the care of patients, the "chattering hopes" of
+those who try to cheer patients by simply telling them that they ought
+to be more cheerful, that of course they will get well and that they
+must not be anxious. She says: "I would appeal most seriously to all
+friends, visitors, and attendants of the sick to leave off this
+practice of attempting to 'cheer' the sick by making light of their
+danger and by exaggerating their probabilities of recovery."
+Cheerfulness and kindness towards the sick are one thing and foolish
+attempts at encouragement not founded on good reasons quite another.
+
+
+Variety of Thoughts.--From the chapter on Variety the following
+quotations show the very practical character of Miss Nightingale's
+persuasion as to the value of influencing the patient's mind:
+
+  "To any but an old nurse or an old patient the degree would be quite
+  inconceivable to which the nerves of the sick suffer from seeing the
+  same walls, the same ceilings, the same surroundings, during a long
+  confinement to one or two rooms." "The nervous frame really suffers
+  as much from this lack of variety as the digestive organs from long
+  monotony of diet." "The effect in sickness, of beautiful objects, of
+  variety of objects, and especially of brilliancy of color is hardly
+  at all appreciated."
+
+As Miss Nightingale insists, flowers are remedies of great value for
+the ailing and especially for those who are confined to their room for
+a long period. She pleads for having the bed placed near a window in
+order that they may see out into the fields and the scenery around
+them, to which I would add with emphasis, and so that, if it is
+possible, they may see the occupations of human beings. Miss
+Nightingale adds: "Well people vary their own objects, their own
+employments many times a day; and while nursing (!) some bedridden
+sufferer then, they let him lie there staring at a dead wall without
+any change of object to enable him to vary his thoughts." Quite
+needless to say, variety is more important for the ailing than the
+well.
+
+
+Pain Psychic Conditions.--Pain after operation is an extremely common
+symptom and often causes much disturbance. Every surgeon knows how
+{763} individual are patients in this respect, and how much depends on
+the personal reaction to pain. There are men and women who have very
+serious lesions, from which much pain might be expected, who complain
+very little. There are, on the other hand, many men as well as women
+who complain exaggeratedly after even trifling surgical intervention.
+We have probably had some of the most striking examples of the
+influence of mind over body in these cases. Many a patient who
+complained bitterly of torment that made it impossible to rest has,
+after being given a preliminary dose of morphine hypodermically,
+subsequently been given less and less of that drug, until finally,
+after a few days, he was getting injections of only distilled water.
+Without their injection he was in agony. After it he settled down to a
+quiet, peaceful night. Very often it is noted that these pains are
+worse at night and there is a tendency for such patients to attract
+attention only at such times as may be productive of considerable
+disturbance of the regular order and as may call special attention to
+them. We used to call such conditions hysteria, though, of course,
+they have nothing to do with the uterus and must be looked for in men
+quite as well as women.
+
+
+Psychoneuroses.--These neurotic conditions, to use a term that carries
+no innuendo with it, may affect other functions besides that of
+sensation. Occasionally a neurologist is asked to see a patient in
+whom, following an operation, usually not very serious, some paralytic
+symptoms have developed. There is an inability to use one or more
+limbs, and the suspicion of thrombosis is raised. It is rather easy,
+however, to differentiate thrombotic conditions from neurotic palsies.
+The ordinary symptoms of the psychoneurosis are present. There is
+likely to be considerable disturbance of sensation, with patches of
+anesthesia and hyperesthesia, some narrowing of the fields of vision,
+and anesthesia of the pharynx, sometimes even of the conjunctiva.
+Often there is something in the history that points to the possible
+occurrence of a neurotic condition. Sometimes it is extremely
+difficult to get such patients over the mental persuasion that is the
+basis of their palsy, but usually it can be accomplished by suggestion
+in connection with certain physical means. Electricity is often of
+excellent effect in demonstrating to these patients that their muscles
+react properly under stimulus and that it is only a question of
+inability to use them because of mental inhibition. Such conditions as
+astasia-abasia may develop quite apart from surgery, but there is
+always some "insult," as the Germans say, that is some physical basis
+for them, and so they are often considered to be surgical.
+
+
+Psychic Disturbance of Function.--Besides motion and pain, other
+functions may be affected through the mind. After operations within
+the abdomen it is sometimes difficult to move the bowels when it is
+desired to do so. It must not be forgotten that not infrequently in
+these cases the patient's mental attitude of extreme solicitude with
+regard to his intestines is inhibiting peristalsis. Such constipation
+will sometimes not yield to even rather strong purgatives, and yet
+will promptly be bettered by something that alters the mental state.
+It must not be forgotten that it is in cases of neurotic constipation
+that _pittulae micarum panis_ have proven particularly useful. In the
+chapter on Constipation there is a discussion of this subject that
+will often prove suggestive to surgeons.
+
+This same thing is true with regard to post-operative urination. In
+women, {764} particularly, there may be difficulty of urination after
+vaginal operations, which may be attributed to some lesion of the
+urinary tract and yet only be due to failure of the patient properly
+to control muscles in these cases. As in obstetrical cases, position,
+the presence of others, and the mental disturbance, may inhibit
+urination. The subject is discussed more fully in the section on
+Psychotherapy in Obstetrics. Surgeons are not so inclined now to
+insist on absolute post-operative immobility, and even a slight change
+of position may enable patients to gain control over their bladders
+without the necessity for the use of the catheter, which always
+carries an element of danger with it.
+
+The influence of the mental attitude with regard to both of these
+functions--intestinal and vesical evacuation--must not be forgotten.
+There are many persons who find it extremely difficult to bring about
+such evacuations in the lying position. Everything is unusual, and
+their exercise of the coordination of muscles necessary to accomplish
+these functions is interfered with. It is somewhat like stuttering and
+the incapacity of an individual who may be able to talk very well to
+close friends and yet stammers just as soon as strangers are present
+or he is placed in unusual conditions. It has even been suggested that
+there should be some exercise of these functions in the lying position
+before operation, in order to accustom patients to the conditions that
+will obtain afterwards. They thus become used to their surroundings
+and the newer methods required, and, above all, if there should be any
+post-operative difficulty, they realize that it is not due directly to
+the operation, but rather to the unaccustomed conditions. This proves
+helpful in saving them from solicitude and consequent unrest and adds
+to the rapidity of convalescence.
+
+
+Food Craving.--When food is to be given in small quantities and there
+is likely to be craving for it, much can be done to save the patient
+disquietude and disturbance by giving small portions rather
+frequently, rather than distributing it over three times a day, as the
+routine of life sometimes suggests. When water has to be denied, small
+pieces of ice may occasionally be used with excellent advantage.
+Patients learn to look forward to breaks at the end of comparatively
+short intervals in their craving, and the accumulative effect is
+greatly lessened. It is well understood that whenever people are
+absolutely denied anything, they are likely to let their minds dwell
+on that fact and crave it much more than would otherwise be the case.
+If they can look forward to having even the minutest quantities of
+anything that they want, however, craving is much less likely to be
+insistent, and the state of mind is much easier to manage. In all of
+these cases the confidence of the patient and the lessening of
+neurotic tendencies by suggestion means more than most of the physical
+remedies that have been recommended. There are some patients who
+respond almost in a hypnotic way to suggestion from a physician in
+whom they have great confidence.
+
+
+Position and Peace of Mind.--The patient's general comfort is very
+important for the maintenance of a favorable state of mind. It used to
+be the custom to keep patients rigidly in one position for days,
+sometimes more than a week, after operation. We know now that this is
+almost never necessary, and that, of course, it is most fatiguing to
+the patient. Keep the ordinary well person absolutely in one position,
+without the opportunity to change from side to side even during a
+single night, and there will be justifiable {765} complaint of tired
+and achy feelings as a consequence. To enforce such a state for
+forty-eight hours in those who are well will produce a highly nervous
+state, consequent upon the fatigue and soreness of muscles induced.
+Hence, the importance of taking every possible means to provide even
+slight changes of position for those who have been operated upon. A
+number of regular-sized pillows should be provided so that the head
+may be raised and lowered, and a number of smaller pillows should be
+at hand which can be so placed as to relieve pressure at various parts
+and permit the patient to make at least slight changes of position
+during the first forty-eight hours. After this, usually definite
+alterations of position may be allowed without danger. The surgeon
+must think of these elements in the treatment and insist on them with
+his nurses, or they will not be carried out. It is possible now to
+permit patients to sit up much sooner than before, and, indeed, in
+pelvic operations, this is said to be definitely beneficial by
+preventing the spread of any infectious material that may be present
+into the general peritoneal cavity, and in older people it prevents
+the development or, at least, greatly facilitates the dispersion of
+congestion or such beginning pneumonic areas from hypostatic
+congestion as may be present.
+
+
+{766}
+
+APPENDIX I
+
+
+ILLUSIONS
+
+
+A physician who wishes to use psychotherapy effectively should know
+something about physiological psychology, or analytical or
+experimental psychology, as it is variously called, because of the
+help that he will derive from it in understanding many of his
+patients' symptoms. Fortunately this branch is now being taught in
+some of the medical schools, and the greater requirements for
+preliminary training bring to the medical school men who have already
+had a course in this subject. The chapter on Illusions is particularly
+important because it affords many illustrations of how easy it is to
+be deceived by the senses and, therefore, how many precautions have to
+be taken in order to be sure that impressions produced on patients'
+minds that seriously disturb them may not merely be due to
+exaggeration of the significance of information brought them by their
+senses.
+
+These illusions are of special interest because they represent not
+only failures of the senses to convey truth, but because they
+illustrate how easy it is for the mind to be led astray by the senses.
+People often declare that they have seen things with their own eyes or
+in some other way have definite sensory knowledge of them, yet these
+illusions make it clear that it is perfectly possible for such sensory
+phenomena to convey quite mistaken information. People who are
+suffering from many symptoms are persuaded that they must pay
+attention to their sensations. The main purpose of the
+psychotherapeutist often is to have them neglect their sensations and
+correct them by means of information gathered from other sources. We
+do this with regard to our sensory illusions, why not also with regard
+to many sensations which are probably quite as mistaken, in certain
+individuals at least, as these universal illusions of mankind. The
+argument from analogy holds very well and can be used to decided
+advantage in many cases.
+
+A startling illusion which makes it clear that care is needed in
+interpreting our sensations, is the so-called tube illusion or
+experiment. If a sheet of note paper be rolled into a tube of
+something less than an inch in diameter and then held close to one
+eye, both eyes being kept open, while the hand opposite to the eye
+before which the tube is held is placed palm faceward against the side
+of the tube about its middle, a hole will be seen, as it were, through
+the palm of the hand. This false vision is as clear as can be and
+persists after any number of repetitions of the experiment. It merely
+illustrates two-eyed vision. We have a picture in each eye and we
+combine them. When the pictures cannot be combined for any reason,
+optical illusions result. There are many more optical illusions than
+we think and there are many reasons besides two-eyed vision for them.
+
+Other illusions of two-eyed vision may be illustrated rather easily.
+If {767} two dots are made on a sheet of paper about two inches apart
+and the eyes look at them in a dreamy way, looking far beyond the
+paper, with vision more or less fixed between them, after a few
+moments a number of things happen. Usually the two dots exhibit a
+tendency to float together.
+
+  [Illustration: Fig. 26 (two dots about two inches apart)]
+
+After an interval four dots will be seen--each of the dots having a
+picture in each eye. Then only one dot may be seen because the
+pictures combine. Sometimes three dots will be seen. When the dots
+swim toward one another, a curious feeling of insecurity comes over
+the experimenter, showing how much our sense of stability is dependent
+on vision and illustrating why vision from a height is so disturbing
+because objects cannot be properly fixed on the distant background.
+
+  [Illustration: Fig. 27 (from left to right--an empty bird cage, a
+  vertical line, a bird)]
+
+Just as the two dots may be made to come together, so, after a little
+practice, a bird may be made to go into a cage (Fig, 27) or an apple
+made to go onto a plate (Fig. 28),
+
+  [Illustration: Fig. 28 (from left to right--an apple, a large plate)]
+
+These illusions show how many things that people {768} "see with their
+own eyes" are not so. All depends on the attention and the state of
+mind at the time when the seeing is done. In day-dreams these
+illusions often occur and may be the basis of delusions.
+
+  [Illustration: Fig, 29 (Several complex line figures)]
+
+There are, however, a number of optical illusions which illustrate
+certain defects of our vision that cannot be corrected, no matter how
+much we may desire to see correctly. We continue to see them not as
+they are but as they seem, and we must correct our vision by
+information from other sources. The Müller-Lyer lines are familiar and
+are given here (Fig. 29) because {769} they show how easily the senses
+may deceive us, even that most acute of our senses, vision, as to the
+sizes of things.
+
+  [Illustration: Fig. 30 ( Two identical figures, one above the other;
+  each is like a funnel cut parallel to its axis and laid flat. )]
+
+Figure 30 illustrates how easy it is to be deceived by the
+juxtaposition of different portions of objects. I have had a woman who
+had cut out high collars for children and who happened to put them in
+the juxtaposition of the sketch here given think that she was either
+losing her sight or her judgment was being affected by the nervous
+condition in which she was. Nothing would persuade her that some
+serious development was not taking place until I showed her this
+illustration. In this illusion the juxtaposition of the short curved
+line to the long curved line of the other figure produces all the
+disturbance of judgment of size.
+
+The illusions of filled and unfilled space are interesting and are
+quite inevitable. They are due to physiological visual effects and are
+very strikingly illustrated by what is known as the sun and moon
+illusion. Both these luminaries seem larger at the horizon than they
+are at the zenith. This is entirely an optical illusion. The horizon
+seems farther away than the zenith because vision to it is
+interrupted. The heavens appear not to be a half sphere, but more like
+an old-fashioned watch glass.
+
+  [Illustration: Fig. 31 (A--a square consisting of closely spaces
+  vertical lines; B--a square consisting of closely spaces horizontal
+  lines; C--a empty square with only its exterior boundaries.)]
+
+Since the sun and moon occupying the same space on the retina are,
+because of this apparent difference of distance, judged to be farther
+away at the horizon than they are at the zenith, we are inevitably
+forced to the conclusion that they are larger in size than when in the
+other position. The over-estimation of filled space as compared with
+{770} the unfilled is mainly due to the interrupted muscular action of
+the eyes in traveling over the space requiring more effort. This makes
+it seem longer. Probably physiological processes on the retina also
+contribute to the illusion. A series of objects, even dots, will cause
+a greater physiological excitation of the retina than an equal amount
+of space, the boundaries of which alone are brought to our attention.
+
+Illusions of size are even more startling than illusions of distance.
+It is perfectly possible to take three spaces, each exactly a square
+inch, and by drawing lines in two of them in different directions to
+make the figures appear of {771} very different size. This is a rather
+disturbing illusion, particularly for women who are apt to think that
+perpendicular lines make them appear tall and thin, while horizontal
+lines have the opposite effect. This is true if the lines are not
+placed quite close together. The reason why women wear many ribbons,
+however, whether they themselves recognize it or not, is that the
+attraction of attention to these makes the space in which they are
+seem longer. Hussars are dressed in uniforms with many rows of gilt
+cord or braid running across their chests in order to increase their
+apparent height. As a rule, a cavalry man must not weigh over 140
+pounds or his horse will break down in long, forced marches. Such men
+are often of small stature and their apparent height must be increased
+by their uniform, so as to make them look formidable. Advantage is
+taken of this optical illusion of filled space to produce this effect.
+
+  [Illustration: Fig. 32 (several complex curved figures,)]
+
+Other illusions of size are quite frequent. It is rather hard for the
+ordinary observer to think that the half circles, _a_ and _a'_ (Fig.
+32), are the same size, or that _b_ and _b'_ in the same chart are the
+same curve. The interruption in the circles _c_ and _c'_ produce very
+curious erroneous impressions which require a knowledge of this
+illusion to correct.
+
+Optical illusions with regard to directions of lines are extremely
+common. Quite unconsciously we translate directions into special
+meanings. This is what enables perspective to be effective in
+drawings. It has many disturbing features, however. Some of these are
+striking illustrations of the defects of our vision.
+
+  [Illustration: Fig. 33 (tall, narrow rectangles covering diagonal
+  lines passing under them.)]
+
+  [Illustration: Fig, 34 (a large black square with several parallel
+  diagonal white lines; each diagonal line has several intersecting
+  lines; the upper left diagonal has horizontal intersecting lines,
+  the next diagonal has vertical intersections; etc.)]
+
+Poggendorf's illustration of the displacement of oblique lines (Figure
+33) {772} and Zöllner's distortion of parallel lines as illustrated by
+Figure 34, make it very clear that our judgment of direction must
+depend on many factors besides our vision, if we are not to make
+serious mistakes.
+
+These optical illusions might seem to be of little significance, but
+the Greeks thought them of so much importance and recognized so
+thoroughly that they could not be corrected, and that the distortions
+and displacements would inevitably take place, that they deliberately
+put certain optical corrections into their great architectural
+monuments in order to avoid these false appearances. These have been
+traced very accurately in the Parthenon, for instance. In a word, the
+Greeks, knowing of these optical illusions, in order to make the lines
+of their buildings appear correct, deliberately made them wrong to a
+sufficient degree to correct the optical illusion; This frank mode of
+yielding to a limitation of human nature is a fine lesson for patients
+to learn if they can only be made to learn it from these
+illustrations.
+
+It is with regard to colors, however, that we have the best examples
+of optical illusions depending on the individual and his special
+anatomy and physiology. Color-blind people are quite sure that they
+see color, just as other people do, until their defect is demonstrated
+to them. A man who is color blind for red thinks that he sees that
+color as other people do, while all that he sees is a particular shade
+of brightness which, because other people call it red, he has come to
+call red. When asked to pick out red from a series of other colors he
+may often succeed. When asked, however, to take a skein of red wool
+selected for him to a basket containing a number of different colored
+wools, and to bring back all those that are of the same color, he will
+select grays and browns and sometimes greens as well as reds, and
+present them as all matched colors. A man who is color blind for all
+colors will still think that he sees colors as other people do. The
+ingenious illustration of the American flag as it appears to people
+suffering from different forms of color blindness, though they are all
+persuaded that they see the same kind of flag, is an interesting
+example of how different may be people's sensations, though their
+conclusions are the same. It may be seen in many of the text books of
+analytical or experimental psychology.
+
+{773}
+
+Dalton, to whom we owe the atomic theory, was himself color blind for
+red and made the first investigations in that subject. He was of
+Quaker origin and found that a great many of his brethren were
+deficient in color vision. It becomes much easier from this to
+understand why they resolved to wear nothing but gray. They did not
+see colors as other people do and therefore could not understand nor
+sympathize with the joy of other people in color. Dalton tells the
+story of a Quaker prominent in his sect who once went to town to buy a
+gray waistcoat and purchased instead one of bright red. When he
+appeared at meeting in this he was promptly tried for heresy and
+violation of church regulations.
+
+There is an interesting tendency on the part of people who are
+themselves defective in certain faculties of sensation, to conclude
+that when other people are wrapt in admiration of something that they
+cannot perceive, it is because these other people have some mental
+defect that leads them to enthuse too easily over their sensations. A
+story is told of a newspaper man who used to insist that all that was
+said about the beauty of the song of birds was due to the vivid
+imagination of the writers, for he could find nothing to admire about
+the songs of birds. He was placed in a room with a number of fine song
+birds all round him and it proved that he could not hear any of the
+higher notes at all. It was easy, then, to understand his condemnation
+of the enthusiasm of others as hysterical and imaginative. Nearly this
+same thing is true of many quite intelligent people with regard to
+music. They hear ordinary sounds, as did the newspaper man, very well.
+They are tone-deaf however, that is, they are quite unable to hear and
+appreciate combinations of sounds or even to catch melodious
+successions of single notes. They cannot recognize one tune from
+another and often do not know "Yankee Doodle" from the "Doxology," or,
+at most, know only the most familiar tunes, but they set themselves up
+very calmly as judges of the intellects of others and conclude that
+music lovers are really a hysterical set of people who go into
+ecstasies over certain quite insignificant sensations.
+
+These interesting tendencies are helpful in enabling the physician to
+understand his patients better. They often serve as texts from which
+the physician can explain curious things to patients who are prone to
+draw wrong conclusions from them and often suggestions unfavorable to
+their health.
+
+These illustrations and their discussion serve to make very clear the
+distinction between illusions, delusions and hallucinations, which are
+often confounded. Illusions are deceptions of the senses. If a man
+walking along a country road where he fears the presence of snakes
+sees in the gathering twilight a piece of rope coiled, he will almost
+surely mistake it for a snake. This is an illusion produced by the
+conditions in which the object is seen. If walking along the same road
+the next day, more timorous than ever as to snakes, he should see in
+broad daylight the same coil of rope, he might in his fright not stay
+long enough to decide whether it was a snake or not, and his illusion
+would continue, though it would partake somewhat of the nature of a
+delusion due to fright disturbing his judgment. If, in spite of
+careful examination, however, of it, such as would satisfy any
+ordinary mind that it was a coil of rope and not a snake, he should
+still insist in believing that it was a snake, this would be a
+delusion. There is always a mental element in delusions. If, having
+seen nothing, he should insist, owing to fright and {774} nervousness
+or to some other cause, that he sees a snake where there is nothing at
+all resembling a snake and where evidently whatever is the basis of
+his idea of the presence of the snake, is within his own mind, then he
+is suffering from an hallucination.
+
+Illusions may be quite inevitable. Most of the optical illusions
+continue to appeal to us as truths even when we know that they
+represent errors of vision. In spite of the fact that we know that the
+sun and moon are not larger at the horizon than they are at the
+zenith, by optical illusion we continue to see them of larger size. It
+is our duty to correct such illusions by information gathered from
+other sources. To follow an illusion, that is, to give it credit, when
+we should correct it, is a delusion. To think that because we cannot
+see red that therefore there is no red, or because we do not hear the
+sounds of notes of birds that they do not utter any notes, in spite of
+the fact that we have the testimony of nearly the whole human race to
+the contrary, is a delusion. When, using the verb in its broadest
+sense, as "perceive," we seem to see things very differently from the
+generality of people around us, there is every reason to suspect that
+there is some specific or individual limitation of our senses which
+makes us fail to perceive these things as others do. We have to
+suspect our sources of information then and to correct them by what we
+can learn from the experience of others. These are important
+considerations for many of the ideas that patients cherish with regard
+to themselves and their ills.
+
+Hallucinations are entirely mental. But the phenomena that sometimes
+appear to be hallucinations may be due to illusions of the senses
+within the organism. For instance, those who indulge in cocaine often
+have the feeling of having a veil over the face, or of having run into
+a cobweb or something of that kind. The presence of the veil or the
+cobweb on the face is probably not an hallucination, but is due to
+certain disturbances in the circulation, or perhaps in the nerves
+themselves, which affect the nerve endings of the face, causing them
+to tingle in a particular way, and this sensation is translated as
+coming from without in terms of something that has been felt before.
+Some of the appearances of _muscae volitantes_, or of specks before
+the eyes, or occasionally of wavy lines, are due to disturbances of
+the circulation within the eyeball which cause corresponding
+disturbances of the optic nerve, with consequent apparent visions.
+When the eyeball is pressed upon, the sensation first produced is that
+of light and not of pain, because whenever a nerve of special sense is
+irritated, it produces its own specific sensation in the brain.
+
+The chilly stage in malaria is a typical example of a physical
+condition having an effect upon sensory nerves that more or less
+necessarily produces a delusion. The patient is actually at the height
+of his fever when the chilliness and shivering come on and when he
+demands a larger amount of covers in order to protect himself from the
+cold he will often have a temperature of 104 degrees Fahrenheit, or
+even higher. What has happened is that the little blood vessels at the
+surface of the body are shut up by the effect of the plasmodium upon
+the system. Whenever we are cold these little blood vessels shut up in
+order to protect the blood from being chilled by the external
+atmosphere. The shutting up of the little blood vessels deprives, for
+the time being, the terminal nerves in the neighborhood of some of
+their nourishment. Their response is to set up a tremor or shivering,
+which will mechanically tend {775} to open the blood vessels so that
+they may have their nourishment once more. Whenever we have a set of
+sensations that correspond to this connected set of events, we
+translate them as feeling cold. The outer air does feel cold to the
+body because the blood is not flowing through to the surface as it
+would normally in order to warm it. Hence the chilliness. This is not
+an hallucination; but an illusion with something of a delusion in it;
+until we know how things are. Nervousness may set our teeth chattering
+just as it may cause tremor through our sympathetic nervous system,
+disturbing the flow of blood through muscles and so disturbing control
+of them. Vehement emotion, anger, fright, and even those of less
+violence may cause similar effects. All these phenomena illustrate the
+close relation between mind and body.
+
+{776}
+
+APPENDIX II
+
+RELIGION AND PSYCHOTHERAPY
+
+
+Religion and psychotherapy have, of late, come to have many relations
+to each other and many interests in common, at least in the minds of a
+number of clergymen, and in popular estimation. There is no doubt but
+that religion can do much to soothe troubled men and women, even when
+their troubles are entirely physical in nature and origin. It at least
+lessens the unfavorable effect of worry in exaggerating such
+pathological processes as are at work. All diseases, functional and
+organic, are rendered worse by solicitude, while many troublesome
+symptoms become quite bearable if only the patient does not dwell on
+them too much but takes them as they come, carefully refraining from
+emphasizing them by over-attention. That is the very essence of
+psychotherapy. Religion, in the sense of trust in divine wisdom, can
+do much to originate and maintain this imperturbed frame of mind.
+People who are without religion, that is, without the feeling that
+somehow all their ills are a part of the great plan of the universe,
+the mystery of which is insoluble, but the recognition of which is
+demanded by reason, and who lack the assurance that somehow, in
+Browning's phrase:
+
+  "God's in His Heaven-
+  All's right with the world!"
+
+-- are more prone to give way to over-anxiety and consequently to make
+themselves suffer more in all their ills, than is necessary or even
+likely in the more favorable state of mind of those whose trust in
+Providence is thorough and efficient.
+
+In recent years there has been in the general population a distinct
+loss of faith in the great religious truths that are so helpful in
+engendering a peaceful state of mind in suffering. Many have come, if
+not to doubt of the Providence of the Creator, at least to feel that
+we do not know enough about it to place any such supreme dependence on
+it in the trials of life as would make it a source of relief, or at
+least consolation, in suffering. This same spirit of doubt has
+paralyzed faith in the hereafter and in all that trust in it brings,
+to sufferers, of consolation to come for their ills if these are borne
+as becomes rational creatures whose suffering has a purpose, though we
+may not comprehend it. Some people are destined by their physical
+make-up or by accidental conditions to considerable suffering. There
+are many ailments that are incurable and are definitely known to be
+incurable. Some of these entail great suffering of body and even more
+suffering of mind. Such suffering becomes quite unbearable unless the
+patient is of a very stoic disposition, or unless the thought of a
+hereafter in which the sufferings of this life will have a meaning is
+present to console.
+
+{777}
+
+Great scientists in the midst of all our advance in science--one need
+but mention here such men as Lord Kelvin, Clerk Maxwell, Johann
+Müller, Laennec, Pasteur, Claude Bernard, though the number might
+easily be multiplied--have insisted that the existence of a Creator is
+absolutely demanded by what we know of the physical universe. "Science
+demonstrates the existence of a Creator," is Lord Kelvin's expression.
+The existence of a Creator implies, also, the existence of laws made
+by Him, by which His universe is regulated in every detail, nothing
+being left to chance. Chance is indeed only a term which indicates
+that we do not know the causes at work. If somehow the Creator's power
+has been sufficient to bring the manifold things of the universe into
+existence according to a plan in which there is no such interference
+with one another as would cause serious disturbance of the universal
+order around us, then He can be trusted also to care for even the
+minutest details of creation and of human life.
+
+In the gradual disintegration of the religious sense which has come as
+a consequence of certain materialistic tendencies in nineteenth
+century education and science, these religious sources of consolation
+have been shut off from a great many people. They have come to the
+feeling of being portions of a machine that moves hopelessly on,
+somehow, on the old principle, "The mills of the gods grind slow, but
+they grind exceeding fine." The sufferings of humanity then, are, for
+these people, only a portion of a great universe of suffering that is
+constantly going on but for which they can see no reason and no
+purpose. Lucretius's lines which make human sufferings the butt of the
+jokes of the gods who look gleefully on from their Elysian happiness,
+would represent the feelings of these doubters better than any
+religious expression. We have come back in this age, when evolution
+has so much influenced the thought of the time, after the curious
+cyclic fashion in which human thought repeats itself from era to era,
+to the attitude of mind of the old Roman poet who almost singly among
+his contemporaries, had been deeply affected by the same doctrine of
+evolution. The pessimism he was prone to as to the significance of
+human life has become once more the fashion.
+
+Such pessimistic thoughts do not come, as a rule, while people are in
+good health, but they assert themselves with double emphasis in
+moments of trial and suffering. Lucretius himself is said to have
+committed suicide. The result of the diffusion of this materialistic
+pessimism in our time has been a gradual preparation for a revulsion
+of feeling in many minds. One manifestation of this reaction has been
+seen in a form of religion which denies entirely the existence of
+evil. God the Creator is good and therefore there can be no evil in
+His world. Whatever of evil there is, is only due to man's failure to
+see the entirety of things. Evil is an error of mortal mind--only that
+and nothing more. In spite of the manifest absurdity of the underlying
+principle, if people can only be brought to persuade themselves that
+there is no such thing as evil or suffering, then many of their
+discomforts disappear, all of their symptoms grow less and a sense of
+well-being results. It is, indeed, surprising how many even physical
+ills will be relieved by this state of mind if sincerely accepted. It
+is the highest possible tribute to psychotherapy and the curative
+influence of mind over body.
+
+Another phase of this revulsion of feeling has been the institution of
+a church movement that would make sufferers realize once more all the
+{778} consolations there are in religion. The sufferer is brought to a
+renewed lively sense of the presence of the Creator in the universe
+and of His care for His creatures. The great purpose of suffering in
+making people better and stripping them of their meanness and
+selfishness is brought out. Anyone who has ever had called to his
+attention the difference between two brothers, one of whom has been
+chastened by suffering above which he has risen by character
+development, and another who has enjoyed good health and prosperity
+all his life, will realize how much of good suffering means in the
+world. Pain is not in itself an evil, but a warning, and most of the
+trials of life can rather readily be shown to partake of this
+character. A man who can be made to submit himself, then, to the will
+of the Creator and be persuaded to acknowledge that somehow we must
+try to work out our part in the great scheme of things behind which
+the Creator stands, is somewhat like the soldier ready even when tired
+and worn out, to go in on a forlorn hope, because he has confidence
+that he is executing a part of the plan of his general for his
+country's welfare, though he does not know how, and he is quite well
+aware that it is going to cost him much in pain and suffering, and
+perhaps his life.
+
+There is no doubt that an abiding sense of religion does much for
+people in the midst of their ailments and, above all, keeps them from
+developing those symptoms due to nervous worry and solicitude which so
+often are more annoying to the patient than the actual sufferings he
+or she may have to bear. While religion is often said to predispose to
+certain mental troubles, it is now well appreciated by psychiatrists
+that it is not religion that has the tendency to disturb the mind, but
+a disequilibrated mind has a tendency to exaggerate out of all reason
+its interests in anything that it takes up seriously. Whether the
+object of the attention be business, or pleasure, or sexuality, or
+religion, the unbalanced mind pays too much attention to it, becomes
+too exclusively occupied with it, and this over-indulgence helps to
+form a vicious circle of unfavorable influence. While many people in
+their insanity, then, show exaggerated interest in religion, this is
+only like other exaggerated interests of the disequilibrated, and
+religion itself is not the cause but only a coincidence in the matter.
+
+Clouston, in his book on "Unsoundness of Mind" (Methuen, London,
+1911), put this very well when he said, "It is true that religion,
+touching as it does, in the most intense way the emotional nature, and
+the spiritual instincts of mankind, sometimes appears to cause and is
+often mixed up with insanity. But in nearly all such cases the brain
+of the individual was originally unstable, specially emotional,
+over-sensitive, hyperconscientious, and often somewhat weak in the
+intellectual and inhibitory faculties and, if looked for, other causes
+will usually be found." He had said just before, "To talk of
+'religious insanity' as if it were a definite and definable form is in
+my judgment a mistake."
+
+On the contrary, there is now a growing conviction that a deep
+religious feeling, a sense of dependence on and trust in the Almighty,
+will do more than anything else to keep people from those neurotic
+manifestations which so often are seen in our day and are growing more
+and more frequent as life becomes more strenuous and more attention is
+paid to the material side of things, to the exclusion of the
+spiritual. How true this is may be judged from expressions that have
+been used in recent years by well-known specialists in {779} nervous
+diseases and in psychology. These have included men who were often not
+believers in religion themselves but who recognized its influence for
+good for others. Such expressions are to be found in the writings of
+men of every nationality. Not infrequently, in spite of their own
+religious affiliation, they acknowledge what a profound influence
+certain forms of religion have over people. These testimonies have
+been multiplying in our medical literature in recent years, because
+apparently physicians have come to appreciate much better by contrast
+the influence for good of religion over some of their patients, since
+so many of the sufferers from nervous diseases they see have not this
+source of consolation to recur to.
+
+In America we have a number of such testimonies. In his "Self Help for
+Nervous Women" Dr. John K. Mitchell of Philadelphia, who may be taken
+to represent in this matter the Philadelphia School of Neurologists,
+to which his father has lent such distinction, said:
+
+  It is certainly true that considering as examples two such widely
+  separated forms of religious belief as the Orthodox Jews and the
+  strict Roman Catholics, one does not see as many patients from them
+  as from their numbers might be expected, especially when it is
+  remembered that Jews as a whole are very nervous people and that the
+  Roman Church includes in this country among its members numbers of
+  the most emotional race in the world.
+
+  Of only one sect can I recall no example. It is not in my memory
+  that a professing Quaker ever came into my hands to be treated for
+  nervousness. If the opinion I have already stated so often is
+  correct, namely that want of control of the emotions and the
+  over-expression of the feelings are prime causes of nervousness,
+  then the fact that discipline of the emotions is a lesson early and
+  constantly taught by the Friends, would help to account for the
+  infrequency of this disorder among them and adds emphasis to the
+  belief in such a causation.
+
+Prof. Münsterberg, who may be fairly taken to represent the German
+school, but whose long years of residence in America have made him a
+cosmopolitan, is quite as positive in his declaration of the place
+that religion may hold in making human suffering less. In his
+"Psychotherapy" he devotes considerable attention to the subject. The
+religious discipline, that is, the training of human beings from their
+earliest years to recognize that there is a higher law than their own
+feelings and that they must suppress many of their desires and take
+evil as it comes as a portion of human life, is of itself, he insists,
+an excellent preparation to enable the individual to bear up under the
+physical and mental trials of life and to make many symptoms that
+would otherwise be almost intolerable, quite bearable. It is from
+earliest years that this training must make itself felt, and Prof.
+Münsterberg insists that from early childhood the self-control has to
+be strong and the child has to learn from the beginning to know the
+limits to the gratification of his desires and to abstain from
+reckless self-indulgence. A good conscience, he says, a congenial home
+and a serious purpose, are, after all, the safest conditions for a
+healthy man, and the community does effective work in preventive
+psychotherapy whenever it facilitates the securing of these factors.
+
+Self-denial has always been one of the main elements of religious
+training, and indeed was declared a chief source of merit for the
+hereafter. The modern psychotherapeutist, however, preaches
+self-denial almost as strenuously as the religious minister of the
+olden time, only now not for any religious {780} merit or reward, but
+because it makes life more pleasant and by that much happier. When men
+and women have learned to deny themselves in their younger years, it
+is not hard to stand even pain when they grow older, and pain is
+inevitable in every human life and the training to stand it is
+therefore worth while. Pain borne with equanimity is lessened by
+one-half if not in its intensity then at least in its power to
+disturb, and since religion will do this it possesses an important
+remedial value. Here is where religion is particularly valuable and
+the passing of it from many minds has thrown them back on themselves
+and left them without profound interests, so that they occupy
+themselves overmuch with the trivial incidents of life within them and
+disturb the course of many of their functions by giving exaggerated
+thought to them. Religion adds a great purpose to life and such a
+purpose keeps men and women to a great extent from being disturbed
+about trifles.
+
+Of course, it would be too bad if religion should do no more than
+this. This, however, is the only phase of it with which we are
+concerned here. We may think very strongly with Prof. Münsterberg,
+that it would be quite wrong to assign to it only this place in life.
+He says: "The meaning of religion in life is entirely too deep that it
+should be employed merely for the purpose of lessening the pains and
+aches of humanity and the dreads that are so often more imaginary than
+real." He insists that "It cheapens religion by putting the accent of
+its meaning in life on personal comfort and absence of pain." He adds,
+"If there is one power in life which ought to develop in us a
+conviction that pleasure is not the highest goal and that pain is not
+the worst evil, then it ought to be philosophy and religion."
+Present-day movements, however, tend to subordinate religion to
+this-worldliness rather than to other-worldliness, and by just that
+much they take out of religion its real significance. We are here on
+trial for another world is the thought that in the past strengthened
+men to bear all manner of ills, if not with equanimity, at least
+without exaggerated reaction. It has still the power to do so for all
+those who accept it simply and sincerely.
+
+{781}
+
+INDEX.
+
+
+Abdominal discomfort, 302;
+  from coffee, 306;
+  from tea, 30;
+  from tone factors, 306.
+Abdominal viscera, 176.
+Abernethy, 268.
+Abortion, frequent, 457.
+Abracadabra, 61.
+Absence of occupation, 219.
+Absent treatment, 141.
+Abstraction, 129.
+Academy, French, telepathy and, 147.
+Accidents, telepathy and, 144.
+Aches,
+  filing, 397;
+  occupation, 390;
+  sawing, 397;
+  sweeping, 397;
+  writing, 396.
+Acid, lactic, as a bactericide, 247.
+Acquirements not transmitted, 628.
+Action, integrative, 123.
+Addictions, drug, 707.
+_Adiposus panniculus_, 299.
+Adjuvants, 163.
+Advertising, psychology of, 690.
+Aerophobia, 612.
+AEsculapius, 7.
+Affairs, knowledge of, 177.
+"After dinner sit awhile," 180, 182.
+Afternoon fever, 180.
+After-treatment,
+  of alcoholism, 705;
+  of tuberculosis, drug habits, 705.
+Agassiz's dream, 137.
+Agate, 62.
+Age, fasting and, 298.
+Agoraphobia, 612.
+Agrippa, Cornelius, 15.
+Aichmophobia, 581, 612.
+Ailurophobia, 612.
+Air,
+  appetite and, 268;
+  fresh, comfort and, 356;
+  in dyspepsia, 262;
+  in intestinal rumbling, 284;
+  in intestinal troubles, 284;
+  rather than exercise, 203;
+  swallowing, 284.
+Alchemy, 40, 41, 56.
+Alcohol, 3;
+
+  in pneumonia, 31;
+  in tuberculosis, 30;
+  in vague affections, 31;
+  milk and, 30;
+  night workers and, 175;
+  suggestive influence and, 31.
+
+Alcoholism,
+  after-treatment in, 705, 706;
+  beginning of, 704;
+  confidence in, 704;
+  contagion in, 697;
+  cures of, moral, 395;
+  cures of, old and new, 694;
+  frequent treatment in, 704;
+  heredity in, 698;
+  inherited resistance to, 698;
+  mental influence in, 696;
+  moral influences in, 704;
+  national, 698;
+  occupation pains and, 398;
+  prophylaxis in, 701;
+  real cures of, 395;
+  religion and, 706;
+  sanitarium question in, 702;
+  supposed inheritance of, 697;
+  "sure cures" of, 696;
+  treatment of, 702;
+  tuberculosis and, 703;
+  warnings as suggestions in, 700;
+  youth and, 701.
+Alexander of Hohenlohe, Prince, 75.
+Alexander of Tralles, 13, 61.
+Alexandria, 11.
+Alteratives, 100.
+Ambrosia, 59.
+Amenorrhea,
+  ductless glands and, 439;
+  dread and, 439;
+  fright and, 437;
+  home sickness and, 437;
+  inanition and, 439;
+  mental causes of, 437;
+  mode of living and, 437;
+  reputed remedies for, 440;
+  suggestion in, 440;
+  tuberculosis and, 437.
+Amethyst, 60.
+Amputation stump, pain in, 86.
+Amulets, 15, 60.
+Amusements,
+  diversified, 9 182;
+  mind and, 227.
+Anatomy of melancholy, 61.
+Anemia in Porto Rico, 106.
+Anesthesia, 111;
+  clasped hands in, 757;
+  deep breathing in, 757;
+  fright in, 757;
+  from fixed attention, 755;
+  game for children, 757;
+  hearing during, 758;
+  hypnotic, 754;
+  local, 758;
+  mental diversion in, 757;
+  mind and, 733;
+  occupation and, 754;
+  rapid breathing: in, 755;
+  suggestive, 756;
+  vomiting after, 758.
+Anesthetist,
+  familiarity with, 756;
+  personality of the, 756.
+Anger, brief madness and, 741.
+_Angina pectoris_, 27, 334;
+  Broadbent on, 339;
+  Charcot on, 337;
+  coffee and, 336;
+  false, 338;
+  in woman, 339;
+  neurotic, 338;
+  psychotherapy and, 337;
+  reflected pains in, 335;
+  spurious, 336;
+  tea and, 336;
+  tobacco and, 336;
+  true and false, 336, 339.
+Anicetum, 59.
+Animal emanations, 375;
+  horse and dog, 244.
+Animal hypnosis, 161.
+Animal magnetism, 142;
+  malicious, 142.
+Animal risibile, 105.
+Anise seed in lichen, 251.
+Anthropology, criminal, 744.
+Anodynes, useless, 219.
+Antidotes, suggestion and, 33.
+Antimony, 3;
+  suggestions and, 26.
+Antiochos, 12.
+Antipathies, gastric, 245.
+Apartment hotels, 183.
+Apoplectic habitus, 518.
+Apoplectics,
+  examples encouraging, 521;
+  new associations for, 521;
+  new interests for, 521.
+Apoplexy,
+  Bacchus and, 517;
+  cerebral, 513;
+  change of occupation in, 519;
+  complications in, 523;
+  daughter as nurse in, 520;
+  exciting occupation and, 517;
+  heredity and, 517;
+  hypochondriac, 514;
+  lack of air and exercise in, 519;
+  life-direction in, 519;
+  mind before and after, 514;
+  misplaced sympathy in, 522;
+  neuroses and, 522;
+  nurse, choice of, in, 520;
+  outings and human interests and, 522;
+  precocious, 510;
+  preliminary motor symptoms in, 516;
+  premonitory symptoms in, 514;
+  prognosis in, 520;
+  prophylaxis in, 517;
+  pyramidal tracts and, 524;
+  sympathetic cure of, 520;
+  strokes, number of, in, 523;
+  thinking and, 517;
+  trained nurse in, 520;
+  treatment of, 513;
+  Venus and, 517;
+  Vulcan and, 517.
+Apparatus, brain,
+  insulating, 123;
+  switching, 123.
+Apparitions, explanation of, 607.
+Appearances, wraith-like, 608.
+Appendicitis,
+  chronic, 252;
+  recurrent attacks of, 282;
+  simulant, 587.
+Appetite, 262, 592;
+  air and, 268;
+  emotion and, 264;
+  feeling of, 264;
+  food preparation and, 266;
+  habit and, 265;
+  increase in, 263;
+  increasing, 301;
+  indoor life and, 264;
+  instinct and, 264;
+  in the morning, 266;
+  nervous loss of, 267;
+  will and, 263, 592.
+Appetizer, frequent eating as an, 267.
+Appetizers, 264.
+Application of psychotherapeutic principles, 104.
+Arabian mental medicine, 13.
+Arabian Nights, 12, 46.
+Arch of the foot, yielding of the, 415, 417.
+Areas of pain transfer, 252.
+Argyria, 36.
+Aristides, ancient hypochondriac, 73.
+Aristotle, 10.
+Arm,
+  pitcher's, 397;
+  motorman's, 397.
+Armless men's foot powers, 419.
+Arnold, Matthew, and number 13, 639.
+Arrhythmia, 322;
+  gastro-cardiac, 329;
+  longevity and, 323.
+Arterial sclerosis, diagnosis of, 514.
+Arteries,
+  calcification of, 512;
+  longitudinal degeneration of, 515;
+  premature degeneration of, 518;
+  tortuous, 515.
+Arterio-sclerosis, 512;
+  dizziness in, 515;
+  dread of, 516;
+  over-eating and, 518;
+  stimulants in, 518;
+  tobacco and, 518;
+  vertigo in, 515.
+Artery of cerebral cortex, 125.
+Arthritis,
+  acute, 379;
+  acute progressive, 423;
+  "acute rheumatoid," 422;
+  chronic, course of, 425.
+Arthritis deformans, 421;
+  climate and, 428;
+  chronic, 424;
+  diet and, 427;
+  electricity and, 427;
+  exercise and, 427;
+  in old persons, 426;
+  knitting and, 427;
+  mechano-therapy and, 427;
+  mental attitude and, 426;
+  muscle disturbances in, 424;
+  nerves and, 422;
+  neurotic additions in, 425;
+  occupation of mind in, 428;
+  symmetrical, 422;
+  treatment of, 426;
+  usefulness in, 426;
+  weather and, 428.
+Arthritises, hysterical, 429.
+Arthropathy, nervous, 422.
+Asafetida, 69.
+Association fibers, diversion of, 601.
+Association of ideas, 123.
+Astasia-abasia, 86.
+Asthma,
+  brothers and, 377;
+  cardiac, 364;
+  cat, 374;
+  cigarettes and, 366;
+  climatotherapy and suggestion in, 368;
+  cubebs and, 366;
+  cures for, 366;
+  cyanosis in, 365;
+  drugs and suggestion in, 368;
+  dust and, 369;
+  emphysema in, 365;
+  essential, 364;
+  eye strain and, 367;
+  horse, 376;
+  horse serum and, 377;
+  horse sensitization and, 377;
+  human emanations and, 377;
+  lavage and, 367;
+  mental influence and, 365;
+  mental shock and, 366;
+  mouth breathing and, 367;
+  neurotic, 364;
+  picture of hayfield and, 375;
+  renal, 364;
+  saltpeter paper and, 366;
+  suggestion in, 366;
+  symptomatic, 364;
+  varied cures for, 367.
+Astrology,
+  Hippocrates on, 38;
+  in surgery, 746;
+  reassurance and, 40;
+  suggestion and, 38;
+  venesection and, 746.
+Ataxia,
+  accessory symptoms of, 526;
+  back knee, 524;
+  depression in, 525;
+  emotional, 572;
+  flat-foot and, 524;
+  from emotion, 572;
+  in talking, walking, etc., 571;
+  locomotor, 524;
+  loose joints and, 524;
+  suggestions, favorable and unfavorable, in, 525.
+Athens, psychotherapy in, 8.
+Athletes,
+  pneumonia and, 202;
+  typhoid and, 202.
+Attacks, auto-hypnotic, 541.
+Attention,
+  concentration of, 755;
+  conscious, 129;
+  memory and, 679;
+  process of, 127;
+  power of, 124;
+  Ramon y Cajal's theory of, 126.
+Attitude, mental, 100.
+Attitudes,
+  influence of, 100;
+  of mind, 103.
+Augustine, St., on warnings, 611.
+Authorities on tuberculosis, American, 359.
+Auto-hypnotism, 161.
+Auto-intoxication,
+  intestinal, 172, 270;
+  supposed, 270.
+Automatism, inhibition of, 601.
+Auto-suggestion and the will, 148.
+Avalanche in nerves, law of. 111.
+Avalanche, law of, 585.
+Aversion
+  to cats, 617;
+  to dead bodies, 617.
+Avicenna on mental influence, 14.
+Awake, lying, 667.
+Awaking, mode of, 165.
+Axis cylinders, 112.
+Axon hillock, 114.
+
+
+B
+
+Babies, fat, 292.
+Bacchae, 688.
+Back ache, 174.
+Bacon, as food, 249.
+Bacteria, lactic, 247.
+Ball for constipation, 278.
+Balneo-therapy, 5.
+Barometer, pains and, 382.
+Baseball interest, 228.
+Basedow's disease, 500.
+Basil, Valentine, 9, 26.
+Basophobia, 613.
+Bath,
+  cold, 166;
+  hot, 166;
+  morning, 166.
+Bathing,
+  abuse of, 166;
+  overfrequent, 167.
+Berkeley, Bishop, 57.
+Bernard, St., 74.
+Bernheim, hypnotism and, 159.
+Biliary colic, pseudo, 588.
+Billiards, 180, 182.
+Binet, 153.
+Biographic Clinics, 258.
+Bishop, the mind-reader, 147, 194.
+Bismarck's second eighty years, 724.
+Bismuth, milk of, 285.
+Bladder,
+  emptying the, 470;
+  evacuation of the, position in, 212.
+Blanched fingers, 63.
+Blanching, 190.
+Bleeding, old-time, 381.
+Blind and deaf training, 215.
+Blind,
+  color recognition in the, 214;
+  training of feeling in the, 213.
+Blood,
+  child's not mother's, 462;
+  turning of the, 64.
+Blood letting, patient's mind and, 14.
+Bloodstone, 60.
+Blue glass, 44.
+Blue light, 44.
+"Blues, the," 641.
+"Bluidy Jock," 357.
+Blush, intestinal and vesical, 282.
+Blushing, 190;
+  obsession, 613.
+Body, influence of, on mind, 100.
+Boerhaave, 17, 71.
+Bonaparte, 85.
+Bouchard, 270.
+Bovary, Madame, 243.
+Bowels, over-attention to, 287.
+Bowling, 182.
+Boyle, Sir Robert, 35.
+Bradycardia, 342;
+  case of, 343.
+Brain,
+  anatomy of, 18;
+  capillaries in the, 125;
+  cells of, vital energy of, 131;
+  cells of, number of, 132;
+  cortex of, 109, 117;
+  complexity of the, 109;
+  intellect and, 549;
+  machine, 132;
+  number of cells in the, 110.
+Brain workers, 601.
+Brains, as food, 244.
+Bramwell, Dr. Byron, 374.
+Bramwell, Dr. J. Milne, 160.
+Bread pills, 88.
+Breakfast,
+  a full, 299;
+  before, 168;
+  company at, 170;
+  habits, 169;
+  mail before, 170;
+  newspaper at, 170.
+Bridgeman, Laura, 214.
+Bright's disease,
+  insidious, 558;
+  latent, 558;
+  neurotic symptoms of, 558.
+Bringer of Peace, 7.
+Broadbent, Sir Wm., 319, 326;
+  on angina, 339.
+Brodie, Sir Benjamin, and hysterical joints, 386, 589, 749.
+Bronchi, dilatation of, relief in, 210.
+Bronchiectasis, position in, 210.
+Brontophobia, 612.
+Brown-Séquard, 48, 67.
+Bunion,
+  formation of, 417;
+  gout and, 416.
+Bunions and flatfoot, 416.
+Bursa,
+  housemaids', 399;
+  miners', 399;
+  organ grinders', 399;
+  sitters', 399.
+Bursae, discomforts of, 399.
+Business,
+  anxieties in, 184;
+  habits of, 178;
+  knowledge of, 177;
+  light, air, and position in, 177;
+  walk to, 171;
+  worries in, 185.
+Butter, microbes in, 95.
+Buxom, etymology of, 297.
+
+
+C
+
+Cabanis, 84.
+Cagliostro, 47.
+_Calamus scriptorius_, 12.
+Calculi, preputial, 485.
+Calculus, biliary, simulation of, 282.
+Calmady, Sir Richard, case of maternal impression in fiction, 221.
+Calomel, 3;
+  in pneumonia, 22;
+  suggestion and, 27.
+Campbell Thompson and cuneiform inscriptions, 38.
+Canals, semi-circular, 97.
+Cancer,
+  abdominal, 303;
+  heredity in, 631;
+  latent indigestion and, 255;
+  mind and, 750;
+  nursing tonic in, 222.
+Capillaries, congestion of, 126.
+Card playing, 182.
+Cardiac conditions, diagnosis of, 316.
+Cardiac exercise, 325.
+Cardiac inhibition, 313.
+Cardiac neurosis and prognosis, 321, 322.
+Cardiac palpitation, the intellectual life and, 323.
+Cardiac stomach disturbance, 333.
+Carlsbad, 278.
+Carlyle's Miscellanies, 47, 685.
+Carminatives, 285.
+Carnelian, 62.
+Cassius, lean and hungry, 297.
+Casts, intestinal and tubular, 286.
+Catalepsy, hypnotic, 159.
+Catarrh, 39, 59;
+  seasonal, 368.
+"Catarrh spring," 369.
+Cathay, cycle of, 517.
+Catherine of Siena, 74.
+Cato learning Greek, 680.
+Cats,
+  conjunctivitis and, 375;
+  consciousness of presence of, 618;
+  coryza and, 374;
+  digestion disturbed by presence of, 254;
+  dread of, 374, 617;
+  dread from memory of killing, 375;
+  fear of, and furs, 618;
+  intolerance of, 374;
+  odor of, 619;
+  smell of, 374;
+  urticaria and, 374.
+Cautery,
+  actual, 68;
+  psychotherapeutics and, 408.
+Cells,
+  complexity of brain, 131;
+  Golgi, 131;
+  of the ventral horn, 133;
+  perivascular, 121;
+  pigment, 121;
+  rest, 652;
+  spindle, 112.
+Cerebral artery, control of, 125.
+Cerebration, unconscious, 128, 132, 134.
+Cervical ribs, 400.
+Chair, comfortable, 210.
+Chamois garments, 168.
+Champneys, on painful menstruation, 445.
+Chance, 776.
+Character,
+  and suffering, 222;
+  in therapeutics, 358;
+  upbuilding of, 222.
+Charcot, Dr., 71;
+  on menstrual mental states, 434.
+Charcot crystals, 364.
+Charms for erysipelas, 22, 60.
+Charmides (Plato), 11.
+Cheese, habituation to, 246.
+Chest protectors, 167.
+Chesterfield, Lord, 225.
+Chesterton, on suicide, 722.
+Chestnuts, horse, for rheumatism, 385.
+Chewing in tuberculosis, 355.
+Cheyne, Dr., 314.
+Child,
+  diversion of the, 228;
+  first years of the, 230;
+  recreation of the, 228.
+Childbirth,
+  dangers of, 458;
+  natural, 458;
+  over-zeal to help in, 458.
+Children,
+  care of, 221;
+  fat, 267;
+  increase of suicide among, 721.
+Chilliness, 773.
+Chloral in hypnotism, 156.
+Chorea,
+  anemia and, 562;
+  endocarditis and, 562;
+  etiology of, 561;
+  expectant treatment of, 563;
+  colds and, 562;
+  consciousness in, 562;
+  cures of, 562;
+  fright in, 562;
+  growing pains and, 562;
+  pathology of, 562;
+  prophylaxis in, 563;
+  pure neurosis and, 561;
+  simple life and, 564;
+  subsequent habit after, 563;
+  treatment of, 562.
+Cicero, 189.
+Circle, vicious, 51, 251.
+Circulation, favoring return of, 208.
+Cirrhosis, alcoholic, 175.
+Civil War, Reports of, 286.
+Clairvoyant, 147.
+Claude, Bernard, 20, 313.
+Claudication, intermittent, 512.
+Claustrophobia, 612, 616.
+Clavus _hystericus_, 547.
+Clergyman's knee, 411;
+  sore throat, 411.
+Clinics, biographic, 601.
+Clitoris, removal of, 488.
+Clothing, 167;
+  warm, 356.
+Clouston, 191;
+  on religion, 777.
+Coccydynia, 428.
+Coccygodynia, 68;
+  causes of, 428;
+  hysterical, 429;
+  labor and, 428;
+  neurotic, 429;
+  over-attention to, 429.
+Coffee and abdominal distress, 307.
+Cohnheim, 251.
+Coincidences, 144;
+  telepathy and, 146.
+Colds,
+  fat and, 298;
+  fresh, 350;
+  fresh air and, 350;
+  more sleep and, 350;
+  night air and, 350;
+  quinine and whiskey for, 349;
+  rational treatment of, 349;
+  settled on lungs, 358;
+  taking, 167.
+Colitis,
+  cures for, 288;
+  excess of salt in, 284;
+  in Civil War, 286;
+  increase of, 287;
+  muco-membranous, 286, 288;
+  resorts, 289;
+  suggestion in, 288;
+  surgery for, 288.
+Colles' Law, 630.
+Color blindness, 771.
+Columbus, 42.
+Comedy, musical, 227.
+Comfort, mental and physical, 761.
+Compensation, 213.
+Concussion of the brain, 118.
+Conditions, mechanical, in pains, 174.
+Confession in sex habits, 486.
+Confidence, 15;
+  of the patient, 14;
+  of the physician, 4.
+Conjunctivitis, cat, 375.
+Constipation, 268;
+  exercise in, 276;
+  fats and sugars in, 276;
+  in obesity, 296;
+  in the stout, 278;
+  oriental, 271;
+  position in, 276;
+  prophylaxis in, 269;
+  reassurance in, 271;
+  tolerance in, 272.
+Contagion,
+  coughing and, 688;
+  expectoration and, 688;
+  fashion and, 691;
+  favorable mental, 692;
+  giggling, 688;
+  health, 692;
+  laughing, 688;
+  moving pictures and, 693;
+  murder, 691;
+  not heredity, 298;
+  psychic, 688;
+  sighing, 688;
+  suicide, 691;
+  yawning, 688.
+Contagious trifles, 688.
+Co-ordination in the organism, 132.
+Copenhagen, Perkins in, 49.
+Copremia, supposed, 270.
+Cornelius Agrippa, 15.
+Corns, soft, 418.
+Corpulency, 290.
+Cortex,
+  diagram of, 113;
+  pyramidal cell in the, 122;
+  visual, 110.
+Coryza,
+  cat, 375;
+  vaso-motoria periodica, 369;
+  yearly, 372.
+Cough,
+  as tic, 348;
+  habit, 347;
+  hemorrhage and, 346;
+  intestinal, 348;
+  in tuberculosis, 348;
+  irrational, 349;
+  mental control of, 361;
+  ordinary, 345;
+  ovarian, 348;
+  reflex, 347;
+  remedies for, 345, 349;
+  stomach, 348;
+  stopping a, 210;
+  suggestion and, 345;
+  unproductive, 345;
+  uterine, 348.
+Coughing, control of, 361.
+Counter irritation in nervous disease, 511.
+Courting and telepathy, 143.
+Coventry Patmore, Mrs., 144.
+Coxalgia, hysterical, 429.
+Cramp rings, 61, 80.
+Cranberries in erysipelas, 22.
+Creator, existence of, 776.
+Crises,
+  gastric, 526;
+  intestinal, 526;
+  tabetic, 526.
+Critias, 11.
+Cromwell, 81.
+Crooke's theory of telepathy, 142.
+Croup, nervous, 669.
+Cure-alls, 3.
+Cure
+  houses, 10;
+  magnetic, 55;
+  relieve, console, 186;
+  smiling and laughing, 104.
+Cured cases as evidence, 52, 60.
+Cures, 50;
+  faith, 78;
+  for colitis, 288;
+  for tuberculosis, 351;
+  hayfever, 373;
+  supposed, 51, 387.
+Curschmann's spirals, 364.
+Cutten, on faith cures, 81.
+Czermak, Prof., on inhibition, 313.
+
+
+D
+
+Dalton, color blind, 772.
+Dangers of hypnotism, 161;
+  Dr. J. K. Mitchell on, 161.
+Darkness,
+  dread of, 620, 668;
+  Romilly and, 621;
+  Rousseau and, 620.
+Dawdling, 182.
+Dead bodies, aversion to, 617.
+Deaf, training of the, 215.
+Death,
+  AEschylus on, 622;
+  After, What? 88;
+  attitude toward, 730;
+  captain of, 350;
+  dread of, 621;
+  fear of early, 622;
+  impending, 336;
+  life and, 89;
+  mind and, 90;
+  moment of, 147;
+  premonition of, 636;
+  put off, 91;
+  socially, 731;
+  Sophocles on, 622.
+Defectives, sexual, 474.
+Deformities,
+  coincidences and, 464;
+  etiology of, 466;
+  falls and, 467;
+  missteps and, 467.
+Degeneration, stigmata of, 744.
+Delusions, 603.
+_Dementia praecox_ and paresis, 532.
+Dendrites, 112.
+Dentist's limp, 398.
+Depression and disease, 641;
+  and diversion, 643;
+  and dyspepsia, 233;
+  and hobbies, 646;
+  and indigestion, 233;
+  an incident, 650;
+  benefits of, 650;
+  care of ailing a cure for, 645;
+  care of animals a cure for, 645:
+  care of plants a cure for, 645;
+  feminine, and children, 644;
+  frequency of, 647;
+  garden cures for, 646;
+  heart disease and, 642;
+  historical examples of, 647;
+  insomnia and, 644;
+  Lord Lytton and, 648
+  Lowell, James Russell, and, 648
+  nephritis and, 642;
+  periodical, 641
+  reading in, 646.
+De Puysegur's instruction in hypnotism, 154.
+Dermatotherapy, the mind in, 495.
+Descartes, 41.
+Desks, comfortable, standing, 176.
+Determinism, 744.
+Deterrent materials and suggestions, 34.
+Deterrent taste and smell, 68.
+Deterrent therapeutics, 63.
+Diabetes
+  acidosis, 500;
+  air and exercise in, 499;
+  causes of, 496;
+  danger of over-treatment in, 497;
+  eczema in, 496;
+  frequent in obese, 294;
+  general condition in, 497;
+  incurable, 496;
+  interval treatment of, 498;
+  oatmeal and, 498;
+  over-treatment of, 497;
+  pancreatic changes in, 496;
+  physician and patient's, 497;
+  potatoes and, 498;
+  rigid diet and solicitude in, 499;
+  secondary symptoms of, 497;
+  individual, the, and, 498;
+  unfavorable suggestion, 496.
+Diagnosis, announcing the, 354.
+Diancecht, Irish physician, 58.
+Diaphragm,
+  excursions of the, 362;
+  movements of the, 362.
+Diarrhea,
+  emotional, 283;
+  fright and, 279;
+  habitual, 280;
+  nervous, 558;
+  nervous, and urticaria, 281;
+  neurotic, 279;
+  worry and, 280.
+Diathesis, uric acid, 380.
+Diet,
+  _do not_, 257;
+  dyspepsia and, 256;
+  fads, 171;
+  limitation of, 275;
+  mixed, 275;
+  restrained, 298;
+  rules, harmful, in, 256;
+  tinkering, 380.
+Diffusion, laws of, 132.
+Digby, Sir Kenelm, 56.
+Digestion,
+  brain workers and, 258;
+  chemistry and, 242;
+  contrary suggestions and, 251;
+  disgust and, 243;
+  influence of mind upon, 242;
+  mental changes and, 247;
+  of cat, disturbed, 254;
+  prejudices and, 242;
+  study and, 253;
+  worries and, 253.
+Digitalis and mental influence, 313.
+Directions to physicians, suggestion and, 197.
+Disappearances, 608.
+Disappointments, mental states of, 643.
+Discipline, of mind, 196; of self, 223.
+Discomfort,
+  digestion and, 253;
+  with eating, 301.
+Discontinuity of the nervous system, 118.
+Discoveries, scientific, 46.
+Discovery, supposedly wonderful, 192.
+Disease,
+  American, 380;
+  incurable, 186;
+  individual, 224;
+  patients and, 163;
+  suggestion of, 94; thinking, 99.
+Disease suggestions, 250.
+Diseases of ductless glands, 496.
+Dislocations, after-effects of, 388.
+Disposition,
+  suggestion and, 101;
+  dual, 150.
+Distension, 332.
+Disuse, atrophy and pain, 394.
+Diversion, 182;
+  children's, 228;
+  from pain, 225;
+  of mind, 9;
+  true, 224.
+Divinity, medical, 7.
+Doctor, "conjure," 64.
+Dog and hog, 243.
+Dominant ideas, 750.
+Donne, Dr., 37.
+Doubting, 732;
+  daily review in, 738;
+  habit, 733;
+  marriage and, 735;
+  opening letters and, 735;
+  ordination and, 735;
+  outdoor air and, 738;
+  prophylaxis in, 737.
+Doubts,
+  Hamlet's, 735;
+  program for day in, 738.
+Dread, 2, 612, 613;
+  habit of control of, 615;
+  mental discipline in, 615:
+  of arterio-sclerosis, 515;
+  of death, 621;
+  of dirt, 615;
+  of heights, 614;
+  of indigestion, 306;
+  of insanity, 623;
+  of small heights, 615;
+  of the dark. 620;
+  of water, 621;
+  physical basis of, 614;
+  subconscious, 625.
+Dreads,
+  heredity and, 626;
+  men of genius and, 623.
+Dreaming,
+  "all the night long," 673;
+  by day, 671;
+  constant, Hazlitt, Mitchell and Owen, 672;
+  Laughing, Blushing and, 607, 672.
+Dreams, 8, 78, 669;
+  and children, 678;
+  and digestion, 100;
+  and fright, 677;
+  and reading, 678;
+  and sensations, 575;
+  art in, 136;
+  children's, 677;
+  erotic, 479;
+  frequency of, 671;
+  insufficient clothing in, 671;
+  life and, 136;
+  mathematical, 136;
+  mercy's, 136;
+  of falling, 670;
+  out of breath, 671;
+  poems and, 136;
+  prophecy fails, 676;
+  prophetic, 675;
+  rearrangement in, 635;
+  short duration of, 673;
+  significance of, 674;
+  suggestions and, 678;
+  telepathic, 674;
+  therapy and, 669.
+Drug addictions, 707.
+Drug habit,
+  after-cures for, 712;
+  confidence in, 711;
+  cures for, 709;
+  curiosity and, 708;
+  early treatment in, 710;
+  forming, 290;
+  heredity and, 712;
+  individual, 707;
+  over-confidence in, 709;
+  pleasant, 708;
+  prophylaxis in, 708;
+  relapses in, 709;
+  sanitarium question and, 710.
+Drugs, 8;
+  effects of, imaginary, 88;
+  in sufficient doses, 4.
+Drunkenness, 117.
+Dualism of disposition, 151.
+Dumas, 47.
+Dumb-bell, a parody of exercise, 204.
+Dundrearyisms, 464.
+Dupré, Giovanni, 136.
+Dupuytren's slap for anesthesia, 754.
+Dust and disease, 172.
+Duval and neurons, 114.
+Dwarf of French king, 314.
+Dysmenorrhea,
+  constipation in, 442
+  cystic ovaries in, 446;
+  extragenital 445;
+  extrapelvic organs in, 442
+  fisherwomen and, 444;
+  individual 446;
+  lack of occupation in, 443
+  membranous, 445;
+  minor lesions in, 446;
+  moral fiber and, 443;
+  operation idea and, 443;
+  running down and, 442;
+  spasmodic, 445;
+  suggestion and, 445.
+Dyspepsia, 301;
+  abdominal muscles and, 261;
+  air and, 262;
+  American, 179;
+  depression and, 233;
+  from diet regulation, 256;
+  mental work and, 253;
+  sleep and, 262;
+  state of mind in, 250.
+Dyspeptics,
+  exercise for, 261;
+  longevity of, 259.
+
+
+E
+
+Eat, the will to, 263.
+Eating,
+  dread of, 264;
+  enough, 299;
+  more, 301;
+  slow, 231;
+  uncomfortable feelings after, 263.
+Eddyism, 60, 386.
+Edema, angio-neurotic, 283.
+Education and discipline, 196.
+Efficiency experts, 179.
+Eggs,
+  biliousness and, 246;
+  idiosyncrasy for, 245;
+  persuasion as to, 248;
+  repugnance to, 246.
+Egypt, psychotherapy in, 8.
+Electric belts, 62.
+Electric insoles, 63.
+Electrical contrivances, 43.
+Electricity, 5.
+Electro-therapy, 5;
+  suggestion and, 42, 43.
+Elijah returned, 82.
+Elixir of life, 44.
+Embryo-complexity, 466.
+Emissions,
+  seminal, alcohol and, 478;
+  constipation and, 478;
+  full bladder and, 478;
+  nocturnal, 477;
+  prophylaxis in, 478;
+  spices and, 478.
+Emotion, heart and, 311.
+Emotions as remedies, 17.
+Encyclopedia Brittanica on mummifies, 64.
+Energy, reserve, 108;
+  law of, 92.
+English, Dr. Thomas Dunn, on life, 724.
+Environment, favorable, 188.
+Epidaurus, 8.
+Epidemic, suicidal, 691.
+Epilepsy, 15;
+  anise seed for, 25;
+  attitude of mind in, 537;
+  Byron and, 536;
+  Caesar and, 536;
+  colony system and, 535;
+  cures for, 537;
+  dread of insanity in, 535;
+  emotion and, 535;
+  fright and, 535;
+  individual in, 536;
+  influence of suggestion in, 535;
+  mental "cures" of, 541;
+  Mohamed, 536;
+  Napoleon, 536;
+  neurotic simulation of, 536;
+  occupation in, 537;
+  operations for, 505, 535;
+  quiet life and, 537;
+  rings in, 61;
+  royal touch and, 79;
+  suggestion in, 25.
+Equilibrium,
+  training in, 215;
+  unstable intestinal, 286.
+Erasistratos, 11.
+Erotic, 480.
+Erysipelas, 3, 21.
+Erythrophobia, 613.
+Esophageal stricture, 676;
+  neurotic, 574.
+Esophagus, constriction of the, 575.
+Esquirol, on child suicide, 721.
+Ether in telepathy, 142.
+Euripides, 688.
+Evacuation,
+  habitual, 273;
+  simulated, 285.
+Evil, denial of, 776.
+Evolution, Lucretius and, 776.
+Excrement, goose and chicken, 34.
+Excretions as remedies, 66.
+Exercise, 198;
+  air and, 203;
+  for heart irregularity, 327;
+  for sake of exercise, 204-7;
+  fun and, 203;
+  graduated, for heart, 328;
+  in dyspepsia, 261;
+  in early years--English and German customs, 199;
+  interest and, 203;
+  mental diversion and, 207;
+  regulation of, 202;
+  sport and, 203;
+  sufficient, 199;
+  treatment for heart and, 328.
+Exhaustion, mental, 138.
+Exhibitionism, 490.
+Exosmosis, 132.
+Expectancy, mental, 46.
+Expectoration, difficulty in, 210.
+Expert in health, 179.
+Expression and feeling, 101.
+Extensors and hate, 194.
+Extra-systole,
+  big beat and, 333;
+  conscious, 333;
+  long-pause, 333;
+  prognosis in, 333.
+Eye,
+  oblique muscles of, 102;
+  superior recti of, 102.
+
+
+F
+
+Fabricius Hildanus, 54.
+Facial expression and feeling, 101.
+Faddists, fruit, milk-product and nut, 258.
+Fads,
+  bathing, 167;
+  harmful, 166;
+  health and, 689.
+Faith, 14, 15;
+  cures by, 61;
+  healing and, 196;
+  power of, 196.
+Familiarity with drugs, 4.
+_Fascia dentata neuroglia_, 120.
+Fashion contagion, 690.
+Fasting ages, 298.
+Fat,
+  anemic, 298;
+  in sick hogs, 303;
+  lack of, 298;
+  useless, 201.
+Father John of Cronstadt, 75.
+Fats in constipation, 276.
+Fatty vicious circle, 292.
+Fearing the worst, 98.
+Feeling, expression and, 101;
+  occupation and, 129.
+Feelings, transferred, 251.
+Feet above heart, 173.
+Femero-coxalgia, 68.
+Feré, 153.
+Ferrier, Chancellor, 323.
+Fever, afternoon, 180;
+  typhoid, 3.
+Filaments, terminal, 117.
+Fish, coloration practice in, 494.
+Fissure, calcarine, 110.
+Flammarion, 607.
+Flashes of heat, 773.
+Flatfoot, 174, 383;
+  circulation in, 419;
+  prevention of, 419;
+  relief for, 209;
+  runs in families, 390;
+  secondary consequences of, 420;
+  sprains and, 420.
+Flatulence, 332.
+Flaubert, 243.
+Fletcher, 231.
+Flexors and liking, 194.
+Flourens, 543.
+Fluid,
+  daily, 274;
+  ingestion of, 274;
+  in obesity, 296.
+Folin, 231.
+Food,
+  amount of, 273;
+  angle worms as, 244;
+  brains, liver and spleen as, 244;
+  caprice and, 266;
+  chewing, 260;
+  craving for, after operation, 763;
+  custom and, 244;
+  dislikes for, 245;
+  dyspepsia and, 301;
+  elimination of, 250;
+  idiosyncrasies and, 282, 301;
+  increase in, 273, 301;
+  natural residue of, 275;
+  preparation of, appetite and, 266;
+  reduction of, 296;
+  sleep and, 207;
+  temptations to, 293;
+  values and habits, 263.
+Food faddists, 258.
+Foot,
+  exercise for the, 420;
+  noises with the, 419.
+Foot troubles,
+  deformities in all classes, 413;
+  mechanical factors in, 413;
+  rarer, 418;
+  significance of, 421;
+  unfavorable suggestions and, 415.
+Force, vital, 133.
+Ford Robertson, 110.
+Forel, Prof., 190, 706.
+Foreskin, long, 484.
+Forgetfulness, limits of normal, 683.
+Formulas, word, 566.
+Fox hunting, 205.
+Fractures,
+  after-effects of, 388;
+  immobilized, 388;
+  manipulation of, 388;
+  massage of, 388;
+  mind and, 751;
+  of the clavicle, 89.
+Francis of Assisi, St., 74.
+Francis Xavier, St., 74.
+Frankenstein, 626.
+Free will, 148, 152, 739;
+  argument for, 739;
+  individual, 741.
+Frenkel's method for tabes, 528.
+Frenkel's treatment, origin of, 528.
+Frere, Robert 36.
+Freud, 595.
+Friedländer on quackery at Rome, 58.
+Fright,
+  epilepsy and, 535;
+  heart and, 315;
+  in chorea, 562;
+  in Graves' disease, 500;
+  in paralysis agitans, 542;
+  loss of bowel control and, 279;
+  tremors from, 581;
+  white hair and, 494.
+Frights, forgotten, 625.
+Fumigation, 60.
+Fun and health, 203.
+
+
+G
+
+Galen, 12;
+  on proprietaries, 59.
+Galen's theriac, 20, 46, 51, 59, 71.
+Gallstones, 80.
+Galton, Sir Francis, 36, 601, 606.
+Galvani, 43.
+Gambling, 182.
+Garments, chamois, 168.
+Gas, 15.
+Gassner, 15, 153.
+Gastralgia, tabetic, 526.
+Gastric crisis, 526, 586.
+Gastric dilatation, 330.
+Gastric fauna, 462.
+Gastric motility, 176, 307.
+Gastric muscular tone, 262.
+Gastric reflexes, 251.
+Gastric secretion neuroses, 586.
+Gastric self digestion, 303.
+Gastric sensations, 306.
+Generalization of visceral pain, 252.
+Genitalia, over-attention to the, 430.
+Genius, De Musset, 624;
+  Goethe, 624;
+  idiosyncrasies and, 245;
+  investigating, 130;
+  Kingsley, 624;
+  Montaigne, 624.
+George Eliot, 135, 141.
+Gerhardt, Prof., 317.
+Ghosts, 605.
+Gilbert, 42.
+Gilles de la Tourette on tics, 564.
+Ginseng, 35.
+Giving up, 93.
+Gladstone, 225.
+Gladstone's chewing, 231.
+Glands, intestinal, over-action of, 288.
+Glycosuria,
+  alimentary, 496;
+  psychological, 291;
+  neurotic, 496.
+Goclenius, 55.
+Gold, chloride of, 61.
+Goldsmith, 223.
+Golgi, 110, 131.
+Gordon Holmes, 151.
+Gordy, Prof. J. P., 230.
+Gould, Dr. George, 258, 601.
+Gout and flatfoot, 415, 416;
+  rheumatic, 421.
+Gowers, Sir William, 556.
+Gowers' rule in writing, 396.
+Grahamism, 256.
+Grass scorpion, 35.
+Grasset, 597.
+Graves' disease,
+  cures of, 504;
+  diagnosis of, 502;
+  diarrhea and, 501;
+  diet and, 506;
+  diversion and, 506;
+  emaciation and, 501;
+  emotion and, 500;
+  etiology of, 500;
+  _formes frustes_ 500, 502;
+  fright and, 500;
+  genital incidents and, 501;
+  larval forms of, 341;
+  menopause and, 502;
+  mummy and, 504;
+  operations for, 505;
+  parathyroid and, 504;
+  prognosis in, 502;
+  responsibility and, 500;
+  serums and, 504;
+  sex incidents and, 501;
+  sleep and, 506;
+  snake skin and, 504;
+  suggestion and, 504;
+  sympathetic, 502;
+  symptomatology of, 501;
+  thyroid in, 469, 504;
+  thymus in, 469, 503;
+  touch of hanged in, 504;
+  women and, 501.
+Gravitation, 41.
+Greatrakes, 81, 153, 386.
+Greece, decadence in, 107.
+Grief,
+  Astley Cooper and, 731;
+  consolation in, 729;
+  Lord Lytton and, 731;
+  melancholia and, 727;
+  motives of consolation in, 728;
+  pathological, 727;
+  physical conditions in, 726;
+  prophylaxis in, 728;
+  Rossetti and, 732.
+Grouch, perennial, 233.
+Gymnasium director, 206.
+Gymnastics, 181, 203.
+Gynecology,
+  dominant ideas in, 432;
+  functional diseases in, 456;
+  mental factors in, 433;
+  mental healing in, 430;
+  reputed remedies in, 431;
+  self-control and, 433;
+  suggested factors in, 431.
+
+
+H
+
+Habit, 125;
+  appetite and, 265;
+  business occupation and, 178;
+  following chorea, 563;
+  formation of, 229;
+  in constipation, 273;
+  is second nature, 229;
+  non-inheritance of, 632;
+  saves reflection, 235.
+Habits,
+  air and exercise, change of, 232;
+  bolting, 231;
+  law of, 230;
+  mental, 233;
+  physical, 231;
+  sexual, 482.
+Hack Tuke, Dr., 190;
+  on warts, 493.
+"Hacks," 361.
+Hahnemann, 41.
+Haldane, Prof., 132.
+Hallucinations, 78, 141, 603, 773;
+  auditory, 609, 773;
+  cocaine, 773;
+  disturbing, 611;
+  dreams and, 606;
+  explanation of, 607;
+  frequency of, 604;
+  insanity and, 609;
+  significance of, 604;
+  statistics of, 605;
+  telepathic, 605;
+  touch, 773;
+  visual, 604.
+Head,
+  discomfort in, local, 552;
+  over-attention to the, 547;
+  raising the, 210.
+Headache, 59;
+  air and, 554;
+  anemic, 553;
+  at Epidaurus, 554;
+  attention, 547;
+  coffee and, 553;
+  congestion, 549, 551;
+  cures for, 546;
+  direct mental treatment of, 553;
+  distraction and, 548;
+  drugs and, 553;
+  exercise and, 554;
+  extraneous, 550;
+  eye strain and, 550;
+  fear of brain lesion and, 549;
+  frequency of, 546;
+  lack of distraction and, 548;
+  local conditions and, 550;
+  loss of meal and, 551;
+  mental treatment for, place of, 554;
+  mental work and, 550;
+  occipital, 552;
+  occupation of mind and, 546;
+  sense of pressure in, 547;
+  source of pain in, 549;
+  spirits and, 553;
+  tea and, 553;
+  tenderness and, 552;
+  weight and, 553.
+Head's studies in sensation, 252.
+Healers of the nineteenth century, 81.
+Healing, irregular mental, 209.
+Health,
+  central nervous system and, 191;
+  good, and happiness, 234;
+  muscle development and, 200;
+  thinking, 99.
+Health resort, 184.
+Hearing, training of the, 686.
+Heart,
+  action of, after dancing, 324;
+  action of, after Marathon, 324;
+  action of, irregularity of, 322, 323;
+  anxiety about the, 311;
+  arrhythmia of the, 322;
+  athletes', 324;
+  coffee and the, 329;
+  crowding of the, 323;
+  cures, faith, and the, 312;
+  defects of the, and quiet lives, 316;
+  difficulties of the, 319;
+  emotion and old physiology of, 311;
+  fatty, and exercise, 326;
+  fright and the, 315;
+  functional affections of the, 321;
+  gastric influence on the, 334;
+  general condition and the, 318;
+  German and Irish schools on the, 318;
+  Indian fakirs and the, 311;
+  in difficulties, 322;
+  individual and the, 317;
+  inhibition of action of the, 313;
+  introspection and the, 327;
+  irregularity of, not to be treated, 327;
+  irritable, 324;
+  limitation of  diet and the, 335;
+  listening to the, 317;
+  meat-eating and the, 335;
+  mental influence on the, 310;
+  missed beats of the, 322;
+  muscular, 322;
+  nervous, Morgagni and Lancisi on, 331;
+  nervous system and the, 311;
+  occupation of mind and the, 320;
+  palpitation of the, 322;
+  physiological work for the, 326;
+  reassurance and the, 334;
+  remedies and suggestion and the, 312;
+  shock and the, 314;
+  sorrow and the, 315;
+  sounds, impure, in the, 324;
+  stimulants and the, 326;
+  stomach distension upward, effect of, upon the, 330;
+  stomach gas and the, 329;
+  suffering and the, 332;
+  surveillance over the, 322;
+  sympathetic, 319;
+  taking, 312;
+  tea and the, 329;
+  therapy of the, psychic factors in, 315;
+  tobacco and the, 329;
+  training, 216, 326;
+  trouble of the, consciousness of, 312;
+  vaso-motors and the, 319;
+  voluntary inhibition of action of the, 314.
+Heart disease,
+  consumption and, 321;
+  declaration of, 321;
+  diagnosis in latent, 316;
+  exaggeration of seriousness in, 317;
+  mental influence and, 311;
+  prognosis in, 315, 316, 332;
+  prophylaxis in, 315;
+  symptoms of, in the young, 321;
+  symptoms of, neglect of, 320;
+  symptoms of, simulated, 319;
+  symptoms of, subjective, 321.
+Heart failure, 334, 341.
+Heart murmurs,
+  significance of, 317;
+  uncertainty of, 318.
+
+Heberden's nodes,
+  causes of, 422;
+  longevity and, 423;
+  progress of, 423;
+  solicitude over, 423.
+Heels, high, 410.
+Hell, Father, mental influence practised by, 153.
+Hemorrhage,
+  cough and, 346;
+  mind and, 360.
+Hen hypnotization, 160.
+Herbal medicine and mental influence, 140.
+Hereditary resistance, 712.
+Hereditary syphilis, 629.
+Hereditary tuberculosis, 629.
+Heredity, alcoholism and, 629;
+  disease and, 628;
+  drug habits and, 712;
+  false impressions concerning, 627;
+  habits and, 632;
+  Hapsburg lip, instance of, 632;
+  mystery of, 633;
+  resistance and, 352;
+  principles of, 699;
+  suggestion and, 251;
+  tuberculosis and, 628;
+  variation and, 633.
+Hermaphrodites, partial, 489.
+Hermaphroditism, mental, 490.
+Herophilus, 11.
+Herpes and mind, 492.
+Hertz, Arthur, 270.
+_Hexenschuss_, 391.
+Hildanus, 54.
+Hilprecht's sleep vision, 137.
+Hilton on Rest and Pain, 52, 188.
+Hippocrates, 10, 71;
+  on astrology, 38.
+Hives and diarrhea, 281.
+Hobbies, 224;
+  Virchow on, 226.
+Hobby, 601.
+Hog's meat, 243.
+Holmes, Oliver Wendell, 4, 48, 50, 54, 56, 311.
+Home work, 182.
+Homo-sexuality, 490.
+Hook-worm,
+  in Egypt, 107;
+  in Porto Rico, 107;
+  in the South, 107.
+Hope, renewal of, 91.
+Horace, 223.
+Horseback riding, 204.
+Horse, outside of a, the, 204.
+Hospitals,
+  mind and, 747;
+  psychic conditions of, 760.
+Hours of diversion, 182.
+Hudson, 251.
+Humor, 105.
+Hunger and sleep, 665.
+Hunter, John, 17.
+Hunyadi Janos, 278.
+Hydrophobia, 613.
+Hydrotherapy, 5.
+Hygiene, personal, 178.
+_Hyperemesis gravidarum_, 457;
+  postanesthetic, 758.
+Hypersecretion, gastric, 586.
+Hypnoidal state, 198, 626.
+Hypnosis, anesthetic, 755;
+  animal, 160;
+  of self, 161.
+Hypnotism,
+  accessories in, 155;
+  Danger and Uses of, 162;
+  drugs in, 156;
+  effects of, 152;
+  essence of, 152;
+  explanation of, 118;
+  for exhibitions, 162;
+  influence of, 76, 111;
+  in obstetrics, 458;
+  lights in, 155;
+  miracles of, 152;
+  mystery of, 151;
+  not mysterious, 158;
+  practice of, 156;
+  sensations of, 156;
+  sound in, 156;
+  stroking in, 156;
+  susceptibility to, 159;
+  three stages of, 158;
+  valuation of, 152;
+  uses of, 162.
+Hypnotizers,
+  Bernheim, 154;
+  Braid, 154;
+  De Puysegur, 154;
+  Liebault, 154;
+  Mesmer, 154.
+Hypochondria, 287.
+Hypochondriac, 94;
+  sympathy with the, 335.
+Hypochondriac organs, 335.
+Hypochondriorum, _ex consensu_, 331.
+Hypothesis,
+  Duval's, for brain mechanism, 123;
+  Ramon y Cajal's, for brain mechanism, 127;
+  for sympathetic system, 127.
+Hysteria, 80, 585, 590;
+  dual personality and, 149;
+  organic change and, 190;
+  secondary personality and, 149.
+Hysterical cutaneous conditions, 495.
+Hystero-epilepsy, 538, 626.
+
+
+I
+
+Idea,
+  single, 195;
+  tends to action, 194.
+Ideas,
+  dominant, 97, 239;
+  body and, 195.
+Idiosyncrasies,
+  food, 282;
+  genuine food, 245;
+  individual and heat, 329;
+  intestinal, 282;
+  physiological, 231.
+I-Em-Hetep, 7, 71.
+Ignatius Loyola, St., 102.
+Ills,
+  imaginary, 191;
+  not fancied, 191.
+Illusions, 603, 764;
+  delusions, hallucinations and, 773;
+  in connection with dots, 776;
+  in connection with a tube, 764;
+  of distance, 769;
+  of  size, 769, 770;
+  of the sun and moon, 768;
+  optical, 770;
+  universal, 764.
+Image, wax, and distant effects, 141.
+Imaginary ills, 191.
+Imagination, 14, 15.
+Immunity,
+  acquired, 358;
+  inborn, 358;
+  lack of, 108;
+  maternal, in syphilis, 629;
+  of nursling, 461.
+Impedimenta, 201.
+Impotence,
+  organic, 476;
+  psychic, 475.
+Impotency obsession, 476.
+Impressions, mental, 346.
+Incisions and suggestion, 752.
+Incubation, 554, 669.
+Incurable, care of the, 223.
+Incurable disease, relieving, 510.
+Incurability, so-called, 48.
+Indigestion,
+  above the neck, 257;
+  auto-suggestive, 250;
+  cancer, latent, and, 255;
+  correction of, 259;
+  depression and, 233;
+  differentiation of, 254;
+  diversion of mind and, 258;
+  dread of, 305, 306;
+  early tuberculosis and, 255;
+  lack of sleep and, 254;
+  neurotic, 169;
+  prevention of, 259;
+  unfavorable states of mind and, 250.
+Individuality, 133.
+Individuals, human, 224.
+Infections, mental, 753.
+Influence,
+  malign, 141;
+  of the mind, 2, 84;
+  of the stars, 39;
+  telepathic, 141.
+Inheritance of defects, 632.
+Inhibition, 46;
+  cardiac, 313;
+  menstrual, lack of, 434;
+  nervous, 87.
+Injuries,
+  old and painful, 387;
+  unconscious, 85.
+Insane, cunning of the, 743.
+Insanity,
+  dread of, 623;
+  genius and, 536;
+  hallucinations in, 609;
+  Perkinean, 49;
+  plea of, 742;
+  religious, 777;
+  self abuse and, 484.
+Insomnia, 125;
+  coffee and, 659;
+  cold and, 656;
+  cold bath and, 658;
+  cold feet and, 656;
+  diet and, 659;
+  direct suggestions and, 660;
+  dread of, 651;
+  drugs and, 654;
+  encyclopedia reading and, 662;
+  evening hours and, 660;
+  food before retiring and, 659;
+  hot foot bath and, 657;
+  Jacinth and, 37;
+  lack of air and, 657;
+  lack of occupation and, 644;
+  not serious, 651;
+  persuasion of, 651;
+  pillow and, 655, 656;
+  sea voyage and, 658;
+  solicitude about, 654;
+  suggestion and, 654;
+  tea and, 659.
+Inspiration, 135.
+Instinct,
+  appetite and, 264;
+  disturbed, 267;
+  not theory, 256.
+Interest,
+  human, 206;
+  in others, 221.
+Intestinal control, 280.
+Intestinal tolerance, 271.
+Intestinal unrest, 255.
+Intestine, 269.
+Introspection, morbid, 302.
+Invalids by profession, 184.
+Irish school on heart, 318.
+Irregularity,
+  functional, of the heart, 327;
+  myocardial, 327.
+Irresponsibility, 744.
+
+
+J
+
+Jacinth for sleep, 37.
+James, Prof., 16, 92.
+Janet, 597.
+Jew's ear, 35.
+John of Cronstadt, 75.
+Johnson, Samuel, 80.
+Joint affections, position in, 212.
+Joint conditions,
+  differentiation of, 381;
+  hysterical, 239;
+  hysterical, frequency of, 387;
+  neurotic, frequency of, 386;
+  old, injured, and dampness, 387;
+  painful, 379.
+Joy and pleasure, 104.
+
+
+K
+
+Ka (Egyptian soul), 9.
+Kaltenbach, 456.
+Keller, Helen, 214, 234.
+Kepler and astrology, 39, 41.
+Khou (Egyptian mind), 9.
+Kidney,
+  abnormal fixity of, 307;
+  backache and, 308;
+  calculus of, 80;
+  floating, operation for, 308;
+  loose, 302;
+  movable, 307;
+  movable, mechanical treatment for, 308;
+  movable, weight, and, 297, 308;
+  of pregnancy, 307;
+  position of calculus in, 209.
+Kidneywort, 35.
+King, Prof., on natural obstetrics, 459.
+King's evil, 79, 81.
+King's touch, 748.
+Kircher, S. J., Father, 42, 160.
+Knee,
+  after loose cartilage, 412;
+  foot troubles and the, 410;
+  high heels and the, 410;
+  hip and the, 410;
+  housemaid's, 39;
+  lumbar discomfort and the, 411;
+  muscle disuse and the, 412;
+  unusual occupations affecting the, 410.
+Knee jerk, 556.
+Kneipp, Father, on hydrotherapy and psychotherapy, 72.
+Kneipp societies, 73.
+Know, I do not, 466.
+Kocher, 505.
+Korsakoff's psychosis, 687.
+Krafft-Ebing, 631.
+Kronecker, 269.
+Kronig, 456.
+
+
+L
+
+Labor,
+  at the ninth month, 454;
+  delayed, suggestion and, 454;
+  natural, 459;
+  patient helps, 459;
+  postures after, 459.
+Labouchère, 147.
+Lachesis, snake venom, 66.
+Laennec pearls in asthma, 364.
+Lancisi, 17, 331.
+Lapax, Indian chorea, 688.
+Larrey, Baron, 68.
+Lauder Brunton, on inhibition, 313.
+Laugh and grow fat, 297.
+Laughing, diaphragm and, 105.
+Laughing cure, 104.
+Laughter, hearty, effect of, 297.
+Law of avalanche, 111.
+Laxatives, abuse of, 287.
+Layer, plexiform cerebral, 126.
+Lead in muscle aches, 398;
+  poisoning from, 172.
+Learn,
+  by heart, 223;
+  failure to, 129.
+Leg exercises in constipation, 277.
+Legs, inequality of, 410
+Leisure, use of, 181.
+Leisure classes, 184.
+Letters, cross, 140.
+Leyden jar, 42;
+  "cures" by the, 42;
+  effects of the, 42;
+  suggestion and the, 42.
+Lichen,
+  anise seed in, 25;
+  snakes in, 25.
+Liebault on hypnotism, 407.
+Life,
+  aimless, 220;
+  and death, 89;
+  dangerous, 512;
+  intellectual, 125, 134, 302;
+  interests in, 169;
+  natural, 267;
+  out-of-door, 358;
+  persuasion of short, 636;
+  principle of, 191;
+  regulation of, 220;
+  worth living, 722.
+Light,
+  and psychotherapy, 44;
+  in hypnotism, 155;
+  lack of, 173.
+Lightning, fear of, 612.
+Lincoln's steamboat, 253.
+Liniments, suggestion with, 29, 393.
+Liquor problem, scientific solution of the, 701.
+Literature and life, 648.
+Lithemia, 380.
+Litton's diaphragm phenomenon, 361.
+Liver,
+  business and the, 253;
+  gastric symptoms from the, 177.
+Liverwort, 35.
+Lloyd Tuckey on mental influence, 156.
+Lobe, occipital, 116.
+Local anaesthesia, personality of operator and, 758.
+Locomotor ataxia, 524.
+Lombroso, 88, 130.
+Longevity and delicate health, 202.
+Looking forward, 183.
+Looking up, 102.
+Lord Bacon, 54.
+Lord Kelvin on the Creator, 730.
+Louis', grief, 732.
+Love, Greek, 482.
+Lowell, James Russell, 649.
+Lucas Malet on maternal impressions, 221.
+Lucian on warts, 493.
+Lucretius' pessimism, 776;
+  evolution and, 776.
+Lumbago, 402;
+  adhesive plaster for, 407;
+  cautery and, 408;
+  electric equilibrium in, 408;
+  etiology of, 404;
+  hypnotism in, 407;
+  paper on loins and, 407;
+  piles and, 403;
+  seminal vesicles and, 403.
+Lunar caustic, 36.
+Lunch,
+  hurried, 171;
+  women's, 180.
+Luncheon, in Vienna, 179.
+Luncheon clubs, 180.
+Lung at rest, 361.
+Lungs not laboratories, 132.
+Lytton, Sir Robert Bulwer, 648;
+  grief and, 731.
+
+
+M
+
+McDougal, 123.
+McGuire, John Francis, on Father Mathew, 75.
+Machines, electrical, 43.
+Mackenzie on the heart, 323.
+Magnan, Prof., on sex perverts, 480.
+Magnetics, 15;
+  application of, 42.
+Magnetism,
+  human, 41;
+  malignant, 142;
+  personal, 14, 70;
+  suggestion and, 41.
+Magnets, 15.
+Malaria,
+  degeneration and, 107;
+  mental, 93.
+Man,
+  of one idea, 195;
+  without habits, 230.
+Manners and disposition, 234.
+Manzoni and memory, 685.
+Martyrs, 112.
+Massage and exercise, 206.
+Mastication,
+  stomach and, 261;
+  wearying, 355.
+Maternal impressions,
+  in old literature, 461;
+  superstition and, 465;
+  supposed examples of, 463;
+  time of, 463.
+Mathematical medicine and suggestion, 41.
+Mathew, Father, and alcoholism, 75.
+Meal,
+  midday, 180;
+  principal, 180.
+Meat, dog, 244.
+Mechanism,
+  of influence of mind on body, 107;
+  of mental influence, 108;
+  peripheral ganglionic, 190.
+Mechano-therapy, 5.
+Médecine, La, des Âmes, 90.
+Medication, 2.
+Medicine man, 78.
+Medicine,
+  minus mental influence, 192;
+  plus mental influence, 192.
+Medieval mind healing, 14.
+Melancholia,
+  neurasthenia and, 556;
+  suicide and, 556.
+Memories,
+  individual, 684;
+  vertigo and, 516.
+Memory,
+  age and, 679;
+  attention and, 679;
+  auditory, 682;
+  brain cells in, 128;
+  Carlyle's, 685;
+  committing to, 223;
+  cultivating looseness of, 683;
+  definite location of, 128;
+  diseases of, 682;
+  disorders of, 678;
+  disturbance of, 124;
+  exercise of, 687;
+  fatigue and, 682;
+  genius and, 684;
+  Goldsmith's, 684;
+  groping, 127;
+  hallucinations of, 635;
+  improvement of, 687;
+  in defectives, 686;
+  intellect and, 684;
+  intimate mechanism of, 128;
+  laxative and, 270;
+  low grade intelligence and, 685;
+  Manzoni's, 685;
+  name, 681;
+  newspapers and, 684;
+  Newton's, 684;
+  of animals, 127;
+  of words, 127;
+  pauses and lapses of, 681;
+  peculiarities of, 680;
+  process underlying, 133;
+  psychotherapy of, 679;
+  public speakers and, 127;
+  Scott's, 684;
+  sensations and, 682;
+  sense defects and, 682;
+  solicitude and, 680;
+  supposed loss of, 679;
+  tone deafness and, 682;
+  training the, 686;
+  tricks of, 685;
+  visual, 682.
+Menière's disease, 516;
+  vertigo and, 516.
+Menopause,
+  air and, 452;
+  benefits of, 452;
+  definite prescriptions for, 451;
+  diversion of mind and, 452;
+  exercise and, 452;
+  family cares and, 451;
+  Graves' disease and, 502;
+  lack of occupation and, 451;
+  old-fashioned attitude toward, 451;
+  pseudo-epilepsy and, 540;
+  unfavorable suggestions and, 450.
+
+Menorrhagia,
+  favorable disposition in, 449;
+  fibroid and, 448;
+  individual and, 449;
+  menopausal, 448;
+  mental factors in, 447.
+"Men's diseases," 474.
+Menstrual condition, 59;
+  disturbance through brain in, 190;
+  hyperemia and, 436;
+  irritability and, 441;
+  over-attention to, 441;
+  over-reaction in, 436;
+  psycho-physical factors in, 436.
+Menstruation,
+  air and, 436;
+  dreads and, 434;
+  emotion and, 438;
+  lack of inhibition in, 434;
+  misophobia in, 434;
+  psychic states of, 434;
+  sensitiveness in, 435.
+Mental attitude, 4.
+Mental energy, law of, 16.
+Mental exhaustion, 599.
+Mental healing, 386;
+  in the Renaissance, 14;
+  3,000 years of, 81.
+Mental incapacity, 597, 598;
+  functional, 599.
+Mental influence,
+  anesthesia and, 753;
+  before operation, 749;
+  distant, 140;
+  in surgery, 747;
+  medieval, 747;
+  on organs, 87;
+  post-operative, 759;
+  therapeutics and, 196;
+  with digitalis, 312.
+Mental medicine, law of, 99, 251.
+Mental short circuit, 5, 601.
+Mentality, physical basis of, 133.
+_Meralgia paresthetica_, 405.
+Mesmer, 51, 153;
+  methods of, 154, 386.
+Mesmerism,
+  "Christian Science" and, 55;
+  surgery and, 748.
+Message, telepathic, 145.
+Metabolism, fatty, 291.
+Meyer, 105.
+Michelangelo on trifles, 164.
+Microbophobia, 612.
+Milk,
+  asses', 246;
+  bovine, humanity and, 461;
+  dislike of, 246;
+  goats', 246;
+  mares', 246;
+  maternal supply of, mind and, 460;
+  more than food, 461:
+  sour, 96, 247.
+Mind,
+  absorption of, 130;
+  abstraction of, 129;
+  body and, 233;
+  brain and, 549;
+  concentration of,  124, 130, 197;
+  diversion of, 182, 224, 225;
+  fractures and, 751;
+  heart and, 311;
+  herpes and, 492;
+  making up, 737;
+  menstrual, Charcot and Möbius on, 434;
+  mortal, evil of, 776;
+  motility and, 86;
+  preoccupation of, 130, 136;
+  relaxation of, 228;
+  urticaria and, 491;
+  vacant and distressed, 219.
+Mind healing,
+  in Greece, 10;
+  novelties in, 5.
+Mind reading, 141.
+Miner's elbow, 399.
+Mirabeau, 27.
+Misophobia, 615.
+Mitchell, Dr. John K., 161.
+Mitchell, Dr. S. Weir, 136, 572.
+Möbius on menstrual mental states, 434.
+Mommsen, 130.
+Monastic work intervals, 226.
+Mondeville, mental influence and, 747.
+Monotony in diet, 296.
+Moodiness, 233.
+Moral, influence of the, on the physical, 84.
+Morgagni, 16, 331;
+  and venesection, 27;
+  on nervous heart, 331.
+Morning,
+  dawdling in the, 165;
+  walks in the, 169.
+Mother and child, distinct beings, 462.
+Mothers of syphilitic children immune, 680.
+Motility, gastric, 261.
+Motion and will, 109.
+Mouth breathing, 105.
+Movements,
+  habitual, 173;
+  pain and, 396.
+Movements, passive, 207.
+Moxa and suggestion, 68.
+Müller, Johann, 18, 607, 678.
+Müller-Lyer lines, 767.
+Müller, Max, 243.
+Mummies in therapy, 64.
+Münsterberg, Prof.;
+  on Pastor Gassner, 778;
+  on psychotherapy, 75.
+Murmurs,
+  heart, 318;
+  extraneous sounds and, 318;
+  significance of, 318.
+Muscle reading, 195.
+Muscles,
+  exercise of the, heart stimulation and, 328;
+  gastric, 261;
+  health and, 200;
+  internal secretions in, 328;
+  overtiredness of, 392;
+  relaxation of, 197;
+  thought and, 194;
+  unconscious regulation of, 230;
+  useless, 201.
+Muscular exertion, unaccustomed, 392.
+Muscular pains and aches,
+  atrophy and, 394;
+  causes of, 391;
+  counter-irritation for, 393;
+  habits and, 392;
+  lead and, 398;
+  local conditions in, 389;
+  treatment of, 406.
+Music as recreation, 139.
+Musk, 69.
+Mutism, hysterical, 574.
+Myotatic, 556.
+Mysteriea, natural, 109.
+
+
+N
+
+Names, euphonious, 59.
+Nancy, hypnotism at, 154, 159.
+Napoleon, 85.
+Narcosis, nervous mechanism in, 123.
+Narcotism, 111.
+Nature, human, 359.
+Natures, two in man, 148.
+Nature's compensations, 508.
+Nauheim,
+  baths at, 328;
+  exercise at, 328;
+  suggestion at, 216.
+Nectarium, proprietary medicine, 59.
+Nephritis, insidious, 642.
+Nerve currents, 123.
+Nerve explosions, 564.
+Nerve fibers, plexuses, systems, 109.
+Nerve impulses and electricity, 110.
+Nerve pressure, anesthetic for, 401.
+Nerves and tissues, 88.
+Nervous diseases, organic, 508.
+Nervous weakness, 555.
+Nervousness, Jews, Quakers, Roman Catholics and, 778.
+Neuralgia, 59.
+Neurasthenia,
+  an American disease, 559;
+  arteriosclerosis and, 557;
+  Bright's disease and, 557;
+  concentration of mind and, 560;
+  diabetes and, 559;
+  due to over-attention, 559;
+  hysterical, 561;
+  in the old, 557;
+  melancholia and, 556;
+  nervous weakness and, 555;
+  paresis and, 532;
+  rheumatism and, 555;
+  significance of, 555, 556;
+  simulation of, 557;
+  splanchnic, 36, 297;
+  substitution of symptoms and, 561;
+  too satisfying, 555.
+Neuritis,
+  deltoid, 397;
+  ulnar, 398.
+Neuroglia cells,
+  perivascular, 122;
+  plexiform, 126;
+  pseudopods of, 122;
+  spinal, 122;
+  subcortical, 122;
+  superficial, 126.
+Neuroglia theory, 86, 119.
+Neurokym, 111.
+Neurons,
+  from optic lobe, 117;
+  in psychic states, 117;
+  movement of, 114, 119;
+  motor, lower, 114;
+  peripheral, 118.
+Neuroses,
+  accessory, 749;
+  biliary, 586;
+  intestinal weight in, 285;
+  motor, 589;
+  secretory, 586;
+  sexual, 472.
+Neurosis,
+  cardiac, 321;
+  exercise and, 326;
+  muscular, 393;
+  neuritis and. 398.
+Neurotic joints, 589.
+Neurotic simulation, forms of, 585.
+Neurotic tendencies, 480.
+New Englanders, religious, 82.
+News, bad, 85.
+Newspapers at breakfast, 170.
+Newton, 130.
+Night air, 450.
+Night duty, 175.
+Night terrors,
+  ghost stories and, 668;
+  melodrama and, 668.
+Night workers and alcohol, 175.
+Nightmare, 339.
+Nihilism, therapeutic, 5.
+Nissl bodies, 114.
+Nitrate of silver, 36.
+Nitrous oxide, 18.
+Nodes, Heberden's, 422.
+Nomenclature of disease, 556.
+_Non nocere_, 187.
+Norman, 42.
+Nosology, preputial, 475.
+Nostrum promoters, 56.
+Nostrum venders, 3, 59.
+Nothing to do, 184, 218.
+Nursing,
+  cheery, 760;
+  suggestions and, 460.
+Nurslings' immunity, 460.
+Nutrition, intrauterine, 465.
+Nux vomica, 5.
+
+
+O
+
+Obese, 290.
+Obesity,
+  alimentary, 293;
+  constipation and, 296;
+  early treatment of, 292;
+  essential, 293;
+  examples and, 293;
+  exercise and, 294, 296;
+  frequency of, with diabetes, 294;
+  heredity and, 293, 295;
+  pathological, with diabetes, 290;
+  prophylaxis in, 293;
+  sleep and, 294.
+Obsession,
+  sexual, 476;
+  subconscious, 476.
+Obsessions, 624.
+Obstacle sense, 214.
+Obstetrics,
+  posture in, 459;
+  suggestion in, 452;
+  sympathy harmful in, 452.
+Occupation,
+  alcohol and, 398;
+  diversion of, 226;
+  dual mental, 139;
+  dusty, 172;
+  feminine, 183;
+  finding mental, 223;
+  lack of, 219;
+  mental condition in, 177;
+  pleasant, 84;
+  position during, 176;
+  sedentary, 302;
+  standing, sitting, intervals of rest in, 173.
+Occupation pains, 396.
+Ointment,
+  expensive, 59;
+  weapon, 54.
+Old-maid, psychasthenic, 221.
+Olfactory acuity, 619.
+Operation,
+  idea of, 751;
+  mental influence after, 759;
+  suggestive, 306, 431;
+  visits after, 760;
+  work after, 760.
+Operations on the abdomen, 303;
+  series of, 304.
+Opium,
+  in hypnotism, 156;
+  mind and, 192.
+Oppenheim, Prof., 323, 511, 512, 527, 660.
+Optic thalamus and dual dispositions, 151.
+Orchitis and epigastric reflex, 252.
+Ordure in therapy, 34.
+Organic disease, mental influence and, 190.
+Organic nervous diseases, 508;
+  adventitious symptoms of, 509;
+  compensation and, 508;
+  incurable, 509;
+  prophylaxis in, 509;
+  unfavorable influence and, 508.
+Organs, feminine, out of pelvis, 430.
+Osler, Sir William, 11, 323.
+Osteoarthritis, 424.
+Osteopath, 52, 381.
+Osteopathy, success of, 207, 385, 386.
+Overcautiousness, 189.
+Overeating, habit of, 266, 291, 297.
+Oversensitiveness, neurotic, 239.
+Overseriousness, 218.
+Overweight,
+  prevention of, 295;
+  short life and, 294.
+Ozena, 98.
+
+
+P
+
+Paget, Sir James, 589;
+  on hysterical joint, 749;
+  on neurotic joints, 386.
+Pain,
+  after operation, 761;
+  a stimulus, 240;
+  bearing, reconstructive, 235;
+  character and, 238;
+  consciousness of, 236;
+  conservative, 240;
+  contraindication to treatment, 394;
+  deterrent, 68;
+  differentiation of, 241;
+  diffusion of, 238;
+  discipline for, 238;
+  dispelling, 130;
+  distraction and, 754;
+  diversion and, 225, 754;
+  equanimity in, 779;
+  in life, 237;
+  location of, difficult, 251;
+  memory of, pleasant, 238; 724;
+  neurotic and organic, 240;
+  on motion, 241;
+  over healthy lung, 362;
+  overattention and, 236;
+  power to bear, and the individual, 441;
+  preoccupation and, 235;
+  psyche in, 761;
+  radiation of, 240;
+  relief of, in gynecology, 431.
+Pains,
+  barometer and, 382;
+  company in, 10;
+  in rainy weather, 382;
+  muscular aches and, 389;
+  occupation of  mind in, 395.
+Paladino, Eusapia, 88.
+Palpitation from over-attention, 324.
+Palsies,
+  musculo-spiral, 401;
+  neurotic, 589.
+Palsy, infantile, training for, 216.
+Panniculus, 299.
+Paracelsus, 15, 688.
+Parallels, distortion of, 770.
+Paralysis agitans, 579;
+  cord stretching in, 544;
+  cures of, 544;
+  drugs in, 544;
+  Frenkel's method in, 544;
+  mental control in, 542;
+  mental influence and, 543;
+  organo-therapeutics and, 544;
+  psychic factors in, 542;
+  psychotherapy and, 545;
+  suspension and, 544;
+  vibration and, 544.
+Paranoia and paresis, 532.
+Paraplegia, mimicry of, 590.
+Paresis,
+  alcohol and, 530, 532;
+  consoling hesitancy in diagnosis of, 533;
+  difficulty of diagnosis of, 534;
+  exciting life and, 530;
+  hereditary factors in, 532;
+  low grade nervous system and, 530;
+  paranoia and, 532;
+  parasyphilitic, 530;
+  psychic influence in, 533;
+  simulants of, 534;
+  sparing relatives in, 533;
+  syphilis and, 631;
+  worry over syphilis in, 530.
+Paris, Dr., 16.
+Parry, old Dr., of Bath, 163.
+Parthenon, optical corrections, 772.
+Pâtés de foie gras, 291.
+Pathology, humoral, 57.
+Pathophobia, 612.
+Patient,
+  individual, 10;
+  his disease and, 163.
+Patients,
+  objective and subjective history of, 164;
+  no incurable, 184.
+Paul of AEgina, 13.
+Paul, St., 148.
+Pawlow on digestion, 269.
+Payot, M. Jules, on will, 220.
+Pelvic discomfort and attention, 430.
+
+Peristalsis,
+  attention and, 270;
+  experiments upon, 269;
+  psychic influence and, 269.
+Perkins' tractors, 5, 48, 51, 386.
+Perversions, sexual, 489.
+Personal influence, 69;
+  place of, 77;
+  relationship and, 77.
+Personality,
+  deeper levels in, 150;
+  dual, hypnotism and, 150;
+  dual, hysteria and, 149;
+  human, 607;
+  impressive, 70, 147;
+  in therapeutics, 69;
+  other. 135;
+  primary, 148;
+  secondary, 149;
+  supernumerary, 149.
+Pessimism, 233.
+Pets, fat, 291.
+Pettigrew, 61.
+Phantasms of the dying, 147.
+Pharmaceutics, father of modern, 15.
+Pharmocopeia, 1.
+Phenomena,
+  healing, 78;
+  hysterical, 149.
+Philip Neri, St., 74.
+Phobophobia, 612.
+Phthisiophobia, 612.
+Phthisis, exaltation in, 642.
+Physicians,
+  abdominal discomfort and, 302;
+  as patients, 191;
+  family and, 729;
+  old family, 714;
+  personality of, 191.
+Physiognomy, 106.
+Pictet, 18.
+Pieta, 36.
+Pigmentation,
+  neurotic, 493;
+  psyche and, 494.
+Pills,
+  bread, 88, 281;
+  ground biscuit. 281.
+Pinel, 8.
+Planes, intermuscular, 393.
+Plasters,
+  medicinal, 63;
+  suggestion of, 34.
+Plato, 10, 94, 99.
+Play and exercise, 204.
+Pleasure,
+  joy and, 104;
+  pain ingredient in, 240.
+Pleural adhesion, 401.
+Plexuses of nerve fibers, 109.
+Pliny,
+  on proprietaries, 59;
+  the elder, 59.
+Plombières, 287.
+Plutarch on suicide, 719.
+Pneumogastric pressure, 315.
+Pneumonia, 3, 22;
+  depression in, 23:
+  heart failure in, 23;
+  hereditary, 383;
+  in athletes, 202;
+  nursing in, 23;
+  suggestion in, 23.
+Podmore, 55, 605, 607, 635.
+Polypharmacy, 41.
+Pomponatius, 14.
+Ponto, 68.
+Pope, 223.
+Pope Leo XIII, 223.
+Pork and cabbage, 249.
+Position,
+  after meals, 176;
+  changes of, 210;
+  in constipation, 276;
+  in emptying the bladder, 472;
+  in therapy, 207;
+  post-operative, 763;
+  relief and suggestion and, 213.
+Pott's disease, 68.
+Poultices,
+  of crushed lice, 34;
+  of deterrent materials, 34;
+  of insects, 34;
+  of moss from mummy skull, 34;
+  ordure, 34;
+  signatures and, 34.
+Powder, sympathetic, 56.
+Power to choose, 149;
+  will, 740;
+  will, responsibility and, 738.
+Practice, metallic, 50.
+Precious stones,
+  signatures and, 36;
+  suggestions and, 36.
+Precordia, pain in, 339.
+Predisposition to tuberculosis, 354.
+Pregnancy, 453;
+  abortion for vomiting in, 455;
+  air in, 453;
+  exercise in, 453;
+  habits of life in, 454;
+  natural life in, 454;
+  obesity in, 454;
+  termination of, natural, 454;
+  vomiting in, 455;
+  vomiting of, remedies for, 455.
+Premonition, 78, 634, 675;
+  fulfilled, 637;
+  memory hallucinations and, 635;
+  paralyzing, 611;
+  suggestion and, 635;
+  superstitions and, 638;
+  unfulfilled, 637.
+Premonitions,
+  coincidence and, 638;
+  telepathy and, 640.
+Prepuce, long, pathology in, 475.
+Preputial cleanliness, 485.
+Prescriptions,
+  earliest, 60;
+  favorite, 3;
+  Latin, 191;
+  many ingrediented, 41;
+  secret, 192.
+Pressure discomfort, abdominal, 252.
+Principles,
+  chemical and physical, 132;
+  vitalistic, 132.
+Prognosis in Graves' Disease, 503.
+Prophylactic psychotherapeutics, 237.
+Prostate and self-abuse, 484.
+Prostatism, 468;
+  castration and, 468;
+  individual, 471;
+  organotherapy and, 468;
+  palliative treatment for, 471;
+  position in, 471;
+  seminal vesicle tissue for, 468;
+  suggestion and, 270;
+  vasectomy and, 469.
+Prostatitis and epigastric reflex, 252.
+Proteus, daughter of, 688.
+Providence, trust in, 775.
+Pruritus,
+  air bath and, 494;
+  diversion of mind in, 495;
+  mental factors in, 494;
+  occupation and, 495.
+Pseudo-angina, 338.
+Pseudo-cyesis, 438.
+Pseudo-epilepsy, 538;
+  auto suggestion and, 539;
+  dread and, 539;
+  menopause and, 540;
+  mental cures of, 541;
+  neuronic disturbance and, 539, 597, 693.
+Pseudo-Messiahs, 81.
+Pseudo-paresis,
+  memory disturbance in, 531;
+  tremor in, 531.
+Pseudopods of neuroglia cells, 127.
+Pseudo-pregnancy, 438.
+Pseudo-presentiments, 635.
+Pseudo-rabies, 753.
+Pseudo-rheumatism, 379.
+Pseudo-science, 43, 61, 81, 35;
+  mental healing and, 38.
+Psychasthenia,
+  heredity and, 603;
+  natural and acquired, 598;
+  post-critical, 602;
+  retirement and, 602.
+Psychic research, 144.
+Psychic states, neurons in, 117.
+Psycho-analysis, 77, 595, 625;
+  dreams and, 595;
+  hysteria and, 595;
+  instruction in, 596;
+  mesmerism, etc., and, 595;
+  reversion and, 595;
+  sex and, 595.
+Psychology
+  of advertising, 690;
+  of the mob, 690, 692;
+  of patent medicines, 690;
+  old and new, 58;
+  principles of, 201.
+Psycho-neuroses, 239, 281;
+  after-treatment for, 591;
+  appetite and, 592;
+  asafetida and, 593;
+  bread pills and, 593;
+  business worries and, 593;
+  children in, 592;
+  disappointments and, 593;
+  diversion and, 592;
+  dominant ideas in, 593;
+  drugs and, 593;
+  love and, 593;
+  lumbar, sciatica and, 406;
+  mental impression and, 591;
+  motor, 589;
+  occupation and, 592;
+  painful, 589;
+  post-operative, 762;
+  quinine and pepper for, 593;
+  sorrow and, 594;
+  subconsciousness and, 594.
+Psychotherapeutics, unconscious, 19.
+Psychotherapy,
+  abuse of, 6;
+  Alexandrian, 11;
+  at Rome, 12;
+  concealed, 192;
+  frank use of, 192;
+  general principles of, 185;
+  history of, 2;
+  indeliberate, 3;
+  individual patient and, 163;
+  Münsterberg, Prof., on, 778;
+  religion and, 775;
+  skin diseases and, 491;
+  surgical, 746;
+  systematized, 192;
+  tact and, 191.
+Pulse, intermission of the, 339;
+  morning, 343.
+Pulse, rapid, hereditary, 340;
+  paroxysmal, 340;
+  persistent, 340;
+  prognosis in, 340.
+Pulse, slow, athletes and, 344;
+  congenital, 344;
+  Napoleon and, 344.
+Punishment,
+  deters, 743;
+  of sub-rational, 743;
+  responsibility and, 740.
+Purgatives, abuse of, 287.
+Purgings, old time, 381.
+Purifiers, blood, 57.
+Pyramid, 7, 112.
+Pythagoras, 26.
+
+
+Q
+
+Quack, 3.
+Quackery,
+  history of, 53;
+  mind cures and, 46.
+Quakers,
+  color blindness in, 772;
+  nervousness among, lack of, 778.
+Quinine,
+  as a febrifuge, 28;
+  as prophylactic, 28;
+  in fever, 28;
+  suggestion and, 28.
+
+
+R
+
+Radiation of pain, 241.
+Radium, 5, 45.
+Rainy weather pains, 382.
+Ramon y Cajal, 110;
+  on attention, 126.
+Rattlesnake bite, 65.
+Raynaud's disease, 63, 492.
+Rays,
+  actinic, 44;
+  ultra-violet, 45.
+Razor, dread of, 195.
+Reaction, exaggerated, 360.
+Reading,
+  for insomnia, 139;
+  in bed, 139;
+  mind quiescent during, 139;
+  muscles during, 195;
+  of newspapers, 138.
+Recreations, 9;
+  mental, 13;
+  music and, 139;
+  social, 139;
+  theater and, 139.
+Re-creation, 124, 138.
+Reduction in weight,
+  alcoholism and, 293;
+  a life task, 293;
+  without effort, 293.
+Reflexes, cardiac, 330.
+Regulation, monastic, 104.
+Reid, Dr. Archdall, on heredity, 230, 699.
+Reil, Island of, 18.
+Relationship, personal, of physician and patient, 164.
+Relaxation,
+  abdominal, 209;
+  mental, 140;
+  of mind, 138;
+  sessions of, 198.
+Relief,
+  in severe injuries, 85;
+  natural, 188.
+Religion,
+  cheapening, 779;
+  insanity and, 777;
+  meaning of, 779;
+  psychotherapy and, 775.
+Religious sense, disintegration of, 776.
+Remedies,
+  new, 19;
+  plus suggestion, 19, 197;
+  proprietary, 59;
+  repugnant, 66;
+  secret, 53;
+  secret, origin of, 53;
+  specific, 186;
+  various, 1, 349.
+Reserve energy, law of, 18, 92, 93, 310.
+Reservoir of energy, 93.
+Residue, intestinal, 274.
+Responsibility, 738;
+  differing, 741;
+  of  defectives, 743;
+  personal, 148;
+  punishment and; 740;
+  will power and, 742.
+Rest,
+  genuine, 224, 237;
+  pain and, 52, 188;
+  wear and, 602.
+Restlessness, conservative, 211.
+Retention, mental, 143.
+Reutergehem, 159.
+Rhazes, 13.
+Rheumatism, 44, 98;
+  acute, 382;
+  anodynes for, 406;
+  classic symptoms of, 406;
+  derivation and relationship of, 380;
+  foot troubles and, 414;
+  heredity of, 382;
+  muscular, 391;
+  no lasting effects in, 379;
+  old injuries and so-called, 387;
+  recurrence of, 384;
+  sequelae of, 384;
+  so-called, 385;
+  so-called chronic, 383;
+  subacute, 384;
+  treatment, abuse of, in, 381;
+  unfavorable suggestion and, 385.
+Rhinitis _sympathetica_, 369.
+Rhythm, nodal, 342.
+Ribot, 138.
+Richardson, Benjamin Ward, 16.
+Riding, horseback, 204.
+Ring-worm, 61.
+Robert Boyle, 61.
+Roberti, S. J., Father, 65.
+Robertson, Dr., 16.
+Roger Bacon, 466.
+Roman life and manners, 58.
+Rome, 8;
+  patent medicine men in, 58.
+Röntgen, 44.
+Rose, catarrh suggested by, 372.
+Rose cold, 369, 375.
+Rose fever, artificial, 372.
+Rossetti's grief, 732.
+Routine, weekly, 183.
+Royal Society, 50.
+Royal touch,
+  Charles I and II and, 79;
+  Edward the Confessor and, 79;
+  James I and, 79;
+  Queen Anne and, 79;
+  Queen Elizabeth and, 79;
+  William III and, 79.
+Royce on premonitions, 635.
+Rubber, 52.
+Rules, dietetic, 256.
+Rumbling, intestinal, 284.
+
+
+S
+
+St. Ives, R. L. Stevenson, 357.
+St. John Long's liniment, 29, 381, 402.
+St. Moritz, 357.
+St. Vitus' dance, 688.
+Sacrocoxalgia, 68.
+Sacro-iliac joint, tuberculosis of, 403.
+"Safe cure," 58.
+Saleeby on gymnastics, 203.
+Salicylates,
+  as specifics, 387;
+  in old and young, elimination of, 387.
+Salivation, pregnancy and, 457.
+Salmon, not tortoise, 338.
+Salpêtrière, 154, 159.
+Salt,
+  excess of, 283;
+  mucous colitis and, 284.
+Sanatoria, modern and ancient, 10.
+Sardonyx and suggestion, 62.
+Sarsaparilla, 5;
+  suggestive value of, 57.
+Sauerkraut, 248.
+Sausage, blood, 77.
+Scheidemantel on psychotherapy, 17.
+Schools, teaching of pathology and physiology in, 95.
+Schopenhauer, 648.
+Schrenk-Notzing and hypnotism, 159.
+Schurz, Carl, and failed premonition, 637.
+Sciatica, 402;
+  acupuncture for, 408;
+  etiology of, 404;
+  hot needles for, 408;
+  intra-pelvic causes of, 405;
+  position at work and, 405;
+  pressure and, 404;
+  stretching and, 408;
+  treatment for, 405.
+Science and a Creator, 776.
+Seasickness, 97;
+  remedies and suggestion, 97.
+Secretions as remedies, 66.
+Sedentary life, preparation for, 200.
+Self,
+  over-attention to, 600;
+  subliminal, 148;
+  the other, 148.
+Self-abuse,
+  after-cure of, 487;
+  air and, 487;
+  breaking off the habit of, 486;
+  cleanliness and, 488;
+  confession and, 486;
+  confidence and, 486;
+  effect of, on prostate, 484;
+  exaggerated effects of, 483;
+  female, 488;
+  habit of, 482;
+  insanity and, 484;
+  occupations and, 488;
+  preputial concretions and, 485;
+  reading and, 488;
+  relapse into, 486;
+  sleep and, 487;
+  times of danger and relapses into, 487.
+Self-consciousness,
+  in clergymen, 582;
+  in teachers, 582.
+Self-control, 148;
+  for obesity, 294.
+Self-denial, 240.
+Self-discipline, 146.
+Self-hypnosis, 161.
+Self-indulgence, 148.
+Self-watching, 600.
+Sensations,
+  ideas and, 109;
+  manifold, 560;
+  missed, 129;
+  over-attention to, 560;
+  simple painful, 131;
+  transfer of, 252;
+  uncomfortable, 218.
+Sense of pressure, 262.
+Sepsis and alcohol in suggestion, 30.
+Serpents in therapeutics, 65.
+Sex,
+  cultivation of, 481;
+  curiosity concerning, 489;
+  exaggerated significance of, 479;
+  expectorating, the, 346;
+  in the background, 481;
+  "mad," 480;
+  on the mind, 479;
+  perversion of, bathing and, 489;
+  ugly habits and, 481.
+Sexual afflictions trivial, 473.
+Sexual neuroses, 472.
+Sexual perversions, 489.
+Sexual solicitude, 477.
+Sexual symptoms, exaggerated, 472.
+Sherrington on nerve mechanism, 123.
+Shilling, live on a, and earn it, 268.
+Shivering, 773.
+Shock,
+  anesthesia and, 754;
+  the heart and, 314.
+Shoe-maker,
+  magic, 414;
+  present day, 418.
+Shoes,
+  old-fashioned, 418;
+  sloppy weather, 414.
+Short circuit, mental, 223, 225.
+Shoulders and feelings, 103.
+Sidis, Boris, on psycho-analysis, 270.
+Sight, lapse of, 129.
+Signature, tremor in, 584.
+Signatures,
+  doctrine of, 21, 34, 35;
+  psychotherapy and, 35.
+Simpson, Sir James, 147.
+Simulation, psycho-neurotic, 588.
+Sitophobia, 264, 612.
+Sitting on foot, 405.
+Skin lesions,
+  artefact, 495;
+  mind and, 493.
+Sleep, 111, 122, 123;
+  amount of, 165;
+  at sea, 658;
+  communications during, 136;
+  encroachment on, 183;
+  habits and, 660;
+  how much necessary, 653;
+  Humboldt on, 653;
+  hypnotic, 152;
+  hypnotism and, 159;
+  loss of, longevity and, 661;
+  mental diversion and, 661;
+  monastic rule and, 295;
+  not dreamless, 672;
+  noise and, 666;
+  on trains, 666;
+  prevention of, 653;
+  solicitude over, 652;
+  starting in, 664;
+  troubles of, 663;
+  troubles of, hunger and, 665;
+  vibration and, 566.
+Sleeping in the light, 669.
+Sleeplessness, 651.
+Smaragdum and suggestion, 62.
+Snake, bite of, suggestion for,
+  prostration and, 32;
+  in stomach, 13;
+  skin of, in lichen, 25.
+Society,
+  Perkinean, 49;
+  Psychic Research, 146.
+Socrates, 11;
+  diversion and, 610;
+  headache cures and, 554.
+Solicitude and prognosis, 237.
+Somnambulism, 138;
+  hypnotic, 161.
+Somnambulistic, 137.
+Sound in hypnotism, 156.
+Sound reproduction, 610.
+Space, filled, illusion of, 768.
+Spasm,
+  expiratory, 364;
+  inspiratory, 364.
+Specialist, advertising, 476, 482.
+Spectacles properly fitted, 258.
+Speech, tricks of, 566.
+_Spes pthisica_, 642.
+Spinal cell, 133.
+Spine, typhoid, 403.
+Spirit rapping through foot tendons, 419.
+Spiritualism, 78.
+Spitting, unnecessary, 346.
+Spleen as food, 244.
+Sport, 228;
+  for its own sake, 229;
+  indoor, 204;
+  winning, 229.
+Sprain and fractures, 387.
+Sputum as a remedy, 67.
+Station, tremor in, 581.
+Steak, camel and elephant, 245.
+Steppes, 23.
+Stereoscopic vision, 766.
+Stevenson, Robert Louis, 356.
+Stew,
+  cat, 245;
+  dog, 245;
+  lion, 245;
+  rat, 245.
+Stigmata, hysterical, 590.
+Stomach,
+  attention and the, 306;
+  dilatation of the, 330;
+  mental states and the, 243;
+  motility of the, 261;
+  not test tubes, 132, 242;
+  resonance in, fifth interspace, 332;
+  snake in the, 13.
+Stout people, constipated, 278.
+Stroke, "third fatal," 523.
+Stroking the forehead, 156;
+  hypnotic, 153.
+Students,
+  medical, 99;
+  symptoms in, 93.
+Study, 125.
+Stupidity, bodily conditions and, 106.
+Stuttering, 570;
+  attention to, 577;
+  breathing and, 578;
+  correction of respiratory defects in, 573;
+  cures of, 576;
+  distraction of mind in, 79;
+  forms of, 570;
+  hindrances to speech and, 577;
+  inserted letters in treatment for, 578;
+  in the young, 573;
+  in women, 573;
+  Itard's fork and, 578;
+  Kingsley's cork and, 578;
+  Leigh methods and, 578;
+  mental influence and, 572;
+  practice in self-control for, 573;
+  regulation of respiration in, 577;
+  singing in treatment for, 577;
+  state of mind in, 57;
+  suggestion for, 579;
+  tongue against teeth in, 578;
+  tongue lowered in, 578;
+  treatment for, 576;
+  type of loss of control in, 570;
+  walking and, 571;
+  writing and, 571.
+Subconscious self, 145, 148.
+Südhoff, 38.
+Suffering,
+  a tonic, 723;
+  real, 222.
+Sugars in constipation, 276.
+Suggestion, 2;
+  antimony and, 25;
+  as to symptoms, 360;
+  coincidence and, 20;
+  death and, 91;
+  for colitis, 288;
+  for surgical lesions, 748;
+  in cold, 21;
+  influence of, 76;
+  in rheumatism, so-called, 385;
+  in tuberculosis, 362;
+  mechanism of, 109;
+  neutralizing contrary, 186;
+  not heredity, 251;
+  pathological, 93;
+  physiological, 260;
+  seasickness and, 97;
+  unfavorable, 186.
+Suggestions, optimistic, 511.
+Suggestive operation, 306.
+Suicide, 713;
+  among children, 720;
+  bureau of, 714;
+  burial in disgrace and, 719;
+  cataclysm and, 718;
+  Chesterton on, 722;
+  confession and, 714;
+  contagious, 691, 720;
+  cowardice of, 721;
+  disgrace and, 719;
+  dread of, 714, 726;
+  earthquakes and, 718;
+  epidemic of, 691;
+  functional irrationality and, 714;
+  Hamlet and, 722;
+  headache and, 715;
+  insomnia and, 715;
+  justification of, 9;
+  melancholia and, 556;
+  mental factors in, 716;
+  most frequent in June, 717;
+  pain and, 723;
+  prevention of, 713;
+  problems of, 718;
+  physician and, 726;
+  prosperity and, 713;
+  rarest in December, 717;
+  reassurance and, 725;
+  religion and, 718;
+  social factors in, 717;
+  suggestion and, 713;
+  underweight and, 297;
+  unexplained, 195;
+  war reduces, 717;
+  weather and, 715;
+  women of Milesia and, 719.
+Supernatural, naturalizing the, 607.
+Superstition concerning "13," 639.
+Superstitions connected with medicine and surgery, 62.
+Suppression of reaction, 86.
+Supreme Being, 78.
+Surgery,
+  astrology in, 746;
+  suggestion and, 748.
+Surveillance,
+  heart, 323;
+  inhibitory, 600;
+  insistent, 269;
+  of function, 269;
+  self, 600.
+Swallowing, 575.
+Sydenham, 16, 71.
+Symonds, J. Addington, and consumption, 357.
+Sympathetic powder, 66.
+Sympathy, 188;
+  as a remedy, 222;
+  heart and, 319.
+Symptoms, hysterical, 590.
+Synapse theory of fatigue, 123, 124.
+Syncope, neurotic, 540.
+Syphilis,
+  curability of, 630;
+  congenital contagion and, 630;
+  heredity and, 629, 631;
+  imaginary, 753;
+  maternal immunity from, 630;
+  paresis and, 631;
+  worry and, 509.
+System, sympathetic, 127.
+Systems of nerve fibers, 109.
+Systoles, extra, 333.
+
+
+T
+
+Tabes,
+  complications in, 527;
+  "cures" of, 529;
+  diphtheria serum in, 529;
+  drugs in, 530;
+  magic shoes and, 529;
+  mental attitude and, 527;
+  mild course in, 527;
+  muscle control in, 528;
+  normal lifetime and, 527;
+  over-stretching the spinal cord in, 530;
+  reassurance in, 528;
+  relearning muscular movements in, 528;
+  suspension in, 530;
+  urethral treatment for, 529.
+Tabetic neuroses, 527.
+Table, leaving the, hungry, 299.
+Tachycardia, 340;
+  essential, 342;
+  Mackenzie on, 342;
+  paroxysmal, 341;
+  Wood's case of, 341.
+Tails, expressions in, 141.
+Talismans, 60.
+Talking, co-ordination and, 230.
+Tar water, 56.
+Taste, cloying, 131.
+Tea and abdominal distress, 307.
+Teaching, disease, 95.
+Tears, 66;
+  grief and, 103;
+  joy and, 103;
+  relief of, 103.
+Telegraphy, wireless, telepathy and, 142.
+Telepathic premonition, 640.
+Telepathy,
+  accidents and, 145;
+  in trade, in ordinary life, and in juries, 143;
+  investigation of, by French Academy, 147;
+  negation of, 144;
+  negative tests of, 147;
+  on the stage, 144;
+  social life and, 143;
+  supposed examples of, 144;
+  twins and, 147;
+  wireless telegraphy and, 142.
+Temper,
+  bad, 739;
+  uncontrollable, 739.
+Temperature, variations of, 203, 354.
+Tennyson, 35.
+Tension, relaxation of, 197.
+Tenting in tuberculosis, 369.
+Thackeray, 35.
+Theater fires, 85.
+Theory, Duval, 123.
+Therapeutic persuasions, 26.
+Therapeutics of position, 208;
+  popular, 186.
+Theriac, 20;
+  Bernard's, 20;
+  Galen's, 3.
+Thick lips, meaning of, 106.
+Thinness, physical disadvantage of, 298.
+Thompson, Francis, 357.
+Thompson, Prof. J. J., 139.
+Thompson, Sir Henry, 494, 657.
+Thomson, Dr. Wm. H., 505.
+Thoreau, 357.
+Thought,
+  for others, 221;
+  New, 209;
+  original, 135;
+  pale cast of, 737;
+  transference of, 141.
+Thunder, fear of, 612.
+Tics, 230, 564;
+  as types of nerve explosions, 564;
+  children's, 568
+  drumming with the fingers, 567
+  emotional, 565;
+  expletives and, 565
+  facial, 565;
+  familiar expressions and; 565;
+  gestures and, 565;
+  heredity and, 569;
+  in games, 567;
+  jerking, 565;
+  mental treatment for, 569
+  motor, 569;
+  prophylaxis in, 569;
+  shrugging, 565;
+  speech, 565, 566
+  squinting, 565;
+  swearing, 568
+  teachers' habits and; 566;
+  winking, 565;
+  writers', 567.
+Time is money, 179.
+Tissues, nervous, changes of, 89.
+Toes,
+  claw, 418;
+  hammer, 418.
+Tolerance, intestinal, 217.
+"Tommyrotic" and erotic, 480.
+Torcular Herophili, 12.
+Torticollis, 393.
+Tortoise and salmon, lives of, 338.
+Touch and sight, 214.
+Tozzi twins, 229.
+Tractoration, 48.
+Tractors,
+  Perkins', 49;
+  in yellow fever, 51.
+Training, 213;
+  appetite, 216;
+  equilibrium and, 215;
+  facial muscles, 101;
+  feeling and, 215;
+  for pain, 217;
+  for weight, 217;
+  hearing, 215, 636;
+  heart, 216;
+  infantile palsy and, 216;
+  in self-control, 745;
+  intellectual, 218;
+  memory, 686;
+  movement, 686;
+  muscles, 215;
+  of defectives, 743;
+  sight, 215;
+  touch, 215.
+Trains and intestinal disturbances, 280.
+Treatment, absent, 5, 141.
+Tremor,
+  senile, longevity and, 580;
+  premature, 580;
+  prognosis of, 580;
+  significance of, 580.
+Tremors, 579;
+  actors and, 582;
+  clergy and, 582;
+  dread and, 581;
+  fright and, 581;
+  hypnotism and, 584;
+  in intention, 581, 583;
+  mental control and, 583;
+  self-discipline and, 584;
+  shaving, dread of, 581;
+  standing, 581;
+  suggestion waking, 584;
+  teachers', 582;
+  types of, 579;
+  writing, 584.
+Treves, Sir Frederick, on alcohol, 30.
+Trifles,
+  fascination of, 651;
+  in health, 164.
+Troubles that do not happen, 233, 612.
+Troy, 62.
+Trudeau, 359.
+Tuberculosis,
+  classes of, 188;
+  contagion and, 353, 628;
+  courage in, 356;
+  "cures" for, 351;
+  early diagnosis in, 354;
+  early stage in, 353;
+  heredity and, 352;
+  heroes of, 356;
+  immunity from, 629;
+  incipient, 348;
+  incurable, 352;
+  predisposition to, 354;
+  prevalence of, 351;
+  protective, 629;
+  pulse and, 354;
+  quitters and, 355;
+  remedies for, 351;
+  slow, 352;
+  stimulating, 356;
+  suggestion and, 362;
+  temperature range in, 354;
+  unfavorable prognosis in, 352;
+  vital resistance and, 351;
+  whooping cough and, 346.
+Tumors, pelvic, sciatica and, 405.
+Twain, Mark, disappearance story of, 608.
+Types of expression, 102.
+Typewriters' fingers, 89.
+Typhoid fever,
+  antisepsis in, 24;
+  in athletes, 202;
+  mental symptoms in, 93;
+  nurses in, 24;
+  spine in, 403;
+  suggestion in, 24.
+
+
+U
+
+Unconscious cerebration, 128.
+Unconsciousness, 119, 123.
+Underclothing, variety in, 167.
+Undereating, 297.
+Underweight, correction of, 300.
+Unguentum _Armarium_, 54.
+Unknown, the, 189, 607.
+Urbantschitsch, hearing training, 686.
+Uric acid diathesis, 270.
+Urinary worries, 470.
+Urination, position in, 459, 472.
+Urticaria,
+  diarrhea and, 281, 282;
+  mind and, 491.
+Use and abuse, 196.
+
+
+V
+
+Vacuum cleaning, 174.
+Valerian, 68.
+Valerianate ammonium, 68.
+Van Eeden and hypnotism, 159.
+Van Helmont, 15, 55, 64.
+Van Swieten, 17, 71.
+Variation, 633.
+Varicocele, 473;
+  depression, mental, and, 474.
+Varicose veins, 208.
+Varicosities,
+  feet elevated in, 208;
+  occupations and, 208.
+Vascular pedicles, 126.
+Vaso-motor disturbance, 492.
+Vegetarianism, 256.
+Venesection,
+  for eye diseases, 28;
+  for migrane, 28;
+  mental influence and, 28;
+  mind and, 14;
+  suggestiveness of, 28.
+Version,
+  by heel in perineum, 459;
+  natural, 459.
+Vertigo,
+  Menière's, 516;
+  over-attention and, 512;
+  significance of, 512.
+Vest, 168.
+Vibrations of cells, moments of, 142.
+Viper venom, 66.
+Virchow, 62, 226, 618, 647;
+  on hobbies, 226.
+Virility, The Ages of Mental, 624.
+Viscera, sensitive nerves and, 560.
+Vision,
+  illusion of two-eyed, 764;
+  stereoscopic, 766.
+Vitalism, 191.
+Vitality, resistive, and muscle, 108, 201.
+Volta, 48.
+Voltaic pile, 43.
+Vomiting,
+  abortion and, 456;
+  after anaesthesia, 758;
+  distraction of mind and, 456;
+  frequency of, 456;
+  neurotic, 455;
+  non-suggestion of abortion and, 456;
+  of live mice, 462;
+  of snakes, 462;
+  pernicious, 455;
+  pregnancy and, 456.
+Von Bülow's case of headache, 550.
+Von Leyden crystals, 364.
+Von Moltke, 647.
+Von Monakow, 115.
+Von Retzius, 121.
+
+
+W
+
+Wakefulness,
+  matutinal, 662;
+  persistent, 652.
+Waking, suggestion method for, 197.
+Walking, 205;
+  complexity of, 229;
+  coordination in, 3.
+Walks, morning, 169.
+Warming up, 92.
+Warning, coincidences and, 611
+Warts,
+  counting of, 493;
+  Lord Bacon and, 493;
+  mental influence and, 493.
+Wash water of little babies, 67.
+Water,
+  dread of, 62;
+  drinking, 232;
+  hypodermic, 88.
+Waters, mineral, 45.
+Waves of nervous energy, 110.
+Weak foot, 391.
+Weakness and discomfort, 299.
+Weapon ointment, 54.
+Weapon salve, 55.
+Weight,
+  abdominal distress and, 309;
+  for height, 299;
+  gain in, 301;
+  good feeling and, 297;
+  in intestinal neuroses, 285.
+Weir Mitchell's disease, 492.
+Wessex Tales, mental influence, instance of, 64.
+Whewell, 14.
+Which? (dream poem), 136.
+Whiskey,
+  in hypnotism, 156;
+  in snake bites, 32.
+White hair and fright, 494.
+Whoop, habit, 25.
+Whooping cough, 24;
+  diphtheria serum in, 25;
+  mine air in, 25;
+  more air in, 25;
+  sea water in, 25;
+  tuberculosis and, 25.
+Wiggs, Mrs., of the Cabbage Patch, 234.
+Will,
+  appetite and, 592;
+  breaking the, 744;
+  disorders of the, 694;
+  education of the, 220;
+  motion and the, 109;
+  over the heart, 313;
+  re-education of the, 737;
+  to live, 90;
+  training the, by punishment, 742, 744.
+Wimshurst machine, 43.
+Wind,
+  second, 92;
+  third and fourth, 92.
+Wine and the doctrine of signatures, 36.
+Winkel on vomiting at pregnancy, 457.
+Witchcraft, 141.
+Woman, average normal, 433.
+Women,
+  feed hearts of, 221;
+  home-keeping, 169;
+  working, 169.
+Woodward, 286.
+Wordsworth, 135.
+Work,
+  at home, 182;
+  latent intellectual, 134;
+  monastic division of, 227;
+  night, 175;
+  six hours of, 182;
+  social, 221;
+  the day's, 165, 171;
+  two-hour periods of, 227.
+Workers, night, 175.
+Working woman, 183.
+Worldliness,
+  this, 779;
+  other, 779.
+Wraiths, 608.
+Writers' cramp, 396, 572.
+Writing rule, Gower's, 174, 396.
+
+
+X
+
+X-rays, 5, 44.
+
+
+Y
+
+Yawning, contagious, 688.
+
+
+Z
+
+Zöllner's distortion of parallels, 771,
+Zoöphobia, 612.
+
+
+
+
+
+
+End of the Project Gutenberg EBook of Psychotherapy, by James J. Walsh
+
+*** END OF THIS PROJECT GUTENBERG EBOOK PSYCHOTHERAPY ***
+
+***** This file should be named 36450-8.txt or 36450-8.zip *****
+This and all associated files of various formats will be found in:
+        http://www.gutenberg.org/3/6/4/5/36450/
+
+Produced by Don Kostuch
+
+Updated editions will replace the previous one--the old editions
+will be renamed.
+
+Creating the works from public domain print editions means that no
+one owns a United States copyright in these works, so the Foundation
+(and you!) can copy and distribute it in the United States without
+permission and without paying copyright royalties.  Special rules,
+set forth in the General Terms of Use part of this license, apply to
+copying and distributing Project Gutenberg-tm electronic works to
+protect the PROJECT GUTENBERG-tm concept and trademark.  Project
+Gutenberg is a registered trademark, and may not be used if you
+charge for the eBooks, unless you receive specific permission.  If you
+do not charge anything for copies of this eBook, complying with the
+rules is very easy.  You may use this eBook for nearly any purpose
+such as creation of derivative works, reports, performances and
+research.  They may be modified and printed and given away--you may do
+practically ANYTHING with public domain eBooks.  Redistribution is
+subject to the trademark license, especially commercial
+redistribution.
+
+
+
+*** START: FULL LICENSE ***
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full Project
+Gutenberg-tm License (available with this file or online at
+http://gutenberg.org/license).
+
+
+Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
+electronic works
+
+1.A.  By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement.  If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or destroy
+all copies of Project Gutenberg-tm electronic works in your possession.
+If you paid a fee for obtaining a copy of or access to a Project
+Gutenberg-tm electronic work and you do not agree to be bound by the
+terms of this agreement, you may obtain a refund from the person or
+entity to whom you paid the fee as set forth in paragraph 1.E.8.
+
+1.B.  "Project Gutenberg" is a registered trademark.  It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement.  There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement.  See
+paragraph 1.C below.  There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this agreement
+and help preserve free future access to Project Gutenberg-tm electronic
+works.  See paragraph 1.E below.
+
+1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
+or PGLAF), owns a compilation copyright in the collection of Project
+Gutenberg-tm electronic works.  Nearly all the individual works in the
+collection are in the public domain in the United States.  If an
+individual work is in the public domain in the United States and you are
+located in the United States, we do not claim a right to prevent you from
+copying, distributing, performing, displaying or creating derivative
+works based on the work as long as all references to Project Gutenberg
+are removed.  Of course, we hope that you will support the Project
+Gutenberg-tm mission of promoting free access to electronic works by
+freely sharing Project Gutenberg-tm works in compliance with the terms of
+this agreement for keeping the Project Gutenberg-tm name associated with
+the work.  You can easily comply with the terms of this agreement by
+keeping this work in the same format with its attached full Project
+Gutenberg-tm License when you share it without charge with others.
+
+1.D.  The copyright laws of the place where you are located also govern
+what you can do with this work.  Copyright laws in most countries are in
+a constant state of change.  If you are outside the United States, check
+the laws of your country in addition to the terms of this agreement
+before downloading, copying, displaying, performing, distributing or
+creating derivative works based on this work or any other Project
+Gutenberg-tm work.  The Foundation makes no representations concerning
+the copyright status of any work in any country outside the United
+States.
+
+1.E.  Unless you have removed all references to Project Gutenberg:
+
+1.E.1.  The following sentence, with active links to, or other immediate
+access to, the full Project Gutenberg-tm License must appear prominently
+whenever any copy of a Project Gutenberg-tm work (any work on which the
+phrase "Project Gutenberg" appears, or with which the phrase "Project
+Gutenberg" is associated) is accessed, displayed, performed, viewed,
+copied or distributed:
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
+from the public domain (does not contain a notice indicating that it is
+posted with permission of the copyright holder), the work can be copied
+and distributed to anyone in the United States without paying any fees
+or charges.  If you are redistributing or providing access to a work
+with the phrase "Project Gutenberg" associated with or appearing on the
+work, you must comply either with the requirements of paragraphs 1.E.1
+through 1.E.7 or obtain permission for the use of the work and the
+Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
+1.E.9.
+
+1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
+terms imposed by the copyright holder.  Additional terms will be linked
+to the Project Gutenberg-tm License for all works posted with the
+permission of the copyright holder found at the beginning of this work.
+
+1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5.  Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6.  You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including any
+word processing or hypertext form.  However, if you provide access to or
+distribute copies of a Project Gutenberg-tm work in a format other than
+"Plain Vanilla ASCII" or other format used in the official version
+posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
+you must, at no additional cost, fee or expense to the user, provide a
+copy, a means of exporting a copy, or a means of obtaining a copy upon
+request, of the work in its original "Plain Vanilla ASCII" or other
+form.  Any alternate format must include the full Project Gutenberg-tm
+License as specified in paragraph 1.E.1.
+
+1.E.7.  Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8.  You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works provided
+that
+
+- You pay a royalty fee of 20% of the gross profits you derive from
+     the use of Project Gutenberg-tm works calculated using the method
+     you already use to calculate your applicable taxes.  The fee is
+     owed to the owner of the Project Gutenberg-tm trademark, but he
+     has agreed to donate royalties under this paragraph to the
+     Project Gutenberg Literary Archive Foundation.  Royalty payments
+     must be paid within 60 days following each date on which you
+     prepare (or are legally required to prepare) your periodic tax
+     returns.  Royalty payments should be clearly marked as such and
+     sent to the Project Gutenberg Literary Archive Foundation at the
+     address specified in Section 4, "Information about donations to
+     the Project Gutenberg Literary Archive Foundation."
+
+- You provide a full refund of any money paid by a user who notifies
+     you in writing (or by e-mail) within 30 days of receipt that s/he
+     does not agree to the terms of the full Project Gutenberg-tm
+     License.  You must require such a user to return or
+     destroy all copies of the works possessed in a physical medium
+     and discontinue all use of and all access to other copies of
+     Project Gutenberg-tm works.
+
+- You provide, in accordance with paragraph 1.F.3, a full refund of any
+     money paid for a work or a replacement copy, if a defect in the
+     electronic work is discovered and reported to you within 90 days
+     of receipt of the work.
+
+- You comply with all other terms of this agreement for free
+     distribution of Project Gutenberg-tm works.
+
+1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
+electronic work or group of works on different terms than are set
+forth in this agreement, you must obtain permission in writing from
+both the Project Gutenberg Literary Archive Foundation and Michael
+Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
+Foundation as set forth in Section 3 below.
+
+1.F.
+
+1.F.1.  Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+public domain works in creating the Project Gutenberg-tm
+collection.  Despite these efforts, Project Gutenberg-tm electronic
+works, and the medium on which they may be stored, may contain
+"Defects," such as, but not limited to, incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other intellectual
+property infringement, a defective or damaged disk or other medium, a
+computer virus, or computer codes that damage or cannot be read by
+your equipment.
+
+1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from.  If you
+received the work on a physical medium, you must return the medium with
+your written explanation.  The person or entity that provided you with
+the defective work may elect to provide a replacement copy in lieu of a
+refund.  If you received the work electronically, the person or entity
+providing it to you may choose to give you a second opportunity to
+receive the work electronically in lieu of a refund.  If the second copy
+is also defective, you may demand a refund in writing without further
+opportunities to fix the problem.
+
+1.F.4.  Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS' WITH NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
+WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5.  Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of damages.
+If any disclaimer or limitation set forth in this agreement violates the
+law of the state applicable to this agreement, the agreement shall be
+interpreted to make the maximum disclaimer or limitation permitted by
+the applicable state law.  The invalidity or unenforceability of any
+provision of this agreement shall not void the remaining provisions.
+
+1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in accordance
+with this agreement, and any volunteers associated with the production,
+promotion and distribution of Project Gutenberg-tm electronic works,
+harmless from all liability, costs and expenses, including legal fees,
+that arise directly or indirectly from any of the following which you do
+or cause to occur: (a) distribution of this or any Project Gutenberg-tm
+work, (b) alteration, modification, or additions or deletions to any
+Project Gutenberg-tm work, and (c) any Defect you cause.
+
+
+Section  2.  Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of computers
+including obsolete, old, middle-aged and new computers.  It exists
+because of the efforts of hundreds of volunteers and donations from
+people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need, are critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come.  In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future generations.
+To learn more about the Project Gutenberg Literary Archive Foundation
+and how your efforts and donations can help, see Sections 3 and 4
+and the Foundation web page at http://www.pglaf.org.
+
+
+Section 3.  Information about the Project Gutenberg Literary Archive
+Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service.  The Foundation's EIN or federal tax identification
+number is 64-6221541.  Its 501(c)(3) letter is posted at
+http://pglaf.org/fundraising.  Contributions to the Project Gutenberg
+Literary Archive Foundation are tax deductible to the full extent
+permitted by U.S. federal laws and your state's laws.
+
+The Foundation's principal office is located at 4557 Melan Dr. S.
+Fairbanks, AK, 99712., but its volunteers and employees are scattered
+throughout numerous locations.  Its business office is located at
+809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
+business@pglaf.org.  Email contact links and up to date contact
+information can be found at the Foundation's web site and official
+page at http://pglaf.org
+
+For additional contact information:
+     Dr. Gregory B. Newby
+     Chief Executive and Director
+     gbnewby@pglaf.org
+
+
+Section 4.  Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without wide
+spread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine readable form accessible by the widest
+array of equipment including outdated equipment.  Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States.  Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements.  We do not solicit donations in locations
+where we have not received written confirmation of compliance.  To
+SEND DONATIONS or determine the status of compliance for any
+particular state visit http://pglaf.org
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States.  U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg Web pages for current donation
+methods and addresses.  Donations are accepted in a number of other
+ways including checks, online payments and credit card donations.
+To donate, please visit: http://pglaf.org/donate
+
+
+Section 5.  General Information About Project Gutenberg-tm electronic
+works.
+
+Professor Michael S. Hart is the originator of the Project Gutenberg-tm
+concept of a library of electronic works that could be freely shared
+with anyone.  For thirty years, he produced and distributed Project
+Gutenberg-tm eBooks with only a loose network of volunteer support.
+
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the U.S.
+unless a copyright notice is included.  Thus, we do not necessarily
+keep eBooks in compliance with any particular paper edition.
+
+
+Most people start at our Web site which has the main PG search facility:
+
+     http://www.gutenberg.org
+
+This Web site includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.