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| author | Roger Frank <rfrank@pglaf.org> | 2025-10-14 20:05:51 -0700 |
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| committer | Roger Frank <rfrank@pglaf.org> | 2025-10-14 20:05:51 -0700 |
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diff --git a/36450-h/36450-h.htm b/36450-h/36450-h.htm new file mode 100644 index 0000000..4d679c3 --- /dev/null +++ b/36450-h/36450-h.htm @@ -0,0 +1,53160 @@ +<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"> +<html> + +<head> +<meta content="text/html;charset=ISO-8859-1" http-equiv="Content-Type"> +<title> +Psychotherapy; by James J. Walsh +</title> + +<style type="text/css"> + +h1 {font-size: 160%; text-align:center;} + +h2 {font-size: 120%; text-align:center;} + +i { font-weight: bold; } + +pre { margin-left: 40px; font-family: Serif; } + +.font80 { font-size: 80%; } + +.cite { margin-left: 5%; } + +.footnote { margin-left: 10%; margin-right: 10%;} + +.center { text-align: center; } + +</style> + +</head> + +<body> + + +<pre> + +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 + + + + + +</pre> + + +<p> +[Transcriber's Notes] +</p> +<p class="cite"> + This book is derived from a copy on the Internet Archive: + psychotherapy00walsgoog/psychotherapy00walsgoog_djvu.txt> +<br><br> + 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. + <a href="http://www.gutenberg.org/ebooks/17439"> + http://www.gutenberg.org/ebooks/17439</a> +<br><br> + 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. +<br><br> + 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. +<br><br> + When clicking on links to other sections, scroll down the page; the + targets are page numbers and the referenced section may be at the + bottom of the page. +<br><br> + Many paragraphs have bold or italic titles. These are rendered + by a extra blank line—a total of two blank lines. +<br><br> + Obvious spelling or typographical errors have been corrected. + Inconsistent spelling of names and inventive and alternative + spelling is left as printed. +<br><br> + The outline format of the book uses these conventions: +</p> +<pre> + 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 + <b>Varieties.</b>— [Bold] + <i>Palpitation.</i>— [italic] +</pre> +<p class="cite"> + 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. +</p> +<p> +[End Transcriber's Notes] +</p> +<br> +<h1>PSYCHOTHERAPY</h1> + +<br><br> + +<h1>PSYCHOTHERAPY</h1> + +<br><br> +<p align=center> +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. +<br><br> + + +BY +<br><br> +JAMES J. WALSH, M.D.. Ph.D. +<br><br> +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. +<br><br><br> + + + + + + + NEW YORK AND LONDON<br> + D. APPLETON AND COMPANY<br> +<br><br> + 1912 +<br><br><br> + + + + +COPYRIGHT, 1912, BY +<br><br> +D. APPLETON AND COMPANY +<br><br><br> + + +Printed in<br> +New York, U. S. A. + +<br><br><br> + + +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 +</p> + + +{vii} + + +<h2>PREFACE</h2> +<p> +"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 <i>apologia pro libro suo</i>. 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. +</p> +<p> +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. +</p> +<p> +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). +</p> +<p> +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 (<i>curare</i>) 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. +</p> +<p class="cite"> + James J. Walsh.<br> + 110 West Seventy-fourth Street,<br> + New York City. +</p> + +{ix} + +<h2>CONTENTS</h2> + + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td><br></td><td><br></td><td> PAGE</td></tr> +<tr><td><br></td><td>Introduction </td><td><a href="#1">1</a></td></tr> +</table> +<br> +<p align=center> +HISTORY OF PSYCHOTHERAPEUTICS +<br><br> +SECTION I +<br><br> + <i>Psychotherapy in the History of Medicine</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Great Physicians in Psychotherapy </td><td><a href="#7">7</a></td></tr> +<tr><td>II. </td><td>Unconscious Psychotherapeutics </td><td><a href="#19">19</a></td></tr> +<tr><td>III. </td><td>Genuine Remedies and Suggestive Exaggeration </td><td><a href="#25">25</a></td></tr> +<tr><td>IV. </td><td>Signatures And Psychotherapy </td><td><a href="#35">35</a></td></tr> +<tr><td>V. </td><td>Pseudo-science and Mental Healing </td><td><a href="#38">38</a></td></tr> +<tr><td>VI. </td><td>Quackery and Mind Cures </td><td><a href="#46">46</a></td></tr> +<tr><td>VII. </td><td>Nostrums and the Healing Power of Suggestion </td><td><a href="#53">53</a></td></tr> +<tr><td>VIII. </td><td>Amulets, Talismans, Charms </td><td><a href="#60">60</a></td></tr> +<tr><td>IX. </td><td>Deterrent Therapeutics </td><td><a href="#63">63</a></td></tr> +<tr><td>X. </td><td>Influence of the Personality in Therapeutics </td><td><a href="#69">69</a></td></tr> +<tr><td>XI. </td><td>Faith Cures </td><td><a href="#77">77</a></td></tr> +</table> + + +<p align=center> +GENERAL PSYCHOTHERAPEUTICS +<br><br> +SECTION II +<br><br> +<i>General Considerations</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Influence of Mind on Body</td><td><a href="#84">84</a></td></tr> +<tr><td>II. </td><td>Unfavorable Mental Influence</td><td><a href="#93">93</a></td></tr> +<tr><td>III.</td><td>The Influence of Body on Mind</td><td><a href="#100">100</a></td></tr> +<tr><td>IV.</td><td>The Mechanism of the Influence of Mind on Body</td><td><a href="#108">108</a></td></tr> +<tr><td>V. </td><td>Brain Cells and Mental Operations</td><td><a href="#124">124</a></td></tr> +<tr><td>VI.</td><td>Unconscious Cerebration</td><td><a href="#134">134</a></td></tr> +<tr><td>VII. </td><td>Distant Mental Influence</td><td><a href="#140">140</a></td></tr> +<tr><td>VIII.</td><td>Secondary Personality</td><td><a href="#147">147</a></td></tr> +<tr><td>IX. </td><td>Hypnotism</td><td><a href="#151">151</a></td></tr> +</table> + +<p align=center> +SECTION III +<br><br> +<i>The Individual Patient</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I.</td><td> Psychotherapy and the Individual Patient </td><td><a href="#163">163</a></td></tr> +<tr><td>II. </td><td>The Morning Hours </td><td><a href="#165">165</a></td></tr> +<tr><td>III. </td><td>The Day's Work </td><td><a href="#171">171</a></td></tr> +<tr><td>IV. </td><td>The Middle of the Day </td><td><a href="#179">179</a></td></tr> +<tr><td>V. </td><td>The Leisure Hours </td><td><a href="#181">181</a></td></tr> +</table> + +{x} + +<p align=center> +SECTION IV +<br><br> +<i>General Psychotherapeutics</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I.</td><td> General Principles of Psychotherapy </td><td><a href="#186">186</a></td></tr> +</tbody> +</table> +<p align=center> +SECTION V +<br><br> +<i>Adjuvants and Disturbing Factors</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Suggestion </td><td><a href="#194">194</a></td></tr> +<tr><td>II. </td><td>Exercise </td><td><a href="#198">198</a></td></tr> +<tr><td>III. </td><td>Position </td><td><a href="#207">207</a></td></tr> +<tr><td>IV.</td><td> Training </td><td><a href="#213">213</a></td></tr> +<tr><td>V. </td><td>Occupation of Mind </td><td><a href="#218">218</a></td></tr> +<tr><td>VI.</td><td> Diversion of Mind—Hobbies </td><td><a href="#224">224</a></td></tr> +<tr><td>VII.</td><td> Habit </td><td><a href="#229">229</a></td></tr> +<tr><td>VIII. </td><td>Pain </td><td><a href="#235">235</a></td></tr> +</table> + +<p align=center> +SPECIAL PSYCHOTHERAPY +<br><br> +SECTION VI +<br><br> + +<i>The Digestive Tract</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Influence of Mind on Food Digestion </td><td><a href="#242">242</a></td></tr> +<tr><td>II. </td><td>Indigestion and Unfavorable States of Mind </td><td><a href="#250">250</a></td></tr> +<tr><td>III. </td><td>Psychic Treatment of Digestive Conditions </td><td><a href="#254">254</a></td></tr> +<tr><td>IV. </td><td>Appetite </td><td><a href="#262">262</a></td></tr> +<tr><td>V.</td><td> Constipation </td><td><a href="#268">268</a></td></tr> +<tr><td>VI. </td><td>Neurotic Intestinal Affections </td><td><a href="#278">278</a></td></tr> +<tr><td>VII.</td><td>Muco-Membranous Colitis </td><td><a href="#286">286</a></td></tr> +<tr><td>VIII.</td><td>Obesity </td><td><a href="#290">290</a></td></tr> +<tr><td>IX. </td><td>Weight and Good Feeling </td><td><a href="#297">297</a></td></tr> +<tr><td>X</td><td>Vague Abdominal Discomforts—Loose Kidney</td><td><a href="#302">302</a></td></tr> +</table> + +<p align=center> +SECTION VII +<br><br> +<i>Cardiotherapy</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>The Heart and Mental Influence </td><td><a href="#310">310</a></td></tr> +<tr><td>II. </td><td>Diagnosis and Prognosis in Heart Disease </td><td><a href="#316">316</a></td></tr> +<tr><td>III. </td><td>Cardiac Neuroses </td><td><a href="#321">321</a></td></tr> +<tr><td>IV.</td><td>Cardiac Palpitation and Gastro-Intestinal Disturbance </td><td><a href="#328">328</a></td></tr> +<tr><td>V. </td><td>Angina Pectoris </td><td><a href="#335">335</a></td></tr> +<tr><td>VI. </td><td>Tachycardia </td><td><a href="#340">340</a></td></tr> +<tr><td>VII. </td><td>Bradycardia </td><td><a href="#342">342</a></td></tr> +</table> + +<p align=center> +SECTION VIII +<br><br> +<i>Respiratory Diseases</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tbody><tr><td>I. </td><td>Coughs and Colds </td><td><a href="#345">345</a></td></tr> +<tr><td>II. </td><td>Tuberculosis </td><td><a href="#350">350</a></td></tr> +<tr><td>III. </td><td>Neurotic Asthma and Cognate Conditions </td><td><a href="#364">364</a></td></tr> +<tr><td>IV. </td><td>Dust Asthma—Seasonal Catarrh, Hay Fever </td><td><a href="#368">368</a></td></tr> +<tr><td>V. </td><td>Dyspnea—Cat and Horse Asthma </td><td><a href="#373">373</a></td></tr> +</table> + +{xi} +<p align=center> +SECTION IX +<br><br> +<i>Psychotherapy in the Joint and Muscular System</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Painful Joint Conditions—Pseudo-Rheumatism</td><td><a href="#379">379</a></td></tr> +<tr><td>II.</td><td> Old Injuries and So-called Rheumatism </td><td><a href="#387">387</a></td></tr> +<tr><td>III. </td><td>Muscular Pains and Aches </td><td><a href="#389">389</a></td></tr> +<tr><td>IV. </td><td>Occupation Muscle and Joint Pains </td><td><a href="#395">395</a></td></tr> +<tr><td>V. </td><td>Painful Arm and Trunk Conditions </td><td><a href="#400">400</a></td></tr> +<tr><td>VI.</td><td>Lumbago and Sciatica </td><td><a href="#402">402</a></td></tr> +<tr><td>VII. </td><td>Painful Knee Conditions </td><td><a href="#409">409</a></td></tr> +<tr><td>VIII.</td><td> Foot Troubles </td><td><a href="#413">413</a></td></tr> +<tr><td>IX.</td><td>Arthritis Deformans </td><td><a href="#421">421</a></td></tr> +<tr><td>X.</td><td> Coccygodynia </td><td><a href="#428">428</a></td></tr> +</table> + +<p align=center> +SECTION X +<br><br> +<i>Gynecological Psychotherapy</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I.</td><td> Mental Healing in Gynecology </td><td><a href="#430">430</a></td></tr> +<tr><td>II. </td><td>Psychic States in Menstruation </td><td><a href="#434">434</a></td></tr> +<tr><td>III.</td><td>Amenorrhea </td><td><a href="#437">437</a></td></tr> +<tr><td>IV. </td><td>Dysmenorrhea </td><td><a href="#440">440</a></td></tr> +<tr><td>V. </td><td>Menorrhagia </td><td><a href="#447">447</a></td></tr> +<tr><td>VI. </td><td>The Menopause </td><td><a href="#450">450</a></td></tr> +</table> + +<p align=center> +SECTION XI +<br><br> +<i>Psychotherapy in Obstetrics</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I.</td><td> Suggestion in Obstetrics </td><td><a href="#453">453</a></td></tr> +<tr><td>II.</td><td> Maternal Impressions </td><td><a href="#461">461</a></td></tr> +</table> + +<p align=center> +SECTION XII +<br><br> +<i>Genito-Urinary Diseases</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Prostatism </td><td><a href="#468">468</a></td></tr> +<tr><td>II.</td><td> Sexual Neuroses </td><td><a href="#472">472</a></td></tr> +<tr><td>III. </td><td>Sexual Habits </td><td><a href="#482">482</a></td></tr> +</table> + +<p align=center> +SECTION XIII +<br><br> +<i>Skin Diseases</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Psychotherapy in Skin Diseases </td><td><a href="#491">491</a></td></tr> +</table> + +<p align=center> +SECTION XIV +<br><br> +<i>Diseases of Ductless Glands</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I.</td><td> Diabetes </td><td><a href="#496">496</a></td></tr> +<tr><td>II. </td><td>Graves' Disease </td><td><a href="#500">500</a></td></tr> +</table> + +{xii} + +<p align=center> +SECTION XV +<br><br> +<i>Organic Nervous Diseases</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Psychotherapy of Organic Nervous Diseases </td><td><a href="#508">508</a></td></tr> +<tr><td>II. </td><td>Cerebral Apoplexy </td><td><a href="#513">513</a></td></tr> +<tr><td>III. </td><td>Locomotor Ataxia </td><td><a href="#524">524</a></td></tr> +<tr><td>IV.</td><td> Paresis </td><td><a href="#530">530</a></td></tr> +<tr><td>V. </td><td>Epilepsy and Pseudo-Epilepsy </td><td><a href="#534">534</a></td></tr> +<tr><td>VI. </td><td>Paralysis Agitans </td><td><a href="#542">542</a></td></tr> +<tr><td>VII. </td><td>Headache </td><td><a href="#546">546</a></td></tr> +</table> + +<p align=center> +SECTION XVI +<br><br> +<i>Neuroses</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Nervous Weakness (Neurasthenia) </td><td><a href="#555">555</a></td></tr> +<tr><td>II. </td><td>Chorea </td><td><a href="#561">561</a></td></tr> +<tr><td>III. </td><td>Tics </td><td><a href="#564">564</a></td></tr> +<tr><td>IV. </td><td>Stuttering, Ataxia in Talking, Walking, Writing, Etc. </td><td><a href="#570">570</a></td></tr> +<tr><td>V. </td><td>Tremors </td><td><a href="#580">580</a></td></tr> +</table> + +<p align=center> +DISORDERS OF THE PSYCHE +<br><br> +SECTION XVII +<br><br> +<i>Psycho-Neuroses</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Psycho-Neuroses (Hysteria) </td><td><a href="#585">585</a></td></tr> +</table> + +<p align=center> +SECTION XVIII +<br><br> +<i>Disorders of Mind</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Mental Incapacity (Psychasthenia) </td><td><a href="#597">597</a></td></tr> +<tr><td>II. </td><td>Hallucinations </td><td><a href="#603">603</a></td></tr> +<tr><td>III. </td><td>Dreads </td><td><a href="#612">612</a></td></tr> +<tr><td>IV.</td><td> Heredity </td><td><a href="#627">627</a></td></tr> +<tr><td>V. </td><td>Premonitions </td><td><a href="#634">634</a></td></tr> +<tr><td>VI. </td><td>Periodical Depression </td><td><a href="#641">641</a></td></tr> +<tr><td>VII. </td><td>Insomnia </td><td><a href="#651">651</a></td></tr> +<tr><td>VIII. </td><td>Some Troubles of Sleep </td><td><a href="#663">663</a></td></tr> +<tr><td>IX. </td><td>Dreams </td><td><a href="#669">669</a></td></tr> +<tr><td>X. </td><td>Disorders of Memory </td><td><a href="#678">678</a></td></tr> +<tr><td>XI. </td><td>Psychic Contagion </td><td><a href="#688">688</a></td></tr> +</table> + +<p align=center> +SECTION XIX +<br><br> +<i>Disorders of Will</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Alcoholism </td><td><a href="#694">694</a></td></tr> +<tr><td>II. </td><td>Drug Addictions </td><td><a href="#707">707</a></td></tr> +<tr><td>III.</td><td> Suicide </td><td><a href="#713">713</a></td></tr> +<tr><td>IV.</td><td> Grief </td><td><a href="#727">727</a></td></tr> +<tr><td>V.</td><td> Doubting </td><td><a href="#732">732</a></td></tr> +<tr><td>VI.</td><td> Responsibility and Will Power </td><td><a href="#738">738</a></td></tr> +</table> + +{xiii} + +<p align=center> +SECTION XX +<br><br> +<i>Psychotherapy in Surgery</i> +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Psychotherapy in Old-Time Surgery </td><td><a href="#746">746</a></td></tr> +<tr><td>II. </td><td>Mental Influence Before Operation </td><td><a href="#749">749</a></td></tr> +<tr><td>III. </td><td>Mental Influence and Anesthesia </td><td><a href="#753">753</a></td></tr> +<tr><td>IV. </td><td>Mental Influence After Operation </td><td><a href="#759">759</a></td></tr> + +</table> + +<p align=center> +APPENDICES +</p> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tr><td>I. </td><td>Illusions </td><td><a href="#766">766</a></td></tr> +<tr><td>II.</td><td> Religion and Psychotherapy </td><td><a href="#776">776</a></td></tr> +<tr><td><br></td><td>INDEX </td><td><a href="#781">781</a></td></tr> +</table> +<br> +{xiv} +<br><br> +{xv} +<br> +<h2>LIST OF ILLUSTRATIONS</h2> + +<table border="0" cellpadding="2" cellspacing="2" width="100%"> +<col width="10%"><col width="80%"><col width="10%"> +<tbody><tr><td>FIG. </td><td> <br></td><td> PAGE</td></tr> +<tr><td><br> +</td><td>The Temple of Epidaurus as a health resort </td><td> Facing page <a href="#9">9</a></td></tr> +<tr><td>1.</td><td>Expressions of the mouth </td><td><a href="#102">102</a></td></tr> +<tr><td>2.</td><td>Cortex of human brain illustrating complexity of the systems and plexuses of nerve fibers </td><td> <a href="#109">109</a></td></tr> +<tr><td>3.</td><td>Small and medium-sized pyramidal cells of the visual cortex of a child twenty days old </td><td> <a href="#110">110</a></td></tr> +<tr><td>4.</td><td>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. </td><td> <a href="#111">111</a></td></tr> +<tr><td>5.</td><td>First, second and third layer of the anterior central convolution +of the brain of a child one month old +</td><td> <a href="#112">112</a></td></tr> +<tr><td>6.</td><td>Layers of the posterior central or ascending parietal convolution of a new-born child </td><td> <a href="#112">112</a></td></tr> +<tr><td>7.</td><td>Diagram of cells of cerebral cortex </td><td> <a href="#113">113</a></td></tr> +<tr><td>8.</td><td>Scheme of lower motor neuron </td><td> <a href="#114">114</a></td></tr> +<tr><td>9.</td><td>Scheme of the visual conduction paths </td><td> <a href="#115">115</a></td></tr> +<tr><td>10.</td><td>Schematic frontal section through the occipital lobe illustrating +manifold connections in a single lobe </td><td> +<a href="#116">116</a></td></tr> +<tr><td>11.</td><td>Isolated cell from human spinal cord </td><td> <a href="#117">117</a></td></tr> +<tr><td>12.</td><td>Neuron from the optic lobe of the embryo chick </td><td> <a href="#118">118</a></td></tr> +<tr><td>13.</td><td>Deep layer of giant pyramidal cells of the posterior central or +ascending parietal convolution of a child thirty days old </td><td> +<a href="#119">119</a></td></tr> +<tr><td>14.</td><td>Pyramidal cell of cerebral cortex of mouse </td><td> <a href="#119">119</a></td></tr> +<tr><td>15.</td><td>Neuroglia cells of the fascia dentata, in the new-born rabbit </td><td> <a href="#121">121</a></td></tr> +<tr><td>16.</td><td>Neuroglia cell from the subcortical layer of the cerebrum from +which two processes go to a blood vessel +</td><td> <a href="#122">122</a></td></tr> +<tr><td>17.</td><td>Neuroglia cells from the spinal cord </td><td> <a href="#122">122</a></td></tr> +<tr><td>18.</td><td>An artery from the cerebral cortex </td><td> <a href="#125">125</a></td></tr> +<tr><td>19.</td><td>Neuroglia cells of the superficial layers of the brain from an infant aged two months </td><td> <a href="#126">126</a></td></tr> +<tr><td>20.</td><td>Complexity of cell of the central nervous system </td><td><a href="#131">131</a></td></tr> +<tr><td>21.</td><td>Section through the cortex of the gyrus occipitalis superior </td><td> <a href="#132">132</a></td></tr> +<tr><td>22.</td><td>Motor cell of ventral horn of spinal cord from the human fetus </td><td> <a href="#133">133</a></td></tr> +<tr><td>23.</td><td>Normal diaphragm curve in normal breathing </td><td> <a href="#577">577</a></td></tr> +<tr><td>24.</td><td>Curve in diaphragm before and during talking by a stutterer </td><td> <a href="#577">577</a></td></tr> +<tr><td>25.</td><td>Illusion of dual vision </td><td> <a href="#615">615</a></td></tr> +<tr><td>26.</td><td>Illusion of dual vision </td><td> <a href="#767">767</a></td></tr> +<tr><td>27.</td><td>Binocular vision </td><td> <a href="#767">767</a></td></tr> +<tr><td>28.</td><td>Binocular vision </td><td> <a href="#767">767</a></td></tr> +<tr><td>29.</td><td>The Müller-Lyer lines </td><td> <a href="#768">768</a></td></tr> +<tr><td>30.</td><td>Illusions of size </td><td> <a href="#769">769</a></td></tr> +<tr><td>31.</td><td>Illusion of filled space (interrupted vision) </td><td> <a href="#769">769</a></td></tr> +<tr><td>32.</td><td>Illusions of size and linear continuity </td><td> <a href="#770">770</a></td></tr> +<tr><td>33.</td><td>Poggendorf's displacement of oblique lines </td><td> <a href="#771">771</a></td></tr> +<tr><td>34.</td><td>Zöllner's distortion of parallel lines </td><td> <a href="#771">771</a></td></tr> +</table> +<br> + + +<a name="1">{1}</a> + + +<h2>PSYCHOTHERAPY +<br><br> +INTRODUCTION</h2> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Coincidence and Consequence</b>.—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. +</p> +<p> +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 <a name="2">{2}</a> +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. +</p> +<br> +<p> +<b>Mental Influence.</b>—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. +</p> +<p> +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. +</p> +<p> +The history of the phases of psychotherapy brings out clearly how much +it has always meant in the curing of human ills. +</p> +<br> +<p> +<b>Constancy of Psychotherapy in Medicine.</b>—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. +</p> +<p> +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 <a name="3">{3}</a> 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. +</p> +<p> +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 <i>theriac</i> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Irregular Phases of Psychotherapy.</b>—The quack has always been a +psycho-therapeutist <i>par excellence</i>. 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. +</p> +<br> +<p> +<b>Drug Therapeutics.</b>—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 <a name="4">{4}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. <a name="5">{5}</a> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Supposed Novelties in Mind Healing.</b>—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. +</p> +<p> +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. +</p> +<p> +We have not yet reached a point in our knowledge of the mode of the <a +name="6">{6}</a> 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. +</p> +<p> +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. +</p> +<p> +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: +</p> +<p class="cite"> + Si quid novisti rectius his candidus imperti<br> + Si non his utere mecum. +</p> + +<a name="7">{7}</a> + +<h2>HISTORY OF PSYCHOTHERAPEUTICS +<br><br> +SECTION I +<br><br> +<i>PSYCHOTHERAPY IN THE HISTORY OF MEDICINE</i> </h2> +<br> + +<h2>CHAPTER I +<br><br> +GREAT PHYSICIANS IN PSYCHOTHERAPY</h2> +<br> +<p class="cite"> +"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." +</p> +<p> +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. +</p> +<br> +<h2>FIRST PHYSICIAN</h2> + +<p> +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. +</p> +<p> +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 <a +name="8">{8}</a> 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. +</p> +<br> +<h2>PSYCHOTHERAPY IN EGYPT</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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." +</p> +<p> +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: +</p> +<p class="cite"> + 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 <a name="9">{9}</a> 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. +</p> +<hr> +<p align=center> +<b>The Temple at Epidaurus as a Health Resort</b> +</p> +<p class="cite"> + 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. +</p> +<p class=center> +<img style="width: 1464px; height: 1140px;" alt="" +src="images/009f0.jpg" border=1> +<br> +</p> +<p class="cite"> + 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.) +</p> +<hr> +<p> +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 <i>secondary personalities</i>. 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 <i>ba</i> somewhat as we play solitaire. He could +talk to and exchange gifts with his <i>ka</i>. He could argue and +remain at variance, but more often come to an agreement, with his +<i>khou</i>. This last was his luminous immortal <i>ego</i>, 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. +</p> +<p> +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 <a +name="10">{10}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>MIND HEALING IN GREECE</h2> + +<p> +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, <i>but also to make the +patient, the attendants and externals coöperate."</i> 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. +</p> +<p> +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 <a name="11">{11}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> + +<p class="footnote"> + [Footnote 1: "AEquanimitas and Other Addresses."] +</p> + +<p class="cite"> + 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. <i>For this,'</i> he said, <i>'is the great error of our day + in the treatment of the human body, that physicians separate the + soul from the body.</i>'" +</p> + +<p> +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. +</p> +<br> +<h2>ALEXANDRIAN PSYCHOTHERAPY</h2> + +<p> +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, <a name="12">{12}</a> +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 <i>torcular</i> within the skull, and it +was he who gave the name <i>calamus scriptorius</i> 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. +</p> +<p> +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. +</p> +<br> +<h2>PSYCHOTHERAPY AT ROME</h2> + +<p> +<b>Galen.</b>—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. +</p> +<p> +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 <a +name="13">{13}</a> 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. +</p> +<br> +<p> +<b>Alexander of Tralles.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Paul of AEgina.</b>—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. +</p> +<br> +<h2>ARABIAN MENTAL MEDICINE</h2> + +<p> +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 <a name="14">{14}</a> 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. +</p> +<p> +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." +</p> +<br> +<h2>MEDIEVAL MIND-HEALING</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>MENTAL HEALING IN THE RENAISSANCE</h2> + +<p> +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 <a name="15">{15}</a> by influence from the minds of +others, and that such treatment, undertaken by physicians +appropriately endowed, produced wonderful effects. He said: +</p> +<p class="cite"> + 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. +</p> +<br> +<h2>PSYCHOTHERAPY AND MODERN MEDICINE</h2> + +<p> +<b>Paracelsus.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Agrippa.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Van Helmont.</b>—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 <a name="16">{16}</a> 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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Sydenham.</b>—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: +</p> +<p class="cite"> + 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." +</p> +<br> +<p> +<b>Morgagni.</b>—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: +</p> +<p class="footnote"> + [Footnote 2: London, 1901] +</p> +<a name="17">{17}</a> + +<p class="cite"> + 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. +<br><br> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>John Hunter.</b>—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." +</p> +<br> +<p> +<b>German Mind Healing.</b>—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 <a name="18">{18}</a> 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. +</p> +<p class="footnote"> + [Footnote 3: "Die Psychische Krankenbehandlung im Ihren + Wissenschaftlichen Grundlagen." Berlin 1910.] +</p> +<p> +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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<p> +Even this necessarily fragmentary and rather disjointed sketch of the +main features of psychotherapeutics, as we see them recognized by the +great <a name="19">{19}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +UNCONSCIOUS PSYCHOTHERAPEUTICS</h2> +<p> +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. +</p> +<p> +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, <i>per se</i>, +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. +</p> +<br> +<h2>REMEDIES PLUS SUGGESTION</h2> +<p> +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 <a +name="20">{20}</a> 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. +</p> +<p> +"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. +</p> +<br> +<p> +<b>Galen's Theriac.</b>—Perhaps the most striking instance of +suggestive therapeutics is Galen's famous <i>theriac</i>, 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. +</p> +<br> +<p> +<b>Bernard's Theriac.</b>—Almost in our own time another +<i>theriac</i> 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 <i>theriac</i>. +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 +<i>theriac</i>." 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. +</p> +<p> +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 <i>theriac</i>. +</p> +<p> +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 <a name="21">{21}</a> 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. +</p> +<br> +<p> +<b>Suggestion in Colds.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Erysipelas.</b>—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 <a name="22">{22}</a> +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! +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Pneumonia.</b>—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. +</p> +<p> +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 <a +name="23">{23}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="24">{24}</a> +by him meant much for his patient. It would have been better had he +exaggerated the mental influence rather than the drug power. +</p> +<br> +<p> +<b>Typhoid Fever.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Whooping Cough.</b>—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 <a name="25">{25}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>CHAPTER III +<br><br> +GENUINE REMEDIES AND SUGGESTIVE EXAGGERATION</h2> + +<p> +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 <a +name="26">{26}</a> 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. +</p> +<br> +<h2>THERAPEUTIC PERSUASION</h2> + +<p> +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." +</p> +<br> +<p> +<b>Suggestion and Antimony.</b>—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. +</p> +<p> +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 <a name="27">{27}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Calomel and Suggestion.</b>—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. +</p> +<br> +<p> +<b>Venesection and Its Suggestiveness.</b>—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. +</p> +<a name="28">{28}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Quinine and Suggestion.</b>—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 +<i>Plasmodium malariae</i> 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. +</p> +<p> +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 <a name="29">{29}</a> +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. +</p> +<br> +<p> +<b>St. John Long's Liniment.</b>—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. +</p> +<p> +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 <a +name="30">{30}</a> 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. +</p> +<br> +<p> +<b>Alcohol Plus Suggestion.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="31">{31}</a> 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. +</p> +<br> +<p> +<i>Alcohol in Pneumonia</i>.—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. +</p> +<br> +<p> +<i>Alcohol in Vague Affections</i>.—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 <a name="32">{32}</a> formation of a +whiskey habit; hence the crusade which has discredited these remedies. +</p> +<p> +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. +</p> +<br> +<p> +<i>Whiskey in Snake-Bites</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Other Cures.</b>—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 <a name="33">{33}</a> +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. +</p> +<br> +<p> +<b>Antidotes and Suggestion.</b>—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. +</p> +<br> +<p> +<b>Poultices in Suggestive Therapeutics.</b>—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. +</p> +<p> +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 <a name="34">{34}</a> 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. +</p> +<br> +<p> +<i>Poultices and the Doctrine of Signatures</i>.—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. +</p> +<br> +<p> +<i>Deterrent Materials and Suggestion</i>.—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. +</p> +<br> +<p> +<b>Ointments.</b>—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 <a name="35">{35}</a> 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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +SIGNATURES AND PSYCHOTHERAPY</h2> + +<p> +<i>Similia similibus curantur</i>, 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 <i>genus +myosotis</i>, 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Signature Details.</b>—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 <a +name="36">{36}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Wines as Remedies.</b>—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. +</p> +<p> +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 <a name="37">{37}</a> 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. +</p> +<br> +<p> +<b>Precious Stones.</b>—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: +</p> +<p class="cite"> + A compassionate turquoise that doth tell<br> + By looking pale, the owner is not well. +</p> +<p> +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 <i>a</i> privative and <i>methuo</i>, "I get +drunk," suggesting strongly to the wearer that he should not get +drunk. +</p> +<p> +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. +</p> +<p> +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 <a name="38">{38}</a> 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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +PSEUDO-SCIENCE AND MENTAL HEALING</h2> + +<p> +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 <i>nil</i>. 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. +</p> +<br> +<h2>ASTROLOGY</h2> + +<p> +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. +</p> +<p> +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 <a +name="39">{39}</a> 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.) +</p> +<p> +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." +</p> +<br> +<p> +<b>Later Astrology.</b>—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. +</p> +<a name="40">{40}</a> +<p> +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. +</p> +<br> +<h2>HERBAL MEDICINE</h2> + +<p> +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. +</p> +<br> +<h2>ALCHEMY</h2> + +<p> +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 +<a name="41">{41}</a> 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. +</p> +<p> +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. +</p> +<br> +<h2>MATHEMATICAL MEDICINE</h2> + +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<br> +<h2>MAGNETISM</h2> + +<p> +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. +</p> +<br> +<p> +<b>Human Magnetism.</b>—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 <a name="42">{42}</a> 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. +</p> +<p> +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. +</p> +<br> +<h2>ELECTROTHERAPY</h2> + +<p> +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. +</p> +<p class="cite"> + 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. +</p> +<p> +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 <a name="43">{43}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="44">{44}</a> +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. +</p> +<br> +<h2>LIGHT AND PSYCHOTHERAPY</h2> + +<p> +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. +</p> +<br> +<h2>THE X-RAY</h2> + +<p> +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 +<a name="45">{45}</a> 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. +</p> +<br> +<h2>RADIUM AND RADIO-ACTIVITY</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>SUGGESTION AND PSEUDO-SCIENCE</h2> + +<p> +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 <a name="46">{46}</a> 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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +QUACKERY AND MIND CURES</h2> + +<p> +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 <i>vis +medicatrix naturae</i> brings about a cure. +</p> +<p> +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 <a name="47">{47}</a> found that +the medicines prescribed were likely to do harm rather than good, yet +many of the patients were benefited. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Cagliostro.</b>—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. +</p> +<p> +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, +<a name="48">{48}</a> 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. +</p> +<br> +<p> +<b>Perkins, Prince of Quacks.</b>—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. +</p> +<p> +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: +</p> +<p class="footnote"> + [Footnote 4: Houghton, Mifflin Co., Boston.] +</p> +<p class="cite"> + 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. +</p> +<p class="footnote"> + [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 <i>tractim + tangere</i>—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.] +</p> +<p> +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 <a name="49">{49}</a> 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. +</p> +<p> +Dr. Holmes continues: +</p> +<p class="cite"> + 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] +</p> +<p class="footnote"> + [Footnote 6:<br> + "See pointed metals, blest with power t' appease<br> + The ruthless rage of merciless disease,<br> + O'er the frail part a subtle fluid pour,<br> + Drenched with the invisible galvanic shower,<br> + Till the arthritic staff and crutch forego<br> + And leap exulting like the bounding roe!"] +</p> +<p> +Miss Watterson [Footnote 7] tells how he attracted attention. Like all +successful quacks, he had an inborn genius for advertising. +</p> +<p class="footnote"> + [Footnote 7: "Mesmer and Perkins's Tractors,"<br> + <i>International Clinics</i>, Vol. III, Series 19. 1909.] +</p> +<p class="cite"> + 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. +<br><br> + "Why, I could have cured you in the same way with my old brick-bat + or tobacco pipe, or even my fingers." +<br><br> + "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?" +<br><br> + 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. +<br><br> + 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] +</p> +<p> +<p class="footnote"> + [Footnote 8: Compare the first effects of the Leyden Jar, related + in the chapter on Pseudo-Science.] +</p> +<p class="cite"> + 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 + <a name="50">{50}</a> to Sir William Watson in London and Dr. Moncriffe + in Bristol, who operated with them with wonderful results. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Holmes wrote: +</p> +<p class="cite"> + 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 + <a name="51">{51}</a> 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!" +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Success of Quackery</b>.—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. +</p> +<p> +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. +</p> +<p> +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, +<a name="52">{52}</a> 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. +</p> +<p> +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": +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<p> +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 <a name="53">{53}</a> +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. +</p> +<br> + +<h2>CHAPTER VII +<br><br> +NOSTRUMS AND THE HEALING POWER OF SUGGESTION</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="54">{54}</a> wants to share the heaven-sent blessing with all +mankind—for a valuable consideration. +</p> +<br> +<p> +<b>The Weapon Ointment.</b>—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 <i>to the weapon which inflicted the +wound</i>. 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. +</p> +<p> +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: +</p> +<p class="footnote"> + [Footnote 9: Houghton Mifflin Co., Boston.] +</p> +<p class="cite"> + 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. <i>Still there was not wanting some + among the more respectable members of the medical profession who + supported its claims</i>. [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. +<br><br> + 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. +</p> +<p> +Holmes says further: +</p> +<p class="cite"> + 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 <a name="55">{55}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <i>usnea</i>, 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. +</p> +<br> +<p> +<b>Sympathetic Powder.</b>—After the weapon ointment, the best known +of the nostrums of older times is probably Sir Kenelm Digby's famous +Sympathetic <a name="56">{56}</a> 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 <i>bloodstained</i> 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +<br><br> + 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, <i>which all succeeded in a surprising manner</i>. +</p> +<br> +<p> +<b>Tar Water and Therapeutic Faith.</b>—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. <a name="57">{57}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Sarsaparilla.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="58">{58}</a> +sarsaparilla had cured them of long-standing ills, and that they +considered it a life-saving remedy. +</p> +<p> +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. +</p> +<br> +<p> +<b>Psychology, Old and New, of Remedies.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Roman Nostrums.</b>—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 <a +name="59">{59}</a> 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. +</p> +<br> +<p> +<i>Proprietary Remedies</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Common Ailments and Nostrums.</b>—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 <a name="60">{60}</a> +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. +</p> +<br> +<p> +<b>Cured Cases as Evidence.</b>—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. +</p> +<br> + +<h2>CHAPTER VIII +<br><br> +AMULETS, TALISMANS, CHARMS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Prophylactic Objects.</b>—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. +</p> +<p class="footnote"> + [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.] +</p> +<p> +The precious metals were used also as powerful cures. Chaucer says, +"for <a name="61">{61}</a> 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. +</p> +<br> +<p> +<b>Rings in Therapy.</b>—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. +</p> +<p> +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 +<a name="62">{62}</a> 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. +</p> +<br> +<p> <b>Precious Stones as Preservatives.</b>—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. </p> +<br> +<p> +<b>Amulets.</b>—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. +</p> +<p> +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 <a name="63">{63}</a> 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. +</p> +<br> + +<h2>CHAPTER IX +<br><br> +DETERRENT THERAPEUTICS</h2> + +<p> +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, <i>cure</i>. +</p> +<br> +<p> +<b>Portions of Corpses.</b>—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. +</p> +<a name="64">{64}</a> +<p> +<b>Touch of the Hanged.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mummies.</b>—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: +</p> +<p class="cite"> + 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 <a name="65">{65}</a> 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. +<br><br> + 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. +</p> +<br> +<p> +<b>Serpents in Therapeutics.</b>—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. +</p> +<p> +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 <a name="66">{66}</a> 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. +</p> +<br> +<p> +<b>Repugnant Remedial Measures.</b>—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. +</p> +<br> +<p> +<i>Ordures as Remedies</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Excretions and Secretions</i>.—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 <a name="67">{67}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Diseases Benefited.</b>—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. +</p> +<br> +<p> +<b>Deterrent Pain.</b>—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 <a name="68">{68}</a> 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. +</p> +<p> +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 <i>par +excellence</i> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Deterrent Taste and Smell.</b>—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 +<i>contrecoup</i> 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 <a name="69">{69}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER X +<br><br> +INFLUENCE OF THE PERSONALITY IN THERAPEUTICS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Place of Personal Influence.</b>—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 <a +name="70">{70}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>IMPRESSIVE PERSONALITY</h2> + +<p> +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 <a name="71">{71}</a> 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. +</p> +<br> +<p> +<b>A Great Modern Physician's Influence.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="72">{72}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>A Modern Healer.</b>—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 <i>by him</i> 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. +</p> +<a name="73">{73}</a> +<p> +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. +</p> +<p> +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 <i>own</i> +forces more successfully. +</p> +<br> +<p> +<b>An Ancient Healer.</b>—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 <a name="74">{74}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Constancy of the Law of Personal Influence.</b>—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. +</p> +<p> +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 <a +name="75">{75}</a> 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. +</p> +<br> +<p> +<b>Modern Examples.</b>—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." +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="76">{76}</a> +<br> + +<h2>SUCCESS IN HEALING</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="77">{77}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>CHAPTER XI +<br><br> +FAITH CURES</h2> + +<p> +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 <a name="78">{78}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Accessories of Faith Cures.</b>—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. +</p> +<br> +<p> +<b>Miracles.</b>—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 <a name="79">{79}</a> +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 <i>"La clinique de Lourdes,"</i> I am convinced that +miracles happen there. There is more than natural power manifest. +</p> +<p> +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. +</p> +<br> +<p> +<b>The Royal Touch.</b>—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." +</p> +<p> +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. +<a name="80">{80}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Cramp Rings.</b>—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. +</p> +<a name="81">{81}</a> +<p> +<b>Mental Healers.</b>—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. +</p> +<p> +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. +</p> +<p> +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" (<i>Scribners</i>, 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. +</p> +<p> +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 <a name="82">{82}</a> 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. +</p> +<p> +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 <i>them</i>. 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. +</p> +<br> +<p> +<i>Schlatter and Dowie.</i>—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. <a name="83">{83}</a> 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. +</p> + +<a name="84">{84}</a> +<br> +<h2>GENERAL PSYCHOTHERAPEUTICS +<br><br> + +SECTION II +<br><br> + +<i>GENERAL CONSIDERATIONS</i> +<br><br> + +CHAPTER I +<br><br> + +INFLUENCE OF MIND ON BODY</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +Cabanis, at the beginning of the nineteenth century, under the title +of <a name="85">{85}</a> "The Influence of the Moral on the Physical," +discusses what we would now call mental influence on the body. He +says: +</p> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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. +</p> +<br> +<p> +<b>Relief in Severe Injuries.</b>—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. +</p> +<p> +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, +<a name="86">{86}</a> ordinarily quite painful and disabling, while +laboring to help others in an accident. +</p> +<br> +<p> +<b>Suppression of Reaction.</b>—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. </p> +<br> +<p> +<b>Amputation Stump Aches.</b>—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. +</p> +<br> +<p> +<b>The Mind and Motility.</b>—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. +</p> +<p> +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. (<a href="#108">See the +chapter on the Mechanism of Suggestion.</a>) 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. +</p> +<a name="87">{87}</a> +<p> +<i>Astasia-abasia.</i>—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. +</p> +<br> +<p> +<b>Mental Influence on Organs.</b>—<i>The Heart</i>.—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. +</p> +<br> +<p> +<i>Digestive Tract</i>.—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. +</p> +<br> +<p> +<b>Nervous Inhibition.</b>—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 <a name="88">{88}</a> 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. +</p> +<p> +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. +</p> +<p class="footnote"> + [Footnote 11: Small, Maynard & Co.. Boston, 1909.] +</p> +<p> +<b>Imaginary Drug Effects.</b>—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. +</p> +<p> +<b>The Nerves and Tissues</b>.—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 <a name="89">{89}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Nerve Supply and Health</i>.—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. +</p> +<p> +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, <a name="90">{90}</a> 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. +</p> +<br> +<p> +<b>Death and the Mind.</b>—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. +</p> +<p> +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. +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Dread and Death</i>.—Dr. Laurent in his little book, "La Médecine +des Âmes," [Footnote 12] has a story of similar kind but from a very +different motive: +</p> +<p class="footnote"> + [Footnote 12: Paris, Maloine, 1804.] +</p> +<p class="cite"> + 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 <a name="91">{91}</a> 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. +<br><br> + "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." +<br><br> + 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. +<br><br> + 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." +<br><br> + 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. +</p> +<br> +<p> +<i>Suggestion and Death.</i>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Renewal of Hope.</i>—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 <a name="92">{92}</a> 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. +</p> +<br> +<p> +<b>Law of Reserve Energy.</b>—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: +</p> +<p class="footnote"> + [Footnote 13: <i>American Magazine</i>, Sept., 1908.] +</p> +<p class="cite"> + 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. +<br><br> + 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. +</p> +<p> +He then states what has come to be called the law of reserve energy. +</p> +<p class="cite"> + <i>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</i>. +</p> +<p> +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 <a name="93">{93}</a> may die +simply because they give up the struggle. Men and women who <i>will +not give up</i> 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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +UNFAVORABLE MENTAL INFLUENCE</h2> + +<p> +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. +</p> +<br> +<p> +<b>Pathological Suggestion.</b>—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 +<a name="94">{94}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Unfavorable Suggestion in Ancient Times.</b>—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. +</p> +<p> +Plato, in the "Republic," says: +</p> +<p class="cite"> + 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." +</p> +<p> +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. +</p> +<p> +Nowhere more than in this matter of knowledge of disease, can weight +<a name="95">{95}</a> 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. +</p> +<br> +<p> +<b>Bacteriphobia.</b>—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. +</p> +<p> +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. +</p> +<p> +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, <a name="96">{96}</a> 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. +</p> +<br> +<p> +<i>Opposing Favorable Suggestion</i>,—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Familiar Examples of Unfavorable Suggestion.</b>—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 +<a name="97">{97}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Suggestion and Seasickness</i>.—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. +</p> +<p> +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. <a name="98">{98}</a> 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. +</p> +<br> +<p> <b>Disease Groups and Suggestion.</b>—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. +</p> +<br> +<p> +<i>Fearing the Worst</i>.—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. +</p> +<br> +<p> +<b>So-called Incurability.</b>—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 +<a name="99">{99}</a> 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 <i>cura</i> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Thinking Health.</b>—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. +</p> +<p class="footnote"> + [Footnote 14: McClurg, Chicago, 1903.] +</p> +<p> +In recent years, to paraphrase Plato's expression, people are much +more <a name="100">{100}</a> 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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +THE INFLUENCE OF BODY ON MIND</h2> + +<p> +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. +</p> +<p> +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 <a name="101">{101}</a> might not suffer the after +consequences, but especially the depression and irritability of mind. +</p> +<br> +<p> +<b>Disposition and Digestion.</b>—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. +</p> +<br> +<p> +<b>Feeling and Expression.</b>—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. +</p> +<p> +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. +</p> +<a name="102">{102}</a> +<p> +<i>The Mouth</i>.—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. +</p> + +<p class=center> +<img style="width: 600px; height: 154px;" alt="" +src="images/102f1.jpg" border=1> +<br> +Fig. 1. Three abstract faces. +</p> +<p> +<i>The Eyes</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Wrinkles</i>.—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 <a name="103">{103}</a> 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. +</p> +<br> +<p> +<b>Attitudes and the Mind.</b>—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. +</p> +<br> +<p> +<b>Tears and Feeling.</b>—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. +</p> +<p> +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 <a name="104">{104}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Application of Principles.</b>—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. +</p> +<br> +<p> +<i>Laughing Cures</i>.—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. +</p> +<a name="105">{105}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +Man is the only animal that laughs, and, as the old philosophers point +out, he might very well be defined as <i>animal risibile</i> with just +as much truth as by the words <i>animal rationale</i>. 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mouth Breathing.</b>—Since Meyer's discovery of the overgrowth of +the <a name="106">{106}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Bodily Conditions and Stupidity.</b>—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 <a +name="107">{107}</a> 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. +</p> +<br> +<p> +<i>Hook-Worm Disease</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Malaria and Degeneration</i>.—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 <i>anopheles</i> 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. <a name="108">{108}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +THE MECHANISM OF THE INFLUENCE OF MIND ON BODY</h2> + +<p> +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? +</p> +<a name="109">{109}</a> +<p> +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. +</p> + +<p class=center> +<img style="width: 728px; height: 1026px;" alt="" +src="images/109f2.jpg" border=1> +</p> +<p class="cite"> + 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). <i>c, z.,</i> + clear zone free from nerve fibers; <i>M.P.,</i> Exner's plexus in the + molecular layer; <i>A. str.,</i> ambiguous cell stratum; <i>Subm, + P.,</i> sub-molecular plexus; <i>Gt. P. P.,</i> great pyramidal + plexus; <i>Pol. P.,</i> polymorphic plexus; <i>W.,</i> white matter. + (Barker.) +</p> + + +<a name="110">{110}</a> +<p> +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. +</p> +<br> +<p> +<b>Brain Complexity.</b>—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. +</p> +<p class=center> +<img style="width: 782px; height: 792px;" alt="" +src="images/110f3.jpg" border=1> +</p> +<p class="cite"> + 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.) +<br><br> + (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.) +</p> +<br> +<p> +<b>Nerve Impulses.</b>—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 <a name="111">{111}</a> 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." +</p> +<br> +<p> +<b>Law of Avalanche.</b>—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. +</p> +<p> +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. +</p> +<p class=center> +<img style="width: 796px; height: 748px;" alt="" +src="images/111f4.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +<b>Psychic States.</b>—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 <a +name="112">{112}</a> 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. +</p> +<p class=center> +<img style="width: 349px; height: 617px;" alt="" +src="images/112f5.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<p class=center> +<img style="width: 207px; height: 613px;" alt="" +src="images/112f6.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<p> +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. +</p> +<a name="113">{113}</a> +<p class=center> +<img style="width: 532px; height: 1002px;" alt="" +src="images/113f7.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<a name="114">{114}</a> +<p class=center> +<img style="width: 338px; height: 936px;" alt="" +src="images/114f8.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +<b>Neurons.</b>—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. +</p> +<br> +<p> +<i>Neuronic Movement</i>.—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. +</p> + +<a name="115">{115}</a> + +<p class=center> +<img style="width: 584px; height: 1004px;" alt="" +src="images/115f9.jpg" border=1> +</p> +<p class="cite"> + 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) +</p> + +<a name="116">{116}</a> + +<p class=center> +<img style="width: 532px; height: 680px;" alt="" +src="images/116f10.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +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. +</p> +<a name="117">{117}</a> +<p class=center> +<img style="width: 554px; height: 328px;" alt="" +src="images/117f11.jpg" border=1> +</p> +<p class="cite"> + FIG. 11.—ISOLATED CELL FROM HUMAN SPINAL CORD (Obersteiner). +</p> +<br> +<p> +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. +</p> +<br> +<p> +<i>Neurons in Psychic States</i>.—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. +</p> +<br> +<p> +<i>Hypnotism</i>.—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 <a +name="118">{118}</a> people to stand pain and fatigue that would +otherwise seem quite unbearable. +</p> +<br> +<p> +<i>Unconsciousness</i>.—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. +</p> +<p class=center> +<img style="width: 352px; height: 1022px;" alt="" +src="images/118f12.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +<i>Tired States</i>.—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 <a name="119">{119}</a> 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. +</p> +<p class=center> +<img style="width: 284px; height: 540px;" alt="" +src="images/119f13.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<p class=center> +<img style="width: 330px; height: 862px;" alt="" +src="images/119f14.jpg" border=1> +</p> +<p class="cite"> + [Illustration: FIG. 14—PYRAMIDAL CELL OF CEREBRAL CORTEX OF MOUSE + (after Ramon y Cajal).] +</p> +<br> +<p> +<i>Voluntary Neuron Motion</i>.—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 +<a name="120">{120}</a> 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 +<i>Medusae</i>. 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. +</p> +<br> +<p> +<b>Neuroglia Theory.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="121">{121}</a> inserted their processes +between the terminal filaments of neurons, thus preventing conduction. +</p> +<p class=center> +<img style="width: 457px; height: 509px;" alt="" +src="images/121f15.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +<i>Varieties of Neuroglia</i>.—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] +</p> +<p class="footnote"> + [Footnote 15: This article is a translation made by the author + shortly after a visit to Ramon y Cajal in Madrid, in 1900. See + <i>International Clinics</i>, Phila., Vol. II Series Eleventh.] +</p> +<p class="cite"> + 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. +<br><br> + 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 <a name="122">{122}</a> 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. +</p> +<br> +<p class=center> +<img style="width: 264px; height: 278px;" alt="" +src="images/122f16.jpg" border=1> +</p> +<p class="cite"> + FIG. 16.—NEUROGLIA CELL FROM THE SUBCORTICAL LAYER OF THE + CEREBRUM FROM WHICH TWO PROCESSES GO TO A BLOOD VESSEL + (Obersteiner). +</p> +<br> +<p class=center> +<img style="width: 164px; height: 354px;" alt="" +src="images/122f17.jpg" border=1> +</p> +<p class="cite"> + FIG. 17.—NEUROGLIA CELLS FROM THE SPINAL CORD. Longitudinal + section (Obersteiner). +</p> +<br> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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. +<br><br> + 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 + <a name="123">{123}</a> 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. +<br><br> + 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. +</p> +<p> +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. +</p> +<p> +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," <i>Brain</i>, +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 +<a name="124">{124}</a> 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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +BRAIN CELLS AND MENTAL OPERATIONS</h2> +<br> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>ATTENTION</h2> + +<p> +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 <a name="125">{125}</a> +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. +</p> +<p class=center> +<img style="width: 222px; height: 450px;" alt="" +src="images/125f18.jpg" border=1> +</p> +<p class="cite"> + FIG. 18.—AN ARTERY FROM THE CEREBRAL CORTEX.—One can see numerous + fine fibers passing over to the brain substance (Obersteiner). +</p> +<br> +<p> +<b>Ease and Pleasure in Mental Operations.</b>—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. +</p> +<br> +<p> +<b>Dangers of Over-attention.</b>—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. +</p> +<p> +For all these reasons, this theory of attention, of the great Spanish +<a name="126">{126}</a> 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] +</p> +<p class="footnote"> + [Footnote 16: <i>International Clinics</i>, Vol II, Series 11.] +</p> +<p class="cite"> + <b>Ramon y Cajal's Theory of Attention.</b>—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. +</p> +<p class=center> +<img style="width: 680px; height: 710px;" alt="" +src="images/126f19.jpg" border=1> +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +This congestion of various parts of the brain has been experimentally +observed <a name="127">{127}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>MEMORY</h2> + +<p> +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. +</p> +<p> +This experience is familiar to everyone. It is especially frequent +with public speakers. Certain words have a habit of slipping away just +when we <a name="128">{128}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>UNCONSCIOUS CEREBRATION</h2> + +<p> +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 +<a name="129">{129}</a> 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. +</p> +<br> +<h2>ABSTRACTION OF MIND</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="130">{130}</a> + + +<h2>PREOCCUPATION OF MIND</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +In all these instances there is evidently a question of the unmaking, +or at <a name="131">{131}</a> 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. +</p> + +<p class=center> +<img style="width: 462px; height: 568px;" alt="" +src="images/131f20.jpg" border=1> +</p> +<p class="cite"> + FIG. 20.—COMPLEXITY OF CELL OF THE CENTRAL NERVOUS SYSTEM. A Golgi + cell after Andriezen. (Barker.) +</p> +<br> +<p> +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. +</p> +<br> +<h2>VITAL ENERGY BEHIND BRAIN CELLS</h2> + +<p> +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 <a name="132">{132}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p class=center> +<img style="width: 126px; height: 884px;" alt="" +src="images/132f21.jpg" border=1> +</p> +<p class="cite"> + Fig. 21.—SECTION THROUGH THE CORTEX OF THE GYRUS OCCIPITALIS + SUPERIOR. (Hammarberg. Barker.) +</p> +<br> +<p> +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 <a +name="133">{133}</a> 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. +</p> +<br> +<p class=center> +<img style="width: 468px; height: 526px;" alt="" +src="images/133f22.jpg" border=1> +</p> +<p class="cite"> + FIG. 22—MOTOR CELL OF VENTRAL HORN OF SPINAL CORD FROM THE HUMAN + FETUS, THIRTY CENTIMETERS LONG (method of Golgi; after von + Lenhossek. Barker.) +</p> +<br> +<p> +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 <i>follow</i> +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, <a name="134">{134}</a> 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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +UNCONSCIOUS CEREBRATION</h2> +<br> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Frequency of Unconscious Cerebration.</b>—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. +</p> +<a name="135">{135}</a> +<p> +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. +</p> +<br> +<p> +<b>Inspiration.</b>—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. +</p> +<br> +<p> +<i>Illustrations</i>.—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. +</p> +<p> +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. +</p> +<a name="136">{136}</a> + + +<h2>SLEEP COMMUNICATIONS</h2> +<p> +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] +</p> +<p class="footnote"> + [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. +<pre> + 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? +</pre> +<p> + For further details on this subject, see the chapter on Dreams. +</p> +<br> +<p> +<b>Art in Dreams.</b>—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 <i>pieta</i> 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. +</p> +<br> +<p> +<b>Mathematical Dreams.</b>—Such phenomena of unconscious cerebration +are not uncommon in the exact sciences. Some of the best examples of +these <a name="137">{137}</a> 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. +</p> +<br> +<p> +<b>Agassiz's Experience.</b>—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] +</p> +<p class="footnote"> + [Footnote 18: "Louis Agassiz, His Life and Correspondence," + edited by Elizabeth Cary Agassiz, Houghton, Mifflin and Co., 1885.] +<br><br> + 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. +</p> +<br> +<p> +<b>Hilprecht's Sleep Vision.</b>—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. +</p> +<a name="138">{138}</a> +<p> +<b>Somnambulism.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<h2>PATHOLOGICAL SIGNIFICANCE</h2> + +<p> +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 +<i>re-creation</i> 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. +</p> +<br> +<p> +<b>Dual Mental Occupation.</b>—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 <a name="139">{139}</a> 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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Social Duties.</b>—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. +</p> +<p> +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 <a +name="140">{140}</a> 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. +</p> +<br> +<h2>MENTAL RELAXATION</h2> + +<p> +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. +</p> +<br> +<h2>REMEDIAL MEASURES</h2> + +<p> +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. +</p> +<br> + +<h2>CHAPTER VII +<br><br> +DISTANT MENTAL INFLUENCE</h2> + +<p> +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 +<a name="141">{141}</a> 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. +</p> +<p> +Telepathy, from the two Greek words, <i>tele</i>, at a distance, and +<i>pathos</i>, 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Witchcraft.</b>—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. +</p> +<br> +<p> +<b>Absent Treatment.</b>—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. <a name="142">{142}</a> 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. +</p> +<br> +<p> +<b>Malignant Magnetism.</b>—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. +</p> +<br> +<p> <b>Action Without a Medium.</b>—The medieval scholastic +philosophers quoted as an absolutely accepted principle the Latin +axiom, <i>"actio in distans repugnat."</i> 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 <i>in distans</i> 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. +</p> +<br> +<p> +<b>Crookes' Theory.</b>—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 +<a name="143">{143}</a> 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. +</p> +<br> +<p> +<b>No Practical Thought Transfer.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mental Retention.</b>—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. +</p> +<p> +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. +</p> +<p> +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! +</p> +<p> +That charming, old-fashioned institution "courting" would go entirely +by <a name="144">{144}</a> 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. +</p> +<br> +<p> +<b>How Much Slight External Expression Conveys.</b>—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. +</p> +<br> +<p> +<b>Negation of Telepathy.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Supposed Examples of Telepathy.</b>—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. +</p> +<p> +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: +</p> +<p> +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 <a name="145">{145}</a> train actually +left the track, and the car in which the subject of the story was +asleep rolled down the bank. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="146">{146}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Twins and Telepathy.</b>—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. +</p> +<p> +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 <a name="147">{147}</a> 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. +</p> +<br> +<p> +<b>Negative Tests.</b>—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 <i>Truth</i>, 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. +</p> +<p class="footnote"> + [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.] +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VIII +<br><br> +SECONDARY PERSONALITY</h2> + +<p> +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 +<a name="148">{148}</a> 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. +</p> +<br> +<p> +<b>The Other Self.</b>—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. +</p> +<br> +<p> +<b>Personal Responsibility.</b>—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 <i>physical</i> 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 +<a name="149">{149}</a> 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. +</p> +<br> +<p> +<b>Hysterical Phenomena.</b>—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 <i>reductio ad +absurdum</i>, of the hypothesis of supernumerary personality has +revealed the real hysteric character of the phenomena. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Other Neurotic Symptoms</i>.—Janet's studies at the Salpetriêre +seem to show that the alterations of memory which bring about what we +call <a name="150">{150}</a> 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. +</p> +<br> +<p> +<b>Dual Dispositions.</b>—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. +</p> +<p> +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 <a name="151">{151}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IX +<br><br> +HYPNOTISM</h2> + +<p> +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. +</p> +<a name="152">{152}</a> +<p> +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. +</p> +<br> +<p> +<b>Effects of Hypnotism.</b>—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. +</p> +<p> +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. <a name="153">{153}</a> 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. +</p> +<br> +<h2>FORMER METHODS OF HYPNOTIZATION</h2> +<p><b></b> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mesmer.</b>—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: +</p> +<a name="154">{154}</a> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>De Puysegur and His Successors.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<p> +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 <a name="155">{155}</a> to secure the +concentration of mind on a single idea or set of ideas that is the +essence of hypnotism. +</p> +<p> +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. +</p> +<br> +<h2>PRESENT DAY METHODS OF HYPNOTIZATION</h2> +<p> +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 <i>rapport</i> +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. +</p> +<br> +<p> +<b>Accessories.</b>—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. +</p> +<a name="156">{156}</a> +<p> +<b>Sensations.</b>—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. +</p> +<br> +<p> +<b>Stroking.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<a name="157">{157}</a> +<p> +<b>Drugs.</b>—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 <i>cannabis indica</i>, 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>PRACTICE OF HYPNOTISM</h2> +<p> +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 +<a name="158">{158}</a> 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. +</p> +<br> +<p> +<b>Hypnotism Simple, Natural, Not Mysterious.</b>—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. +</p> +<br> +<p> +<b>Stages.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="159">{159}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Susceptibility.</b>—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 +<a name="160">{160}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Repeated Efforts</i>.—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. +</p> +<p class="footnote"> + [Footnote 20: "Hypnotism. Its History, Practice and Theory," by J. M. + Bramwell, 2nd edn. London, The De la More Press, 1906.] +</p> +<br> + +<h2>ANIMAL HYPNOTISM</h2> +<p> +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 <a name="161">{161}</a> +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. +</p> +<br> +<h2>DANGERS OF HYPNOTISM</h2> +<p> +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: +</p> +<p class="footnote"> + [Footnote 21: Philadelphia, Lippincott, 1909.] +</p> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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. +<br><br> + 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. +</p> + +<a name="162">{162}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> + +<a name="163">{163}</a> +<br> +<h2>SECTION III +<br><br> +<i>THE INDIVIDUAL PATIENT</i> </h2> +<br> + +<h2>CHAPTER I +<br><br> +PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="164">{164}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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." +</p> + +<a name="165">{165}</a> + +<h2>CHAPTER II +<br><br> +THE MORNING HOURS</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mode of Awaking.</b>—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. +</p> +<br> +<p> +<b>Amount of Sleep.</b>—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 <a name="166">{166}</a> 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. +</p> +<br> +<p> +<b>Bathing.</b>—<i>Morning Bath</i>.—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="167">{167}</a> 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. +</p> +<br> +<p> +<i>Bathing Fads</i>.—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. +</p> +<br> +<p> +<b>Clothing.</b>—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. +</p> +<p> +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 <a name="168">{168}</a> 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. +</p> +<br> +<p> +<b>Before Breakfast.</b>—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 <i>very hot water</i>, 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Breakfast.</b>—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. +</p> +<p> +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 <a name="169">{169}</a> 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. +</p> +<br> +<p> +<b>Working Women.</b>—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. +</p> +<br> +<p> +<b>Home Keeping Women.</b>—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. +</p> +<br> +<p> +<b>Interest in life.</b>—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 <a name="170">{170}</a> 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. +</p> +<br> +<p> +<b>Mail Before Breakfast.</b>—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. +</p> +<br> +<p> +<b>Company at Breakfast.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Morbid Habits.</b>—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 <a name="171">{171}</a> 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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +THE DAY'S WORK</h2> +<p> +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. +</p> +<br> +<p> +<b>Getting to Work.</b>—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. +</p> +<p> +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, <a name="172">{172}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Details of the Day's Work.</b>—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. +</p> +<p class="footnote"> + [Footnote 22: "Curiosities of Lead Poisoning," + <i>International Clinics</i>, Eighth Series, Vol. II.] +</p> +<br> +<p> +<i>Dust and Respiratory Affections</i>.—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 <a name="173">{173}</a> 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. +</p> +<br> +<p> +<i>Lack of Light</i>.—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. +</p> +<br> +<p> +<i>Habitual Movements</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="174">{174}</a> 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. +</p> +<br> +<p> +<i>Habitual Motions and So-Called Rheumatism</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="175">{175}</a> almost +inevitably develop if the work is long continued. These details are +discussed in the chapters on joint and muscular affections. +</p> +<br> +<p> +<b>Night Work.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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, +<a name="176">{176}</a> 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. +</p> +<br> +<p> +<b>Positions During Occupations.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Positions After Meals</i>.—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 +<a name="177">{177}</a> another tart, said that he thought he could if he +stood up. (<a href="#207">See chapter on Position.</a>) +</p> +<br> +<p> +<b>Mental Conditions of Occupations.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="178">{178}</a> 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. +</p> +<br> +<p> +<b>Business Habits.</b>—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. +</p> +<br> +<p> +<b>Personal Hygiene.—Expert Advice.</b>—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. +</p> +<p> +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 <a +name="179">{179}</a> 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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +THE MIDDLE OP THE DAY</h2> + +<p> +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!" +</p> +<br> +<p> +<b>Hurried Lunch.</b>—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 <a name="180">{180}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Women's Lunch.</b>—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. +</p> +<br> +<p> +<b>Nature of the Noon Meal.</b>—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, <a name="181">{181}</a> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +THE LEISURE HOURS.</h2> + +<p> +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. +</p> +<br> +<p> +<b>Gymnastics.</b>—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 <a name="182">{182}</a> +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. +</p> +<br> +<p> +<b>Work at Home.</b>—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. +</p> +<br> +<p> +<b>After-Dinner Hours.</b>—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. +</p> +<br> +<p> +<i>Amusements</i>.—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 +<a href="#224">Diversion of Mind</a> +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 <a name="183">{183}</a> already well-distended +abdominal viscera, but walks around and gives his viscera a better +chance for their work and aids rather than retards peristalsis. +</p> +<br> +<p> +<i>Encroachment on Sleep</i>.—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. +</p> +<br> +<p> +<b>Leisure of the Working Woman.</b>—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. +</p> +<br> +<p> +<b>Feminine Occupations.</b>—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 <a name="184">{184}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>The Ambition to Have Nothing to Do.</b>—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. +</p> +<br> +<p> +<b>Business Anxieties.</b>—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 <a +name="185">{185}</a> 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. +</p> +<p> +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. +</p> + +<a name="186">{186}</a> + +<h2>SECTION IV +<br><br> +<i>GENERAL PSYCHOTHERAPEUTICS</i> +<br><br><br> +CHAPTER I +<br><br> +GENERAL PRINCIPLES OF PSYCHOTHERAPY</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>No Incurable Patients.</b>—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. +</p> +<br> +<p> +<b>Unfavorable Suggestions.</b>—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 +<a name="187">{187}</a> 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 <i>rapport</i> 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. +</p> +<br> +<p> +<i>Study of the Individual</i>.—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 <i>non nocere</i>—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. +</p> +<br> +<p> +<i>Neutralizing Contrary Suggestion</i>.—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. +</p> +<br> +<p> +<b>Favorable Suggestion.</b>—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. +</p> +<p> +Münsterberg, in his recent book on Psychotherapy, has emphasized this +in a way that deserves to be recalled: +</p> +<p class="cite"> + 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 <a name="188">{188}</a> 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. +</p> +<br> +<p> +<b>Favorable Environment.</b>—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. +</p> +<br> +<p> +<b>Natural Relief.</b>—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, <a name="189">{189}</a> 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. +</p> +<br> +<p> +<b>Neuroses in Organic Disease.</b>—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. +</p> +<br> +<p> +<b>Application of Principles.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="190">{190}</a> prognosis habitually, for this +acts deterrently on the vital resistance and delays recovery. +</p> +<br> +<p> +<i>Symptoms of Organic Disease</i>.—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. +</p> +<p> +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 <i>supposed</i> 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. +</p> +<br> +<p> +<i>Tissue Changes From Nerves</i>.—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: +</p> +<p class="cite"> + 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 <a name="191">{191}</a> the place in + which they appear. It is for the same reason that such disturbances + can be cured by hypnotic suggestion. +</p> +<br> +<p> +<i>Health and the Central Nervous System</i>.—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: +</p> +<p class="footnote"> + [Footnote 23: <i>British Medical Journal</i>, January 18, 1896.] +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Psychotherapy in Its Relation to Patient and Physician</i>.—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. +</p> +<p> +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 +<a name="192">{192}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +In brief, the applications of the general principles of psychotherapy +<a name="193">{193}</a> 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. +</p> + +<a name="194">{194}</a> +<br> +<h2>SECTION V +<br><br> +<i>ADJUVANTS AND DISTURBING FACTORS</i> +<br><br><br> +CHAPTER I +<br><br> +SUGGESTION</h2> +<p> +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. +</p> +<p> +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. +<i>Every idea tends to act itself out</i>. 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. +</p> +<p> +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 <a name="195">{195}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="196">{196}</a> 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. +</p> +<p> +This is the power that the physician must learn to use. In <i>The +Lancet</i> for November, 1905, Dr. J. W. Springthorpe, writing on the +"Position, Use and Abuse of Mental Therapeutics," said: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="197">{197}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="198">{198}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +EXERCISE</h2> +<p> +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 <a name="199">{199}</a> +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. +</p> +<br> +<p> +<b>Sufficient Exercise.</b>—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. +</p> +<br> +<p> +<b>National Customs.</b>—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. +</p> +<br> +<p> +<b>Exercise in Early Years.</b>—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. +</p> +<p> +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 <a name="200">{200}</a> 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. +</p> +<br> +<p> +<i>Preparation for a Sedentary Life</i>.—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. +</p> +<p> +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. +</p> +<a name="201">{201}</a> +<p> +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. +</p> +<br> +<p> +<b>Useless Muscles.</b>—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, <i>impedimenta</i>. Prof. James, in his +"Principles of Psychology," sums up the law very well: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Useless Fat.</b>—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 <a href="#290">chapter on obesity</a>, 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. +</p> +<br> +<p> +<b>Resistive Vitality.</b>—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 +<a name="202">{202}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Regulation of Exercise.</b>—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 <a name="203">{203}</a> 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. +</p> +<br> +<p> +<b>Air and Exercise.</b>—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. +</p> +<br> +<p> +<b>Gymnastics.</b>—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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +<br><br> + 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 + <a name="204">{204}</a> impel, are essential to bodily welfare. Whoever + forbids them, forbids the divinely appointed means to physical + development. +</p> +<br> +<p> +<b>Play and Exercise.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Indoor Sport.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Horseback Biding.</b>—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 <a name="205">{205}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Walking.</b>—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 <a name="206">{206}</a> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Massage as Exercise.</b>—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. +</p> +<p> +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 +<a name="207">{207}</a> 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. +</p> +<br> +<p> +<b>Passive Movements.</b>—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. +</p> +<br> +<p> +<b>Summary.</b>—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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +POSITION</h2> + +<p> +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 <a name="208">{208}</a> 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. +</p> +<br> +<p> +<b>Favoring Return Circulation</b>.—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. +</p> +<br> +<p> +<b>Varicose Veins.</b>—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. +</p> +<p> +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 <a name="209">{209}</a> 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. +</p> +<br> +<p> +<b>Relief for Flat Foot.</b>—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. +</p> +<br> +<p> +<b>Abdominal Relaxation.</b>—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. +</p> +<p> +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 <a name="210">{210}</a> 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. +</p> +<br> +<p> +<b>Raising the Head.</b>—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. +</p> +<p> +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 <a name="211">{211}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Heart Cases.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Restlessness.</b>—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 <a name="212">{212}</a> 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. +</p> +<br> +<p> +<b>Joint Affections.</b>—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. +</p> +<br> +<p> +<b>Bladder Evacuation.</b>—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. +</p> +<a name="213">{213}</a> +<p> +<b>Intra-abdominal Conditions.</b>—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. +</p> +<br> +<p> +<b>Importance to the Physician.</b>—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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +TRAINING</h2> +<p> +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 <a name="214">{214}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Obstacle Sense.</b>—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. +</p> +<br> +<p> +<b>Touch and Sight.</b>—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 +<a name="215">{215}</a> 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. +</p> +<br> +<p> +<b>Hearing.</b>—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 +<i>International Clinics</i>. [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. +</p> +<p class="footnote"> + [Footnote 24: Lippincott & Co., Phila., Vol. IV, 8th series, 1899.] +</p> +<br> +<p> +<b>Equilibrium.</b>—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. +</p> +<br> +<p> +<b>Muscle Training.</b>—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. +</p> +<p> +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 <a name="216">{216}</a> general condition, for +occupation of attention saves them from neurotic disturbance of +themselves. +</p> +<p> +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. +</p> +<br> +<p> +<b>Heart Training.</b>—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. +</p> +<br> +<p> +<b>Respiratory Training.</b>—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. +</p> +<br> +<p> +<b>Training the Appetite.</b>—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 <a name="217">{217}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Training to Stand Pain.</b>—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 <a href="#413">Foot Troubles</a> and <a href="#409">Painful Conditions of the Knee.</a> +</p> +<p> +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 +<a name="218">{218}</a> 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. +</p> +<br> +<p> +<b>Intellectual Faculties.</b>—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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +OCCUPATION OF MIND</h2> + +<p> +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. +</p> +<br> +<p> +<b>Uncomfortable Sensations, Their Location and Causes.</b>—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. +</p> +<a name="219">{219}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Lack of Occupation</i>.—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. +</p> +<p> +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. +</p> +<p> +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: +</p> +<p class="cite"> + Absence of occupation is not rest;<br> + A mind quite vacant is a mind distressed. +</p> + +<a name="220">{220}</a> +<p> +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. +</p> +<br> +<p> +<i>Mental Short-Circuit</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Regulation of Life.</b>—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. +</p> +<p class="footnote"> + [Footnote 25: English translation by Dr. Smith Ely Jelliffe. New + York, 1909.] +</p> +<p> +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 <a name="221">{221}</a> 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. +</p> +<br> +<p> +<b>Thought for Others.</b>—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. +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Care of Children</i>.—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. +</p> +<br> +<p> +<i>Interest in Others</i>.—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 <a name="222">{222}</a> +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. +</p> +<br> +<p> +<i>Touch with Real Suffering</i>,—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. +</p> +<br> +<p> +<i>Sympathy as a Remedy</i>.—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. +</p> +<p> +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. +</p> +<a name="223">{223}</a> +<p> +<i>Care of the Incurable</i>.—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. +</p> +<br> +<p> +<b>Finding Mental Occupation.</b>—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. +</p> +<p> +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 <a name="224">{224}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +DIVERSION OF MIND—HOBBIES</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="225">{225}</a> 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. +</p> +<br> +<p> +<b>Possibility of Diversion of Attention from Ills.</b>—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. +</p> +<br> +<p> +<b>Hobbies.</b>—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. +</p> +<br> +<p> +<i>Gladstone</i>.—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. +</p> +<a name="226">{226}</a> +<p> +<i>Virchow</i>.—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Necessity for Diversity of Occupation.</b>—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 <a name="227">{227}</a> 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. +</p> +<br> +<p> +<b>Intervals in Work.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Amusement and the Mind.</b>—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 <a name="228">{228}</a> 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. +</p> +<p> +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!" +</p> +<br> +<p> +<b>Sports.</b>—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, <i>O fortunati nimium</i>, that make the best kind of +diversion. Fortunately, in recent years golf has become a favorite and +for many makes a genuine diversion. +</p> +<br> +<p> +<b>Children's Diversions.</b>—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 <a name="229">{229}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VII +<br><br> +HABIT</h2> + +<p> +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. +</p> +<br> +<p> +<b>Formation of Habits.</b>—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 <a name="230">{230}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Unconscious Regulation of Muscles</i>.—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: +</p> +<p class="cite"> + 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. +</p> +<p> +Commenting on this Prof. J. P. Gordy, in his "New Psychology," +[Footnote 26] says: +</p> +<p class="footnote"> + [Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.] +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Law of Habit.</b>—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 <a name="231">{231}</a> experiencing +that affection under similar circumstances, than we had before. In the +<a href="#564">chapter on Tics</a>, 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. +</p> +<br> +<h2>PHYSICAL HABITS</h2> +<p> +<b>Habit and Food.</b>—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. +</p> +<br> +<p> +<b>Slow Eating.</b>—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. +</p> +<p> +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. +</p> +<a name="232">{232}</a> + +<p> +<b>Water Drinking.</b>—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. +</p> +<br> +<p> +<b>Air and Exercise Habits.</b>—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. +</p> +<br> +<p> +<b>Change of Habits.</b>—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. +</p> +<p> +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. +</p> +<a name="233">{233}</a> +<br> +<h2>MENTAL HABITS</h2> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Pessimism.</b>—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. +</p> +<br> +<p> +<b>Depression of Mind and Body.</b>—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. +</p> +<br> +<p> +<b>Moodiness.</b>—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 <a name="234">{234}</a> 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. <i>Mrs. Wiggs of the +Cabbage Patch</i> 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. +</p> +<p> +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. +</p> +<br> +<h2>MANNERS AND DISPOSITION</h2> +<p> +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. +</p> +<p> +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. +</p> +<a name="235">{235}</a> +<p> +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. +</p> +<br> +<h2>THERAPEUTIC IMPORTANCE OF HABIT</h2> +<p> +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. +</p> +<br> + +<h2>CHAPTER VIII +<br><br> +PAIN</h2> +<p> +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. +</p> +<a name="236">{236}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Pain from Over-Attention.</b>—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. +</p> +<p> +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 +<a name="237">{237}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Rest and Pain.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Pain in Its Relation to Life.</b>—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 +<a name="238">{238}</a> 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. +</p> +<br> +<p> +<b>Self-Denial.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="239">{239}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>The Discipline of Pain</i>.—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. +</p> +<br> +<p> +<b>Pain Diffusion.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<p> +As pain can be suppressed by diversion of mind, or concentration of +thought on something that creates great preoccupation, it must not be +<a name="240">{240}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Neurotic and Organic Pain.</b>—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 <a name="241">{241}</a> 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. +</p> +<p> +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. +</p> + +<a name="242">{242}</a> +<br> +<h2>SPECIAL PSYCHOTHERAPY +<br><br> +SECTION VI +<br><br> +<i>THE DIGESTIVE TRACT</i> +<br><br><br> +CHAPTER I +<br><br> +INFLUENCE OF MIND ON FOOD DIGESTION</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Prejudices and Digestion.</b>—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 +<a name="243">{243}</a> 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. +</p> +<br> +<p> +<b>Mental States and the Stomach.</b>—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. +</p> +<br> +<p> +<i>Disgust and Disturbance of Digestion</i>.—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. +</p> +<p> +Under 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 <a name="244">{244}</a> principle behind our objection to +dog meal then—only the unfamiliarity of the idea of eating it. +</p> +<p> +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. +</p> +<br> +<p> +<i>Custom and Food</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Gastric Antipathies</i>.—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 +<a name="245">{245}</a> 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. +</p> +<br> +<p> +<i>Food Varieties and the Mind</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Genuine Food Idiosyncrasies.</b>—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 <a name="246">{246}</a> subjective and the +subjective feelings can probably always be overcome by habit and +training. +</p> +<br> +<p> +<b>Food Dislikes.</b>—<i>Milk</i>.—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. +</p> +<p> +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. +</p> +<p> +The beverages of various countries illustrate this same principle. The +wines the Spaniards care for are not palatable to the Italians, and +<i>vice versa</i>. 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. +</p> +<br> +<p> +<i>Eggs</i>.—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 +<a name="247">{247}</a> ways of cooking eggs and this variety of +preparation will often make them palatable, and nearly always +digestible. +</p> +<p> +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." +</p> +<br> +<p> +<b>Mental Changes and Digestion.</b>—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. +</p> +<br> +<p> +<i>Lactic Acid as a Bactericide</i>.—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. +</p> +<p> +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. +</p> +<a name="248">{248}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Another Organic Acid</i>.—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, +<a name="249">{249}</a> 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. +</p> +<br> +<p> +<i>Bacon and a Change in Suggestion</i>,—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. +</p> +<p> +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. +</p> + +<a name="250">{250}</a> +<br> + +<h2>CHAPTER II +<br><br> +INDIGESTION AND UNFAVORABLE STATES OF MIND</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Disease Suggestions.</b>—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 +<a name="251">{251}</a> leaves little residue and taking insufficient +fluid leads to constipation. This reacts still further to disturb +digestion, and to interfere with appetite. +</p> +<p> +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. +</p> +<br> +<p> +<b>Contrary Suggestion and Digestion.</b>—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. +</p> +<br> +<p> +<b>Transferred Feelings.</b>—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. +</p> +<br> +<p> +<i>Gastric Reflexes</i>.—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 <a name="252">{252}</a> 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: +</p> +<p class="cite"> + 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.] +<br><br> + 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. +<br><br> + 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. +</p> +<p> +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. +</p> +<p> +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 <a name="253">{253}</a> 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. +</p> +<br> +<p> +<i>Discomfort and Digestion</i>.—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. +</p> +<br> +<p> +<b>Division of Energy.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="254">{254}</a> +<p> +<i>Lack of Sleep Repair</i>.—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. +</p> +<br> +<p> +<i>Worries and Irritations During Meals</i>.—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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +Once the presence of these serious organic lesions of the stomach can +be <a name="255">{255}</a> 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. +</p> +<p> +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. +</p> +<br> +<h2>MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION</h2> +<p> +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. +</p> +<p> +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: +</p> +<a name="256">{256}</a> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Dietetic Rules of a Former Day.</b>—In order to make definite just +what were the views of the olden times which he deprecates, he stated +them briefly and forcibly: +</p> +<p class="cite"> + 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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 <a name="257">{257}</a> 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. +</p> +<br> +<p> +<b>Dietetic Instructions.</b>—Finally Dr. Flint has a series of +instructions for those suffering from indigestion: +</p> +<p class="cite"> + 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. <i>Insomnia is often attributable to + hunger</i> [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. +</p> +<br> +<p> +<b>Removal of Solicitude as a Remedial Measure.</b>—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. +</p> +<p> +The explanation of the many fads and remedies that <i>cure</i> +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. +</p> +<p> +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 <a name="258">{258}</a> 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." +</p> +<br> +<p> +<b>Brain Workers and Indigestion.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Food Faddists.</b>—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. +</p> +<p> +These intellectuals are always improved by their fads, no matter what +they <a name="259">{259}</a> 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 <i>"cure"</i> is due to psychotherapy and common sense, and not in +any way to the special fad. +</p> +<br> +<p> +<b>Worry.</b>—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. +</p> +<br> + +<h2>PREVENTION AND CORRECTION</h2> +<p> +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. +</p> +<br> +<p> +<b>Longevity of Dyspeptics.</b>—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 +<a name="260">{260}</a> 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. +</p> +<br> +<p> +<b>Pharmaceutic Remedies.</b>—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. +</p> +<br> +<p> +<b>Circumstantial Suggestions.</b>—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. +</p> +<br> +<p> +<b>Physiological Measures.</b>—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 +<a name="261">{261}</a> afterwards at their leisure bring it up once more +into the mouth and chew it again. +</p> +<br> +<p> +<i>Mastication and the Stomach</i>.—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. +</p> +<br> +<p> +<i>Exercise</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="262">{262}</a> needs to +take sufficient exercise to tone abdominal muscles and reflexly also +tone even involuntary muscles, and with them the gastric muscularis. +</p> +<br> +<p> +<i>Air</i>.—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. +</p> +<br> +<p> +<i>Sleep</i>.—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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +APPETITE</h2> + +<p> +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 <a name="263">{263}</a> 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. +</p> +<br> +<p> +<b>Power of Mind Over Appetite.</b>—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. +</p> +<br> +<p> +<i>The Will to Eat</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="264">{264}</a> 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. +</p> +<br> +<p> +<i>Sitophobia</i>.—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 <a href="#297">Weight and Good Feeling</a>, 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. +</p> +<br> +<p> +<b>Disturbance of Mind and Its Influence on Appetite.</b>—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. +</p> +<br> +<p> +<i>Feelings and Appetite</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="265">{265}</a> 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. +</p> +<br> +<p> +<b>Appetizers.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Appetite and Habit.</b>—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 <a href="#297">Weight and Good Feeling</a> 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 <a name="266">{266}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Food and Caprice</i>.—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. +</p> +<br> +<p> +<i>Appetite and Food Preparation</i>.—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. +</p> +<br> +<p> +<i>Habit of Overeating</i>.—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 <a name="267">{267}</a> 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. +</p> +<br> +<p> +<b>Frequent Eating as an Appetizer.</b>—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. +</p> +<br> +<p> +<b>Nervous Loss of Appetite.</b>—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. +</p> +<br> +<p> +<b>Instinct and Natural Life.</b>—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 <a name="268">{268}</a> 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. +</p> +<br> +<p> +<b>Application of Principles.</b>—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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +CONSTIPATION</h2> + +<p> +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, +<a name="269">{269}</a> partly by the modification of unfortunate +auto-suggestion, and partly through auxiliary favorable suggestions of +one kind or another. +</p> +<br> +<p> +<b>Prophylaxis.</b>—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. +</p> +<p> +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. +</p> +<p> +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. <i>It +cannot be too often repeated that nature resents too close +surveillance of her functions and operations</i>. 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. +</p> +<br> +<p> +<b>The Mind and Peristalsis.</b>—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. +</p> +<p> +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, +<a name="270">{270}</a> 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. +</p> +<br> +<p> +<b>So-called Intestinal Auto-intoxication.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="271">{271}</a> 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. +</p> +<br> +<p> +<b>Reassurance as an Element in Treatment.</b>—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. +</p> +<br> +<p> +<i>Examples of Intestinal Tolerance</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="272">{272}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Individual Variation</i>.—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, <a name="273">{273}</a> +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. +</p> +<br> +<p> +<i>Anatomical Peculiarities</i>.—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. +</p> +<br> +<p> +<b>Amount of Food as a Causative Factor.</b>—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. +</p> +<br> +<p> +<b>Habit in Treatment.</b>—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. +</p> +<br> +<p> +<i>Habitual Evacuations</i>.—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 +<a name="274">{274}</a> 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. +</p> +<br> +<p> +<b>Ingestion of Fluids an Important Influence.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Residual Material.</b>—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 <a name="275">{275}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Diet.</b>—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. +</p> +<br> +<p> +<i>Limitation of Diet</i>.—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 +<a name="276">{276}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Fats</i>.—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. +</p> +<br> +<p> +<i>Sugars</i>.—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. +</p> +<br> +<p> +<i>Supposed Idiosyncrasies</i>.—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. +</p> +<p> +Not infrequently young persons who are thin and inclined to be +<a name="277">{277}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Exercise.</b>—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. +</p> +<p> +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. +</p> +<a name="278">{278}</a> +<p> +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. +</p> +<br> +<p> +<b>Influence of Position.</b>—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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +NEUROTIC INTESTINAL AFFECTIONS</h2> + +<p> +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 <a href="#268">separate chapter</a>. 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 <a name="279">{279}</a> 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. +</p> +<br> +<p> +<b>Neurotic Diarrhea.</b>—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. +</p> +<br> +<p> +<i>Fright and Loss of Bowel Control</i>.—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. +</p> +<p> +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. +</p> +<a name="280">{280}</a> +<p> +<b>Habitual Diarrhea.</b>—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. +</p> +<br> +<p> +<i>Worry as a Factor</i>.—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. +</p> +<br> +<p> +<b>Change of Mode of life and Intestinal Control.</b>—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. +</p> +<a name="281">{281}</a> +<p> +<b>Mental Influence and Indifferent Remedies.</b>—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. <i>Pillulae micarum panis</i> +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. +</p> +<br> +<p> +<b>Skin and Intestinal Sympathy.</b>—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 <a name="282">{282}</a> 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. +</p> +<br> +<p> +<i>Urticaria and Diarrhea</i>.—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. +</p> +<p> +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. +</p> +<p> +In the chapter on <a href="#302">Abdominal Discomfort</a>, 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. +</p> +<br> +<p> +<b>Intestinal Idiosyncrasies.</b>—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. <a name="283">{283}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="284">{284}</a> 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. +</p> +<br> +<p> +<b>Intestinal Troubles Due to Air.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Air Swallowing</i>.—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. +</p> +<p> +In many of these cases habit may add to the necessity for relief of +this <a name="285">{285}</a> 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. +</p> +<br> +<p> +<i>Intestinal Uneasiness</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Physical Basis</i>.—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 +<a name="286">{286}</a> the abdominal cavity seemed properly to balance +the intestines and to dampen peristalsis. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VII +<br><br> +MUCO-MEMBRANOUS COLITIS</h2> +<p> +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. +</p> +<br> +<p> +<b>Neurotic Etiology.</b>—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, <i>faute de mieux</i>, worry about +themselves. Most of its victims are self-centered, though not +hysterical. +</p> +<br> +<p> +<b>Recent Increase in Number of Cases.</b>—According to all the +authorities, there has been a considerable increase in the number of +cases in recent years. <a name="287">{287}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +<b>Unfavorable Suggestion and Over-attention.</b>—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. +</p> +<a name="288">{288}</a> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<br> +<p> +<i>Surgery and Suggestion</i>.—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 <a name="289">{289}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Direct Suggestion</i>.—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. +</p> +<br> +<p> +<i>Resort Cures and Suggestion</i>.—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. +</p> +<p> +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 <a name="290">{290}</a> used at these +health resorts are not nearly so efficient when used at a distance +because of this lack of additional suggestion. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VIII +<br><br> +OBESITY</h2> + +<p> +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 +<a href="#300">Weight and Good Feeling</a>.) 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 <i>panniculus adiposus</i> 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. +</p> +<p> +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 <a name="291">{291}</a> 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. +</p> +<br> +<p> +<b>Over-eating.</b>—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. +</p> +<br> +<p> +<b>Under Exercise.</b>—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 <i>pates de foie gras</i> 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. +</p> +<p> +What is true of the dog and the goose is exemplified in the lives of +all other <a name="292">{292}</a> 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. +</p> +<br> +<p> +<b>Prophylaxsis.</b>—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! +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>The Will in Treatment.</b>—The important element in the treatment +of obesity is the readiness of the patient to follow directions. Nine +out of every <a name="293">{293}</a> 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 <i>will</i> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Food Temptations</i>.—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 <i>menus</i> 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. +</p> +<p> +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 <a name="294">{294}</a> 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. +</p> +<br> +<p> +<i>Motives for Self-Control</i>.—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. +</p> +<p> +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. +</p> +<p> +If there were no other reason but the greater frequency of +<i>diabetes</i> 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. +</p> +<br> +<p> +<b>Sleep and Exercise.</b>—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 <a name="295">{295}</a> 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. +</p> +<br> +<p> +<b>Heredity.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="296">{296}</a> +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. +</p> +<br> +<p> +<b>Principles of Treatment.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="297">{297}</a> 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. +</p> +<br> + +<h2>CHAPTER IX +<br><br> +WEIGHT AND GOOD FEELING</h2> + +<p> +Probably the most important single condition for the maintenance of +good health and <i>good feeling</i> 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. +</p> +<p class="footnote"> + [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 <i>buxom</i>, + derived from the German <i>biegsam</i>, 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.] +</p> +<br> +<p> +<b>Thinness and Discontent.</b>—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. <a name="298">{298}</a> 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. +</p> +<br> +<p> +<b>Physical Disadvantages of Thinness.</b>—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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Discomfort Due to Lack of Fat</i>.—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 <a name="299">{299}</a> 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. +</p> +<br> +<p> +<i>Muscular Weakness and Discomfort</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Eating Enough.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Weight for Height.</b>—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 <a name="300">{300}</a> 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: +</p> +<p> +ADJUSTED TABLE OF WEIGHTS FOR INSURED WOMEN, BASED ON 58,855 ACCEPTED LIVES +</p> +<table class="font80" border="0" cellpadding="1" cellspacing="1" width="100%"> + +<tr><td><br> +</td><td> 15-19 </td><td>20-24 </td><td>25-29 </td><td>30-34</td><td> 35-39 </td><td>40-44 </td><td>45-49</td><td> 50-54 </td><td>55-59 </td><td>60-64 </td><td>Combined Ages</td></tr> +<tr><td>4' 11" </td><td> 111 </td><td> 113 </td><td> 115 </td><td> 117 </td><td>119 </td><td> 119 </td><td> 122 </td><td> 125 </td><td> 128 </td><td> 126 </td><td>118</td></tr> +<tr><td>5' 0" </td><td>113 </td><td>114 </td><td> 117 </td><td> 119 </td><td>122 </td><td> 122 </td><td> 125 </td><td> 128</td><td> 130</td><td> 129 </td><td> 120</td></tr> +<tr><td>5' 1" </td><td>115 </td><td>116 </td><td> 118 </td><td>121 </td><td> 124 </td><td> 124 </td><td> 128 </td><td> 131 </td><td> 133 </td><td> 132 </td><td> 122</td></tr> +<tr><td>5' 2" </td><td> 117 </td><td>118 </td><td> 120 </td><td> 123 </td><td> 127 </td><td> 127 </td><td>132 </td><td>134 </td><td> 137 </td><td>136 </td><td>125</td></tr> +<tr><td>5' 3" </td><td> 120 </td><td>122 </td><td> 124 </td><td> 127 </td><td>131 </td><td>131 </td><td>135 </td><td>138 </td><td> 141 </td><td> 140 </td><td> 128</td></tr> +<tr><td>5' 4" </td><td> 123 </td><td>125 </td><td> 127 </td><td> 130 </td><td>134 </td><td> 134</td><td> 138 </td><td>142 </td><td>145 </td><td> 144 </td><td>131</td></tr> +<tr><td>5' 5" </td><td> 125 </td><td>128 </td><td> 131 </td><td> 135 </td><td>139 </td><td> 139 </td><td> 143 </td><td>147 </td><td> 149 </td><td> 148 </td><td> 135</td></tr> +<tr><td>5' 6" </td><td> 128 </td><td> 132 </td><td> 135 </td><td> 139 </td><td> 143 </td><td> 143 </td><td> 146 </td><td> 151 </td><td> 153 </td><td> 152 </td><td>139</td></tr> +<tr><td>5' 7" </td><td> 132 </td><td> 135 </td><td> 139 </td><td> 143 </td><td> 147 </td><td> 147 </td><td> 150 </td><td> 154 </td><td>157 </td><td>155 </td><td>143</td></tr> +<tr><td>5' 8" </td><td> 136 </td><td> 140 </td><td> 143 </td><td> 147 </td><td> 151</td><td> 151 </td><td>155 </td><td> 158 </td><td> 161 </td><td>160 </td><td>147</td></tr> +<tr><td>5' 9" </td><td> 140 </td><td> 144 </td><td> 147 </td><td> 151 </td><td> 155 </td><td> 155 </td><td> 159 </td><td>163 </td><td> 166 </td><td>165 </td><td>151</td></tr> +<tr><td>5' 10" </td><td> 144 </td><td> 147 </td><td> 151 </td><td>155 </td><td>159 </td><td> 159 </td><td> 163 </td><td>167 </td><td>170 </td><td> 169 </td><td>155</td></tr> +<tr><td>Combined Heights </td><td>123 </td><td> 126 </td><td> 129 </td><td> 132 </td><td> 136 </td><td> 136 </td><td>139 </td><td> 142 </td><td>145 </td><td> 142 </td><td> 133</td></tr> +</table> + +<br> +The average shoes of the average woman will raise her about 1-1/2 to 1-3/4 +inches. +<br> +<p> +DR. SHEPHERD'S TABLE OF HEIGHT AND WEIGHT FOR MEN AT DIFFERENT AGES +</p> +<table class="font80" border="0" cellpadding="1" cellspacing="1" width="100%"> +<tr><td><br> +</td><td>15-24</td><td>25-29</td><td>30-34</td><td>35-39</td><td>40-44</td><td>45-49</td><td>50-54</td><td>55-59</td><td>60-64</td><td>65-69</td></tr> +<tr><td>5' 0'</td><td>120</td><td>125</td><td>128</td><td>131</td><td>133</td><td>134</td><td>134</td><td>134</td><td>131</td></tr> +<tr><td>5' 1'</td><td>122</td><td>126</td><td>129</td><td>131</td><td>134</td><td>136</td><td>136</td><td>136</td><td>134</td></tr> +<tr><td>5' 2'</td><td>124</td><td>128</td><td>131</td><td>133</td><td>136</td><td>138</td><td>138</td><td>138</td><td>137</td></tr> +<tr><td>5' 3'</td><td>127</td><td>131</td><td>134</td><td>136</td><td>139</td><td>141</td><td>141</td><td>141</td><td>140</td><td>140</td></tr> +<tr><td>5' 4'</td><td>131</td><td>135</td><td>138</td><td>140</td><td>143</td><td>144</td><td>145</td><td>145</td><td>144</td><td>143</td></tr> +<tr><td>5' 5'</td><td>134</td><td>138</td><td>141</td><td>143</td><td>146</td><td>147</td><td>149</td><td>149</td><td>148</td><td>147</td></tr> +<tr><td>5' 6'</td><td>138</td><td>142</td><td>145</td><td>147</td><td>150</td><td>151</td><td>153</td><td>153</td><td>153</td><td>151</td></tr> +<tr><td>5' 7'</td><td>142</td><td>147</td><td>150</td><td>152</td><td>155</td><td>156</td><td>158</td><td>158</td><td>158</td><td>156</td></tr> +<tr><td>5' 8'</td><td>146</td><td>151</td><td>154</td><td>157</td><td>160</td><td>161</td><td>163</td><td>163</td><td>163</td><td>162</td></tr> +<tr><td>5' 9'</td><td>150</td><td>155</td><td>159</td><td>162</td><td>165</td><td>166</td><td>167</td><td>168</td><td>168</td><td>168</td></tr> +<tr><td>5' 10'</td><td>154</td><td>159</td><td>164</td><td>167</td><td>170</td><td>171</td><td>172</td><td>173</td><td>174</td><td>174</td></tr> +<tr><td>5' 11'</td><td>159</td><td>164</td><td>169</td><td>173</td><td>175</td><td>177</td><td>177</td><td>178</td><td>180</td><td>180</td></tr> +<tr><td>6' 0'</td><td>165</td><td>170</td><td>175</td><td>179</td><td>180</td><td>183</td><td>182</td><td>183</td><td>185</td><td>185</td></tr> +<tr><td>6' 1'</td><td>170</td><td>177</td><td>181</td><td>185</td><td>186</td><td>189</td><td>188</td><td>189</td><td>189</td><td>189</td></tr> +<tr><td>6' 2'</td><td>176</td><td>184</td><td>188</td><td>192</td><td>194</td><td>196</td><td>194</td><td>194</td><td>192</td><td>192</td></tr> +<tr><td>6' 3'</td><td>181</td><td>190</td><td>195</td><td>200</td><td>203</td><td>204</td><td>201</td><td>198</td></tr> +</table> +<br> + +<p> +<b>Correction of Underweight.</b>—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 <a name="301">{301}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Nervous Patients</i>.—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 +<a name="302">{302}</a> 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. +</p> +<br> + +<h2>CHAPTER X +<br><br> +VAGUE ABDOMINAL DISCOMFORTS—LOOSE KIDNEY</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Such reassurance cannot be given until the abdominal region is +carefully palpated, and especially the right side explored as +thoroughly as possible. <a name="303">{303}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="304">{304}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="305">{305}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="306">{306}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Toxic Factors.</b>—<i>Tea</i>.—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. +</p> +<a name="307">{307}</a> +<p> +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. +</p> +<br> +<p> +<i>Coffee</i>.—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. +</p> +<br> +<p> +<b>Loose Kidney.</b>—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. +</p> +<p> +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, <a name="308">{308}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Mechanical Treatment</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Question of Operation</i>.—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 <a name="309">{309}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Intermittent Discomfort</i>.—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. +</p> +<p> +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. +</p> +<p> +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. +</p> + +<a name="310">{310}</a> +<br> +<h2>SECTION VII +<br><br> +<i>CARDIOTHERAPY</i> +<br><br><br> +CHAPTER I +<br><br> +THE HEART AND MENTAL INFLUENCE</h2> + +<p> +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. +</p> +<p> +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. +</p> +<a name="311">{311}</a> +<p> +<b>Emotion and the Heart.</b>—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. +</p> +<br> +<p> +<b>The Heart and the Nervous System.</b>—Prof. Von Leyden ten years +ago recalled attention to the fact that the heart is literally the +<i>primum movens</i> 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. +</p> +<br> +<p> +<i>Primitive Heart Action</i>.—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 <i>primum movens</i>, 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. +</p> +<br> +<p> +<b>Mental Influence over Diseased Hearts.</b>—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 <a name="312">{312}</a> 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Heart Remedies and Suggestion.</b>—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. +</p> +<p> +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. <a name="313">{313}</a> 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. +</p> +<br> +<p> +<b>Cardiac Inhibition.</b>—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. +</p> +<p class="cite"> + 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. +<br><br> + 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. +</p> +<p> +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. +</p> +<a name="314">{314}</a> +<p> +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. +</p> +<p class="cite"> + 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Shock and the Heart.</b>—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. +</p> +<p> +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. <a name="315">{315}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Place of Psychotherapy in Treatment.</b>—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. +</p> +<p> +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. +</p> +<a name="316">{316}</a> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +DIAGNOSIS AND PROGNOSIS IN HEART DISEASE</h2> + +<p> +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. +</p> +<br> +<p> +<b>Mental Attitude of Patient.</b>—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. +</p> +<p> +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 <a name="317">{317}</a> 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. +</p> +<br> +<p> +<b>The Apex Beat and Heart Murmurs.</b>—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. +</p> +<p> +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 <i>listening</i> 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: +</p> +<a name="318">{318}</a> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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. . . . +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="319">{319}</a> 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Broadbent on Cardiac Diagnosis.</b>—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: +</p> +<p class="cite"> + 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. +<br><br> + 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. <i>There is in such + subjects no form or degree of cardiac disease which may not he + simulated</i>. [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. +</p> +<br> +<p> +<b>Typical Case.</b>—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. +</p> +<a name="320">{320}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="321">{321}</a> +<p> +<b>Heart Symptoms in the Young.</b>—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. +</p> +<p> +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." +</p> +<br> + +<h2>CHAPTER III +<br><br> +CARDIAC NEUROSES</h2> + +<p> +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 +<a name="322">{322}</a> hampers heart activity and leads to functional +disturbances of other organs which make the heart's work harder. +</p> +<br> +<p> +<b>Varieties.</b>—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. +</p> +<br> +<p> +<i>Palpitation</i>.—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. +</p> +<br> +<p> +<i>Missed Beats</i>.—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. +</p> +<br> +<p> +<i>Arrhythmia</i>.—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. +</p> +<br> +<p> +<b>Etiology.</b>—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 <a href="#328">separate chapter</a>. +</p> +<br> +<p> +<b>Prognosis.</b>—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 <a name="323">{323}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>The Intellectual Life and Cardiac Palpitation.</b>—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. +</p> +<br> +<p> +<b>Heart Surveillance.</b>—Prof. Oppenheim of Berlin has in his usual +direct way expressed the power of the mind to influence the heart +beat, and he does <a name="324">{324}</a> 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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Irritable Heart of Athletes.</b>—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. +</p> +<p> +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 <a +name="325">{325}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Dietetic Regulation</i>.—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. +</p> +<br> +<p> +<i>Exercise</i>.—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 <a name="326">{326}</a> 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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: +<br><br> + 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. +</p> +<p> +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. <a name="327">{327}</a> +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." +</p> +<p> +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: +</p> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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. +</p> +<p> +This last remark of MacKenzie's is particularly important, for at the +beginning of an attempt to relieve the symptoms by insisting on more +<a name="328">{328}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE</h2> + +<p> +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. +</p> +<a name="329">{329}</a> +<p> +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. +</p> +<br> +<p> +<b>Gastro Cardiac Arrhythmia.</b>—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. +</p> +<br> +<p> +<i>Mechanical Cardiac Interference</i>.—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. +</p> +<p> +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. +</p> +<a name="330">{330}</a> +<p> +<i>Cardiac Reflexes</i>.—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. +</p> +<br> +<p> +<i>Gastric Dilatation</i>.—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. +</p> +<br> +<p> +<i>Upward Distention</i>.—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 <a name="331">{331}</a> +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. +</p> +<br> +<p> +<b>Old-time Clinicians—Morgagni, Lancisi.</b>—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. +</p> +<br> +<p> +<i>Morgagni</i>.—Morgagni, for instance, whose clinical remarks are always +precious, said: +</p> +<p class="cite"> + 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 <i>Sepulchretum</i> 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. +</p> +<br> +<p> +<i>Lancisi</i>.—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 <i>ex +hypochondriorum consensu</i>, 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 +<a name="332">{332}</a> about it, yet has recovered without incident and +without any serious development. +</p> +<br> +<p> +<b>English Opinion.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Prognosis.</b>—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. +</p> +<p> +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 +<a name="333">{333}</a> 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. +</p> +<p> +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: +</p> +<p class="footnote"> + [Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D., + 1910, Oxford Medical Publications.] +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<p> +He says further: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Cardiac Stomach Disturbance.</b>—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 +<a name="334">{334}</a> 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." +</p> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="335">{335}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +ANGINA PECTORIS</h2> + +<p> +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 +<a name="336">{336}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Differential Diagnosis of True and False Angina.</b>—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. +</p> +<p> +For the differentiation of true and spurious angina Huchard's table as +given by Osler is valuable: +</p> + + +<table border="1" cellpadding="2" cellspacing="2" width="100%"> +<tr><td>TRUE ANGINA</td> + <td>NEUROTIC FORM</td></tr> +<tr><td>Most common between the ages of forty and fifty years.</td> + <td>At every age, even six years.</td></tr> +<tr><td>More common in men. Attacks brought on by exertion.</td> + <td>More common in women. Attacks spontaneous.</td></tr> +<tr><td>Attacks rarely periodical or nocturnal.</td> + <td>Often periodical and nocturnal.</td></tr> +<tr><td>Not associated with other symptoms.</td> + <td>Associated with nervous symptoms.</td></tr> +<tr><td>Vaso-motor form rare. Agonizing pain and sensation of compression by a vice.</td> + <td>Vaso-motor form common. Pain less severe; sensation of distention.</td></tr> +<tr><td>Pain of short duration. Attitude: silence, immobility.</td> + <td>Pain lasts one or two hours. Agitation and activity.</td></tr> +<tr><td>Lesions. Sclerosis of coronary artery.</td> + <td>Neuralgia of nerves and cardioplexus.</td></tr> +<tr><td>Prognosis: grave, often fatal.</td> + <td>Never fatal.</td></tr> +<tr><td>Arterial medication.</td> + <td>Antineuralgic medication.</td></tr> +</table> +<br> +<a name="337">{337}</a> + +<p> +<b>True Angina and Psychotherapy.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Solicitude and Prognosis</i>.—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. +</p> +<p> +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 <a name="338">{338}</a> 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." +</p> +<p> +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. +</p> +<br> +<p> +<b>Pseudo-Angina.</b>—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. +</p> +<p> +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 +<a name="339">{339}</a> some of its forms. Nightmare from indigestion, +Broadbent thought, is not a bad imitation of true angina. +</p> +<p> +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." +</p> +<p> +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. +</p> +<p> +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. +</p> + +<a name="340">{340}</a> +<br> + +<h2>CHAPTER VI +<br><br> +TACHYCARDIA</h2> +<p> +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. +</p> +<br> +<p> +<b>Favorable Prognosis.</b>—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. +</p> +<p> +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 +<a name="341">{341}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Paroxysmal Tachycardia.</b>—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. +</p> +<a name="342">{342}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VII +<br><br> +BRADYCARDIA</h2> + +<p> +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. +</p> +<a name="343">{343}</a> +<p> +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. +</p> +<br> +<p> +<b>Depressed Mental States.</b>—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. +</p> +<br> +<p> +<b>Illustrative Case.</b>—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. +</p> +<p class="footnote"> + [Footnote 29: <i>The Medical News</i>, November 10, 1900.] +</p> +<p> +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 <a name="344">{344}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Compatibility with Health and Activity.</b>—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. +</p> + +<a name="345">{345}</a> +<br> +<h2>SECTION VIII +<br><br> +<i>RESPIRATORY DISEASES</i> +<br><br><br> +CHAPTER I +<br><br> +COUGHS AND COLDS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Cough and Suggestion.</b>—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. +</p> +<p> +Dry coughing, when persistent, is greatly a matter of habit acquired +by yielding to slight irritation. When children scratch their heads we +train them <a name="346">{346}</a> not to, and the same thing should +be done with regard to yielding to reactions from slight irritations +of their lungs. +</p> +<p> +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." +</p> +<br> +<p> +<b>Unnecessary Coughing Harmful.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="347">{347}</a> 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. +</p> +<br> +<p> +<b>Reflex Coughs.</b>—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. +</p> +<br> +<p> +<b>Habit Coughs.</b>—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 <a name="348">{348}</a> 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. +</p> +<br> +<p> +<b>Coughs as Tics.</b>—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. +</p> +<br> +<p> +<b>Diagnosis.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Removing Unfavorable Suggestions.</b>—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. +</p> +<p> +This principle of treatment must be applied for coughs and colds. +While <a name="349">{349}</a> 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. +</p> +<br> +<p> +<b>Irrational Remedies.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Rational Treatment.</b>—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, <a name="350">{350}</a> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +TUBERCULOSIS</h2> + +<p> +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 <a name="351">{351}</a> 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. +</p> +<p> +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. <i>These</i> 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. +</p> +<br> +<h2>PROGNOSIS AND SUGGESTION</h2> +<p> +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. +</p> +<p> +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 +<a name="352">{352}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>No Incurable Cases.</b>—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. +</p> +<br> +<p> +<b>Heredity of Resistance.</b>—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 <a name="353">{353}</a> their +weight or even more, and yet after the external lesions began to +discharge freely, recovery occurred. +</p> +<br> +<p> +<b>Slow Cases.</b>—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. +</p> +<br> +<p> +<b>The Specter of Heredity.</b>—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 <a href="#627">Heredity</a>. 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. +</p> +<p> +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 <a name="354">{354}</a> these get the +disease. Predisposition counts for so little that it is a vanishing +factor. +</p> +<p> +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 <a href="#627">Heredity</a>, 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. +</p> +<br> +<h2>ANNOUNCING THE DIAGNOSIS</h2> +<p> +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. +</p> +<br> +<h2>EARLY DIAGNOSIS</h2> +<p> +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. +</p> +<p> +In the <i>Medical News</i> 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 <a name="355">{355}</a> 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. +</p> +<p> +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. +</p> +<br> +<h2>FAVORABLE MENTAL ATTITUDE</h2> +<p> +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. +</p> +<br> +<p> <b>Eating.</b>—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. +</p> +<p> +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. +</p> +<p> +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, <a name="356">{356}</a> +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. +</p> +<br> +<p> +<b>Air and Comfort.</b>—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. +</p> +<br> +<p> +<b>Stimulating Examples.</b>—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. +</p> +<br> +<p> +<i>Robert Louis Stevenson</i>.—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 <a name="357">{357}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>J. Addington Symonds</i>.—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. +</p> +<br> +<p> +<i>Thoreau</i>.—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. +<a name="358">{358}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHARACTER AS A THERAPEUTIC ASSET</h2> +<p> +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. +</p> +<br> +<p> +<b>Courage and Constancy.</b>—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 +<a name="359">{359}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Persistence.</b>—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. +</p> +<p> +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. +</p> +<a name="360">{360}</a> +<p> +<br> +<h2>SUGGESTION AS TO SYMPTOMS</h2> +<p> +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. +</p> +<br> +<p> +<b>Hemorrhage.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="361">{361}</a> +<p> +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. +</p> +<br> +<p> +<b>Cough.</b>—In the chapter on <a href="#345">Coughs and Colds</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Thoracic Discomfort.</b>—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 <a name="362">{362}</a> 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. +</p> +<br> +<p> +<b>Altitude.</b>—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. +</p> +<br> +<p> +<b>Suggestion and Treatment.</b>—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. +</p> +<p> +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 <a name="363">{363}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Negative Suggestions</i>.—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. +</p> +<p> +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. +</p> +<a name="364">{364}</a> +<br> + +<h2>CHAPTER III +<br><br> +NEUROTIC ASTHMA AND COGNATE CONDITIONS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Etiology.</b>—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." +</p> +<p class="footnote"> + [Footnote 30: Frowde, Oxford Univ. Press. 1908.] +</p> +<p> +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 <a name="365">{365}</a> 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. +</p> +<br> +<p> +<b>Symptomatic Picture.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mental Influence.</b>—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 <a name="366">{366}</a> 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. +</p> +<br> +<p> +<i>Suggestion</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Mental Shock</i>.—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 +<a name="367">{367}</a> 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. +</p> +<br> +<p> +<i>Loss of Control</i>.—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. +</p> +<br> +<p> +<b>Treatment.</b>—<i>Varied Cures</i>.—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. +</p> +<br> +<p> +<i>Negative and Positive Suggestion</i>.—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 <a name="368">{368}</a> +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. +</p> +<br> +<p> +<i>Drugs and Suggestion</i>.—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. +</p> +<br> +<p> +<i>Climatotherapy and Suggestion</i>.—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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +DUST ASTHMA, SEASONAL CATARRH, HAY FEVER</h2> + +<p> +Grouped under the term "hay fever" there are probably as many +different affections as there are under the term "chronic rheumatism." +There are <a name="369">{369}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p class="footnote"> + [Footnote 31: <i>American Journal of Medical Sciences</i>, 1886.] +</p> +<p class="cite"> + According to our conception, the so-called nasal reflex neuroses, + whether taken singly or collectively, as the cause of the + <i>ensemble</i> 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 <a name="370">{370}</a> 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. +</p> +<p> +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. +</p> +<p> +Dr. MacKenzie continues: +</p> +<p class="cite"> + 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? . . . +<br><br> + . . .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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Railroad Asthma.</b>—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. +<a name="371">{371}</a> 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. +</p> +<p> +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 +<i>International Clinics</i>, 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. +</p> +<br> +<p> +<b>The Personal Element and Power of Suggestion.</b>—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. +</p> +<p> +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 <a name="372">{372}</a> 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. +</p> +<p class="cite"> + 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 + <a name="373">{373}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +DYSPNEA—CAT AND HORSE ASTHMA</h2> + +<p> +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 <a name="374">{374}</a> 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. +</p> +<br> +<p> +<b>Cat Asthma.</b>—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." +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<p> +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": +</p> +<p class="cite"> + 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. +</p> +<p class="footnote"> + [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.] +</p> +<p> +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 <a href="#612">Dreads</a>. +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. +</p> +<a name="375">{375}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<i>Proceedings of the Massachusetts Medical Society</i>, 1896-98, +tells the story of a young woman in whom he saw conjunctivitis +developing while she was fondling a cat. In many cases +<a name="376">{376}</a> 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. +</p> +<br> +<p> +<b>Horse Asthma.</b>—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. +</p> +<p> +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. +</p> +<a name="377">{377}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Other Forms.</b>—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. +</p> +<br> +<p> +<b>Treatment.</b>—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 +<a name="378">{378}</a> 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. +</p> +<p> +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. +</p> +<a name="379">{379}</a> +<br> +<h2>SECTION IX +<br><br> +<i>PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM</i> +<br><br><br> +CHAPTER I +<br><br> +PAINFUL JOINT CONDITIONS—PSEUDO-RHEUMATISM. <sub>[Footnote 33]</sub></h2> +<p class="footnote"> + [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.] +</p> +<p> +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. +</p> +<br> +<p> +<b>Exaggeration of Significance.</b>—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. <i>"Omne ignotum pro magnifico,"</i> 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 <a name="380">{380}</a> 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. +</p> +<br> +<p> +<b>Rheumatism, Gout, Catarrh.</b>—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 <i>gutta</i>, 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. +</p> +<br> +<p> +<b>The Uric Acid Diathesis.</b>—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. +</p> +<br> +<p> +<b>Diet Tinkering.</b>—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 <a name="381">{381}</a> 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. +</p> +<br> +<p> +<b>Irregular Treatment.</b>—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. +</p> +<br> +<p> +<b>Differentiation of Joint Conditions.</b>—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 <a name="382">{382}</a> 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. +</p> +<br> +<p> +<b>Painful Joint Affections.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Classes of Sufferers</i>.—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. +</p> +<br> +<p> +<b>Heredity of Rheumatism.</b>—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 <a name="383">{383}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>So-called Chronic Rheumatism.</b>—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. +</p> +<p> +In this it resembles pneumonia rather strikingly. True lobar pneumonia +<a name="384">{384}</a> 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. +</p> +<br> +<p> +<i>Recurrence</i>.—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. +</p> +<br> +<p> +<b>Unclassified Forms.</b>—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. +</p> +<br> +<p> +<b>The Individual Case and Reassurance.</b>—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. +</p> +<p> +Unless such reassurance is given, and especially if the ordinary drug +treatment for so-called chronic rheumatism is persisted in, after a +time these <a name="385">{385}</a> 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. +</p> +<br> + +<h2>SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS</h2> +<p> +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 +<a name="386">{386}</a> them, intelligent men and women, are persuaded it +lessens their pains and aches. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +<a name="387">{387}</a> 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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +OLD INJURIES AND SO-CALLED RHEUMATISM</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Not a few of the lesions called sprains, especially those of the +ankles and <a name="388">{388}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Active and vigorous movement while the affected part is supported at +<i>skin pressure</i> (there must be no constriction) is even more +valuable than <a name="389">{389}</a> 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 <i>is immediate</i>, 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. +</p> +<p> +Recent sprains or bruises treated in this way recover perfectly and do +not leave old scar tissue to be a future seat of pain. +</p> +<br> + +<h2>CHAPTER III +<br><br> +MUSCULAR PAINS AND ACHES</h2> + +<p> +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. +</p> +<p> +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, +</p> +<br> +<p> +<b>Local and Constitutional Conditions.</b>—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. +</p> +<a name="390">{390}</a> +<p> +<i>Individual Cases</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Occupation Aches.</b>—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. +</p> +<p> +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 <a name="391">{391}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mode of Occurrence.</b>—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 <i>Hexenschuss</i>—"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. +</p> +<p> +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 +<a name="392">{392}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <i>must</i> 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. +</p> +<p> +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 <a name="393">{393}</a> 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. +</p> +<br> +<p> +<b>Treatment.</b>—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 <i>ought</i> to be better. +</p> +<p> +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. +</p> +<p> +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 <a name="394">{394}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Disuse, Atrophy and Pain.</b>—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 <a name="395">{395}</a> +comes when they are not employed for their proper purpose. Power to +use depends on continuance of function. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +OCCUPATION MUSCLE AND JOINT PAINS</h2> + +<p> +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 +<a name="396">{396}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Writers' Ache.</b>—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. +</p> +<br> +<p> +<i>Gowers' Rule</i>.—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 <a name="397">{397}</a> 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. +</p> +<br> +<p> +<b>Occupation Pains and Habitual Muscle Movements.</b>—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. +</p> +<br> +<p> +<i>Arm and Shoulder</i>.—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. +</p> +<p> +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 <a name="398">{398}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Leg Occupation Pains</i>.—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. +</p> +<br> +<p> +<b>Neurosis and Neuritis.</b>—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 <a name="399">{399}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Discomforts of Bursae.</b>—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. +</p> +<p> +Other bursae are not commonly seen in America. I have seen bursae over +<a name="400">{400}</a> 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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +PAINFUL ARM AND TRUNK CONDITIONS</h2> + +<p> +<b>Cervical Ribs.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Local Conditions</i>.—The subjective symptoms in these cases often +include <a name="401">{401}</a> 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. +</p> +<br> +<p> +<b>Pleural Adhesions.</b>—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. +</p> +<br> +<p> +<b>Other Conditions.</b>—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. +</p> +<p> +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. +</p> +<a name="402">{402}</a> +<br> + +<h2>CHAPTER VI +<br><br> +LUMBAGO AND SCIATICA</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Conditions Mistaken for Sciatica or Lumbago.</b>—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 +<a name="403">{403}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Old Injuries and Discomfort</i>.—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. +</p> +<br> +<p> +<i>Typhoid Spine</i>.—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 <a name="404">{404}</a> +symptoms. Diversion of attention, gentle movements, plenty of air, and +regulation of the functions of the body will bring about a cure. +</p> +<br> +<p> +<b>Stooping Occupations.</b>—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. +</p> +<br> +<h2>SCIATICA</h2> + +<p> +<b>Etiology.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Pressure</i>.—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. +</p> +<br> +<p> +<i>Alcoholic Neuritis</i>.—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 +<a name="405">{405}</a> 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. +</p> +<br> +<p> +<i>Intrapelvic Causes</i>.—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. +</p> +<br> +<p> +<i>Position at Work</i>.—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. +</p> +<p> +This question of the position in occupation, even though sedentary, is +very important. I have seen a strikingly typical case of the so-called +<i>neuralgia paresthetica</i>, 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. +</p> +<br> +<p> +<b>Treatment.</b>—<i>Mental Persuasion</i>.—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, <a name="406">{406}</a> 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—<i>tumor, +color, rubor</i> and <i>dolor</i>. Pain alone is never sufficient to +justify the diagnosis. Painful disability is usually due to local +causes. +</p> +<br> +<p> +<i>Treatment of Acute Symptoms</i>.—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. +</p> +<br> +<p> +<i>Counter-Irritation and Its Suggestive Value</i>.—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. +</p> +<br> +<p> +<i>Lumbar and Sciatic Psychoneuroses</i>.—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 +<a name="407">{407}</a> 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. +</p> +<br> +<p> +<i>Diversion of Attention</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Mechanical Agents</i>.—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 <a name="408">{408}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Hypnotism</i>.—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 <a name="409">{409}</a> +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. +</p> +<p class="footnote"> + [Footnote 34: On Suggestion and its Applications in Therapeutics.] +</p> +<br> + +<h2>CHAPTER VII +<br><br> +PAINFUL KNEE CONDITIONS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Etiological Factors.</b>—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 +<a name="410">{410}</a> 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. +</p> +<br> +<p> +<i>Inequality of Legs</i>.—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. +</p> +<br> +<p> +<i>High Heels</i>.—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. +</p> +<br> +<p> +<i>Unusual Occupations</i>.—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 <a name="411">{411}</a> +making exaggerated calls upon the muscles in order to keep the joint +in proper position in spite of the over motion in it. +</p> +<p> +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 +<a href="#413">Foot Troubles</a>. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Associated Lumbar Discomfort.</b>—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 +<a name="412">{412}</a> 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. +</p> +<br> +<p> +<b>Heavy and Light Patients.</b>—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. +</p> +<br> +<p> +<b>Muscle Disuse.</b>—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 <i>The American +Journal of the Medical Sciences,</i> August, 1903. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="413">{413}</a> +<p> +<br> +<h2>CHAPTER VIII +<br><br> +FOOT TROUBLES</h2> + +<p> +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. +</p> +<br> +<p> +<b>Foot Deformities in All Classes.</b>—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. +</p> +<br> +<p> +<b>Mechanical Factors.</b>—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 <a name="414">{414}</a> +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. +</p> +<br> +<p> +<b>Confusion of Rheumatism and Foot Troubles.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Unfavorable Disease Suggestions.</b>—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 <a name="415">{415}</a> 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. +</p> +<br> +<p> +<b>Gout and Flatfoot.</b>—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. +</p> +<p> +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. +</p> +<a name="416">{416}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Bunions and Flatfoot.</b>—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 <a name="417">{417}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="418">{418}</a> 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. +</p> +<br> +<p> +<b>Rarer Foot Troubles.</b>—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." +</p> +<br> +<p> +<i>Hammer Toes—Clam Toes</i>.—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. +</p> +<br> +<p> +<b>Present-day Shoes.</b>—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 <a name="419">{419}</a> +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] +</p> +<p class="footnote"> + [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. +<br><br> + 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.] +</p> +<br> +<p> +<b>Prophylaxis.</b>—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. +</p> +<br> +<p> +<b>Circulatory Disturbances Due to Flatfoot.</b>—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 <a name="420">{420}</a> 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. +</p> +<p> +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 <a href="#651">Insomnia</a> 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. +</p> +<br> +<p> +<b>Secondary Consequences.</b>—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. +</p> +<br> +<p> +<b>Exercises.</b>—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 <a name="421">{421}</a> 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. +</p> +<br> +<p> +<b>Significance of Foot Troubles.</b>—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. +</p> +<br> + +<h2>CHAPTER IX +<br><br> +ARTHRITIS DEFORMANS</h2> + +<p> +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. +</p> +<p> +Supposed under the old theory to be a constitutional, probably a +blood disease, patients who saw the ugly, crippling deformities +produced by it and <a name="422">{422}</a> 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. +</p> +<p> +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. +</p> +<p> +There is a good study of the three types of the disease in <i>Guy's +Hospital Reports</i>, 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. +</p> +<br> + +<h2>HEBERDEN'S NODES</h2> +<p> +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. +</p> +<p> +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 <a name="423">{423}</a> 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. +</p> +<p> +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." +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>ACUTE PROGRESSIVE ARTHRITIS</h2> + +<p> +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 <a name="424">{424}</a> both sexes used to living +and working out of doors who take up an occupation in a damp interior. +</p> +<p> +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. +</p> +<br> + +<h2>CHRONIC ARTHRITIS DEFORMANS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Preliminary Stage.</b>—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. +</p> +<p> +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 <a name="425">{425}</a> 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. +</p> +<br> +<p> +<b>Course of Chronic Arthritis.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Neurotic Additions.</b>—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 <a name="426">{426}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>TREATMENT</h2> + +<p> +In the treatment of arthritis deformans the most important object is +the general health of the patient. Owing to the confinement, the +pains, which <a name="427">{427}</a> 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. +</p> +<br> +<p> +<b>Systematic Exercises</b>.—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. +</p> +<br> +<p> +<b>Electricity and Mechano-therapy.</b>—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. +</p> +<p> +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. +</p> +<p> +Something that has distinct hope in it must always be done for these +patients. For this local treatment means more than anything else. +Unfavorable <a name="428">{428}</a> 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. +</p> +<br> +<p> +<b>General Condition.</b>—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. +</p> +<br> + +<h2>CHAPTER X +<br><br> +COCCYGODYNIA</h2> + +<p> +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. +</p> +<p> +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. +<a name="429">{429}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> + +<a name="430">{430}</a> + +<h2>SECTION X +<br><br> +<i>GYNECOLOGICAL PSYCHOTHERAPY</i> +<br><br><br> +CHAPTER I +<br><br> +MENTAL HEALING IN GYNECOLOGY</h2> + +<p> +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. +</p> +<p> +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. +</p> +<a name="431">{431}</a> +<p> +<b>Place of Psychotherapy.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Pain Relief</i>.—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 +<a href="#235">Pain</a>, 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. +</p> +<br> +<p> +<b>Reputed Remedies and Suggestion.</b>—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 +<a name="432">{432}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>The Mind as a Factor in Gynecological Affections.</b>—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. +</p> +<p> +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 <a name="433">{433}</a> 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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<p> +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. +</p> + +<a name="434">{434}</a> +<br> + +<h2>CHAPTER II +<br><br> +PSYCHIC STATES IN MENSTRUATION</h2> + +<p> +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. +</p> +<br> +<p> +<b>Irritability.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Lack of Inhibition.</b>—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 <a name="435">{435}</a> 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. +</p> +<br> +<p> +<b>Exaggeration of Sensitiveness.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Symptomatic Conditions</i>.—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. +</p> +<a name="436">{436}</a> +<p> +<b>Over-reactions.</b>—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. +</p> +<br> +<p> +<b>Physical Basis of Psychic States.</b>—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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<a name="437">{437}</a> +<br> + +<h2>CHAPTER III +<br><br> +AMENORRHEA</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Fright and Amenorrhea.</b>—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 <a name="438">{438}</a> +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. +</p> +<br> +<p> +<b>Pseudocyesis.</b>—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. +</p> +<p> +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. +</p> +<a name="439">{439}</a> +<p> +<b>Amenorrhea from Dread.</b>—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. +</p> +<br> +<p> +<b>Ductless Gland Disease.</b>—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. +</p> +<br> +<p> +<b>Tuberculosis.</b>—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. +</p> +<br> +<p> +<b>Inanition Amenorrhea.</b>—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 <a name="440">{440}</a> 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. +</p> +<br> +<p> +<b>Psychotherapy and Treatment.</b>—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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +DYSMENORRHEA</h2> + +<p> +Practically every woman of menstrual age has more or less discomfort +during menstruation. In most cases this does not rise beyond a heavy +depressed <a name="441">{441}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +The amount of pain suffered from any cause is dependent on two +factors, the pathological condition and the power of the individual to +withstand <a name="442">{442}</a> 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. +</p> +<br> +<p> +<b>Physical Condition.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="443">{443}</a> 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 <i>that</i> +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. +</p> +<br> +<p> +<b>Moral Fiber.</b>—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. +</p> +<br> +<p> +<b>Pain and Occupation of Mind.</b>—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 <i>have</i> 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 <a +name="444">{444}</a> 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. +</p> +<br> +<p> +<b>Working Women.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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, <a +name="445">{445}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Spasmodic Dysmenorrhea.</b>—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. +</p> +<br> +<p> +<b>Membranous Dysmenorrhea.</b>—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 <a name="446">{446}</a> +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. +</p> +<br> +<p> +<b>Minor Ovarian Lesions.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>The Individual.</b>—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 <a name="447">{447}</a> association with +other people, is the best basis of psychic treatment. Improvement of +the general health and the relief of various symptoms are auxiliaries. +</p> +<br> +<p> +<b>Unfavorable Suggestion.</b>—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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +MENORRHAGIA</h2> + +<p> +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. +</p> +<p> +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 <a name="448">{448}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="449">{449}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="450">{450}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +THE MENOPAUSE</h2> + +<p> +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. +</p> +<br> +<p> +<b>Neutralizing Unfavorable Mental Attitude.</b>—Psychotherapy can do +more <a name="451">{451}</a> 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. +</p> +<br> +<p> +<b>Favorable Suggestion.</b>—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. +</p> +<br> +<p> +<b>Definite Prescriptions.</b>—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. +</p> +<p> +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 <a name="452">{452}</a> 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. +</p> +<br> +<p> +<b>Dread of Insanity.</b>—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. +</p> +<br> +<p> +<b>Diversion of Mind.</b>—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. +</p> +<br> +<p> +<b>Summary of Treatment.</b>—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. +</p> + +<a name="453">{453}</a> +<br> + +<h2>SECTION XI +<br><br> +<i>PSYCHOTHERAPY IN OBSTETRICS</i> +<br><br><br> +CHAPTER I +<br><br> +SUGGESTION IN OBSTETRICS</h2> + +<p> +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 +<i>post-partum</i> 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. +</p> +<br> + +<h2>PREGNANCY</h2> + +<p> +<b>Maintenance of Health.</b>—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 <a name="454">{454}</a> +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. +</p> +<br> +<p> +<b>Obesity and Pregnancy.</b>—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. +</p> +<br> +<p> +<b>Delayed Labor and Suggestion.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="455">{455}</a> 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. +</p> +<br> +<p> +<b>Vomiting of Pregnancy.</b>—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. +</p> +<p> +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 <i>cervix uteri</i> 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. +</p> +<p> +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 <a name="456">{456}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <i>Archiv für Gynaekologie</i> (Band 18 Heft 2 page 310) said that +he had seen [in a very large obstetrical practice] three cases of +so-called pernicious vomiting (<i>unstillbaren Erbrechen</i>) 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 <i>hyperemesis gravidarum</i> set down as +the result of a functional neurosis, hysterical in character. A large +number of gynaecologists have accepted this opinion in recent +<a name="457">{457}</a> years (men of all nations) among others +Calderini, Charpentier, Schaeffer, Klein, and Graefe." +</p> +<p class="footnote"> + [Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten + für die Diagnostik und Therapie in der Gynakologie von Dr. B. + Kronig. Leipzig, 1902.] +</p> +<p> +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. +</p> +<p> +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 +<i>hyperemesis</i> 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. +</p> +<br> +<p> +<b>Excessive Salivary Secretion.</b>—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. +</p> +<br> + +<h2>LABOR</h2> + +<p> +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 +<a name="458">{458}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p class="footnote"> + [Footnote 37: "L'Hypnotisme et la Suggestion en Obstétrique," Paris, + 1888.] +</p> +<br> +<p> +<b>Nature's Methods.</b>—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 +<a name="459">{459}</a> 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. +</p> +<p> +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] +</p> +<p class="footnote"> + [Footnote 38: <i>Bulletin of the Lying-in Hospital</i>, + Vol. V, No. IV.] +</p> +<p> +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. +</p> +<br> +<p> +<b>Postures after Labor.</b>—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. +</p> +<a name="460">{460}</a> +<br> + +<h2>NURSING</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="461">{461}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +MATERNAL IMPRESSIONS</h2> + +<p> +"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 <i>in utero</i>, 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 <i>in utero</i>. 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. +</p> +<br> +<p> +<b>Maternal Impressions in Old Literature.</b>—The belief in the +influence of maternal impression on the child <i>in utero</i> 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 <a name="462">{462}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mother and Child Distinct Beings.</b>—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. +</p> +<br> +<p> +<i>Absence of Circulatory Connection</i>.—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 <a name="463">{463}</a> impossible to +conceive that during this passage through a membrane of nutrient +elements, soluble proteids, gases, etc., mental influences should also +pass over. +</p> +<br> +<p> +<b>Supposed Examples of Maternal Impression.</b>—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. +</p> +<p> +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 (<i>actio in distans +repugnat</i>) 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. +</p> +<br> +<p> +<b>Period of Occurrence.</b>—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 <a name="464">{464}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <i>reductio ad +absurdum</i> of the whole process that have quite discredited the +belief in maternal impressions. +</p> +<br> +<p> +<b>Some Figures and Coincidences.</b>—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. <a name="465">{465}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Intrauterine Nutrition and Nursing.</b>—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. +</p> +<br> +<p> +<b>Maternal Solicitude and Superstition.</b>—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. +</p> +<br> +<p> +<b>Favorable Maternal Influences.</b>—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 <a name="466">{466}</a> +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. +</p> +<br> +<p> +<b>Etiology of Deformities.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="467">{467}</a> 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. +</p> + +<a name="468">{468}</a> +<br> +<h2>SECTION XII +<br><br> +<i>GENITO-URINARY DISEASES</i> +<br><br><br> +CHAPTER I +<br><br> +PROSTATISM</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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, +<a name="469">{469}</a> however, continued to improve. German medical +journals made fun of the whole proceeding and most people will +consider the ridicule deserved. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="470">{470}</a> 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. +</p> +<br> +<p> +<b>Unfavorable Suggestion.</b>—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. +</p> +<br> +<p> +<i>Urinary Worries</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Emptying the Bladder</i>.—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 <a name="471">{471}</a> 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. +</p> +<br> +<p> +<i>The Question of Operation</i>.—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Position Suggestions.</b>—An important suggestion for treatment in +prostatism with residual urine seems to be to teach the patient to +urinate lying down, <a name="472">{472}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +SEXUAL NEUROSES</h2> + +<p> +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. +</p> +<a name="473">{473}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Trivial Afflictions—Varicocele.</b>—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. +</p> +<p> +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 <a name="474">{474}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="475">{475}</a> neurotic and psychic conditions which +develop in those who are suffering from any sexual ailment, real or +imaginary. +</p> +<br> +<p> +<b>Long Prepuce.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Psychic Impotence.</b>—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. +</p> +<br> +<p> +<i>Reassurance</i>.—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 <a name="476">{476}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Subconscious Obsession</i>.—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. +</p> +<br> +<p> +<b>Organic Impotence.</b>—Certain forms of sexual impotence are +really preliminary signs of serious organic nervous disease. Sometimes +it is the first <a name="477">{477}</a> 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. +</p> +<br> +<p> +<b>Nocturnal Emissions.</b>—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. +</p> +<p> +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 <a name="478">{478}</a> 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. +</p> +<br> +<p> +<i>Prophylaxis</i>.—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="479">{479}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Erotic Dreams</i>.—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. +</p> +<br> +<p> +<b>Sexual Mental Troubles.</b>—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. +</p> +<p> +We often hear it said in our time that the great fact of life is sex. +Indeed, this has been insisted on <i>ad nauseam</i> 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 +<a name="480">{480}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> 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 <a name="481">{481}</a> 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. +</p> +<p> +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. +</p> +<p> +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 +<a name="482">{482}</a> who bathe most are often those with the strongest +tendency to sexuality. Refinement instead of lessening the tendency to +sexual indulgence rather increases it. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +SEXUAL HABITS</h2> + +<p> +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. +</p> +<p> +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. +</p> +<a name="483">{483}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="484">{484}</a> 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. +</p> +<br> +<p> +<b>Mental Disturbances.</b>—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. +</p> +<br> +<p> +<b>Effect on Prostate.</b>—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. +</p> +<br> +<p> +<b>Physical Factors.</b>—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. +</p> +<p> +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 <a name="485">{485}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Physical Effects.</b>—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. +</p> +<p> +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 <a name="486">{486}</a> to drop the habit just as +soon as they took the measures necessary to prevent predisposing +conditions. +</p> +<br> +<p> +<b>Breaking the Habit.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="487">{487}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>After Cure.</b>—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 <a name="488">{488}</a> 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. +</p> +<br> +<p> +<i>Supposed After-effects</i>.—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. +</p> +<br> +<p> +<b>Female Habits.</b>—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. +</p> +<p> +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. <a name="489">{489}</a> 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. +</p> +<br> +<p> +<b>Sexual Perversion.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +<a name="490">{490}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> + +<a name="491">{491}</a> +<br> + +<h2>SECTION XIII +<br><br> +<i>SKIN DISEASES</i> +<br><br><br> +CHAPTER I +<br><br> +PSYCHOTHERAPY IN SKIN DISEASES</h2> + +<p> +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. +</p> +<br> +<p> +<b>Urticarias.</b>—Certain skin diseases, especially those allied to +the urticaria group, are prone to occur in connection with excitement +and worry. In the chapter on <a href="#278">Neurotic Intestinal Affections</a> 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. +</p> +<br> +<p> +<b>Eczema.</b>—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 <a name="492">{492}</a> 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. +</p> +<br> +<p> +<b>Herpes.</b>—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. +</p> +<br> +<p> +<b>Vasomotor Disturbance.</b>—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. +</p> +<br> +<p> +<b>Scurvy.</b>—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, <a name="493">{493}</a> 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. +</p> +<br> +<p> +<b>Warts.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Neurotic Pigmentation.</b>—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 +<a name="494">{494}</a> 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 <i>Journal de l'Anatomie et de +Physiologie</i> 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. +</p> +<br> +<p> +<b>Pruritus.</b>—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. +</p> +<p> +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 +<a name="495">{495}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Hysterical Cutaneous Conditions.</b>—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. +</p> +<br> +<p> +<b>Artefact Skin Lesions.</b>—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. +</p> +<br> +<p> +<b>The Mind in Dermatotherapy.</b>—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. +</p> + +<a name="496">{496}</a> +<br> +<h2>SECTION XIV +<br><br> +<i>DISEASES OF DUCTLESS GLANDS</i> +<br><br><br> +CHAPTER I +<br><br> +DIABETES</h2> + +<p> +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. +</p> +<br> +<p> +<b>Unfavorable Suggestion.</b>—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. +</p> +<p> +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 <a name="497">{497}</a> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Favorable Suggestion.</b>—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. +</p> +<br> +<p> +<b>Danger of Over-treatment.</b>—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. +</p> +<a name="498">{498}</a> +<p> +<b>Interval Treatment.</b>—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. +</p> +<br> +<p> +<b>The Individual in Diabetes.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Physical Condition.</b>—The most important element in the +treatment of <a name="499">{499}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Solicitude.</b>—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. +</p> +<br> +<p> +<b>Dangers of Rigid Diet.</b>—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 <a name="500">{500}</a> 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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +GRAVES' DISEASE</h2> + +<p> +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. +</p> +<br> +<p> +<b>Etiology.</b>—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 <a name="501">{501}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Symptomatology.</b>—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 <a name="502">{502}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Diagnosis.</b>—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 <i>formes +frustes</i>, 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Prognosis in Young Patients.</b>—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 <a name="503">{503}</a> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="504">{504}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <i>Usnea</i>, 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Operations</i>.—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 <a name="505">{505}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>General Condition</i>.—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 <a name="506">{506}</a> its possible connection with other organs +that have an internal secretion, to be able to say anything definite +about it. +</p> +<p> +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. +</p> +<br> +<p> +<i>Diversion of Mind</i>.—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. +</p> +<br> +<p> +<i>Mental Treatment</i>.—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 <a name="507">{507}</a> +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. +</p> +<br> +<p> +<i>Diet Suggestions</i>.—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. +</p> + +<a name="508">{508}</a> +<br> +<h2>SECTION XV +<br><br> +<i>ORGANIC NERVOUS DISEASES</i> +<br><br><br> +CHAPTER I +<br><br> +PSYCHOTHERAPY OF ORGANIC NERVOUS DISEASES</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Nature's Compensation.</b>—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. +</p> +<p> +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. +</p> +<a name="509">{509}</a> +<p> +<b>Unfavorable Suggestion.</b>—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. +</p> +<br> +<p> +<i>Adventitious Symptoms</i>.—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. +</p> +<br> +<p> +<b>Suggestive Prophylaxis.</b>—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. +</p> +<p> +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 +<a name="510">{510}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—It is important to remember that as physicians we +do not treat disease but patients. We <i>care</i> for patients, that +is the real etymological significance of the Latin <i>curare</i>, we +do not cure diseases in the modern sense that has come to be given to +that term, of completely removing the <i>materies morbi</i> and +setting the patient on his feet once more just as well as he was +before his illness. +</p> +<br> +<p> +<i>Relieving Incurable Disease</i>.—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. +</p> +<p> +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 <a name="511">{511}</a> that is +no reason for thinking that they cannot be relieved even though no +improvement of the spinal-cord lesions is expected. +</p> +<p> +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. +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Optimistic Suggestions</i>.—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: +</p> +<p class="cite"> + 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 <a name="512">{512}</a> the misery + and despair which popular fancy has associated with the conception + of locomotor + ataxia. +</p> +<br> +<p> +<i>Arteriosclerosis</i>.—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." +</p> +<p> +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. +</p> +<p> +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": +</p> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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 <a name="513">{513}</a> 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. +<br><br> + 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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +CEREBRAL APOPLEXY</h2> + +<p> +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. +</p> +<p> +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. +</p> +<a name="514">{514}</a> +<p> +<b>The Mind Before and After.</b>— +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. +</p> +<p> +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. +</p> +<p> +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." +</p> +<br> +<p> +<b>Diagnosing Arterial Sclerosis.</b>—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 <a name="515">{515}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Differentiation</i>.—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. +</p> +<br> +<p> +<b>Symptoms.</b>—<i>Dreads—Dizziness</i>.—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. +</p> +<a name="516">{516}</a> +<p> +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). +</p> +<br> +<p> +<i>Vertigo</i>.—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. +</p> +<br> +<p> +<i>Motor Symptoms and Over-solicitude</i>.—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. +</p> +<p> +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 +<a name="517">{517}</a> 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. +</p> +<br> +<p> +<b>Prophylaxis.</b>—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. +</p> +<br> +<p> +<i>Over-indulgence</i>.—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. +</p> +<p> +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. +</p> +<p class="cite"> + "Better fifty years of Europe than a cycle of Cathay." +</p> +<p> +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 <a name="518">{518}</a> 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. +</p> +<br> +<p> +<i>Life-direction</i>.—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. +</p> +<p> +Certain people have what is called the <i>apoplectic habitus</i>, 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. +</p> +<br> +<p> +<i>Certain Abuses</i>.—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, +<a name="519">{519}</a> 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. </p> +<p> +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. +</p> +<br> +<p> +<i>Change of Occupation</i>.—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. +</p> +<br> +<p> +<b>After the Stroke.</b>—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. +</p> +<br> +<p> +<i>Lack of Air and Exercise</i>.—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. +</p> +<p> +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 <a name="520">{520}</a> family for some time to +wear anything but the resigned air that indicates that they fear the +worst. +</p> +<br> +<p> +<i>Sympathetic Care</i>.—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. +</p> +<br> +<p> +<i>Trained Attendance</i>.—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. +</p> +<br> +<p> +<i>Outlook</i>.—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 <a name="521">{521}</a> 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. +</p> +<br> +<p> +<i>Encouraging Examples</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Change of Mental Interest</i>.—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. +</p> +<a name="522">{522}</a> +<br> +<p> +<i>Misplaced Sympathy</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Outings and Human Interests</i>.—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 <a name="523">{523}</a> patient +at home and even that not too often unless they are of his immediate +family. +</p> +<p> +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. +</p> +<br> +<p> +<b>Prognosis of Strokes.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Complications.</b>—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 +<a name="524">{524}</a> 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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +LOCOMOTOR ATAXIA</h2> + +<p> +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. +</p> +<p> +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 +<a name="525">{525}</a> 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. +</p> +<br> +<p> +<b>Value of Favorable Suggestion.</b>—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. +</p> +<br> +<p> +<b>Removing Unfavorable Suggestions.</b>—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 <a name="526">{526}</a> 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. +</p> +<br> +<p> +<b>Treating Accessory Symptoms.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="527">{527}</a> 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. +</p> +<br> +<p> +<b>Neurotic Complications.</b>—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. +</p> +<br> +<p> +<b>Mental Attitude.</b>—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: +</p> +<p class="cite"> + 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. +<br><br> + From this miserable condition I desire to protect you, and I would + ask you to <a name="528">{528}</a> 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. +</p> +<p> +<b>Relearning Muscular Movements.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="529">{529}</a> was made and fortunately the hint of its +significance for treatment was taken and developed. +</p> +<br> +<p> +<b>Effect of Favorable Suggestion.</b>—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. +</p> +<p> +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 <i>after</i> 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. +</p> +<p class="footnote"> + [Footnote 39: Tomo 1 No. 7, July, 1910.] +</p> +<p> +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 +<a name="530">{530}</a> 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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +PARESIS</h2> + +<p> +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. +</p> +<p> +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, <a name="531">{531}</a> he puts himself in the condition most +likely to encourage the development of the pathological changes that +underlie the disease. +</p> +<br> +<p> +<b>Prophylaxis.</b>—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. +</p> +<br> +<p> +<i>Sources of Worry</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="532">{532}</a> 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. +</p> +<br> +<p> +<i>Prophylactic Reassurance</i>.—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. +</p> +<br> +<p> +<i>Alcohol</i>.—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. +</p> +<br> +<p> +<b>Unconclusive Diagnosis.</b>—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. +</p> +<br> +<p> +<b>Prognosis.</b>—<i>Seeing the Worst</i>.—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 <a name="533">{533}</a> 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. +</p> +<br> +<p> +<i>Consoling Hesitancy of Final Judgment</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Rôle of Psychotherapy.</b>—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. +</p> +<p> +The psychic care of the patient is the most important element in any +<a name="534">{534}</a> 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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +EPILEPSY AND PSEUDO-EPILEPSY +<br><br> +EPILEPSY</h2> +<br> +<p> +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 +<a name="535">{535}</a> 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. +</p> +<br> +<p> +<b>Mental Influences.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Power of Suggestion.</b>—-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. +</p> +<p> +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 <a name="536">{536}</a> 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. +</p> +<br> +<p> +<b>The Individual in Epilepsy.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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 <a name="537">{537}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> + +<a name="538">{538}</a> +<br> +<h2>PSEUDO-EPILEPSY</h2> + +<p> +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. +</p> +<br> +<p> +<b>Neurotic Simulation of Epilepsy.</b>—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. +</p> +<p> +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 <a name="539">{539}</a> 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. +</p> +<br> +<p> +<i>The Suggestive Element</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="540">{540}</a> to them, too, that their +anxiety in the matter means much more for the continuance of the +attacks than any physical condition. +</p> +<p> +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. +</p> +<br> +<p> +<b>Neurotic Syncopal Attacks.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Pseudo-Epilepsy and the Menopause.</b>—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 <a name="541">{541}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Cure by Suggestion.</b>—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. +</p> + +<a name="542">{542}</a> +<br> + +<h2>CHAPTER VI +<br><br> +PARALYSIS AGITANS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Psychic Factors.</b>—<i>Fright</i>.—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. +</p> +<br> +<p> +<b>Mental Control of Symptoms.</b>—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 <a name="543">{543}</a> +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. +</p> +<br> +<p> +<b>Pathology.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mental Influences.</b>—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 <a name="544">{544}</a> tremor becomes +more marked and various inconveniences associated with these two +cardinal symptoms are emphasized. +</p> +<br> +<p> +<b>Methods of Treatment.</b>—<i>The Vibrating Chair</i>.—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. +</p> +<br> +<p> +<i>The Suspension Treatment</i>.—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. +</p> +<br> +<p> +<i>Psychic Elements and Other Remedies</i>.—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. <a name="545">{545}</a> 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. +</p> +<br> +<p> +<i>The Frenkel Method</i>.—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. +</p> +<br> +<p> +<i>Psychotherapy</i>.—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. +</p> + +<a name="546">{546}</a> +<br> + +<h2>CHAPTER VII +<br><br> +HEADACHE</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="547">{547}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Attention Headaches.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<p> +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 <a name="548">{548}</a> +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. +</p> +<br> +<p> +<i>Power of Distraction</i>.—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. +</p> +<br> +<p> +<i>Lack of Distractions</i>.—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. +</p> +<p> +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 <i>bonnes</i> 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. +</p> +<p> +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 <a name="549">{549}</a> 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. +</p> +<br> +<p> +<b>Source of Pain.</b>—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. +</p> +<br> +<p> +<b>Pressure Headaches.</b>—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. +</p> +<p> +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 <a name="550">{550}</a> pushing frontal convolutions from +their ordinary positions without any noticeable effect upon the +individual. +</p> +<br> +<p> +<b>Hard Study and Headache.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Local Conditions</i>.—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. +</p> +<p> +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 <a name="551">{551}</a> +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. +</p> +<br> +<p> +<b>Congestion Headaches.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="552">{552}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Some Occipital Aches.</b>—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. +</p> +<br> +<p> +<b>Local Head Discomfort.</b>—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. +</p> +<br> +<p> +<b>Toxic Headaches.</b>—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 <a name="553">{553}</a> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Direct Mental Treatment.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="554">{554}</a> be neurotic or psychic, +will bring about relief, and each patient is a problem quite distinct +from any other. +</p> +<p> +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 <a href="#11">Great Physicians in Psychotherapy</a> the quotation from Plato +with regard to Socrates curing the headache of his young friend +Charmides illustrates this very well. +</p> +<p> +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. +</p> +<p class="footnote"> + [Footnote 40: London, 1906.] +</p> + +<a name="555">{555}</a> +<br> + +<h2>SECTION XVI +<br><br> +<i>NEUROSES</i> +<br><br><br> +CHAPTER I +<br><br> +NERVOUS WEAKNESS (NEURASTHENIA)</h2> + +<p> +Neurasthenia, from the Greek roots, <i>neur</i>, meaning nerve, and +<i>sthenos</i>, strength, joined by the negative particle <i>a</i>, +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. +</p> +<p> +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. +</p> +<p> +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, +<a name="556">{556}</a> 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. +</p> +<p> +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: +</p> +<p class="footnote"> + [Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy + and Other Lectures," Philadelphia, 1904.] +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Neurasthenia and Melancholia.</b>—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 +<a name="557">{557}</a> 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. +</p> +<br> +<p> +<b>Neurasthenia Simulation by Organic Disease.</b>—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. +</p> +<br> +<p> +<i>Neurasthenia and Arteriosclerosis</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Neurasthenia and Bright' s Disease</i>.—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 <a name="558">{558}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Nervous Diarrhea and Organic Disease</i>.—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 +<a name="559">{559}</a> 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. +</p> +<br> +<p> +<i>Neurasthenia and Diabetes</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Simulated Neurasthenia Due to Over-attention.</b>—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 +<a name="560">{560}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="561">{561}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +CHOREA</h2> + +<p> +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. +</p> +<br> +<p> +<b>Etiology.</b>—Two elements must be considered in the problem of +the etiology <a name="562">{562}</a> 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. +</p> +<br> +<p> +<i>Immediate Causation</i>.—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. +</p> +<br> +<p> +<b>Pathology.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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 <a name="563">{563}</a> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Habit Following Chorea.</b>—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 <a name="564">{564}</a> 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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +TICS</h2> + +<p> +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. +</p> +<p> +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 <a name="565">{565}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Varieties of Tics.</b>—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 <a name="566">{566}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Teachers' Habits</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Tricks of Speech</i>.—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 <a name="567">{567}</a> 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. +</p> +<br> +<p> +<i>Fussiness</i>.—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Writers' Tics</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>In Games</i>.—The tendency to the formation of curious habits of +associated movements can be seen very well in most games where skill +is combined <a name="568">{568}</a> 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. +</p> +<br> +<p> +<i>Children's Tics</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="569">{569}</a> 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. +</p> +<br> +<p> +<i>Motor Tics</i>.—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. +</p> +<br> +<p> +<b>Heredity.</b>—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. +</p> +<br> +<p> +<b>Mental Treatment.</b>—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 <a name="570">{570}</a> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC.</h2> + +<p> +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. +</p> +<p> +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 +<a name="571">{571}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>State of Mind.</b>—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. +</p> +<br> +<p> +<b>Stuttering in Complex Activities.</b>—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. +</p> +<br> +<p> +<i>Stuttering Walk</i>.—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. +</p> +<br> +<p> +<i>Stuttering Writing</i>.—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 <a name="572">{572}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Emotional Ataxia.</b>—Dr. S. Weir Mitchell in his article on +"Motor Ataxia from Emotion" in the May number (1910) of <i>The Journal +of Nervous and Mental Disease</i>, discusses some cases in which +inability to write even a signature came as a consequence of +nervousness and emotional disturbance. +</p> +<p> +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. +</p> +<br> +<p> +<b>Mental Influence.</b>—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 <a name="573">{573}</a> 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. +</p> +<br> +<p> +<i>Practice in Self-Control</i>.—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. +</p> +<br> +<p> +<b>Stuttering in the Young.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>In Women.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Correction of Respiratory Defects.</b>—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 <a name="574">{574}</a> 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. +</p> +<br> +<p> +<b>Realization of Allied Conditions.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="575">{575}</a> to +influence the patient and will completely destroy his +psychotherapeutic efficiency. +</p> +<br> +<p> +<i>Neurotic Esophageal Stricture</i>.—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="576">{576}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<p> +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 +<a name="577">{577}</a> 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. +</p> +<br> +<p> +<i>Singing in Treatment</i>.—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. +</p> +<br> +<p> +<i>Regulation of Respiration</i>.—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. +</p> +<p class="footnote"> + [Footnote 42: See my translation of one of his clinical + lectures In <i>The International Clinic</i> for July, 1899.] +</p> +<p class=center> +<img style="width: 402px; height: 84px;" alt="" +src="images/577f23.jpg" border=1> +</p> +<p class="cite"> + Fig. 23.—Normal Diaphragm Curve in Normal Breathing. + Expiration as we Talk Normally. +</p> +<br> +<p class=center> +<img style="width: 684px; height: 226px;" alt="" +src="images/577f24.jpg" border=1> +</p> +<p class="cite"> + Fig. 24.—Curve in Diaphragm Before and During Talking + by a Stutterer. +</p> +<br> +<p> +<i>Attention to Something Besides Speech</i>.—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 <a name="578">{578}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Very simple methods of diverting the attention from speech are quite +<a name="579">{579}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Suggestion for Stuttering</i>.—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. +</p> +<br> +<p> +<i>Distraction of Mind</i>.—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. +</p> + +<a name="580">{580}</a> +<br> + +<h2>CHAPTER V +<br><br> +TREMORS</h2> + +<p> +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 +<a href="#542">special chapter</a> 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. +</p> +<br> +<p> +<b>Senile Tremor.</b>—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. +</p> +<br> +<p> +<i>Significance</i>.—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. +</p> +<br> +<p> +<i>Reassurance</i>.—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 +<a name="581">{581}</a> 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. +</p> +<br> +<p> +<b>Intention Tremors.</b>—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 <a href="#542">Paralysis Agitans</a> illustrates how +these tremors may be induced. +</p> +<br> +<p> +<i>Tremors from Fright</i>.—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. +</p> +<br> +<p> +<b>Influence of Dread.</b>—Tremors of all kinds can be made worse by +the dread of them. In the chapter on <a href="#612">Dreads</a> 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. +</p> +<p> +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 <a +name="582">{582}</a> 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. +</p> +<br> +<p> +<b>Self-consciousness.</b>—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. +</p> +<br> +<p> +<i>Stage Fright</i>.—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. +</p> +<p> +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. +<a name="583">{583}</a> 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. +</p> +<p class="footnote"> + [Footnote 43: O'Malley and Walsh, + "Pastoral Medicine." Longmans, 1906.] +</p> +<br> +<p> +<b>The General Health.</b>—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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<br> +<p> +<i>Mental Control</i>.—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 <a name="584">{584}</a> 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. +</p> +<br> +<p> +<i>Self-Discipline</i>.—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. +</p> +<br> +<p> +<i>Hypnotism and Waking Suggestion</i>.—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. +</p> + +<a name="585">{585}</a> +<br> +<h1>DISORDERS OF THE PSYCHE</h1> +<br> + +<h2>SECTION XVII +<br><br> +<i>PSYCHO-NEUROSES</i> +<br><br><br> +CHAPTER I +<br><br> +PSYCHO-NEUROSES (HYSTERIA)</h2> + +<p> +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. +</p> +<p> +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. +</p> +<a name="586">{586}</a> +<br> + +<h2>FORMS OF NEUROTIC SIMULATION</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Secretory Neuroses.</b>—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. +</p> +<br> +<p> +<b>Neurotic Vomiting.</b>—Persistent vomiting occurs in these cases +but is not <a name="587">{587}</a> 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. +</p> +<br> +<p> +<b>Simulant Appendicitis.</b>—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. +</p> +<p> +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 +<a name="588">{588}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Pseudo Biliary Colic.</b>—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. +</p> +<br> +<p> +<b>Other Simulated Conditions.</b>—There are many painful conditions +of the <a name="589">{589}</a> 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 <a href="#546">Headache</a>, 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Motor Neuroses.</b>—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. +</p> +<p> +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. +</p> +<p> +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, <a name="590">{590}</a> +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." +</p> +<br> + +<h2>DIFFERENTIAL DIAGNOSIS</h2> + +<p> +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. +</p> +<p> +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 <a name="591">{591}</a> 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. +</p> +<br> + +<h2>TREATMENT</h2> + +<p> +<b>Strong Mental Impression.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>After Treatment.</b>—The after treatment of these cases is +directed mainly to such alterations of the mental attitude and +physical condition as shall prevent <a name="592">{592}</a> +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 +<a href="#262">Appetite</a>, is largely a matter of will, and anything that is eaten, +provided it stays down, will do good unless there is organic disease. +</p> +<p> +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. +</p> +<br> +<p> +<i>Diversion of Mind</i>.—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. +</p> +<p> +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 +<a name="593">{593}</a> 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. +</p> +<br> +<p> +<b>Oldtime Cures.</b>—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. +</p> +<br> +<p> +<b>Dominant Ideas.</b>—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. +</p> +<p> +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 +<a name="594">{594}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="595">{595}</a> 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. +</p> +<br> +<p> +<b>Psycho-Analysis.</b>—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. +</p> +<p> +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. +</p> +<p> +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. <a name="596">{596}</a> 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. +</p> + +<a name="597">{597}</a> +<br> +<h2>SECTION XVIII +<br><br> +<i>DISORDERS OF MIND</i> +<br><br><br> +CHAPTER I +<br><br> +MENTAL INCAPACITY (PSYCHASTHENIA)</h2> + +<p> +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. +</p> +<p> +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." +</p> +<p> +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 <a name="598">{598}</a> 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. +</p> +<br> +<p> +<b>Psychasthenia, Natural and Acquired.</b>—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. +</p> +<br> +<p> +<b>Differential Diagnosis.</b>—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. +</p> +<p> +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 +<a name="599">{599}</a> 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. +</p> +<br> +<p> +<i>Mental Exhaustion</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Functional Mental Incapacity.</b>—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 <a name="600">{600}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Inhibitory Surveillance</i>.—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. +</p> +<a name="601">{601}</a> +<p> +<i>Inhibition of Automatism</i>.—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. +</p> +<br> +<p> +<i>Mental Short-Circuit</i>.—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. +</p> +<br> +<p> +<b>Association Fibers Diversion.</b>—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. +</p> +<p class="footnote"> + [Footnote 44: <i>Proceedings of Manchester Literary and Philosophical + Association</i>, 1898.] +</p> +<br> +<p> +<b>Occurrence of Psychasthenia.</b>—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 <a name="602">{602}</a> 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. +</p> +<p class="cite"> + 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. +</p> +<p> +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." +</p> +<br> +<p> +<b>Etiological Factors.</b>—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. +</p> +<p> +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 <a name="603">{603}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +HALLUCINATIONS</h2> + +<p> +<b>Hallucinations Differentiated from Illusions and +Delusions.</b>—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. <a name="604">{604}</a> 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 +<a href="#766">illusions</a> see +chapter with that title in the Appendix.) +</p> +<p> +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. +</p> +<br> +<p> +<b>Frequency.</b>—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. +</p> +<p> +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. +</p> +<p> +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 <a name="605">{605}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="606">{606}</a> +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. +</p> +<p class="footnote"> + [Footnote 45: The Twentieth Century Science Series, New York, 1910.] +</p> +<p> +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 <i>Proceedings of the +Royal Institution</i> (London, 1882). +</p> +<p class="footnote"> + [Footnote 46: New York, 1909.] +</p> +<p> +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. +</p> +<p> +A typical example of such visual hallucinations is the following +incident told by a prominent London physician of himself: +</p> +<p class="cite"> + 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. +</p> +<p> +Those who are especially interested in this subject will find any +number of similar stories, some apparently rich with meaning, most of +them quite <a name="607">{607}</a> 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. +</p> +<br> +<p> +<b>Hallucinations in the Past.</b>—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: +</p> +<p class="cite"> + 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.) +</p> +<br> +<p> +<b>Apparitions and their Explanation.</b>—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: +</p> +<p class="footnote"> + [Footnote 47: Longmans, London, 1900, page 21.] +</p> +<a name="608">{608}</a> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>A Disappearance.</b>—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 +<a name="609">{609}</a> 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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<br> +<p> +<b>Auditory Hallucinations.</b>—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. +</p> +<p> +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 <a name="610">{610}</a> +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. +</p> +<p> +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 <a href="#134">Unconscious Cerebration</a>, 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. +</p> +<br> +<p> +<i>Explanation by Sound Reproduction</i>.—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. +</p> +<p> +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 <a name="611">{611}</a> 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. +</p> +<br> +<p> +<b>Coincidences.</b>—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. +</p> +<br> +<p> +<b>Dangers of Serious Considerations.</b>—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. +</p> +<a name="612">{612}</a> +<br> + +<h2>CHAPTER III +<br><br> +DREADS</h2> + +<p> +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. +</p> +<br> +<h2>DEFINITE DREADS</h2> +<p> +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 +<a name="613">{613}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="614">{614}</a> 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. +</p> +<br> +<p> +<b>Dread of Heights.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Physical Basis</i>.—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 +<a name="615">{615}</a> each of the dots on a part of the retina not +corresponding to that on which the other eye sees it (see Fig. 25). +</p> +<p class=center> +<img style="width: 393px; height: 55px;" alt="" +src="images/615f25.jpg" border=0> +<br> + Fig. 25. +</p> +<p> +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. +</p> +<br> +<p> +<i>Dread of Small Heights</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Mental Discipline</i>.—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 <a name="616">{616}</a> 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. +</p> +<br> +<p> +<b>So-called Misophobia—Dread of Dirt.</b>—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. +</p> +<br> +<p> +<b>Claustrophobia.</b>—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. +</p> +<p> +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 <a name="617">{617}</a> +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." +</p> +<br> +<p> +<b>Dread of Cats.</b>—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. +</p> +<p> +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 +<a name="618">{618}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>The Spectator on Dreads</i>.—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 +<i>The Spectator</i> 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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Cat Fear and Furs</i>.—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 <a name="619">{619}</a> 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. +</p> +<br> +<p> +<i>Recognition of Presence</i>.—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 <i>Transactions of the Association of +American Physicians</i>, 1905, discusses odor in this connections as +follows: +</p> +<p class="cite"> + 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. +<br><br> + We must admit that all animals and human beings emit emanations + which are recognizable by many animals and are in wild creatures + protectively valuable. +<br><br> + 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. +<br><br> + 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. +<br><br> + Two French observers believe that they have proved the sense of + olfaction to be nine times more acute in women than in men. +<br><br> + 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] +</p> +<p class="footnote"> + [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. ] +</p> +<a name="620">{620}</a> +<br> +<p> +<b>Dread of the Dark.</b>—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. +</p> +<p> +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. +</p> +<p> +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, <a name="621">{621}</a> 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. +</p> +<p> +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. +</p> +<p class="footnote"> + [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.] +</p> +<br> +<p> +<b>Dreads Connected with Water.</b>—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 <a name="622">{622}</a> 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. +</p> +<br> +<p> +<b>Dread of Death.</b>—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: +</p> +<p class="cite"> + None cleave to life so fondly as the old, +</p> +<p> +—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: +</p> +<p class="cite"> + How far from just the hate men bear to death<br> + Which comes as safeguard against many ills, +</p> +<p> +—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": +</p> +<p class="cite"> + Cowards die many times before their deaths.<br> + The valiant never taste of death but once, +</p> +<p> +—and people may be aroused to appreciate this. +</p> +<p> +<i>Fear of Early Death</i>.—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. +</p> +<p> +It would not be difficult to add many other names to those mentioned +by Metchnikoff. Naturally his thoughts recurred to men of distinction +on <a name="623">{623}</a> 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. +</p> +<br> +<p> +<b>Dread of Insanity.</b>—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. +</p> +<p> +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. +</p> + +<a name="624">{624}</a> +<br> +<h2>DREADS OF MEN OF GENIUS</h2> + +<p> +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. +</p> +<p> +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: +</p> +<p class="footnote"> + [Footnote 50: The Century Co., New York, 1908] +</p> +<p class="cite"> + 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. +</p> +<p> +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 +<a name="625">{625}</a> 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. +</p> +<br> +<h2>OBSESSIONS</h2> +<p> +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. +</p> +<p> +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. +</p> +<br> +<h2>FORGOTTEN FRIGHTS AND DREADS</h2> +<p> +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. +</p> +<p> +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 <a name="626">{626}</a> 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. +</p> +<p> +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. +</p> +<br> +<h2>TREATMENT</h2> +<p> +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. +</p> +<a name="627">{627}</a> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +HEREDITY</h2> + +<p> +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. +</p> +<p> +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 +<a name="628">{628}</a> 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. +</p> +<br> +<p> +<b>False Impressions and Expression.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="629">{629}</a> 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. +</p> +<br> +<p> +<b>Family History Favorable.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Hereditary Syphilis.</b>—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, +<a name="630">{630}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Mothers of Syphilitic Children</i>.—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 +<a name="631">{631}</a> 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. +</p> +<br> +<p> +<i>Late Lesions and Heredity</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Heredity in Cancer.</b>—With regard to other diseases, the +evidence for any inheritance has been founded entirely on coincidence. +All the human race <a name="632">{632}</a> 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. +</p> +<br> +<p> +<b>Heredity in Other Affections.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Inheritance of Defects.</b>—Acquired characters are not +transmitted, though family traits are the subject of inheritance. +Disease is not hereditary, but <a name="633">{633}</a> 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. +</p> +<br> +<p> +<b>Variation.</b>—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. +</p> +<p> +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. +</p> +<p> +To this must be added another mystery quite as great and even more +<a name="634">{634}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +PREMONITIONS</h2> + +<p> +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, <a name="635">{635}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Etiology.</b>—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. +</p> +<p> +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 <a name="636">{636}</a> +presentiments comes there is the sudden responsive feeling "why, this +is what I saw or must have seen in my dream." +</p> +<p> +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. +</p> +<br> +<p> +<b>Premonitions of Death.</b>—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. +</p> +<br> +<p> +<b>Persuasion of Short Life.</b>—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 +<a name="637">{637}</a> be at all introspective, that they had felt sure +that they would not have long life. +</p> +<p> +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. +</p> +<br> +<p> +<b>Publication of Fulfilled Premonitions.</b>—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. +</p> +<br> +<p> +<b>An Unfulfilled Premonition.</b>—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. +</p> +<a name="638">{638}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Rôle of Coincidence.</b>—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. +</p> +<a name="639">{639}</a> +<br> +<p> +<b>Premonitions and Superstitions—Thirteen.</b>—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. +</p> +<p> +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. +</p> +<p> +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 +<a name="640">{640}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Premonitions and Telepathy.</b>—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. +</p> +<p> +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 +<a name="641">{641}</a> 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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +PERIODICAL DEPRESSION</h2> + +<p> +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. +</p> +<br> +<p> +<b>Serious Pathological Conditions.</b>—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 <a name="642">{642}</a> it as a peculiarity +unamenable to treatment, but to look for the underlying pathological +basis of the new condition. +</p> +<p> +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. +</p> +<br> +<p> +<i>Heart Disease</i>.—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. +</p> +<br> +<p> +<i>Respiratory Affections</i>.—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. <i>Spes phthisica</i>, 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 <a name="643">{643}</a> +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. +</p> +<br> +<h2>MENTAL STATES OF DISAPPOINTMENT</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Occupation of Mind.</b>—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 <a name="644">{644}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Provision of Occupation</i>.—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. +</p> +<br> +<p> +<i>Place of Children in Psychotherapy</i>.—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 +<a name="645">{645}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Occupation with Living Things</i>.—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. +</p> +<p> +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 <a name="646">{646}</a> 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. +</p> +<br> +<p> +<i>Garden Cures</i>.—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. +</p> +<br> +<p> +<i>Intellectual Occupations</i>.—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. +</p> +<p> +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, <a name="647">{647}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Consolation from History</i>.—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. +</p> +<p> +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. +</p> +<a name="648">{648}</a> +<p> +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. +</p> +<br> +<p> +<i>Literature and Life</i>.—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. +</p> +<p class="footnote"> + [Footnote 51: Personal and Literary Letters of Lord Lytton, + edited by Lady Betty Balfour. New York, 1909.] +</p> +<p> +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 +<a name="649">{649}</a> 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: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="650">{650}</a> +<p> +<b>Depression an Incident, not a State.</b>—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. +</p> +<br> +<p> +<b>Suggestive Treatment.</b>—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. +</p> +<p> +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. +</p> + +<a name="651">{651}</a> +<br> + +<h2>CHAPTER VII +<br><br> +INSOMNIA</h2> + +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Absolute Sleeplessness.</b>—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 <a name="652">{652}</a> the need of sleep. <i>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.</i> +</p> +<br> +<p> +<b>Individual Differences.</b>—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. +</p> +<br> +<p> +<b>Cell Rest.</b>—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. +</p> +<br> +<p> +<b>Solicitude Over Sleep.</b>—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 <a name="653">{653}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>TREATMENT</h2> + +<p> +Probably the most important immediate assurance that can be given to +those who come complaining of insomnia is that practically no one has +ever <a name="654">{654}</a> 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. +</p> +<br> +<p> +<b>Suggestive Treatment.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Drugs.</b>—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 <a name="655">{655}</a> 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. +</p> +<br> +<p> +<b>External Conditions to be Inhibited.</b>—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. +</p> +<br> +<p> +<i>No Pillow</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Too high Pillow</i>.—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 <a name="656">{656}</a> 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. +</p> +<br> +<p> +<i>Discomfort Due to Cold</i>.—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. +</p> +<br> +<p> +<i>Cold Feet</i>.—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 <a name="657">{657}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <a href="#413">Foot Troubles3</a>.) +</p> +<br> +<p> +<i>Lack of Air</i>.—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. <a name="658">{658}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Sleep at Sea.</b>—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. +</p> +<br> +<p> +<b>Cold Water.</b>—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. +</p> +<a name="659">{659}</a> +<br> +<p> +<b>Diet.</b>—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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="660">{660}</a> +<br> +<p> +<b>The Evening Hours.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Direct Sleep Suggestions.</b>—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. +</p> +<br> +<p> +<b>Diminishing Solicitude.</b>—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 <a name="661">{661}</a> 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. +</p> +<br> +<p> +<i>Dread of Consequences</i>.—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. +</p> +<br> +<p> +<b>Mental Diversion.</b>—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. +</p> +<a name="662">{662}</a> +<p> +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. +</p> +<br> +<p> +<b>Treatment of Early Morning Wakefulness.</b>—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. +</p> +<p> +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. +</p> +<a name="663">{663}</a> +<br> +<p> +<b>Habits.</b>—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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER VIII +<br><br> +SOME TROUBLES OF SLEEP</h2> + +<p> +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 <a name="664">{664}</a> 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. +</p> +<br> +<p> +<b>Starting.</b>—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. +</p> +<p> +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. +</p> +<p> +At times this starting from sleep seems due to some unusual noise. In +<a name="665">{665}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <a name="666">{666}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Noise.</b>—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. +</p> +<p> +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 <a name="667">{667}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Lying Awake.</b>—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 +<a name="668">{668}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Night Terrors.</b>—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. +</p> +<br> +<p> +<b>Respiratory Interference.</b>—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 <a name="669">{669}</a> 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. +</p> +<br> +<p> +<b>Sleeping in the Light.</b>—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. +</p> +<br> + +<h2>CHAPTER IX +<br><br> +DREAMS</h2> + +<p> +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. +</p> +<a name="670">{670}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="671">{671}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Frequency of Dreams.</b>—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, <a name="672">{672}</a> +and of settlement houses and then Hull House, Chicago, and then of the +Adamses in Massachusetts, and so on. +</p> +<p> +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. +</p> +<p> +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: +</p> +<p class="cite"> + 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." +<br><br> + 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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 <a name="673">{673}</a> 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. <br><br> + 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." +<br><br> + 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. +</p> +<p> +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. +</p> +<br> +<p> <b>Short Duration of Dreams.</b>—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. +</p> +<p> +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 <a name="674">{674}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Significance of Dreams.</b>—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. +</p> +<p> +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 <a name="675">{675}</a> +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. +</p> +<p> +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 <i>"Le Sommeil et les Rêves"</i> about +the middle of the last century and Freud <i>"Ueber den Traum"</i> and +Sante de Sanctis' <i>"I Sogni"</i> 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. +</p> +<p> +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 <a href="#634">Premonitions</a> 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. +</p> +<p> +What is thus true of premonitions can readily be applied to dreams. +<a name="676">{676}</a> 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. +</p> +<p> +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. +</p> +<p class="cite"> + Sir William T. Gairdner, K. C. B., whose interesting typhus delirium + experience appears in the paper by Professor Coates on "Sleep, + Dreams and Delirium" (<i>Glas. Med. Jour.,</i> 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 + <a name="677">{677}</a> 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." +<br><br> + 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. +<br><br> + 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. +</p> +<br> +<p> +<b>Children's Dreams.</b>—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. +</p> +<p> +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. +</p> +<a name="678">{678}</a> +<p> +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. +</p> +<br> + +<h2>CHAPTER X +<br><br> +DISORDERS OF MEMORY</h2> + +<p> +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. +</p> +<p> +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 +<a name="679">{679}</a> 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. +</p> +<br> +<p> +<b>Reasons for Memory Difficulties.</b>—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. +</p> +<br> +<p> +<i>Attention and Memory</i>.—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. +</p> +<br> +<p> +<i>Age and Memory</i>.—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 <a name="680">{680}</a> 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. +</p> +<br> +<p> +<i>Solicitude and Memory</i>.—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. +</p> +<br> +<p> +<b>Peculiarities of Memory.</b>—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 <a name="681">{681}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Name Memory</i>.—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 +<a name="682">{682}</a> 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. +</p> +<br> +<p> +<b>Fatigue and Memory.</b>—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. +</p> +<p> +Ribot gives an excellent personal illustration of this peculiarity of +memory in his "Diseases of Memory," which is worth recalling here. He +says: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Sensations and Memory.</b>—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 <a name="683">{683}</a> 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. +</p> +<br> +<p> +<b>Limits of Normal Forgetfulness.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Attention not Memory.</b>—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. +</p> +<br> +<p> +<b>Cultivating Looseness of Memory.</b>—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 <a name="684">{684}</a> 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. +</p> +<br> +<p> +<b>Memories Individual.</b>—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. +</p> +<p> +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 <a name="685">{685}</a> life, so far as +outward appearance went, was a numbsknll. This was due to a lack of +readiness rather than any lack of wit. +</p> +<br> +<p> +<b>Tricks of Memory.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Memory and Low Grade Intelligence.</b>—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 +<a name="686">{686}</a> 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. +</p> +<p class="footnote"> + [Footnote 52: International Scientific Series, D. Appleton & Co., + New York.] +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Training Memory.</b>—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 +<a name="687">{687}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Gregor in the <i>Monattschrift für Psychiatrie und Neurologie</i>, +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. +</p> + + +<a name="688">{688}</a> +<br> + + +<h2>CHAPTER XI +<br><br> +PSYCHIC CONTAGION</h2> + +<p> +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. +</p> +<p> +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 <i>Bacchae</i> 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. +</p> +<p> +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 <i>lapax</i>. 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. +</p> +<br> +<p> +<b>Contagions Trifles.</b>—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 <a name="689">{689}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Fads and Health.</b>—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. <a name="690">{690}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <a name="691">{691}</a> will be, and must be reckoned with by +anyone who wishes to recognize the principles that underlie +psychotherapy. +</p> +<br> +<p> +<b>Suicide Contagions.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Murder.</b>—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. +</p> +<a name="692">{692}</a> +<br> +<p> +<b>Place of Psychic Contagion.</b>—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. +</p> +<br> +<p> +<b>Favorable Influence.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Psychology of the Mob.</b>—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, <a name="693">{693}</a> +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. +</p> +<br> +<p> +<b>Prevention.</b>—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. +</p> +<p> +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 +<i>schadenfreude</i>, "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. +</p> +<p> +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. +</p> +<a name="694">{694}</a> +<br> + +<h2>SECTION XIX +<br><br> +<i>DISORDERS OF WILL</i> +<br><br><br> + +CHAPTER I +<br><br> +ALCOHOLISM</h2> + +<p> +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. +</p> +<br> +<p> +<b>Historical Résumé of Cures.</b>—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 <a name="695">{695}</a> 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. +</p> +<br> +<p> +<i>Moral Cures</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Modern Cures</i>.—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. +</p> +<p> +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 +<a name="696">{696}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Mental Influence</i>.—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 <a name="697">{697}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Supposed Inheritance.</b>—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. +</p> +<br> +<p> +<i>Contagion More than Heredity</i>.—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, <a name="698">{698}</a> 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. +</p> +<br> +<p> +<i>Inherited Resistance</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="699">{699}</a> +since eliminated and it is a personal weakness and not a family +characteristic that leads people to indulge this appetite to their own +destruction. +</p> +<br> +<p> +<i>Unfavorable Suggestion of Heredity Idea</i>.—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): +</p> +<p class="footnote"> + [Footnote 53: Author of "The Present Evolution of Man," + "Alcoholism," "A Study in Heredity," etc. Chapman and Hall, London, + 1905.] +</p> +<p class="cite"> + 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. +</p> +<p> +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): +</p> +<p class="cite"> + 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. +</p> +<p> +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: +</p> +<a name="700">{700}</a> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Warnings as Suggestions.</b>—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 <a name="701">{701}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Prophylaxis.</b>—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 <a href="#290">Obesity</a>, 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: +</p> +<p class="cite"> + 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. +</p> +<p> +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: +</p> +<p class="footnote"> + [Footnote 54: <i>McClure's Magazine</i>, February. 1909.] +</p> +<a name="702">{702}</a> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Treatment.</b>—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. +</p> +<br> +<p> +<i>Sanitarium Question</i>.—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. +</p> +<p> +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 <a name="703">{703}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="704">{704}</a> <i>will +live</i> 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. +</p> +<br> +<p> +<i>Confidence</i>.—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. +</p> +<p> +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. +</p> +<p> +For alcoholism, as for the drug habits and also the sex habits, moral +influences are all-important. Hence the necessity for exercising them +<a name="705">{705}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>After-Treatment.</b>—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. +</p> +<p> +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 <a name="706">{706}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<i>Religious Motives</i>.—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. +</p> +<p> +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 <a name="707">{707}</a> +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." +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +DRUG ADDICTIONS</h2> + +<p> +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. +</p> +<br> +<p> +<b>Treating the Patient rather than the Habit.</b>—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 +<a name="708">{708}</a> 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. +</p> +<br> +<p> +<b>Prophylaxis.</b>—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. +</p> +<p> +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. +</p> +<a name="709">{709}</a> +<br> +<p> +<i>Favorable Suggestion</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="710">{710}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Early Treatment.</b>—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. +</p> +<p> +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 <a name="711">{711}</a> 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. +</p> +<p> +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. +</p> +<p> +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 +<a name="712">{712}</a> no one is ever so enslaved by a habit as to be +incapable of relief—this alone is <i>right</i> teaching, justifiable +moreover by records well substantiated of recoveries from desperate +plights." +</p> +<br> +<p> +<b>Heredity and Unfavorable Suggestion.</b>—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. +</p> +<br> +<p> +<b>Hereditary Resistance.</b>—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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>After-Cures.</b>—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 +<a name="713">{713}</a> 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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +SUICIDE</h2> + +<p> +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. +</p> +<p> +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 +<a name="714">{714}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="715">{715}</a> 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. +</p> +<br> +<p> +<b>Physical Factors.</b>—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. +</p> +<br> +<p> +<i>So-called Insomnia</i>.—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 <a href="#651">Insomnia</a> and +<a href="#663">Some Troubles of Sleep</a> which make it clear that +suicide, because of insomnia is due to a delusion. +</p> +<br> +<p> +<i>Headache</i>.—Persistent supposedly incurable headache is another +prominent feature of the stories of suicides and here once more we +have to deal rather <a name="716">{716}</a> 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. +</p> +<br> +<p> +<b>Mental Factors.</b>—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. +</p> +<br> +<p> +<i>Suicide and the Weather</i>.—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 <a name="717">{717}</a> +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. +</p> +<p class="footnote"> + [Footnote 55: <i>Popular Science Monthly</i>, April, 1901. ] +</p> +<p> +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: +</p> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Social Factors that Restrain Suicides.</b>—<i>War</i>.—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 <a name="718">{718}</a> with what happens everywhere. Mr. +George Kennan in his article on "The Problems of Suicide" +(<i>McClure's Magazine</i>, June, 1908), has a paragraph which brings +this out very well. He says: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Great Cataclysms</i>.—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. +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<b>Individual Restraints.</b>—<i>Religion</i>.—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. +</p> +<p> +It is well-known that Roman Catholics the world over have much less +tendency to suicide than their Protestant neighbors living in the same +<a name="719">{719}</a> 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: +</p> +<p class="cite"> + 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. +</p> +<br> +<p> +<i>Disgrace as a Restraint</i>.—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. +</p> +<p> +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. +</p> +<p> +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 <a name="720">{720}</a> 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. +</p> +<br> +<p> +<b>Favoring Factors.</b>—<i>Psychic Contagion</i>.—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Child Suicides.</b>—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. +</p> +<p class="footnote"> + [Footnote 56: "Statistics of Child Suicide," <i>Transactions of + American Statistical Association</i>, Vol. X., pp. 1906-1907.] +</p> + +<a name="721">{721}</a> +<p> +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. +</p> +<br> +<p> +<i>Causes at Work</i>.—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." +</p> +<br> +<p> +<b>Cowardice of Suicide.</b>—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 <a name="722">{722}</a> else to make the +prospective suicide realize the true status of his act better than +anything else. +</p> +<p> +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. +</p> +<p> +Besides, the thought that deterred Hamlet may well be urged: +</p> +<pre> + 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? +</pre> +<br> +<p> +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] +</p> +<p class="footnote"> + [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. ] +</p> +<p> +There has sometimes been an erroneous tendency to confuse suicide and +heroism, but Chesterton, in "Orthodoxy," [Footnote 58] +has well expressed the difference: +</p> +<p class="footnote"> + [Footnote 58: + <a href="http://www.gutenberg.org/ebooks/130">"Orthodoxy"</a> by + Gilbert K. Chesterton, New York, John Lane Co., 1909.] + +</p> +<a name="723">{723}</a> +<p class="cite"> + 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Real Suffering a Tonic.</b>—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. +</p> +<br> +<p> +<b>Euthanasia.</b>—Every now and then there is a discussion in the +newspapers <a name="724">{724}</a> 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. +</p> +<p> +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, <i>"Forsan et hoc olim +meminisse juvabit"</i>—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. +</p> +<p> +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 <a name="725">{725}</a> 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. +</p> +<br> +<p> +<b>Dread of Suicide.</b>—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. +</p> +<p> +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. +</p> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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. +</p> +<p> +It may seem to some physicians as though they would be assuming too +much responsibility in giving patients such positive assurance that +their dreads <a name="726">{726}</a> 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. +</p> +<br> +<p> +<b>The Physician and Suicide.</b>—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. +</p> +<br> +<h2>CHAPTER IV +<br><br> +GRIEF</h2> + +<p> +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 <a name="727">{727}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Natural and Pathological Grief.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Etiology.</b>—The cause of exaggerated, prolonged grief is, in a +considerable proportion of the cases, a melancholic tendency, that is, +a failure on the <a name="728">{728}</a> 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. +</p> +<br> +<p> +<b>Prophylaxis.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Treatment.</b>—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. <a name="729">{729}</a> It +is because of overestimation of their own importance and of the +importance of their loss that these people suffer severely. +</p> +<br> +<p> +<i>Motives of Consolation</i>.—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. +</p> +<p> +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. +<i>Mens sana in corpore sano</i> 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. +</p> +<br> +<p> +<i>The Family Physician</i>.—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 +<a name="730">{730}</a> 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. +</p> +<p> +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. +</p> +<p> +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: +</p> +<pre> + 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. +</pre> +<p> +<i>Attitude Toward Death</i>.—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: +</p> +<a name="731">{731}</a> +<br> +<pre> + 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." +</pre> +<br> +<p> +<i>Death and Pain</i>.—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. +</p> +<br> +<p> +<i>Therapy by Example</i>.—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." +</p> +<a name="732">{732}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER V +<br><br> +DOUBTING</h2> + +<p> +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 +<a name="733">{733}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Exaggeration of Ordinary State of Mind.</b>—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. +</p> +<p> +"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 +<a name="734">{734}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Extent of Affection.</b>—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 <a name="735">{735}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Trivial Doubts.</b>—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. +</p> +<a name="736">{736}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 <a name="737">{737}</a> +pitiable. It gets worse rather than better unless a definite +discipline of opposition and control is organized. +</p> +<p> +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. +</p> +<p> +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." +</p> +<p> +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. +</p> +<br> +<p> +<b>Prophylaxis.</b>—<i>Serious Occupation</i>.—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 <a name="738">{738}</a> 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. +</p> +<br> +<p> +<b>Physical Treatment.</b>—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. +</p> +<br> +<p> +<b>Mental Treatment.</b>—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. +</p> +<br> + +<h2>CHAPTER VI +<br><br> +RESPONSIBILITY AND WILL POWER</h2> + +<p> +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 <a name="739">{739}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Bad Temper.</b>—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 <a name="740">{740}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +In recent years we have seriously impaired the idea of responsibility +in <a name="741">{741}</a> 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. +</p> +<p class="footnote"> + [Footnote 59, the following lengthy citation is from an article on + "Responsibility and Punishment," in the <i>American Journal of + Medical Science</i>, 1909.] +</p> +<p class="cite"> + 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. +<br><br> + 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. +<br><br> + 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 <a name="742">{742}</a> 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. +<br><br> + 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. +<br><br> + 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. +<br><br> + 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. +<br><br> + 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 <a name="743">{743}</a> 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. +<br><br> + 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. +<br><br> + 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. +</p> +<p class="cite"> + 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. <a name="744">{744}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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, <a name="745">{745}</a> 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. +</p> + +<a name="746">{746}</a> +<br> + +<h2>SECTION XX +<br><br> +<i>PSYCHOTHERAPY IN SURGERY</i> +<br><br><br> +CHAPTER I +<br><br> +PSYCHOTHERAPY IN OLD-TIME SURGERY</h2> + +<p> +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. +</p> +<br> +<p> +<b>Astrology in Surgery.</b>—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. +</p> +<br> +<p> +<i>Venesection and the Stars</i>.—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 <a +name="747">{747}</a> 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. +</p> +<br> +<p> +<b>Mental Influence in Old Hospitals.</b>—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 <a href="#9">p. 9</a>.) +</p> +<br> +<p> +<b>Medieval Hospitals and the Mind.</b>—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. +</p> +<br> +<p> +<b>Medieval Surgeons and Mental Influence.</b>—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 <a name="748">{748}</a> Germany. I have translated in +<a href="http://www.gutenberg.org/ebooks/20216"> +"Old-time Makers of Medicine"</a> +[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." +</p> +<p class="footnote"> + [Footnote 60: Fordham University Press, 1911.] +</p> +<p> +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. +</p> +<br> +<p> +<b>Surgical Lesions Influenced.</b>—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. +</p> +<a name="749">{749}</a> +<p> +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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER II +<br><br> +MENTAL INFLUENCE BEFORE OPERATION</h2> + +<p> +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. +</p> +<p> +<b>Accessory Neuroses.</b>—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 <a name="750">{750}</a> 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. +</p> +<br> +<p> +<b>Dominant Ideas.</b>—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. +</p> +<p> +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. +</p> +<a name="751">{751}</a> +<p> +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. +</p> +<br> +<p> +<b>Operative Persuasions.</b>—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 <i>their</i> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Fractures and the Mind.</b>—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 <a name="752">{752}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Incisions and Suggestion.</b>—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 +<a name="753">{753}</a> 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. +</p> +<br> +<p> +<b>Pseudo-rabies.</b>—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. +</p> +<p> +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. <i>Herpes preputialis</i> 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. +</p> +<br> + +<h2>CHAPTER III +<br><br> +MENTAL INFLUENCE IN ANESTHESIA</h2> + +<p> +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 <a name="754">{754}</a> +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. +</p> +<br> +<p> +<b>Pain and Diversion of Mind.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Hypnotic Anesthesia.</b>—When, in the first half of the nineteenth +century, <a name="755">{755}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Concentration of Attention.</b>—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 +<a name="756">{756}</a> 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. +</p> +<br> +<p> +<b>Waking Suggestion.</b>—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. +</p> +<br> +<p> +<b>Personality of Anesthetist.</b>—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. +</p> +<p> +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 <a name="757">{757}</a> 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. +</p> +<br> +<p> +<b>Mental Diversion.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Fright in Anesthesia.</b>—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 <a name="758">{758}</a> +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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Local Anesthesia.</b>—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. +</p> +<br> +<p> +<b>Vomiting After Anesthesia.</b>—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 <a name="759">{759}</a> 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. +</p> +<p> +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. +</p> +<br> + +<h2>CHAPTER IV +<br><br> +MENTAL INFLUENCE AFTER OPERATION</h2> + +<p> +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. +</p> +<br> +<p> +<b>Removal of Worries.</b>—Worries of all kinds not associated with +the operation must have been thoroughly removed beforehand and must +not be allowed <a name="760">{760}</a> 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. +</p> +<br> +<p> +<b>Pleasant Visits.</b>—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. +</p> +<br> +<p> +<b>Psychic Conditions of Hospitals.</b>—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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Surgeon's Visits.</b>—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 +<a name="761">{761}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Comfort, Mental and Physical.</b>—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. +</p> +<br> +<p> +<b>Nursing.</b>—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 +<a href="http://www.gutenberg.org/ebooks/12439">"Notes on Nursing,"</a> +[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 +<i>sine qua non</i> 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 <a name="762">{762}</a> 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." +</p> +<p class="footnote"> + [Footnote 61: American edition, Appleton, N. Y.. 1860.] +</p> +<p> +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. +</p> +<br> +<p> +<b>Chattering Hopes.</b>—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. +</p> +<br> +<p> +<b>Variety of Thoughts.</b>—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: +</p> +<p class="cite"> + "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." +</p> +<p> +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. +</p> +<br> +<p> +<b>Pain Psychic Conditions.</b>—Pain after operation is an extremely +common symptom and often causes much disturbance. Every surgeon knows +how <a name="763">{763}</a> 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. +</p> +<br> +<p> +<b>Psychoneuroses.</b>—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. +</p> +<br> +<p> +<b>Psychic Disturbance of Function.</b>—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 <i>pittulae micarum panis</i> have proven +particularly useful. In the chapter on Constipation there is a +discussion of this subject that will often prove suggestive to +surgeons. +</p> +<p> +This same thing is true with regard to post-operative urination. In +women, <a name="764">{764}</a> 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. +</p> +<p> +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. +</p> +<br> +<p> +<b>Food Craving.</b>—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. +</p> +<br> +<p> <b>Position and Peace of Mind.</b>—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 +<a name="765">{765}</a> 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. +</p> + +<a name="766">{766}</a> +<br> +<h2>APPENDIX I +<br><br> +ILLUSIONS</h2> + +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Other illusions of two-eyed vision may be illustrated rather easily. +If <a name="767">{767}</a> 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. +</p> +<p class=center> +<img style="width: 396px; height: 60px;" alt="" +src="images/767f26.jpg" border=1> +<br> + Fig. 26 +</p> +<p> +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. +</p> +<p class=center> +<img style="width: 538px; height: 322px;" alt="" +src="images/767f27.jpg" border=1> +<br> + Fig. 27 +</p> +<p> +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), +</p> +<p class=center> +<img style="width: 540px; height: 338px;" alt="" +src="images/767f28.jpg" border=1> +<br> + Fig. 28 +</p> +<p> +These illusions show how many things that people +<a name="768">{768}</a> "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. +</p> +<p class=center> +<img style="width: 676px; height: 920px;" alt="" +src="images/768f29.jpg" border=1> +<br> + Fig. 29 +</p> +<p> +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 <a name="769">{769}</a> they show how +easily the senses may deceive us, even that most acute of our senses, +vision, as to the sizes of things. +</p> +<p class=center> +<img style="width: 378px; height: 384px;" alt="" +src="images/769f30.jpg" border=1> +<br> + Fig. 30 +</p> +<p> +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. +</p> +<p> +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. +</p> +<p class=center> +<img style="width: 446px; height: 156px;" alt="" +src="images/769f31.jpg" border=1> +<br> + Fig. 31 +</p> +<p> +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 +<a name="770">{770}</a> 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. +</p> +<p> +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 <a name="771">{771}</a> 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. +</p> +<p class=center> +<img style="width: 594px; height: 886px;" alt="" +src="images/770f32.jpg" border=1> +<br> +Fig. 32 +</p> +<p> +Other illusions of size are quite frequent. It is rather hard for the +ordinary observer to think that the half circles, <i>a</i> and +<i>a'</i> (Fig. 32), are the same size, or that <i>b</i> and <i>b'</i> +in the same chart are the same curve. The interruption in the circles +<i>c</i> and <i>c'</i> produce very curious erroneous impressions +which require a knowledge of this illusion to correct. +</p> +<p> +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. +</p> +<p class=center> +<img style="width: 668px; height: 506px;" alt="" +src="images/771f33.jpg" border=1> +<br> +Fig. 33 +</p> + +<p class=center> +<img style="width: 352px; height: 346px;" alt="" +src="images/772f34.jpg" border=1> +<br> +Fig. 34 +</p> +<p> +Poggendorf's illustration of the displacement of oblique lines (Figure +33) <a name="772">{772}</a> 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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<a name="773">{773}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +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 +<a name="774">{774}</a> 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. +</p> +<p> +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. +</p> +<p> +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 <i>muscae volitantes</i>, 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. +</p> +<p> +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 <a name="775">{775}</a> 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. +</p> +<a name="776">{776}</a> +<p> +<br> +<h2>APPENDIX II +<br><br> +RELIGION AND PSYCHOTHERAPY</h2> + +<p> +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: +</p> +<pre> + "God's in His Heaven- + All's right with the world!" +</pre> +<p> +—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. +</p> +<p> +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. +</p> +<a name="777">{777}</a> +<p> +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. +</p> +<p> +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. +</p> +<p> +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. +</p> +<p> +Another phase of this revulsion of feeling has been the institution of +a church movement that would make sufferers realize once more all the +<a name="778">{778}</a> 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. +</p> +<p> +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. +</p> +<p> +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." +</p> +<p> +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 +<a name="779">{779}</a> 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. +</p> +<p> +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: +</p> +<p class="cite"> + 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. +<br><br> + 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. +</p> +<p> +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. +</p> +<p> +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 <a name="780">{780}</a> +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. +</p> +<p> +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. +</p> +<a name="781">{781}</a> +<br> +<h1>INDEX.</h1> + +<pre> +Abdominal discomfort, <a href="#302">302</a>; + from coffee, <a href="#306">306</a>; + from tea, <a href="#30">30</a>; + from tone factors, <a href="#306">306</a>. +Abdominal viscera, <a href="#176">176</a>. +Abernethy, <a href="#268">268</a>. +Abortion, frequent, <a href="#457">457</a>. +Abracadabra, <a href="#61">61</a>. +Absence of occupation, <a href="#219">219</a>. +Absent treatment, <a href="#141">141</a>. +Abstraction, <a href="#129">129</a>. +Academy, French, telepathy and, <a href="#147">147</a>. +Accidents, telepathy and, <a href="#144">144</a>. +Aches, + filing, <a href="#397">397</a>; + occupation, <a href="#390">390</a>; + sawing, <a href="#397">397</a>; + sweeping, <a href="#397">397</a>; + writing, <a href="#396">396</a>. +Acid, lactic, as a bactericide, <a href="#247">247</a>. +Acquirements not transmitted, <a href="#628">628</a>. +Action, integrative, <a href="#123">123</a>. +Addictions, drug, <a href="#707">707</a>. +<i>Adiposus panniculus</i>, <a href="#299">299</a>. +Adjuvants, <a href="#163">163</a>. +Advertising, psychology of, <a href="#690">690</a>. +Aerophobia, <a href="#612">612</a>. +AEsculapius, <a href="#7">7</a>. +Affairs, knowledge of, <a href="#177">177</a>. +"After dinner sit awhile," <a href="#180">180</a>, <a href="#182">182</a>. +Afternoon fever, <a href="#180">180</a>. +After-treatment, + of alcoholism, <a href="#705">705</a>; + of tuberculosis, drug habits, <a href="#705">705</a>. +Agassiz's dream, <a href="#137">137</a>. +Agate, <a href="#62">62</a>. +Age, fasting and, <a href="#298">298</a>. +Agoraphobia, <a href="#612">612</a>. +Agrippa, Cornelius, <a href="#15">15</a>. +Aichmophobia, <a href="#581">581</a>, <a href="#612">612</a>. +Ailurophobia, <a href="#612">612</a>. +Air, + appetite and, <a href="#268">268</a>; + fresh, comfort and, <a href="#356">356</a>; + in dyspepsia, <a href="#262">262</a>; + in intestinal rumbling, <a href="#284">284</a>; + in intestinal troubles, <a href="#284">284</a>; + rather than exercise, <a href="#203">203</a>; + swallowing, <a href="#284">284</a>. +Alchemy, <a href="#40">40</a>, <a href="#41">41</a>, <a href="#56">56</a>. +Alcohol, <a href="#3">3</a>; + + in pneumonia, <a href="#31">31</a>; + in tuberculosis, <a href="#30">30</a>; + in vague affections, <a href="#31">31</a>; + milk and, <a href="#30">30</a>; + night workers and, <a href="#175">175</a>; + suggestive influence and, <a href="#31">31</a>. + +Alcoholism, + after-treatment in, <a href="#705">705</a>, <a href="#706">706</a>; + beginning of, <a href="#704">704</a>; + confidence in, <a href="#704">704</a>; + contagion in, <a href="#697">697</a>; + cures of, moral, <a href="#395">395</a>; + cures of, old and new, <a href="#694">694</a>; + frequent treatment in, <a href="#704">704</a>; + heredity in, <a href="#698">698</a>; + inherited resistance to, <a href="#698">698</a>; + mental influence in, <a href="#696">696</a>; + moral influences in, <a href="#704">704</a>; + national, <a href="#698">698</a>; + occupation pains and, <a href="#398">398</a>; + prophylaxis in, <a href="#701">701</a>; + real cures of, <a href="#395">395</a>; + religion and, <a href="#706">706</a>; + sanitarium question in, <a href="#702">702</a>; + supposed inheritance of, <a href="#697">697</a>; + "sure cures" of, <a href="#696">696</a>; + treatment of, <a href="#702">702</a>; + tuberculosis and, <a href="#703">703</a>; + warnings as suggestions in, <a href="#700">700</a>; + youth and, <a href="#701">701</a>. +Alexander of Hohenlohe, Prince, <a href="#75">75</a>. +Alexander of Tralles, <a href="#13">13</a>, <a href="#61">61</a>. +Alexandria, <a href="#11">11</a>. +Alteratives, <a href="#100">100</a>. +Ambrosia, <a href="#59">59</a>. +Amenorrhea, + ductless glands and, <a href="#439">439</a>; + dread and, <a href="#439">439</a>; + fright and, <a href="#437">437</a>; + home sickness and, <a href="#437">437</a>; + inanition and, <a href="#439">439</a>; + mental causes of, <a href="#437">437</a>; + mode of living and, <a href="#437">437</a>; + reputed remedies for, <a href="#440">440</a>; + suggestion in, <a href="#440">440</a>; + tuberculosis and, <a href="#437">437</a>. +Amethyst, <a href="#60">60</a>. +Amputation stump, pain in, <a href="#86">86</a>. +Amulets, <a href="#15">15</a>, <a href="#60">60</a>. +Amusements, + diversified, <a href="#9">9</a> <a href="#182">182</a>; + mind and, <a href="#227">227</a>. +Anatomy of melancholy, <a href="#61">61</a>. +Anemia in Porto Rico, <a href="#106">106</a>. +Anesthesia, <a href="#111">111</a>; + clasped hands in, <a href="#757">757</a>; + deep breathing in, <a href="#757">757</a>; + fright in, <a href="#757">757</a>; + from fixed attention, <a href="#755">755</a>; + game for children, <a href="#757">757</a>; + hearing during, <a href="#758">758</a>; + hypnotic, <a href="#754">754</a>; + local, <a href="#758">758</a>; + mental diversion in, <a href="#757">757</a>; + mind and, <a href="#733">733</a>; + occupation and, <a href="#754">754</a>; + rapid breathing: in, <a href="#755">755</a>; + suggestive, <a href="#756">756</a>; + vomiting after, <a href="#758">758</a>. +Anesthetist, + familiarity with, <a href="#756">756</a>; + personality of the, <a href="#756">756</a>. +Anger, brief madness and, <a href="#741">741</a>. +<i>Angina pectoris</i>, <a href="#27">27</a>, <a href="#334">334</a>; + Broadbent on, <a href="#339">339</a>; + Charcot on, <a href="#337">337</a>; + coffee and, <a href="#336">336</a>; + false, <a href="#338">338</a>; + in woman, <a href="#339">339</a>; + neurotic, <a href="#338">338</a>; + psychotherapy and, <a href="#337">337</a>; + reflected pains in, <a href="#335">335</a>; + spurious, <a href="#336">336</a>; + tea and, <a href="#336">336</a>; + tobacco and, <a href="#336">336</a>; + true and false, <a href="#336">336</a>, <a href="#339">339</a>. +Anicetum, <a href="#59">59</a>. +Animal emanations, <a href="#375">375</a>; + horse and dog, <a href="#244">244</a>. +Animal hypnosis, <a href="#161">161</a>. +Animal magnetism, <a href="#142">142</a>; + malicious, <a href="#142">142</a>. +Animal risibile, <a href="#105">105</a>. +Anise seed in lichen, <a href="#251">251</a>. +Anthropology, criminal, <a href="#744">744</a>. +Anodynes, useless, <a href="#219">219</a>. +Antidotes, suggestion and, <a href="#33">33</a>. +Antimony, <a href="#3">3</a>; + suggestions and, <a href="#26">26</a>. +Antiochos, <a href="#12">12</a>. +Antipathies, gastric, <a href="#245">245</a>. +Apartment hotels, <a href="#183">183</a>. +Apoplectic habitus, <a href="#518">518</a>. +Apoplectics, + examples encouraging, <a href="#521">521</a>; + new associations for, <a href="#521">521</a>; + new interests for, <a href="#521">521</a>. +Apoplexy, + Bacchus and, <a href="#517">517</a>; + cerebral, <a href="#513">513</a>; + change of occupation in, <a href="#519">519</a>; + complications in, <a href="#523">523</a>; + daughter as nurse in, <a href="#520">520</a>; + exciting occupation and, <a href="#517">517</a>; + heredity and, <a href="#517">517</a>; + hypochondriac, <a href="#514">514</a>; + lack of air and exercise in, <a href="#519">519</a>; + life-direction in, <a href="#519">519</a>; + mind before and after, <a href="#514">514</a>; + misplaced sympathy in, <a href="#522">522</a>; + neuroses and, <a href="#522">522</a>; + nurse, choice of, in, <a href="#520">520</a>; + outings and human interests and, <a href="#522">522</a>; + precocious, <a href="#510">510</a>; + preliminary motor symptoms in, <a href="#516">516</a>; + premonitory symptoms in, <a href="#514">514</a>; + prognosis in, <a href="#520">520</a>; + prophylaxis in, <a href="#517">517</a>; + pyramidal tracts and, <a href="#524">524</a>; + sympathetic cure of, <a href="#520">520</a>; + strokes, number of, in, <a href="#523">523</a>; + thinking and, <a href="#517">517</a>; + trained nurse in, <a href="#520">520</a>; + treatment of, <a href="#513">513</a>; + Venus and, <a href="#517">517</a>; + Vulcan and, <a href="#517">517</a>. +Apparatus, brain, + insulating, <a href="#123">123</a>; + switching, <a href="#123">123</a>. +Apparitions, explanation of, <a href="#607">607</a>. +Appearances, wraith-like, <a href="#608">608</a>. +Appendicitis, + chronic, <a href="#252">252</a>; + recurrent attacks of, <a href="#282">282</a>; + simulant, <a href="#587">587</a>. +Appetite, <a href="#262">262</a>, <a href="#592">592</a>; + air and, <a href="#268">268</a>; + emotion and, <a href="#264">264</a>; + feeling of, <a href="#264">264</a>; + food preparation and, <a href="#266">266</a>; + habit and, <a href="#265">265</a>; + increase in, <a href="#263">263</a>; + increasing, <a href="#301">301</a>; + indoor life and, <a href="#264">264</a>; + instinct and, <a href="#264">264</a>; + in the morning, <a href="#266">266</a>; + nervous loss of, <a href="#267">267</a>; + will and, <a href="#263">263</a>, <a href="#592">592</a>. +Appetizer, frequent eating as an, <a href="#267">267</a>. +Appetizers, <a href="#264">264</a>. +Application of psychotherapeutic principles, <a href="#104">104</a>. +Arabian mental medicine, <a href="#13">13</a>. +Arabian Nights, <a href="#12">12</a>, <a href="#46">46</a>. +Arch of the foot, yielding of the, <a href="#415">415</a>, <a href="#417">417</a>. +Areas of pain transfer, <a href="#252">252</a>. +Argyria, <a href="#36">36</a>. +Aristides, ancient hypochondriac, <a href="#73">73</a>. +Aristotle, <a href="#10">10</a>. +Arm, + pitcher's, <a href="#397">397</a>; + motorman's, <a href="#397">397</a>. +Armless men's foot powers, <a href="#419">419</a>. +Arnold, Matthew, and number <a href="#13">13</a>, <a href="#639">639</a>. +Arrhythmia, <a href="#322">322</a>; + gastro-cardiac, <a href="#329">329</a>; + longevity and, <a href="#323">323</a>. +Arterial sclerosis, diagnosis of, <a href="#514">514</a>. +Arteries, + calcification of, <a href="#512">512</a>; + longitudinal degeneration of, <a href="#515">515</a>; + premature degeneration of, <a href="#518">518</a>; + tortuous, <a href="#515">515</a>. +Arterio-sclerosis, <a href="#512">512</a>; + dizziness in, <a href="#515">515</a>; + dread of, <a href="#516">516</a>; + over-eating and, <a href="#518">518</a>; + stimulants in, <a href="#518">518</a>; + tobacco and, <a href="#518">518</a>; + vertigo in, <a href="#515">515</a>. +Artery of cerebral cortex, <a href="#125">125</a>. +Arthritis, + acute, <a href="#379">379</a>; + acute progressive, <a href="#423">423</a>; + "acute rheumatoid," <a href="#422">422</a>; + chronic, course of, <a href="#425">425</a>. +Arthritis deformans, <a href="#421">421</a>; + climate and, <a href="#428">428</a>; + chronic, <a href="#424">424</a>; + diet and, <a href="#427">427</a>; + electricity and, <a href="#427">427</a>; + exercise and, <a href="#427">427</a>; + in old persons, <a href="#426">426</a>; + knitting and, <a href="#427">427</a>; + mechano-therapy and, <a href="#427">427</a>; + mental attitude and, <a href="#426">426</a>; + muscle disturbances in, <a href="#424">424</a>; + nerves and, <a href="#422">422</a>; + neurotic additions in, <a href="#425">425</a>; + occupation of mind in, <a href="#428">428</a>; + symmetrical, <a href="#422">422</a>; + treatment of, <a href="#426">426</a>; + usefulness in, <a href="#426">426</a>; + weather and, <a href="#428">428</a>. +Arthritises, hysterical, <a href="#429">429</a>. +Arthropathy, nervous, <a href="#422">422</a>. +Asafetida, <a href="#69">69</a>. +Association fibers, diversion of, <a href="#601">601</a>. +Association of ideas, <a href="#123">123</a>. +Astasia-abasia, <a href="#86">86</a>. +Asthma, + brothers and, <a href="#377">377</a>; + cardiac, <a href="#364">364</a>; + cat, <a href="#374">374</a>; + cigarettes and, <a href="#366">366</a>; + climatotherapy and suggestion in, <a href="#368">368</a>; + cubebs and, <a href="#366">366</a>; + cures for, <a href="#366">366</a>; + cyanosis in, <a href="#365">365</a>; + drugs and suggestion in, <a href="#368">368</a>; + dust and, <a href="#369">369</a>; + emphysema in, <a href="#365">365</a>; + essential, <a href="#364">364</a>; + eye strain and, <a href="#367">367</a>; + horse, <a href="#376">376</a>; + horse serum and, <a href="#377">377</a>; + horse sensitization and, <a href="#377">377</a>; + human emanations and, <a href="#377">377</a>; + lavage and, <a href="#367">367</a>; + mental influence and, <a href="#365">365</a>; + mental shock and, <a href="#366">366</a>; + mouth breathing and, <a href="#367">367</a>; + neurotic, <a href="#364">364</a>; + picture of hayfield and, <a href="#375">375</a>; + renal, <a href="#364">364</a>; + saltpeter paper and, <a href="#366">366</a>; + suggestion in, <a href="#366">366</a>; + symptomatic, <a href="#364">364</a>; + varied cures for, <a href="#367">367</a>. +Astrology, + Hippocrates on, <a href="#38">38</a>; + in surgery, <a href="#746">746</a>; + reassurance and, <a href="#40">40</a>; + suggestion and, <a href="#38">38</a>; + venesection and, <a href="#746">746</a>. +Ataxia, + accessory symptoms of, <a href="#526">526</a>; + back knee, <a href="#524">524</a>; + depression in, <a href="#525">525</a>; + emotional, <a href="#572">572</a>; + flat-foot and, <a href="#524">524</a>; + from emotion, <a href="#572">572</a>; + in talking, walking, etc., <a href="#571">571</a>; + locomotor, <a href="#524">524</a>; + loose joints and, <a href="#524">524</a>; + suggestions, favorable and unfavorable, in, <a href="#525">525</a>. +Athens, psychotherapy in, <a href="#8">8</a>. +Athletes, + pneumonia and, <a href="#202">202</a>; + typhoid and, <a href="#202">202</a>. +Attacks, auto-hypnotic, <a href="#541">541</a>. +Attention, + concentration of, <a href="#755">755</a>; + conscious, <a href="#129">129</a>; + memory and, <a href="#679">679</a>; + process of, <a href="#127">127</a>; + power of, <a href="#124">124</a>; + Ramon y Cajal's theory of, <a href="#126">126</a>. +Attitude, mental, <a href="#100">100</a>. +Attitudes, + influence of, <a href="#100">100</a>; + of mind, <a href="#103">103</a>. +Augustine, St., on warnings, <a href="#611">611</a>. +Authorities on tuberculosis, American, <a href="#359">359</a>. +Auto-hypnotism, <a href="#161">161</a>. +Auto-intoxication, + intestinal, <a href="#172">172</a>, <a href="#270">270</a>; + supposed, <a href="#270">270</a>. +Automatism, inhibition of, <a href="#601">601</a>. +Auto-suggestion and the will, <a href="#148">148</a>. +Avalanche in nerves, law of. <a href="#111">111</a>. +Avalanche, law of, <a href="#585">585</a>. +Aversion + to cats, <a href="#617">617</a>; + to dead bodies, <a href="#617">617</a>. +Avicenna on mental influence, <a href="#14">14</a>. +Awake, lying, <a href="#667">667</a>. +Awaking, mode of, <a href="#165">165</a>. +Axis cylinders, <a href="#112">112</a>. +Axon hillock, <a href="#114">114</a>. + + +B + +Babies, fat, <a href="#292">292</a>. +Bacchae, <a href="#688">688</a>. +Back ache, <a href="#174">174</a>. +Bacon, as food, <a href="#249">249</a>. +Bacteria, lactic, <a href="#247">247</a>. +Ball for constipation, <a href="#278">278</a>. +Balneo-therapy, <a href="#5">5</a>. +Barometer, pains and, <a href="#382">382</a>. +Baseball interest, <a href="#228">228</a>. +Basedow's disease, <a href="#500">500</a>. +Basil, Valentine, <a href="#9">9</a>, <a href="#26">26</a>. +Basophobia, <a href="#613">613</a>. +Bath, + cold, <a href="#166">166</a>; + hot, <a href="#166">166</a>; + morning, <a href="#166">166</a>. +Bathing, + abuse of, <a href="#166">166</a>; + overfrequent, <a href="#167">167</a>. +Berkeley, Bishop, <a href="#57">57</a>. +Bernard, St., <a href="#74">74</a>. +Bernheim, hypnotism and, <a href="#159">159</a>. +Biliary colic, pseudo, <a href="#588">588</a>. +Billiards, <a href="#180">180</a>, <a href="#182">182</a>. +Binet, <a href="#153">153</a>. +Biographic Clinics, <a href="#258">258</a>. +Bishop, the mind-reader, <a href="#147">147</a>, <a href="#194">194</a>. +Bismarck's second eighty years, <a href="#724">724</a>. +Bismuth, milk of, <a href="#285">285</a>. +Bladder, + emptying the, <a href="#470">470</a>; + evacuation of the, position in, <a href="#212">212</a>. +Blanched fingers, <a href="#63">63</a>. +Blanching, <a href="#190">190</a>. +Bleeding, old-time, <a href="#381">381</a>. +Blind and deaf training, <a href="#215">215</a>. +Blind, + color recognition in the, <a href="#214">214</a>; + training of feeling in the, <a href="#213">213</a>. +Blood, + child's not mother's, <a href="#462">462</a>; + turning of the, <a href="#64">64</a>. +Blood letting, patient's mind and, <a href="#14">14</a>. +Bloodstone, <a href="#60">60</a>. +Blue glass, <a href="#44">44</a>. +Blue light, <a href="#44">44</a>. +"Blues, the," <a href="#641">641</a>. +"Bluidy Jock," <a href="#357">357</a>. +Blush, intestinal and vesical, <a href="#282">282</a>. +Blushing, <a href="#190">190</a>; + obsession, <a href="#613">613</a>. +Body, influence of, on mind, <a href="#100">100</a>. +Boerhaave, <a href="#17">17</a>, <a href="#71">71</a>. +Bonaparte, <a href="#85">85</a>. +Bouchard, <a href="#270">270</a>. +Bovary, Madame, <a href="#243">243</a>. +Bowels, over-attention to, <a href="#287">287</a>. +Bowling, <a href="#182">182</a>. +Boyle, Sir Robert, <a href="#35">35</a>. +Bradycardia, <a href="#342">342</a>; + case of, <a href="#343">343</a>. +Brain, + anatomy of, <a href="#18">18</a>; + capillaries in the, <a href="#125">125</a>; + cells of, vital energy of, <a href="#131">131</a>; + cells of, number of, <a href="#132">132</a>; + cortex of, <a href="#109">109</a>, <a href="#117">117</a>; + complexity of the, <a href="#109">109</a>; + intellect and, <a href="#549">549</a>; + machine, <a href="#132">132</a>; + number of cells in the, <a href="#110">110</a>. +Brain workers, <a href="#601">601</a>. +Brains, as food, <a href="#244">244</a>. +Bramwell, Dr. Byron, <a href="#374">374</a>. +Bramwell, Dr. J. Milne, <a href="#160">160</a>. +Bread pills, <a href="#88">88</a>. +Breakfast, + a full, <a href="#299">299</a>; + before, <a href="#168">168</a>; + company at, <a href="#170">170</a>; + habits, <a href="#169">169</a>; + mail before, <a href="#170">170</a>; + newspaper at, <a href="#170">170</a>. +Bridgeman, Laura, <a href="#214">214</a>. +Bright's disease, + insidious, <a href="#558">558</a>; + latent, <a href="#558">558</a>; + neurotic symptoms of, <a href="#558">558</a>. +Bringer of Peace, <a href="#7">7</a>. +Broadbent, Sir Wm., <a href="#319">319</a>, <a href="#326">326</a>; + on angina, <a href="#339">339</a>. +Brodie, Sir Benjamin, and hysterical joints, <a href="#386">386</a>, <a href="#589">589</a>, <a href="#749">749</a>. +Bronchi, dilatation of, relief in, <a href="#210">210</a>. +Bronchiectasis, position in, <a href="#210">210</a>. +Brontophobia, <a href="#612">612</a>. +Brown-Séquard, <a href="#48">48</a>, <a href="#67">67</a>. +Bunion, + formation of, <a href="#417">417</a>; + gout and, <a href="#416">416</a>. +Bunions and flatfoot, <a href="#416">416</a>. +Bursa, + housemaids', <a href="#399">399</a>; + miners', <a href="#399">399</a>; + organ grinders', <a href="#399">399</a>; + sitters', <a href="#399">399</a>. +Bursae, discomforts of, <a href="#399">399</a>. +Business, + anxieties in, <a href="#184">184</a>; + habits of, <a href="#178">178</a>; + knowledge of, <a href="#177">177</a>; + light, air, and position in, <a href="#177">177</a>; + walk to, <a href="#171">171</a>; + worries in, <a href="#185">185</a>. +Butter, microbes in, <a href="#95">95</a>. +Buxom, etymology of, <a href="#297">297</a>. + + +C + +Cabanis, <a href="#84">84</a>. +Cagliostro, <a href="#47">47</a>. +<i>Calamus scriptorius</i>, <a href="#12">12</a>. +Calculi, preputial, <a href="#485">485</a>. +Calculus, biliary, simulation of, <a href="#282">282</a>. +Calmady, Sir Richard, case of maternal impression in fiction, <a href="#221">221</a>. +Calomel, <a href="#3">3</a>; + in pneumonia, <a href="#22">22</a>; + suggestion and, <a href="#27">27</a>. +Campbell Thompson and cuneiform inscriptions, <a href="#38">38</a>. +Canals, semi-circular, <a href="#97">97</a>. +Cancer, + abdominal, <a href="#303">303</a>; + heredity in, <a href="#631">631</a>; + latent indigestion and, <a href="#255">255</a>; + mind and, <a href="#750">750</a>; + nursing tonic in, <a href="#222">222</a>. +Capillaries, congestion of, <a href="#126">126</a>. +Card playing, <a href="#182">182</a>. +Cardiac conditions, diagnosis of, <a href="#316">316</a>. +Cardiac exercise, <a href="#325">325</a>. +Cardiac inhibition, <a href="#313">313</a>. +Cardiac neurosis and prognosis, <a href="#321">321</a>, <a href="#322">322</a>. +Cardiac palpitation, the intellectual life and, <a href="#323">323</a>. +Cardiac stomach disturbance, <a href="#333">333</a>. +Carlsbad, <a href="#278">278</a>. +Carlyle's Miscellanies, <a href="#47">47</a>, <a href="#685">685</a>. +Carminatives, <a href="#285">285</a>. +Carnelian, <a href="#62">62</a>. +Cassius, lean and hungry, <a href="#297">297</a>. +Casts, intestinal and tubular, <a href="#286">286</a>. +Catalepsy, hypnotic, <a href="#159">159</a>. +Catarrh, <a href="#39">39</a>, <a href="#59">59</a>; + seasonal, <a href="#368">368</a>. +"Catarrh spring," <a href="#369">369</a>. +Cathay, cycle of, <a href="#517">517</a>. +Catherine of Siena, <a href="#74">74</a>. +Cato learning Greek, <a href="#680">680</a>. +Cats, + conjunctivitis and, <a href="#375">375</a>; + consciousness of presence of, <a href="#618">618</a>; + coryza and, <a href="#374">374</a>; + digestion disturbed by presence of, <a href="#254">254</a>; + dread of, <a href="#374">374</a>, <a href="#617">617</a>; + dread from memory of killing, <a href="#375">375</a>; + fear of, and furs, <a href="#618">618</a>; + intolerance of, <a href="#374">374</a>; + odor of, <a href="#619">619</a>; + smell of, <a href="#374">374</a>; + urticaria and, <a href="#374">374</a>. +Cautery, + actual, <a href="#68">68</a>; + psychotherapeutics and, <a href="#408">408</a>. +Cells, + complexity of brain, <a href="#131">131</a>; + Golgi, <a href="#131">131</a>; + of the ventral horn, <a href="#133">133</a>; + perivascular, <a href="#121">121</a>; + pigment, <a href="#121">121</a>; + rest, <a href="#652">652</a>; + spindle, <a href="#112">112</a>. +Cerebral artery, control of, <a href="#125">125</a>. +Cerebration, unconscious, <a href="#128">128</a>, <a href="#132">132</a>, <a href="#134">134</a>. +Cervical ribs, <a href="#400">400</a>. +Chair, comfortable, <a href="#210">210</a>. +Chamois garments, <a href="#168">168</a>. +Champneys, on painful menstruation, <a href="#445">445</a>. +Chance, <a href="#776">776</a>. +Character, + and suffering, <a href="#222">222</a>; + in therapeutics, <a href="#358">358</a>; + upbuilding of, <a href="#222">222</a>. +Charcot, Dr., <a href="#71">71</a>; + on menstrual mental states, <a href="#434">434</a>. +Charcot crystals, <a href="#364">364</a>. +Charms for erysipelas, <a href="#22">22</a>, <a href="#60">60</a>. +Charmides (Plato), <a href="#11">11</a>. +Cheese, habituation to, <a href="#246">246</a>. +Chest protectors, <a href="#167">167</a>. +Chesterfield, Lord, <a href="#225">225</a>. +Chesterton, on suicide, <a href="#722">722</a>. +Chestnuts, horse, for rheumatism, <a href="#385">385</a>. +Chewing in tuberculosis, <a href="#355">355</a>. +Cheyne, Dr., <a href="#314">314</a>. +Child, + diversion of the, <a href="#228">228</a>; + first years of the, <a href="#230">230</a>; + recreation of the, <a href="#228">228</a>. +Childbirth, + dangers of, <a href="#458">458</a>; + natural, <a href="#458">458</a>; + over-zeal to help in, <a href="#458">458</a>. +Children, + care of, <a href="#221">221</a>; + fat, <a href="#267">267</a>; + increase of suicide among, <a href="#721">721</a>. +Chilliness, <a href="#773">773</a>. +Chloral in hypnotism, <a href="#156">156</a>. +Chorea, + anemia and, <a href="#562">562</a>; + endocarditis and, <a href="#562">562</a>; + etiology of, <a href="#561">561</a>; + expectant treatment of, <a href="#563">563</a>; + colds and, <a href="#562">562</a>; + consciousness in, <a href="#562">562</a>; + cures of, <a href="#562">562</a>; + fright in, <a href="#562">562</a>; + growing pains and, <a href="#562">562</a>; + pathology of, <a href="#562">562</a>; + prophylaxis in, <a href="#563">563</a>; + pure neurosis and, <a href="#561">561</a>; + simple life and, <a href="#564">564</a>; + subsequent habit after, <a href="#563">563</a>; + treatment of, <a href="#562">562</a>. +Cicero, <a href="#189">189</a>. +Circle, vicious, <a href="#51">51</a>, <a href="#251">251</a>. +Circulation, favoring return of, <a href="#208">208</a>. +Cirrhosis, alcoholic, <a href="#175">175</a>. +Civil War, Reports of, <a href="#286">286</a>. +Clairvoyant, <a href="#147">147</a>. +Claude, Bernard, <a href="#20">20</a>, <a href="#313">313</a>. +Claudication, intermittent, <a href="#512">512</a>. +Claustrophobia, <a href="#612">612</a>, <a href="#616">616</a>. +Clavus <i>hystericus</i>, <a href="#547">547</a>. +Clergyman's knee, <a href="#411">411</a>; + sore throat, <a href="#411">411</a>. +Clinics, biographic, <a href="#601">601</a>. +Clitoris, removal of, <a href="#488">488</a>. +Clothing, <a href="#167">167</a>; + warm, <a href="#356">356</a>. +Clouston, <a href="#191">191</a>; + on religion, <a href="#777">777</a>. +Coccydynia, <a href="#428">428</a>. +Coccygodynia, <a href="#68">68</a>; + causes of, <a href="#428">428</a>; + hysterical, <a href="#429">429</a>; + labor and, <a href="#428">428</a>; + neurotic, <a href="#429">429</a>; + over-attention to, <a href="#429">429</a>. +Coffee and abdominal distress, <a href="#307">307</a>. +Cohnheim, <a href="#251">251</a>. +Coincidences, <a href="#144">144</a>; + telepathy and, <a href="#146">146</a>. +Colds, + fat and, <a href="#298">298</a>; + fresh, <a href="#350">350</a>; + fresh air and, <a href="#350">350</a>; + more sleep and, <a href="#350">350</a>; + night air and, <a href="#350">350</a>; + quinine and whiskey for, <a href="#349">349</a>; + rational treatment of, <a href="#349">349</a>; + settled on lungs, <a href="#358">358</a>; + taking, <a href="#167">167</a>. +Colitis, + cures for, <a href="#288">288</a>; + excess of salt in, <a href="#284">284</a>; + in Civil War, <a href="#286">286</a>; + increase of, <a href="#287">287</a>; + muco-membranous, <a href="#286">286</a>, <a href="#288">288</a>; + resorts, <a href="#289">289</a>; + suggestion in, <a href="#288">288</a>; + surgery for, <a href="#288">288</a>. +Colles' Law, <a href="#630">630</a>. +Color blindness, <a href="#771">771</a>. +Columbus, <a href="#42">42</a>. +Comedy, musical, <a href="#227">227</a>. +Comfort, mental and physical, <a href="#761">761</a>. +Compensation, <a href="#213">213</a>. +Concussion of the brain, <a href="#118">118</a>. +Conditions, mechanical, in pains, <a href="#174">174</a>. +Confession in sex habits, <a href="#486">486</a>. +Confidence, <a href="#15">15</a>; + of the patient, <a href="#14">14</a>; + of the physician, <a href="#4">4</a>. +Conjunctivitis, cat, <a href="#375">375</a>. +Constipation, <a href="#268">268</a>; + exercise in, <a href="#276">276</a>; + fats and sugars in, <a href="#276">276</a>; + in obesity, <a href="#296">296</a>; + in the stout, <a href="#278">278</a>; + oriental, <a href="#271">271</a>; + position in, <a href="#276">276</a>; + prophylaxis in, <a href="#269">269</a>; + reassurance in, <a href="#271">271</a>; + tolerance in, <a href="#272">272</a>. +Contagion, + coughing and, <a href="#688">688</a>; + expectoration and, <a href="#688">688</a>; + fashion and, <a href="#691">691</a>; + favorable mental, <a href="#692">692</a>; + giggling, <a href="#688">688</a>; + health, <a href="#692">692</a>; + laughing, <a href="#688">688</a>; + moving pictures and, <a href="#693">693</a>; + murder, <a href="#691">691</a>; + not heredity, <a href="#298">298</a>; + psychic, <a href="#688">688</a>; + sighing, <a href="#688">688</a>; + suicide, <a href="#691">691</a>; + yawning, <a href="#688">688</a>. +Contagious trifles, <a href="#688">688</a>. +Co-ordination in the organism, <a href="#132">132</a>. +Copenhagen, Perkins in, <a href="#49">49</a>. +Copremia, supposed, <a href="#270">270</a>. +Cornelius Agrippa, <a href="#15">15</a>. +Corns, soft, <a href="#418">418</a>. +Corpulency, <a href="#290">290</a>. +Cortex, + diagram of, <a href="#113">113</a>; + pyramidal cell in the, <a href="#122">122</a>; + visual, <a href="#110">110</a>. +Coryza, + cat, <a href="#375">375</a>; + vaso-motoria periodica, <a href="#369">369</a>; + yearly, <a href="#372">372</a>. +Cough, + as tic, <a href="#348">348</a>; + habit, <a href="#347">347</a>; + hemorrhage and, <a href="#346">346</a>; + intestinal, <a href="#348">348</a>; + in tuberculosis, <a href="#348">348</a>; + irrational, <a href="#349">349</a>; + mental control of, <a href="#361">361</a>; + ordinary, <a href="#345">345</a>; + ovarian, <a href="#348">348</a>; + reflex, <a href="#347">347</a>; + remedies for, <a href="#345">345</a>, <a href="#349">349</a>; + stomach, <a href="#348">348</a>; + stopping a, <a href="#210">210</a>; + suggestion and, <a href="#345">345</a>; + unproductive, <a href="#345">345</a>; + uterine, <a href="#348">348</a>. +Coughing, control of, <a href="#361">361</a>. +Counter irritation in nervous disease, <a href="#511">511</a>. +Courting and telepathy, <a href="#143">143</a>. +Coventry Patmore, Mrs., <a href="#144">144</a>. +Coxalgia, hysterical, <a href="#429">429</a>. +Cramp rings, <a href="#61">61</a>, <a href="#80">80</a>. +Cranberries in erysipelas, <a href="#22">22</a>. +Creator, existence of, <a href="#776">776</a>. +Crises, + gastric, <a href="#526">526</a>; + intestinal, <a href="#526">526</a>; + tabetic, <a href="#526">526</a>. +Critias, <a href="#11">11</a>. +Cromwell, <a href="#81">81</a>. +Crooke's theory of telepathy, <a href="#142">142</a>. +Croup, nervous, <a href="#669">669</a>. +Cure-alls, <a href="#3">3</a>. +Cure + houses, <a href="#10">10</a>; + magnetic, <a href="#55">55</a>; + relieve, console, <a href="#186">186</a>; + smiling and laughing, <a href="#104">104</a>. +Cured cases as evidence, <a href="#52">52</a>, <a href="#60">60</a>. +Cures, <a href="#50">50</a>; + faith, <a href="#78">78</a>; + for colitis, <a href="#288">288</a>; + for tuberculosis, <a href="#351">351</a>; + hayfever, <a href="#373">373</a>; + supposed, <a href="#51">51</a>, <a href="#387">387</a>. +Curschmann's spirals, <a href="#364">364</a>. +Cutten, on faith cures, <a href="#81">81</a>. +Czermak, Prof., on inhibition, <a href="#313">313</a>. + + +D + +Dalton, color blind, <a href="#772">772</a>. +Dangers of hypnotism, <a href="#161">161</a>; + Dr. J. K. Mitchell on, <a href="#161">161</a>. +Darkness, + dread of, <a href="#620">620</a>, <a href="#668">668</a>; + Romilly and, <a href="#621">621</a>; + Rousseau and, <a href="#620">620</a>. +Dawdling, <a href="#182">182</a>. +Dead bodies, aversion to, <a href="#617">617</a>. +Deaf, training of the, <a href="#215">215</a>. +Death, + AEschylus on, <a href="#622">622</a>; + After, What? <a href="#88">88</a>; + attitude toward, <a href="#730">730</a>; + captain of, <a href="#350">350</a>; + dread of, <a href="#621">621</a>; + fear of early, <a href="#622">622</a>; + impending, <a href="#336">336</a>; + life and, <a href="#89">89</a>; + mind and, <a href="#90">90</a>; + moment of, <a href="#147">147</a>; + premonition of, <a href="#636">636</a>; + put off, <a href="#91">91</a>; + socially, <a href="#731">731</a>; + Sophocles on, <a href="#622">622</a>. +Defectives, sexual, <a href="#474">474</a>. +Deformities, + coincidences and, <a href="#464">464</a>; + etiology of, <a href="#466">466</a>; + falls and, <a href="#467">467</a>; + missteps and, <a href="#467">467</a>. +Degeneration, stigmata of, <a href="#744">744</a>. +Delusions, <a href="#603">603</a>. +<i>Dementia praecox</i> and paresis, <a href="#532">532</a>. +Dendrites, <a href="#112">112</a>. +Dentist's limp, <a href="#398">398</a>. +Depression and disease, <a href="#641">641</a>; + and diversion, <a href="#643">643</a>; + and dyspepsia, <a href="#233">233</a>; + and hobbies, <a href="#646">646</a>; + and indigestion, <a href="#233">233</a>; + an incident, <a href="#650">650</a>; + benefits of, <a href="#650">650</a>; + care of ailing a cure for, <a href="#645">645</a>; + care of animals a cure for, <a href="#645">645</a>: + care of plants a cure for, <a href="#645">645</a>; + feminine, and children, <a href="#644">644</a>; + frequency of, <a href="#647">647</a>; + garden cures for, <a href="#646">646</a>; + heart disease and, <a href="#642">642</a>; + historical examples of, <a href="#647">647</a>; + insomnia and, <a href="#644">644</a>; + Lord Lytton and, <a href="#648">648</a> + Lowell, James Russell, and, <a href="#648">648</a> + nephritis and, <a href="#642">642</a>; + periodical, <a href="#641">641</a> + reading in, <a href="#646">646</a>. +De Puysegur's instruction in hypnotism, <a href="#154">154</a>. +Dermatotherapy, the mind in, <a href="#495">495</a>. +Descartes, <a href="#41">41</a>. +Desks, comfortable, standing, <a href="#176">176</a>. +Determinism, <a href="#744">744</a>. +Deterrent materials and suggestions, <a href="#34">34</a>. +Deterrent taste and smell, <a href="#68">68</a>. +Deterrent therapeutics, <a href="#63">63</a>. +Diabetes + acidosis, <a href="#500">500</a>; + air and exercise in, <a href="#499">499</a>; + causes of, <a href="#496">496</a>; + danger of over-treatment in, <a href="#497">497</a>; + eczema in, <a href="#496">496</a>; + frequent in obese, <a href="#294">294</a>; + general condition in, <a href="#497">497</a>; + incurable, <a href="#496">496</a>; + interval treatment of, <a href="#498">498</a>; + oatmeal and, <a href="#498">498</a>; + over-treatment of, <a href="#497">497</a>; + pancreatic changes in, <a href="#496">496</a>; + physician and patient's, <a href="#497">497</a>; + potatoes and, <a href="#498">498</a>; + rigid diet and solicitude in, <a href="#499">499</a>; + secondary symptoms of, <a href="#497">497</a>; + individual, the, and, <a href="#498">498</a>; + unfavorable suggestion, <a href="#496">496</a>. +Diagnosis, announcing the, <a href="#354">354</a>. +Diancecht, Irish physician, <a href="#58">58</a>. +Diaphragm, + excursions of the, <a href="#362">362</a>; + movements of the, <a href="#362">362</a>. +Diarrhea, + emotional, <a href="#283">283</a>; + fright and, <a href="#279">279</a>; + habitual, <a href="#280">280</a>; + nervous, <a href="#558">558</a>; + nervous, and urticaria, <a href="#281">281</a>; + neurotic, <a href="#279">279</a>; + worry and, <a href="#280">280</a>. +Diathesis, uric acid, <a href="#380">380</a>. +Diet, + <i>do not</i>, <a href="#257">257</a>; + dyspepsia and, <a href="#256">256</a>; + fads, <a href="#171">171</a>; + limitation of, <a href="#275">275</a>; + mixed, <a href="#275">275</a>; + restrained, <a href="#298">298</a>; + rules, harmful, in, <a href="#256">256</a>; + tinkering, <a href="#380">380</a>. +Diffusion, laws of, <a href="#132">132</a>. +Digby, Sir Kenelm, <a href="#56">56</a>. +Digestion, + brain workers and, <a href="#258">258</a>; + chemistry and, <a href="#242">242</a>; + contrary suggestions and, <a href="#251">251</a>; + disgust and, <a href="#243">243</a>; + influence of mind upon, <a href="#242">242</a>; + mental changes and, <a href="#247">247</a>; + of cat, disturbed, <a href="#254">254</a>; + prejudices and, <a href="#242">242</a>; + study and, <a href="#253">253</a>; + worries and, <a href="#253">253</a>. +Digitalis and mental influence, <a href="#313">313</a>. +Directions to physicians, suggestion and, <a href="#197">197</a>. +Disappearances, <a href="#608">608</a>. +Disappointments, mental states of, <a href="#643">643</a>. +Discipline, of mind, <a href="#196">196</a>; of self, <a href="#223">223</a>. +Discomfort, + digestion and, <a href="#253">253</a>; + with eating, <a href="#301">301</a>. +Discontinuity of the nervous system, <a href="#118">118</a>. +Discoveries, scientific, <a href="#46">46</a>. +Discovery, supposedly wonderful, <a href="#192">192</a>. +Disease, + American, <a href="#380">380</a>; + incurable, <a href="#186">186</a>; + individual, <a href="#224">224</a>; + patients and, <a href="#163">163</a>; + suggestion of, <a href="#94">94</a>; thinking, <a href="#99">99</a>. +Disease suggestions, <a href="#250">250</a>. +Diseases of ductless glands, <a href="#496">496</a>. +Dislocations, after-effects of, <a href="#388">388</a>. +Disposition, + suggestion and, <a href="#101">101</a>; + dual, <a href="#150">150</a>. +Distension, <a href="#332">332</a>. +Disuse, atrophy and pain, <a href="#394">394</a>. +Diversion, <a href="#182">182</a>; + children's, <a href="#228">228</a>; + from pain, <a href="#225">225</a>; + of mind, <a href="#9">9</a>; + true, <a href="#224">224</a>. +Divinity, medical, <a href="#7">7</a>. +Doctor, "conjure," <a href="#64">64</a>. +Dog and hog, <a href="#243">243</a>. +Dominant ideas, <a href="#750">750</a>. +Donne, Dr., <a href="#37">37</a>. +Doubting, <a href="#732">732</a>; + daily review in, <a href="#738">738</a>; + habit, <a href="#733">733</a>; + marriage and, <a href="#735">735</a>; + opening letters and, <a href="#735">735</a>; + ordination and, <a href="#735">735</a>; + outdoor air and, <a href="#738">738</a>; + prophylaxis in, <a href="#737">737</a>. +Doubts, + Hamlet's, <a href="#735">735</a>; + program for day in, <a href="#738">738</a>. +Dread, <a href="#2">2</a>, <a href="#612">612</a>, <a href="#613">613</a>; + habit of control of, <a href="#615">615</a>; + mental discipline in, <a href="#615">615</a>: + of arterio-sclerosis, <a href="#515">515</a>; + of death, <a href="#621">621</a>; + of dirt, <a href="#615">615</a>; + of heights, <a href="#614">614</a>; + of indigestion, <a href="#306">306</a>; + of insanity, <a href="#623">623</a>; + of small heights, <a href="#615">615</a>; + of the dark. <a href="#620">620</a>; + of water, <a href="#621">621</a>; + physical basis of, <a href="#614">614</a>; + subconscious, <a href="#625">625</a>. +Dreads, + heredity and, <a href="#626">626</a>; + men of genius and, <a href="#623">623</a>. +Dreaming, + "all the night long," <a href="#673">673</a>; + by day, <a href="#671">671</a>; + constant, Hazlitt, Mitchell and Owen, <a href="#672">672</a>; + Laughing, Blushing and, <a href="#607">607</a>, <a href="#672">672</a>. +Dreams, <a href="#8">8</a>, <a href="#78">78</a>, <a href="#669">669</a>; + and children, <a href="#678">678</a>; + and digestion, <a href="#100">100</a>; + and fright, <a href="#677">677</a>; + and reading, <a href="#678">678</a>; + and sensations, <a href="#575">575</a>; + art in, <a href="#136">136</a>; + children's, <a href="#677">677</a>; + erotic, <a href="#479">479</a>; + frequency of, <a href="#671">671</a>; + insufficient clothing in, <a href="#671">671</a>; + life and, <a href="#136">136</a>; + mathematical, <a href="#136">136</a>; + mercy's, <a href="#136">136</a>; + of falling, <a href="#670">670</a>; + out of breath, <a href="#671">671</a>; + poems and, <a href="#136">136</a>; + prophecy fails, <a href="#676">676</a>; + prophetic, <a href="#675">675</a>; + rearrangement in, <a href="#635">635</a>; + short duration of, <a href="#673">673</a>; + significance of, <a href="#674">674</a>; + suggestions and, <a href="#678">678</a>; + telepathic, <a href="#674">674</a>; + therapy and, <a href="#669">669</a>. +Drug addictions, <a href="#707">707</a>. +Drug habit, + after-cures for, <a href="#712">712</a>; + confidence in, <a href="#711">711</a>; + cures for, <a href="#709">709</a>; + curiosity and, <a href="#708">708</a>; + early treatment in, <a href="#710">710</a>; + forming, <a href="#290">290</a>; + heredity and, <a href="#712">712</a>; + individual, <a href="#707">707</a>; + over-confidence in, <a href="#709">709</a>; + pleasant, <a href="#708">708</a>; + prophylaxis in, <a href="#708">708</a>; + relapses in, <a href="#709">709</a>; + sanitarium question and, <a href="#710">710</a>. +Drugs, <a href="#8">8</a>; + effects of, imaginary, <a href="#88">88</a>; + in sufficient doses, <a href="#4">4</a>. +Drunkenness, <a href="#117">117</a>. +Dualism of disposition, <a href="#151">151</a>. +Dumas, <a href="#47">47</a>. +Dumb-bell, a parody of exercise, <a href="#204">204</a>. +Dundrearyisms, <a href="#464">464</a>. +Dupré, Giovanni, <a href="#136">136</a>. +Dupuytren's slap for anesthesia, <a href="#754">754</a>. +Dust and disease, <a href="#172">172</a>. +Duval and neurons, <a href="#114">114</a>. +Dwarf of French king, <a href="#314">314</a>. +Dysmenorrhea, + constipation in, <a href="#442">442</a> + cystic ovaries in, <a href="#446">446</a>; + extragenital <a href="#445">445</a>; + extrapelvic organs in, <a href="#442">442</a> + fisherwomen and, <a href="#444">444</a>; + individual <a href="#446">446</a>; + lack of occupation in, <a href="#443">443</a> + membranous, <a href="#445">445</a>; + minor lesions in, <a href="#446">446</a>; + moral fiber and, <a href="#443">443</a>; + operation idea and, <a href="#443">443</a>; + running down and, <a href="#442">442</a>; + spasmodic, <a href="#445">445</a>; + suggestion and, <a href="#445">445</a>. +Dyspepsia, <a href="#301">301</a>; + abdominal muscles and, <a href="#261">261</a>; + air and, <a href="#262">262</a>; + American, <a href="#179">179</a>; + depression and, <a href="#233">233</a>; + from diet regulation, <a href="#256">256</a>; + mental work and, <a href="#253">253</a>; + sleep and, <a href="#262">262</a>; + state of mind in, <a href="#250">250</a>. +Dyspeptics, + exercise for, <a href="#261">261</a>; + longevity of, <a href="#259">259</a>. + + +E + +Eat, the will to, <a href="#263">263</a>. +Eating, + dread of, <a href="#264">264</a>; + enough, <a href="#299">299</a>; + more, <a href="#301">301</a>; + slow, <a href="#231">231</a>; + uncomfortable feelings after, <a href="#263">263</a>. +Eddyism, <a href="#60">60</a>, <a href="#386">386</a>. +Edema, angio-neurotic, <a href="#283">283</a>. +Education and discipline, <a href="#196">196</a>. +Efficiency experts, <a href="#179">179</a>. +Eggs, + biliousness and, <a href="#246">246</a>; + idiosyncrasy for, <a href="#245">245</a>; + persuasion as to, <a href="#248">248</a>; + repugnance to, <a href="#246">246</a>. +Egypt, psychotherapy in, <a href="#8">8</a>. +Electric belts, <a href="#62">62</a>. +Electric insoles, <a href="#63">63</a>. +Electrical contrivances, <a href="#43">43</a>. +Electricity, <a href="#5">5</a>. +Electro-therapy, <a href="#5">5</a>; + suggestion and, <a href="#42">42</a>, <a href="#43">43</a>. +Elijah returned, <a href="#82">82</a>. +Elixir of life, <a href="#44">44</a>. +Embryo-complexity, <a href="#466">466</a>. +Emissions, + seminal, alcohol and, <a href="#478">478</a>; + constipation and, <a href="#478">478</a>; + full bladder and, <a href="#478">478</a>; + nocturnal, <a href="#477">477</a>; + prophylaxis in, <a href="#478">478</a>; + spices and, <a href="#478">478</a>. +Emotion, heart and, <a href="#311">311</a>. +Emotions as remedies, <a href="#17">17</a>. +Encyclopedia Brittanica on mummifies, <a href="#64">64</a>. +Energy, reserve, <a href="#108">108</a>; + law of, <a href="#92">92</a>. +English, Dr. Thomas Dunn, on life, <a href="#724">724</a>. +Environment, favorable, <a href="#188">188</a>. +Epidaurus, <a href="#8">8</a>. +Epidemic, suicidal, <a href="#691">691</a>. +Epilepsy, <a href="#15">15</a>; + anise seed for, <a href="#25">25</a>; + attitude of mind in, <a href="#537">537</a>; + Byron and, <a href="#536">536</a>; + Caesar and, <a href="#536">536</a>; + colony system and, <a href="#535">535</a>; + cures for, <a href="#537">537</a>; + dread of insanity in, <a href="#535">535</a>; + emotion and, <a href="#535">535</a>; + fright and, <a href="#535">535</a>; + individual in, <a href="#536">536</a>; + influence of suggestion in, <a href="#535">535</a>; + mental "cures" of, <a href="#541">541</a>; + Mohamed, <a href="#536">536</a>; + Napoleon, <a href="#536">536</a>; + neurotic simulation of, <a href="#536">536</a>; + occupation in, <a href="#537">537</a>; + operations for, <a href="#505">505</a>, <a href="#535">535</a>; + quiet life and, <a href="#537">537</a>; + rings in, <a href="#61">61</a>; + royal touch and, <a href="#79">79</a>; + suggestion in, <a href="#25">25</a>. +Equilibrium, + training in, <a href="#215">215</a>; + unstable intestinal, <a href="#286">286</a>. +Erasistratos, <a href="#11">11</a>. +Erotic, <a href="#480">480</a>. +Erysipelas, <a href="#3">3</a>, <a href="#21">21</a>. +Erythrophobia, <a href="#613">613</a>. +Esophageal stricture, <a href="#676">676</a>; + neurotic, <a href="#574">574</a>. +Esophagus, constriction of the, <a href="#575">575</a>. +Esquirol, on child suicide, <a href="#721">721</a>. +Ether in telepathy, <a href="#142">142</a>. +Euripides, <a href="#688">688</a>. +Evacuation, + habitual, <a href="#273">273</a>; + simulated, <a href="#285">285</a>. +Evil, denial of, <a href="#776">776</a>. +Evolution, Lucretius and, <a href="#776">776</a>. +Excrement, goose and chicken, <a href="#34">34</a>. +Excretions as remedies, <a href="#66">66</a>. +Exercise, <a href="#198">198</a>; + air and, <a href="#203">203</a>; + for heart irregularity, <a href="#327">327</a>; + for sake of exercise, <a href="#204">204</a>-7; + fun and, <a href="#203">203</a>; + graduated, for heart, <a href="#328">328</a>; + in dyspepsia, <a href="#261">261</a>; + in early years—English and German customs, <a href="#199">199</a>; + interest and, <a href="#203">203</a>; + mental diversion and, <a href="#207">207</a>; + regulation of, <a href="#202">202</a>; + sport and, <a href="#203">203</a>; + sufficient, <a href="#199">199</a>; + treatment for heart and, <a href="#328">328</a>. +Exhaustion, mental, <a href="#138">138</a>. +Exhibitionism, <a href="#490">490</a>. +Exosmosis, <a href="#132">132</a>. +Expectancy, mental, <a href="#46">46</a>. +Expectoration, difficulty in, <a href="#210">210</a>. +Expert in health, <a href="#179">179</a>. +Expression and feeling, <a href="#101">101</a>. +Extensors and hate, <a href="#194">194</a>. +Extra-systole, + big beat and, <a href="#333">333</a>; + conscious, <a href="#333">333</a>; + long-pause, <a href="#333">333</a>; + prognosis in, <a href="#333">333</a>. +Eye, + oblique muscles of, <a href="#102">102</a>; + superior recti of, <a href="#102">102</a>. + + +F + +Fabricius Hildanus, <a href="#54">54</a>. +Facial expression and feeling, <a href="#101">101</a>. +Faddists, fruit, milk-product and nut, <a href="#258">258</a>. +Fads, + bathing, <a href="#167">167</a>; + harmful, <a href="#166">166</a>; + health and, <a href="#689">689</a>. +Faith, <a href="#14">14</a>, <a href="#15">15</a>; + cures by, <a href="#61">61</a>; + healing and, <a href="#196">196</a>; + power of, <a href="#196">196</a>. +Familiarity with drugs, <a href="#4">4</a>. +<i>Fascia dentata neuroglia</i>, <a href="#120">120</a>. +Fashion contagion, <a href="#690">690</a>. +Fasting ages, <a href="#298">298</a>. +Fat, + anemic, <a href="#298">298</a>; + in sick hogs, <a href="#303">303</a>; + lack of, <a href="#298">298</a>; + useless, <a href="#201">201</a>. +Father John of Cronstadt, <a href="#75">75</a>. +Fats in constipation, <a href="#276">276</a>. +Fatty vicious circle, <a href="#292">292</a>. +Fearing the worst, <a href="#98">98</a>. +Feeling, expression and, <a href="#101">101</a>; + occupation and, <a href="#129">129</a>. +Feelings, transferred, <a href="#251">251</a>. +Feet above heart, <a href="#173">173</a>. +Femero-coxalgia, <a href="#68">68</a>. +Feré, <a href="#153">153</a>. +Ferrier, Chancellor, <a href="#323">323</a>. +Fever, afternoon, <a href="#180">180</a>; + typhoid, <a href="#3">3</a>. +Filaments, terminal, <a href="#117">117</a>. +Fish, coloration practice in, <a href="#494">494</a>. +Fissure, calcarine, <a href="#110">110</a>. +Flammarion, <a href="#607">607</a>. +Flashes of heat, <a href="#773">773</a>. +Flatfoot, <a href="#174">174</a>, <a href="#383">383</a>; + circulation in, <a href="#419">419</a>; + prevention of, <a href="#419">419</a>; + relief for, <a href="#209">209</a>; + runs in families, <a href="#390">390</a>; + secondary consequences of, <a href="#420">420</a>; + sprains and, <a href="#420">420</a>. +Flatulence, <a href="#332">332</a>. +Flaubert, <a href="#243">243</a>. +Fletcher, <a href="#231">231</a>. +Flexors and liking, <a href="#194">194</a>. +Flourens, <a href="#543">543</a>. +Fluid, + daily, <a href="#274">274</a>; + ingestion of, <a href="#274">274</a>; + in obesity, <a href="#296">296</a>. +Folin, <a href="#231">231</a>. +Food, + amount of, <a href="#273">273</a>; + angle worms as, <a href="#244">244</a>; + brains, liver and spleen as, <a href="#244">244</a>; + caprice and, <a href="#266">266</a>; + chewing, <a href="#260">260</a>; + craving for, after operation, <a href="#763">763</a>; + custom and, <a href="#244">244</a>; + dislikes for, <a href="#245">245</a>; + dyspepsia and, <a href="#301">301</a>; + elimination of, <a href="#250">250</a>; + idiosyncrasies and, <a href="#282">282</a>, <a href="#301">301</a>; + increase in, <a href="#273">273</a>, <a href="#301">301</a>; + natural residue of, <a href="#275">275</a>; + preparation of, appetite and, <a href="#266">266</a>; + reduction of, <a href="#296">296</a>; + sleep and, <a href="#207">207</a>; + temptations to, <a href="#293">293</a>; + values and habits, <a href="#263">263</a>. +Food faddists, <a href="#258">258</a>. +Foot, + exercise for the, <a href="#420">420</a>; + noises with the, <a href="#419">419</a>. +Foot troubles, + deformities in all classes, <a href="#413">413</a>; + mechanical factors in, <a href="#413">413</a>; + rarer, <a href="#418">418</a>; + significance of, <a href="#421">421</a>; + unfavorable suggestions and, <a href="#415">415</a>. +Force, vital, <a href="#133">133</a>. +Ford Robertson, <a href="#110">110</a>. +Forel, Prof., <a href="#190">190</a>, <a href="#706">706</a>. +Foreskin, long, <a href="#484">484</a>. +Forgetfulness, limits of normal, <a href="#683">683</a>. +Formulas, word, <a href="#566">566</a>. +Fox hunting, <a href="#205">205</a>. +Fractures, + after-effects of, <a href="#388">388</a>; + immobilized, <a href="#388">388</a>; + manipulation of, <a href="#388">388</a>; + massage of, <a href="#388">388</a>; + mind and, <a href="#751">751</a>; + of the clavicle, <a href="#89">89</a>. +Francis of Assisi, St., <a href="#74">74</a>. +Francis Xavier, St., <a href="#74">74</a>. +Frankenstein, <a href="#626">626</a>. +Free will, <a href="#148">148</a>, <a href="#152">152</a>, <a href="#739">739</a>; + argument for, <a href="#739">739</a>; + individual, <a href="#741">741</a>. +Frenkel's method for tabes, <a href="#528">528</a>. +Frenkel's treatment, origin of, <a href="#528">528</a>. +Frere, Robert <a href="#36">36</a>. +Freud, <a href="#595">595</a>. +Friedländer on quackery at Rome, <a href="#58">58</a>. +Fright, + epilepsy and, <a href="#535">535</a>; + heart and, <a href="#315">315</a>; + in chorea, <a href="#562">562</a>; + in Graves' disease, <a href="#500">500</a>; + in paralysis agitans, <a href="#542">542</a>; + loss of bowel control and, <a href="#279">279</a>; + tremors from, <a href="#581">581</a>; + white hair and, <a href="#494">494</a>. +Frights, forgotten, <a href="#625">625</a>. +Fumigation, <a href="#60">60</a>. +Fun and health, <a href="#203">203</a>. + + +G + +Galen, <a href="#12">12</a>; + on proprietaries, <a href="#59">59</a>. +Galen's theriac, <a href="#20">20</a>, <a href="#46">46</a>, <a href="#51">51</a>, <a href="#59">59</a>, <a href="#71">71</a>. +Gallstones, <a href="#80">80</a>. +Galton, Sir Francis, <a href="#36">36</a>, <a href="#601">601</a>, <a href="#606">606</a>. +Galvani, <a href="#43">43</a>. +Gambling, <a href="#182">182</a>. +Garments, chamois, <a href="#168">168</a>. +Gas, <a href="#15">15</a>. +Gassner, <a href="#15">15</a>, <a href="#153">153</a>. +Gastralgia, tabetic, <a href="#526">526</a>. +Gastric crisis, <a href="#526">526</a>, <a href="#586">586</a>. +Gastric dilatation, <a href="#330">330</a>. +Gastric fauna, <a href="#462">462</a>. +Gastric motility, <a href="#176">176</a>, <a href="#307">307</a>. +Gastric muscular tone, <a href="#262">262</a>. +Gastric reflexes, <a href="#251">251</a>. +Gastric secretion neuroses, <a href="#586">586</a>. +Gastric self digestion, <a href="#303">303</a>. +Gastric sensations, <a href="#306">306</a>. +Generalization of visceral pain, <a href="#252">252</a>. +Genitalia, over-attention to the, <a href="#430">430</a>. +Genius, De Musset, <a href="#624">624</a>; + Goethe, <a href="#624">624</a>; + idiosyncrasies and, <a href="#245">245</a>; + investigating, <a href="#130">130</a>; + Kingsley, <a href="#624">624</a>; + Montaigne, <a href="#624">624</a>. +George Eliot, <a href="#135">135</a>, <a href="#141">141</a>. +Gerhardt, Prof., <a href="#317">317</a>. +Ghosts, <a href="#605">605</a>. +Gilbert, <a href="#42">42</a>. +Gilles de la Tourette on tics, <a href="#564">564</a>. +Ginseng, <a href="#35">35</a>. +Giving up, <a href="#93">93</a>. +Gladstone, <a href="#225">225</a>. +Gladstone's chewing, <a href="#231">231</a>. +Glands, intestinal, over-action of, <a href="#288">288</a>. +Glycosuria, + alimentary, <a href="#496">496</a>; + psychological, <a href="#291">291</a>; + neurotic, <a href="#496">496</a>. +Goclenius, <a href="#55">55</a>. +Gold, chloride of, <a href="#61">61</a>. +Goldsmith, <a href="#223">223</a>. +Golgi, <a href="#110">110</a>, <a href="#131">131</a>. +Gordon Holmes, <a href="#151">151</a>. +Gordy, Prof. J. P., <a href="#230">230</a>. +Gould, Dr. George, <a href="#258">258</a>, <a href="#601">601</a>. +Gout and flatfoot, <a href="#415">415</a>, <a href="#416">416</a>; + rheumatic, <a href="#421">421</a>. +Gowers, Sir William, <a href="#556">556</a>. +Gowers' rule in writing, <a href="#396">396</a>. +Grahamism, <a href="#256">256</a>. +Grass scorpion, <a href="#35">35</a>. +Grasset, <a href="#597">597</a>. +Graves' disease, + cures of, <a href="#504">504</a>; + diagnosis of, <a href="#502">502</a>; + diarrhea and, <a href="#501">501</a>; + diet and, <a href="#506">506</a>; + diversion and, <a href="#506">506</a>; + emaciation and, <a href="#501">501</a>; + emotion and, <a href="#500">500</a>; + etiology of, <a href="#500">500</a>; + <i>formes frustes</i> <a href="#500">500</a>, <a href="#502">502</a>; + fright and, <a href="#500">500</a>; + genital incidents and, <a href="#501">501</a>; + larval forms of, <a href="#341">341</a>; + menopause and, <a href="#502">502</a>; + mummy and, <a href="#504">504</a>; + operations for, <a href="#505">505</a>; + parathyroid and, <a href="#504">504</a>; + prognosis in, <a href="#502">502</a>; + responsibility and, <a href="#500">500</a>; + serums and, <a href="#504">504</a>; + sex incidents and, <a href="#501">501</a>; + sleep and, <a href="#506">506</a>; + snake skin and, <a href="#504">504</a>; + suggestion and, <a href="#504">504</a>; + sympathetic, <a href="#502">502</a>; + symptomatology of, <a href="#501">501</a>; + thyroid in, <a href="#469">469</a>, <a href="#504">504</a>; + thymus in, <a href="#469">469</a>, <a href="#503">503</a>; + touch of hanged in, <a href="#504">504</a>; + women and, <a href="#501">501</a>. +Gravitation, <a href="#41">41</a>. +Greatrakes, <a href="#81">81</a>, <a href="#153">153</a>, <a href="#386">386</a>. +Greece, decadence in, <a href="#107">107</a>. +Grief, + Astley Cooper and, <a href="#731">731</a>; + consolation in, <a href="#729">729</a>; + Lord Lytton and, <a href="#731">731</a>; + melancholia and, <a href="#727">727</a>; + motives of consolation in, <a href="#728">728</a>; + pathological, <a href="#727">727</a>; + physical conditions in, <a href="#726">726</a>; + prophylaxis in, <a href="#728">728</a>; + Rossetti and, <a href="#732">732</a>. +Grouch, perennial, <a href="#233">233</a>. +Gymnasium director, <a href="#206">206</a>. +Gymnastics, <a href="#181">181</a>, <a href="#203">203</a>. +Gynecology, + dominant ideas in, <a href="#432">432</a>; + functional diseases in, <a href="#456">456</a>; + mental factors in, <a href="#433">433</a>; + mental healing in, <a href="#430">430</a>; + reputed remedies in, <a href="#431">431</a>; + self-control and, <a href="#433">433</a>; + suggested factors in, <a href="#431">431</a>. + + +H + +Habit, <a href="#125">125</a>; + appetite and, <a href="#265">265</a>; + business occupation and, <a href="#178">178</a>; + following chorea, <a href="#563">563</a>; + formation of, <a href="#229">229</a>; + in constipation, <a href="#273">273</a>; + is second nature, <a href="#229">229</a>; + non-inheritance of, <a href="#632">632</a>; + saves reflection, <a href="#235">235</a>. +Habits, + air and exercise, change of, <a href="#232">232</a>; + bolting, <a href="#231">231</a>; + law of, <a href="#230">230</a>; + mental, <a href="#233">233</a>; + physical, <a href="#231">231</a>; + sexual, <a href="#482">482</a>. +Hack Tuke, Dr., <a href="#190">190</a>; + on warts, <a href="#493">493</a>. +"Hacks," <a href="#361">361</a>. +Hahnemann, <a href="#41">41</a>. +Haldane, Prof., <a href="#132">132</a>. +Hallucinations, <a href="#78">78</a>, <a href="#141">141</a>, <a href="#603">603</a>, <a href="#773">773</a>; + auditory, <a href="#609">609</a>, <a href="#773">773</a>; + cocaine, <a href="#773">773</a>; + disturbing, <a href="#611">611</a>; + dreams and, <a href="#606">606</a>; + explanation of, <a href="#607">607</a>; + frequency of, <a href="#604">604</a>; + insanity and, <a href="#609">609</a>; + significance of, <a href="#604">604</a>; + statistics of, <a href="#605">605</a>; + telepathic, <a href="#605">605</a>; + touch, <a href="#773">773</a>; + visual, <a href="#604">604</a>. +Head, + discomfort in, local, <a href="#552">552</a>; + over-attention to the, <a href="#547">547</a>; + raising the, <a href="#210">210</a>. +Headache, <a href="#59">59</a>; + air and, <a href="#554">554</a>; + anemic, <a href="#553">553</a>; + at Epidaurus, <a href="#554">554</a>; + attention, <a href="#547">547</a>; + coffee and, <a href="#553">553</a>; + congestion, <a href="#549">549</a>, <a href="#551">551</a>; + cures for, <a href="#546">546</a>; + direct mental treatment of, <a href="#553">553</a>; + distraction and, <a href="#548">548</a>; + drugs and, <a href="#553">553</a>; + exercise and, <a href="#554">554</a>; + extraneous, <a href="#550">550</a>; + eye strain and, <a href="#550">550</a>; + fear of brain lesion and, <a href="#549">549</a>; + frequency of, <a href="#546">546</a>; + lack of distraction and, <a href="#548">548</a>; + local conditions and, <a href="#550">550</a>; + loss of meal and, <a href="#551">551</a>; + mental treatment for, place of, <a href="#554">554</a>; + mental work and, <a href="#550">550</a>; + occipital, <a href="#552">552</a>; + occupation of mind and, <a href="#546">546</a>; + sense of pressure in, <a href="#547">547</a>; + source of pain in, <a href="#549">549</a>; + spirits and, <a href="#553">553</a>; + tea and, <a href="#553">553</a>; + tenderness and, <a href="#552">552</a>; + weight and, <a href="#553">553</a>. +Head's studies in sensation, <a href="#252">252</a>. +Healers of the nineteenth century, <a href="#81">81</a>. +Healing, irregular mental, <a href="#209">209</a>. +Health, + central nervous system and, <a href="#191">191</a>; + good, and happiness, <a href="#234">234</a>; + muscle development and, <a href="#200">200</a>; + thinking, <a href="#99">99</a>. +Health resort, <a href="#184">184</a>. +Hearing, training of the, <a href="#686">686</a>. +Heart, + action of, after dancing, <a href="#324">324</a>; + action of, after Marathon, <a href="#324">324</a>; + action of, irregularity of, <a href="#322">322</a>, <a href="#323">323</a>; + anxiety about the, <a href="#311">311</a>; + arrhythmia of the, <a href="#322">322</a>; + athletes', <a href="#324">324</a>; + coffee and the, <a href="#329">329</a>; + crowding of the, <a href="#323">323</a>; + cures, faith, and the, <a href="#312">312</a>; + defects of the, and quiet lives, <a href="#316">316</a>; + difficulties of the, <a href="#319">319</a>; + emotion and old physiology of, <a href="#311">311</a>; + fatty, and exercise, <a href="#326">326</a>; + fright and the, <a href="#315">315</a>; + functional affections of the, <a href="#321">321</a>; + gastric influence on the, <a href="#334">334</a>; + general condition and the, <a href="#318">318</a>; + German and Irish schools on the, <a href="#318">318</a>; + Indian fakirs and the, <a href="#311">311</a>; + in difficulties, <a href="#322">322</a>; + individual and the, <a href="#317">317</a>; + inhibition of action of the, <a href="#313">313</a>; + introspection and the, <a href="#327">327</a>; + irregularity of, not to be treated, <a href="#327">327</a>; + irritable, <a href="#324">324</a>; + limitation of diet and the, <a href="#335">335</a>; + listening to the, <a href="#317">317</a>; + meat-eating and the, <a href="#335">335</a>; + mental influence on the, <a href="#310">310</a>; + missed beats of the, <a href="#322">322</a>; + muscular, <a href="#322">322</a>; + nervous, Morgagni and Lancisi on, <a href="#331">331</a>; + nervous system and the, <a href="#311">311</a>; + occupation of mind and the, <a href="#320">320</a>; + palpitation of the, <a href="#322">322</a>; + physiological work for the, <a href="#326">326</a>; + reassurance and the, <a href="#334">334</a>; + remedies and suggestion and the, <a href="#312">312</a>; + shock and the, <a href="#314">314</a>; + sorrow and the, <a href="#315">315</a>; + sounds, impure, in the, <a href="#324">324</a>; + stimulants and the, <a href="#326">326</a>; + stomach distension upward, effect of, upon the, <a href="#330">330</a>; + stomach gas and the, <a href="#329">329</a>; + suffering and the, <a href="#332">332</a>; + surveillance over the, <a href="#322">322</a>; + sympathetic, <a href="#319">319</a>; + taking, <a href="#312">312</a>; + tea and the, <a href="#329">329</a>; + therapy of the, psychic factors in, <a href="#315">315</a>; + tobacco and the, <a href="#329">329</a>; + training, <a href="#216">216</a>, <a href="#326">326</a>; + trouble of the, consciousness of, <a href="#312">312</a>; + vaso-motors and the, <a href="#319">319</a>; + voluntary inhibition of action of the, <a href="#314">314</a>. +Heart disease, + consumption and, <a href="#321">321</a>; + declaration of, <a href="#321">321</a>; + diagnosis in latent, <a href="#316">316</a>; + exaggeration of seriousness in, <a href="#317">317</a>; + mental influence and, <a href="#311">311</a>; + prognosis in, <a href="#315">315</a>, <a href="#316">316</a>, <a href="#332">332</a>; + prophylaxis in, <a href="#315">315</a>; + symptoms of, in the young, <a href="#321">321</a>; + symptoms of, neglect of, <a href="#320">320</a>; + symptoms of, simulated, <a href="#319">319</a>; + symptoms of, subjective, <a href="#321">321</a>. +Heart failure, <a href="#334">334</a>, <a href="#341">341</a>. +Heart murmurs, + significance of, <a href="#317">317</a>; + uncertainty of, <a href="#318">318</a>. + +Heberden's nodes, + causes of, <a href="#422">422</a>; + longevity and, <a href="#423">423</a>; + progress of, <a href="#423">423</a>; + solicitude over, <a href="#423">423</a>. +Heels, high, <a href="#410">410</a>. +Hell, Father, mental influence practised by, <a href="#153">153</a>. +Hemorrhage, + cough and, <a href="#346">346</a>; + mind and, <a href="#360">360</a>. +Hen hypnotization, <a href="#160">160</a>. +Herbal medicine and mental influence, <a href="#140">140</a>. +Hereditary resistance, <a href="#712">712</a>. +Hereditary syphilis, <a href="#629">629</a>. +Hereditary tuberculosis, <a href="#629">629</a>. +Heredity, alcoholism and, <a href="#629">629</a>; + disease and, <a href="#628">628</a>; + drug habits and, <a href="#712">712</a>; + false impressions concerning, <a href="#627">627</a>; + habits and, <a href="#632">632</a>; + Hapsburg lip, instance of, <a href="#632">632</a>; + mystery of, <a href="#633">633</a>; + resistance and, <a href="#352">352</a>; + principles of, <a href="#699">699</a>; + suggestion and, <a href="#251">251</a>; + tuberculosis and, <a href="#628">628</a>; + variation and, <a href="#633">633</a>. +Hermaphrodites, partial, <a href="#489">489</a>. +Hermaphroditism, mental, <a href="#490">490</a>. +Herophilus, <a href="#11">11</a>. +Herpes and mind, <a href="#492">492</a>. +Hertz, Arthur, <a href="#270">270</a>. +<i>Hexenschuss</i>, <a href="#391">391</a>. +Hildanus, <a href="#54">54</a>. +Hilprecht's sleep vision, <a href="#137">137</a>. +Hilton on Rest and Pain, <a href="#52">52</a>, <a href="#188">188</a>. +Hippocrates, <a href="#10">10</a>, <a href="#71">71</a>; + on astrology, <a href="#38">38</a>. +Hives and diarrhea, <a href="#281">281</a>. +Hobbies, <a href="#224">224</a>; + Virchow on, <a href="#226">226</a>. +Hobby, <a href="#601">601</a>. +Hog's meat, <a href="#243">243</a>. +Holmes, Oliver Wendell, <a href="#4">4</a>, <a href="#48">48</a>, <a href="#50">50</a>, <a href="#54">54</a>, <a href="#56">56</a>, <a href="#311">311</a>. +Home work, <a href="#182">182</a>. +Homo-sexuality, <a href="#490">490</a>. +Hook-worm, + in Egypt, <a href="#107">107</a>; + in Porto Rico, <a href="#107">107</a>; + in the South, <a href="#107">107</a>. +Hope, renewal of, <a href="#91">91</a>. +Horace, <a href="#223">223</a>. +Horseback riding, <a href="#204">204</a>. +Horse, outside of a, the, <a href="#204">204</a>. +Hospitals, + mind and, <a href="#747">747</a>; + psychic conditions of, <a href="#760">760</a>. +Hours of diversion, <a href="#182">182</a>. +Hudson, <a href="#251">251</a>. +Humor, <a href="#105">105</a>. +Hunger and sleep, <a href="#665">665</a>. +Hunter, John, <a href="#17">17</a>. +Hunyadi Janos, <a href="#278">278</a>. +Hydrophobia, <a href="#613">613</a>. +Hydrotherapy, <a href="#5">5</a>. +Hygiene, personal, <a href="#178">178</a>. +<i>Hyperemesis gravidarum</i>, <a href="#457">457</a>; + postanesthetic, <a href="#758">758</a>. +Hypersecretion, gastric, <a href="#586">586</a>. +Hypnoidal state, <a href="#198">198</a>, <a href="#626">626</a>. +Hypnosis, anesthetic, <a href="#755">755</a>; + animal, <a href="#160">160</a>; + of self, <a href="#161">161</a>. +Hypnotism, + accessories in, <a href="#155">155</a>; + Danger and Uses of, <a href="#162">162</a>; + drugs in, <a href="#156">156</a>; + effects of, <a href="#152">152</a>; + essence of, <a href="#152">152</a>; + explanation of, <a href="#118">118</a>; + for exhibitions, <a href="#162">162</a>; + influence of, <a href="#76">76</a>, <a href="#111">111</a>; + in obstetrics, <a href="#458">458</a>; + lights in, <a href="#155">155</a>; + miracles of, <a href="#152">152</a>; + mystery of, <a href="#151">151</a>; + not mysterious, <a href="#158">158</a>; + practice of, <a href="#156">156</a>; + sensations of, <a href="#156">156</a>; + sound in, <a href="#156">156</a>; + stroking in, <a href="#156">156</a>; + susceptibility to, <a href="#159">159</a>; + three stages of, <a href="#158">158</a>; + valuation of, <a href="#152">152</a>; + uses of, <a href="#162">162</a>. +Hypnotizers, + Bernheim, <a href="#154">154</a>; + Braid, <a href="#154">154</a>; + De Puysegur, <a href="#154">154</a>; + Liebault, <a href="#154">154</a>; + Mesmer, <a href="#154">154</a>. +Hypochondria, <a href="#287">287</a>. +Hypochondriac, <a href="#94">94</a>; + sympathy with the, <a href="#335">335</a>. +Hypochondriac organs, <a href="#335">335</a>. +Hypochondriorum, <i>ex consensu</i>, <a href="#331">331</a>. +Hypothesis, + Duval's, for brain mechanism, <a href="#123">123</a>; + Ramon y Cajal's, for brain mechanism, <a href="#127">127</a>; + for sympathetic system, <a href="#127">127</a>. +Hysteria, <a href="#80">80</a>, <a href="#585">585</a>, <a href="#590">590</a>; + dual personality and, <a href="#149">149</a>; + organic change and, <a href="#190">190</a>; + secondary personality and, <a href="#149">149</a>. +Hysterical cutaneous conditions, <a href="#495">495</a>. +Hystero-epilepsy, <a href="#538">538</a>, <a href="#626">626</a>. + + +I + +Idea, + single, <a href="#195">195</a>; + tends to action, <a href="#194">194</a>. +Ideas, + dominant, <a href="#97">97</a>, <a href="#239">239</a>; + body and, <a href="#195">195</a>. +Idiosyncrasies, + food, <a href="#282">282</a>; + genuine food, <a href="#245">245</a>; + individual and heat, <a href="#329">329</a>; + intestinal, <a href="#282">282</a>; + physiological, <a href="#231">231</a>. +I-Em-Hetep, <a href="#7">7</a>, <a href="#71">71</a>. +Ignatius Loyola, St., <a href="#102">102</a>. +Ills, + imaginary, <a href="#191">191</a>; + not fancied, <a href="#191">191</a>. +Illusions, <a href="#603">603</a>, <a href="#764">764</a>; + delusions, hallucinations and, <a href="#773">773</a>; + in connection with dots, <a href="#776">776</a>; + in connection with a tube, <a href="#764">764</a>; + of distance, <a href="#769">769</a>; + of size, <a href="#769">769</a>, <a href="#770">770</a>; + of the sun and moon, <a href="#768">768</a>; + optical, <a href="#770">770</a>; + universal, <a href="#764">764</a>. +Image, wax, and distant effects, <a href="#141">141</a>. +Imaginary ills, <a href="#191">191</a>. +Imagination, <a href="#14">14</a>, <a href="#15">15</a>. +Immunity, + acquired, <a href="#358">358</a>; + inborn, <a href="#358">358</a>; + lack of, <a href="#108">108</a>; + maternal, in syphilis, <a href="#629">629</a>; + of nursling, <a href="#461">461</a>. +Impedimenta, <a href="#201">201</a>. +Impotence, + organic, <a href="#476">476</a>; + psychic, <a href="#475">475</a>. +Impotency obsession, <a href="#476">476</a>. +Impressions, mental, <a href="#346">346</a>. +Incisions and suggestion, <a href="#752">752</a>. +Incubation, <a href="#554">554</a>, <a href="#669">669</a>. +Incurable, care of the, <a href="#223">223</a>. +Incurable disease, relieving, <a href="#510">510</a>. +Incurability, so-called, <a href="#48">48</a>. +Indigestion, + above the neck, <a href="#257">257</a>; + auto-suggestive, <a href="#250">250</a>; + cancer, latent, and, <a href="#255">255</a>; + correction of, <a href="#259">259</a>; + depression and, <a href="#233">233</a>; + differentiation of, <a href="#254">254</a>; + diversion of mind and, <a href="#258">258</a>; + dread of, <a href="#305">305</a>, <a href="#306">306</a>; + early tuberculosis and, <a href="#255">255</a>; + lack of sleep and, <a href="#254">254</a>; + neurotic, <a href="#169">169</a>; + prevention of, <a href="#259">259</a>; + unfavorable states of mind and, <a href="#250">250</a>. +Individuality, <a href="#133">133</a>. +Individuals, human, <a href="#224">224</a>. +Infections, mental, <a href="#753">753</a>. +Influence, + malign, <a href="#141">141</a>; + of the mind, <a href="#2">2</a>, <a href="#84">84</a>; + of the stars, <a href="#39">39</a>; + telepathic, <a href="#141">141</a>. +Inheritance of defects, <a href="#632">632</a>. +Inhibition, <a href="#46">46</a>; + cardiac, <a href="#313">313</a>; + menstrual, lack of, <a href="#434">434</a>; + nervous, <a href="#87">87</a>. +Injuries, + old and painful, <a href="#387">387</a>; + unconscious, <a href="#85">85</a>. +Insane, cunning of the, <a href="#743">743</a>. +Insanity, + dread of, <a href="#623">623</a>; + genius and, <a href="#536">536</a>; + hallucinations in, <a href="#609">609</a>; + Perkinean, <a href="#49">49</a>; + plea of, <a href="#742">742</a>; + religious, <a href="#777">777</a>; + self abuse and, <a href="#484">484</a>. +Insomnia, <a href="#125">125</a>; + coffee and, <a href="#659">659</a>; + cold and, <a href="#656">656</a>; + cold bath and, <a href="#658">658</a>; + cold feet and, <a href="#656">656</a>; + diet and, <a href="#659">659</a>; + direct suggestions and, <a href="#660">660</a>; + dread of, <a href="#651">651</a>; + drugs and, <a href="#654">654</a>; + encyclopedia reading and, <a href="#662">662</a>; + evening hours and, <a href="#660">660</a>; + food before retiring and, <a href="#659">659</a>; + hot foot bath and, <a href="#657">657</a>; + Jacinth and, <a href="#37">37</a>; + lack of air and, <a href="#657">657</a>; + lack of occupation and, <a href="#644">644</a>; + not serious, <a href="#651">651</a>; + persuasion of, <a href="#651">651</a>; + pillow and, <a href="#655">655</a>, <a href="#656">656</a>; + sea voyage and, <a href="#658">658</a>; + solicitude about, <a href="#654">654</a>; + suggestion and, <a href="#654">654</a>; + tea and, <a href="#659">659</a>. +Inspiration, <a href="#135">135</a>. +Instinct, + appetite and, <a href="#264">264</a>; + disturbed, <a href="#267">267</a>; + not theory, <a href="#256">256</a>. +Interest, + human, <a href="#206">206</a>; + in others, <a href="#221">221</a>. +Intestinal control, <a href="#280">280</a>. +Intestinal tolerance, <a href="#271">271</a>. +Intestinal unrest, <a href="#255">255</a>. +Intestine, <a href="#269">269</a>. +Introspection, morbid, <a href="#302">302</a>. +Invalids by profession, <a href="#184">184</a>. +Irish school on heart, <a href="#318">318</a>. +Irregularity, + functional, of the heart, <a href="#327">327</a>; + myocardial, <a href="#327">327</a>. +Irresponsibility, <a href="#744">744</a>. + + +J + +Jacinth for sleep, <a href="#37">37</a>. +James, Prof., <a href="#16">16</a>, <a href="#92">92</a>. +Janet, <a href="#597">597</a>. +Jew's ear, <a href="#35">35</a>. +John of Cronstadt, <a href="#75">75</a>. +Johnson, Samuel, <a href="#80">80</a>. +Joint affections, position in, <a href="#212">212</a>. +Joint conditions, + differentiation of, <a href="#381">381</a>; + hysterical, <a href="#239">239</a>; + hysterical, frequency of, <a href="#387">387</a>; + neurotic, frequency of, <a href="#386">386</a>; + old, injured, and dampness, <a href="#387">387</a>; + painful, <a href="#379">379</a>. +Joy and pleasure, <a href="#104">104</a>. + + +K + +Ka (Egyptian soul), <a href="#9">9</a>. +Kaltenbach, <a href="#456">456</a>. +Keller, Helen, <a href="#214">214</a>, <a href="#234">234</a>. +Kepler and astrology, <a href="#39">39</a>, <a href="#41">41</a>. +Khou (Egyptian mind), <a href="#9">9</a>. +Kidney, + abnormal fixity of, <a href="#307">307</a>; + backache and, <a href="#308">308</a>; + calculus of, <a href="#80">80</a>; + floating, operation for, <a href="#308">308</a>; + loose, <a href="#302">302</a>; + movable, <a href="#307">307</a>; + movable, mechanical treatment for, <a href="#308">308</a>; + movable, weight, and, <a href="#297">297</a>, <a href="#308">308</a>; + of pregnancy, <a href="#307">307</a>; + position of calculus in, <a href="#209">209</a>. +Kidneywort, <a href="#35">35</a>. +King, Prof., on natural obstetrics, <a href="#459">459</a>. +King's evil, <a href="#79">79</a>, <a href="#81">81</a>. +King's touch, <a href="#748">748</a>. +Kircher, S. J., Father, <a href="#42">42</a>, <a href="#160">160</a>. +Knee, + after loose cartilage, <a href="#412">412</a>; + foot troubles and the, <a href="#410">410</a>; + high heels and the, <a href="#410">410</a>; + hip and the, <a href="#410">410</a>; + housemaid's, <a href="#39">39</a>; + lumbar discomfort and the, <a href="#411">411</a>; + muscle disuse and the, <a href="#412">412</a>; + unusual occupations affecting the, <a href="#410">410</a>. +Knee jerk, <a href="#556">556</a>. +Kneipp, Father, on hydrotherapy and psychotherapy, <a href="#72">72</a>. +Kneipp societies, <a href="#73">73</a>. +Know, I do not, <a href="#466">466</a>. +Kocher, <a href="#505">505</a>. +Korsakoff's psychosis, <a href="#687">687</a>. +Krafft-Ebing, <a href="#631">631</a>. +Kronecker, <a href="#269">269</a>. +Kronig, <a href="#456">456</a>. + + +L + +Labor, + at the ninth month, <a href="#454">454</a>; + delayed, suggestion and, <a href="#454">454</a>; + natural, <a href="#459">459</a>; + patient helps, <a href="#459">459</a>; + postures after, <a href="#459">459</a>. +Labouchère, <a href="#147">147</a>. +Lachesis, snake venom, <a href="#66">66</a>. +Laennec pearls in asthma, <a href="#364">364</a>. +Lancisi, <a href="#17">17</a>, <a href="#331">331</a>. +Lapax, Indian chorea, <a href="#688">688</a>. +Larrey, Baron, <a href="#68">68</a>. +Lauder Brunton, on inhibition, <a href="#313">313</a>. +Laugh and grow fat, <a href="#297">297</a>. +Laughing, diaphragm and, <a href="#105">105</a>. +Laughing cure, <a href="#104">104</a>. +Laughter, hearty, effect of, <a href="#297">297</a>. +Law of avalanche, <a href="#111">111</a>. +Laxatives, abuse of, <a href="#287">287</a>. +Layer, plexiform cerebral, <a href="#126">126</a>. +Lead in muscle aches, <a href="#398">398</a>; + poisoning from, <a href="#172">172</a>. +Learn, + by heart, <a href="#223">223</a>; + failure to, <a href="#129">129</a>. +Leg exercises in constipation, <a href="#277">277</a>. +Legs, inequality of, <a href="#410">410</a> +Leisure, use of, <a href="#181">181</a>. +Leisure classes, <a href="#184">184</a>. +Letters, cross, <a href="#140">140</a>. +Leyden jar, <a href="#42">42</a>; + "cures" by the, <a href="#42">42</a>; + effects of the, <a href="#42">42</a>; + suggestion and the, <a href="#42">42</a>. +Lichen, + anise seed in, <a href="#25">25</a>; + snakes in, <a href="#25">25</a>. +Liebault on hypnotism, <a href="#407">407</a>. +Life, + aimless, <a href="#220">220</a>; + and death, <a href="#89">89</a>; + dangerous, <a href="#512">512</a>; + intellectual, <a href="#125">125</a>, <a href="#134">134</a>, <a href="#302">302</a>; + interests in, <a href="#169">169</a>; + natural, <a href="#267">267</a>; + out-of-door, <a href="#358">358</a>; + persuasion of short, <a href="#636">636</a>; + principle of, <a href="#191">191</a>; + regulation of, <a href="#220">220</a>; + worth living, <a href="#722">722</a>. +Light, + and psychotherapy, <a href="#44">44</a>; + in hypnotism, <a href="#155">155</a>; + lack of, <a href="#173">173</a>. +Lightning, fear of, <a href="#612">612</a>. +Lincoln's steamboat, <a href="#253">253</a>. +Liniments, suggestion with, <a href="#29">29</a>, <a href="#393">393</a>. +Liquor problem, scientific solution of the, <a href="#701">701</a>. +Literature and life, <a href="#648">648</a>. +Lithemia, <a href="#380">380</a>. +Litton's diaphragm phenomenon, <a href="#361">361</a>. +Liver, + business and the, <a href="#253">253</a>; + gastric symptoms from the, <a href="#177">177</a>. +Liverwort, <a href="#35">35</a>. +Lloyd Tuckey on mental influence, <a href="#156">156</a>. +Lobe, occipital, <a href="#116">116</a>. +Local anaesthesia, personality of operator and, <a href="#758">758</a>. +Locomotor ataxia, <a href="#524">524</a>. +Lombroso, <a href="#88">88</a>, <a href="#130">130</a>. +Longevity and delicate health, <a href="#202">202</a>. +Looking forward, <a href="#183">183</a>. +Looking up, <a href="#102">102</a>. +Lord Bacon, <a href="#54">54</a>. +Lord Kelvin on the Creator, <a href="#730">730</a>. +Louis', grief, <a href="#732">732</a>. +Love, Greek, <a href="#482">482</a>. +Lowell, James Russell, <a href="#649">649</a>. +Lucas Malet on maternal impressions, <a href="#221">221</a>. +Lucian on warts, <a href="#493">493</a>. +Lucretius' pessimism, <a href="#776">776</a>; + evolution and, <a href="#776">776</a>. +Lumbago, <a href="#402">402</a>; + adhesive plaster for, <a href="#407">407</a>; + cautery and, <a href="#408">408</a>; + electric equilibrium in, <a href="#408">408</a>; + etiology of, <a href="#404">404</a>; + hypnotism in, <a href="#407">407</a>; + paper on loins and, <a href="#407">407</a>; + piles and, <a href="#403">403</a>; + seminal vesicles and, <a href="#403">403</a>. +Lunar caustic, <a href="#36">36</a>. +Lunch, + hurried, <a href="#171">171</a>; + women's, <a href="#180">180</a>. +Luncheon, in Vienna, <a href="#179">179</a>. +Luncheon clubs, <a href="#180">180</a>. +Lung at rest, <a href="#361">361</a>. +Lungs not laboratories, <a href="#132">132</a>. +Lytton, Sir Robert Bulwer, <a href="#648">648</a>; + grief and, <a href="#731">731</a>. + + +M + +McDougal, <a href="#123">123</a>. +McGuire, John Francis, on Father Mathew, <a href="#75">75</a>. +Machines, electrical, <a href="#43">43</a>. +Mackenzie on the heart, <a href="#323">323</a>. +Magnan, Prof., on sex perverts, <a href="#480">480</a>. +Magnetics, <a href="#15">15</a>; + application of, <a href="#42">42</a>. +Magnetism, + human, <a href="#41">41</a>; + malignant, <a href="#142">142</a>; + personal, <a href="#14">14</a>, <a href="#70">70</a>; + suggestion and, <a href="#41">41</a>. +Magnets, <a href="#15">15</a>. +Malaria, + degeneration and, <a href="#107">107</a>; + mental, <a href="#93">93</a>. +Man, + of one idea, <a href="#195">195</a>; + without habits, <a href="#230">230</a>. +Manners and disposition, <a href="#234">234</a>. +Manzoni and memory, <a href="#685">685</a>. +Martyrs, <a href="#112">112</a>. +Massage and exercise, <a href="#206">206</a>. +Mastication, + stomach and, <a href="#261">261</a>; + wearying, <a href="#355">355</a>. +Maternal impressions, + in old literature, <a href="#461">461</a>; + superstition and, <a href="#465">465</a>; + supposed examples of, <a href="#463">463</a>; + time of, <a href="#463">463</a>. +Mathematical medicine and suggestion, <a href="#41">41</a>. +Mathew, Father, and alcoholism, <a href="#75">75</a>. +Meal, + midday, <a href="#180">180</a>; + principal, <a href="#180">180</a>. +Meat, dog, <a href="#244">244</a>. +Mechanism, + of influence of mind on body, <a href="#107">107</a>; + of mental influence, <a href="#108">108</a>; + peripheral ganglionic, <a href="#190">190</a>. +Mechano-therapy, <a href="#5">5</a>. +Médecine, La, des Âmes, <a href="#90">90</a>. +Medication, <a href="#2">2</a>. +Medicine man, <a href="#78">78</a>. +Medicine, + minus mental influence, <a href="#192">192</a>; + plus mental influence, <a href="#192">192</a>. +Medieval mind healing, <a href="#14">14</a>. +Melancholia, + neurasthenia and, <a href="#556">556</a>; + suicide and, <a href="#556">556</a>. +Memories, + individual, <a href="#684">684</a>; + vertigo and, <a href="#516">516</a>. +Memory, + age and, <a href="#679">679</a>; + attention and, <a href="#679">679</a>; + auditory, <a href="#682">682</a>; + brain cells in, <a href="#128">128</a>; + Carlyle's, <a href="#685">685</a>; + committing to, <a href="#223">223</a>; + cultivating looseness of, <a href="#683">683</a>; + definite location of, <a href="#128">128</a>; + diseases of, <a href="#682">682</a>; + disorders of, <a href="#678">678</a>; + disturbance of, <a href="#124">124</a>; + exercise of, <a href="#687">687</a>; + fatigue and, <a href="#682">682</a>; + genius and, <a href="#684">684</a>; + Goldsmith's, <a href="#684">684</a>; + groping, <a href="#127">127</a>; + hallucinations of, <a href="#635">635</a>; + improvement of, <a href="#687">687</a>; + in defectives, <a href="#686">686</a>; + intellect and, <a href="#684">684</a>; + intimate mechanism of, <a href="#128">128</a>; + laxative and, <a href="#270">270</a>; + low grade intelligence and, <a href="#685">685</a>; + Manzoni's, <a href="#685">685</a>; + name, <a href="#681">681</a>; + newspapers and, <a href="#684">684</a>; + Newton's, <a href="#684">684</a>; + of animals, <a href="#127">127</a>; + of words, <a href="#127">127</a>; + pauses and lapses of, <a href="#681">681</a>; + peculiarities of, <a href="#680">680</a>; + process underlying, <a href="#133">133</a>; + psychotherapy of, <a href="#679">679</a>; + public speakers and, <a href="#127">127</a>; + Scott's, <a href="#684">684</a>; + sensations and, <a href="#682">682</a>; + sense defects and, <a href="#682">682</a>; + solicitude and, <a href="#680">680</a>; + supposed loss of, <a href="#679">679</a>; + tone deafness and, <a href="#682">682</a>; + training the, <a href="#686">686</a>; + tricks of, <a href="#685">685</a>; + visual, <a href="#682">682</a>. +Menière's disease, <a href="#516">516</a>; + vertigo and, <a href="#516">516</a>. +Menopause, + air and, <a href="#452">452</a>; + benefits of, <a href="#452">452</a>; + definite prescriptions for, <a href="#451">451</a>; + diversion of mind and, <a href="#452">452</a>; + exercise and, <a href="#452">452</a>; + family cares and, <a href="#451">451</a>; + Graves' disease and, <a href="#502">502</a>; + lack of occupation and, <a href="#451">451</a>; + old-fashioned attitude toward, <a href="#451">451</a>; + pseudo-epilepsy and, <a href="#540">540</a>; + unfavorable suggestions and, <a href="#450">450</a>. + +Menorrhagia, + favorable disposition in, <a href="#449">449</a>; + fibroid and, <a href="#448">448</a>; + individual and, <a href="#449">449</a>; + menopausal, <a href="#448">448</a>; + mental factors in, <a href="#447">447</a>. +"Men's diseases," <a href="#474">474</a>. +Menstrual condition, <a href="#59">59</a>; + disturbance through brain in, <a href="#190">190</a>; + hyperemia and, <a href="#436">436</a>; + irritability and, <a href="#441">441</a>; + over-attention to, <a href="#441">441</a>; + over-reaction in, <a href="#436">436</a>; + psycho-physical factors in, <a href="#436">436</a>. +Menstruation, + air and, <a href="#436">436</a>; + dreads and, <a href="#434">434</a>; + emotion and, <a href="#438">438</a>; + lack of inhibition in, <a href="#434">434</a>; + misophobia in, <a href="#434">434</a>; + psychic states of, <a href="#434">434</a>; + sensitiveness in, <a href="#435">435</a>. +Mental attitude, <a href="#4">4</a>. +Mental energy, law of, <a href="#16">16</a>. +Mental exhaustion, <a href="#599">599</a>. +Mental healing, <a href="#386">386</a>; + in the Renaissance, <a href="#14">14</a>; + <a href="#3">3</a>,000 years of, <a href="#81">81</a>. +Mental incapacity, <a href="#597">597</a>, <a href="#598">598</a>; + functional, <a href="#599">599</a>. +Mental influence, + anesthesia and, <a href="#753">753</a>; + before operation, <a href="#749">749</a>; + distant, <a href="#140">140</a>; + in surgery, <a href="#747">747</a>; + medieval, <a href="#747">747</a>; + on organs, <a href="#87">87</a>; + post-operative, <a href="#759">759</a>; + therapeutics and, <a href="#196">196</a>; + with digitalis, <a href="#312">312</a>. +Mental medicine, law of, <a href="#99">99</a>, <a href="#251">251</a>. +Mental short circuit, <a href="#5">5</a>, <a href="#601">601</a>. +Mentality, physical basis of, <a href="#133">133</a>. +<i>Meralgia paresthetica</i>, <a href="#405">405</a>. +Mesmer, <a href="#51">51</a>, <a href="#153">153</a>; + methods of, <a href="#154">154</a>, <a href="#386">386</a>. +Mesmerism, + "Christian Science" and, <a href="#55">55</a>; + surgery and, <a href="#748">748</a>. +Message, telepathic, <a href="#145">145</a>. +Metabolism, fatty, <a href="#291">291</a>. +Meyer, <a href="#105">105</a>. +Michelangelo on trifles, <a href="#164">164</a>. +Microbophobia, <a href="#612">612</a>. +Milk, + asses', <a href="#246">246</a>; + bovine, humanity and, <a href="#461">461</a>; + dislike of, <a href="#246">246</a>; + goats', <a href="#246">246</a>; + mares', <a href="#246">246</a>; + maternal supply of, mind and, <a href="#460">460</a>; + more than food, <a href="#461">461</a>: + sour, <a href="#96">96</a>, <a href="#247">247</a>. +Mind, + absorption of, <a href="#130">130</a>; + abstraction of, <a href="#129">129</a>; + body and, <a href="#233">233</a>; + brain and, <a href="#549">549</a>; + concentration of, <a href="#124">124</a>, <a href="#130">130</a>, <a href="#197">197</a>; + diversion of, <a href="#182">182</a>, <a href="#224">224</a>, <a href="#225">225</a>; + fractures and, <a href="#751">751</a>; + heart and, <a href="#311">311</a>; + herpes and, <a href="#492">492</a>; + making up, <a href="#737">737</a>; + menstrual, Charcot and Möbius on, <a href="#434">434</a>; + mortal, evil of, <a href="#776">776</a>; + motility and, <a href="#86">86</a>; + preoccupation of, <a href="#130">130</a>, <a href="#136">136</a>; + relaxation of, <a href="#228">228</a>; + urticaria and, <a href="#491">491</a>; + vacant and distressed, <a href="#219">219</a>. +Mind healing, + in Greece, <a href="#10">10</a>; + novelties in, <a href="#5">5</a>. +Mind reading, <a href="#141">141</a>. +Miner's elbow, <a href="#399">399</a>. +Mirabeau, <a href="#27">27</a>. +Misophobia, <a href="#615">615</a>. +Mitchell, Dr. John K., <a href="#161">161</a>. +Mitchell, Dr. S. Weir, <a href="#136">136</a>, <a href="#572">572</a>. +Möbius on menstrual mental states, <a href="#434">434</a>. +Mommsen, <a href="#130">130</a>. +Monastic work intervals, <a href="#226">226</a>. +Mondeville, mental influence and, <a href="#747">747</a>. +Monotony in diet, <a href="#296">296</a>. +Moodiness, <a href="#233">233</a>. +Moral, influence of the, on the physical, <a href="#84">84</a>. +Morgagni, <a href="#16">16</a>, <a href="#331">331</a>; + and venesection, <a href="#27">27</a>; + on nervous heart, <a href="#331">331</a>. +Morning, + dawdling in the, <a href="#165">165</a>; + walks in the, <a href="#169">169</a>. +Mother and child, distinct beings, <a href="#462">462</a>. +Mothers of syphilitic children immune, <a href="#680">680</a>. +Motility, gastric, <a href="#261">261</a>. +Motion and will, <a href="#109">109</a>. +Mouth breathing, <a href="#105">105</a>. +Movements, + habitual, <a href="#173">173</a>; + pain and, <a href="#396">396</a>. +Movements, passive, <a href="#207">207</a>. +Moxa and suggestion, <a href="#68">68</a>. +Müller, Johann, <a href="#18">18</a>, <a href="#607">607</a>, <a href="#678">678</a>. +Müller-Lyer lines, <a href="#767">767</a>. +Müller, Max, <a href="#243">243</a>. +Mummies in therapy, <a href="#64">64</a>. +Münsterberg, Prof.; + on Pastor Gassner, <a href="#778">778</a>; + on psychotherapy, <a href="#75">75</a>. +Murmurs, + heart, <a href="#318">318</a>; + extraneous sounds and, <a href="#318">318</a>; + significance of, <a href="#318">318</a>. +Muscle reading, <a href="#195">195</a>. +Muscles, + exercise of the, heart stimulation and, <a href="#328">328</a>; + gastric, <a href="#261">261</a>; + health and, <a href="#200">200</a>; + internal secretions in, <a href="#328">328</a>; + overtiredness of, <a href="#392">392</a>; + relaxation of, <a href="#197">197</a>; + thought and, <a href="#194">194</a>; + unconscious regulation of, <a href="#230">230</a>; + useless, <a href="#201">201</a>. +Muscular exertion, unaccustomed, <a href="#392">392</a>. +Muscular pains and aches, + atrophy and, <a href="#394">394</a>; + causes of, <a href="#391">391</a>; + counter-irritation for, <a href="#393">393</a>; + habits and, <a href="#392">392</a>; + lead and, <a href="#398">398</a>; + local conditions in, <a href="#389">389</a>; + treatment of, <a href="#406">406</a>. +Music as recreation, <a href="#139">139</a>. +Musk, <a href="#69">69</a>. +Mutism, hysterical, <a href="#574">574</a>. +Myotatic, <a href="#556">556</a>. +Mysteriea, natural, <a href="#109">109</a>. + + +N + +Names, euphonious, <a href="#59">59</a>. +Nancy, hypnotism at, <a href="#154">154</a>, <a href="#159">159</a>. +Napoleon, <a href="#85">85</a>. +Narcosis, nervous mechanism in, <a href="#123">123</a>. +Narcotism, <a href="#111">111</a>. +Nature, human, <a href="#359">359</a>. +Natures, two in man, <a href="#148">148</a>. +Nature's compensations, <a href="#508">508</a>. +Nauheim, + baths at, <a href="#328">328</a>; + exercise at, <a href="#328">328</a>; + suggestion at, <a href="#216">216</a>. +Nectarium, proprietary medicine, <a href="#59">59</a>. +Nephritis, insidious, <a href="#642">642</a>. +Nerve currents, <a href="#123">123</a>. +Nerve explosions, <a href="#564">564</a>. +Nerve fibers, plexuses, systems, <a href="#109">109</a>. +Nerve impulses and electricity, <a href="#110">110</a>. +Nerve pressure, anesthetic for, <a href="#401">401</a>. +Nerves and tissues, <a href="#88">88</a>. +Nervous diseases, organic, <a href="#508">508</a>. +Nervous weakness, <a href="#555">555</a>. +Nervousness, Jews, Quakers, Roman Catholics and, <a href="#778">778</a>. +Neuralgia, <a href="#59">59</a>. +Neurasthenia, + an American disease, <a href="#559">559</a>; + arteriosclerosis and, <a href="#557">557</a>; + Bright's disease and, <a href="#557">557</a>; + concentration of mind and, <a href="#560">560</a>; + diabetes and, <a href="#559">559</a>; + due to over-attention, <a href="#559">559</a>; + hysterical, <a href="#561">561</a>; + in the old, <a href="#557">557</a>; + melancholia and, <a href="#556">556</a>; + nervous weakness and, <a href="#555">555</a>; + paresis and, <a href="#532">532</a>; + rheumatism and, <a href="#555">555</a>; + significance of, <a href="#555">555</a>, <a href="#556">556</a>; + simulation of, <a href="#557">557</a>; + splanchnic, <a href="#36">36</a>, <a href="#297">297</a>; + substitution of symptoms and, <a href="#561">561</a>; + too satisfying, <a href="#555">555</a>. +Neuritis, + deltoid, <a href="#397">397</a>; + ulnar, <a href="#398">398</a>. +Neuroglia cells, + perivascular, <a href="#122">122</a>; + plexiform, <a href="#126">126</a>; + pseudopods of, <a href="#122">122</a>; + spinal, <a href="#122">122</a>; + subcortical, <a href="#122">122</a>; + superficial, <a href="#126">126</a>. +Neuroglia theory, <a href="#86">86</a>, <a href="#119">119</a>. +Neurokym, <a href="#111">111</a>. +Neurons, + from optic lobe, <a href="#117">117</a>; + in psychic states, <a href="#117">117</a>; + movement of, <a href="#114">114</a>, <a href="#119">119</a>; + motor, lower, <a href="#114">114</a>; + peripheral, <a href="#118">118</a>. +Neuroses, + accessory, <a href="#749">749</a>; + biliary, <a href="#586">586</a>; + intestinal weight in, <a href="#285">285</a>; + motor, <a href="#589">589</a>; + secretory, <a href="#586">586</a>; + sexual, <a href="#472">472</a>. +Neurosis, + cardiac, <a href="#321">321</a>; + exercise and, <a href="#326">326</a>; + muscular, <a href="#393">393</a>; + neuritis and. <a href="#398">398</a>. +Neurotic joints, <a href="#589">589</a>. +Neurotic simulation, forms of, <a href="#585">585</a>. +Neurotic tendencies, <a href="#480">480</a>. +New Englanders, religious, <a href="#82">82</a>. +News, bad, <a href="#85">85</a>. +Newspapers at breakfast, <a href="#170">170</a>. +Newton, <a href="#130">130</a>. +Night air, <a href="#450">450</a>. +Night duty, <a href="#175">175</a>. +Night terrors, + ghost stories and, <a href="#668">668</a>; + melodrama and, <a href="#668">668</a>. +Night workers and alcohol, <a href="#175">175</a>. +Nightmare, <a href="#339">339</a>. +Nihilism, therapeutic, <a href="#5">5</a>. +Nissl bodies, <a href="#114">114</a>. +Nitrate of silver, <a href="#36">36</a>. +Nitrous oxide, <a href="#18">18</a>. +Nodes, Heberden's, <a href="#422">422</a>. +Nomenclature of disease, <a href="#556">556</a>. +<i>Non nocere</i>, <a href="#187">187</a>. +Norman, <a href="#42">42</a>. +Nosology, preputial, <a href="#475">475</a>. +Nostrum promoters, <a href="#56">56</a>. +Nostrum venders, <a href="#3">3</a>, <a href="#59">59</a>. +Nothing to do, <a href="#184">184</a>, <a href="#218">218</a>. +Nursing, + cheery, <a href="#760">760</a>; + suggestions and, <a href="#460">460</a>. +Nurslings' immunity, <a href="#460">460</a>. +Nutrition, intrauterine, <a href="#465">465</a>. +Nux vomica, <a href="#5">5</a>. + + +O + +Obese, <a href="#290">290</a>. +Obesity, + alimentary, <a href="#293">293</a>; + constipation and, <a href="#296">296</a>; + early treatment of, <a href="#292">292</a>; + essential, <a href="#293">293</a>; + examples and, <a href="#293">293</a>; + exercise and, <a href="#294">294</a>, <a href="#296">296</a>; + frequency of, with diabetes, <a href="#294">294</a>; + heredity and, <a href="#293">293</a>, <a href="#295">295</a>; + pathological, with diabetes, <a href="#290">290</a>; + prophylaxis in, <a href="#293">293</a>; + sleep and, <a href="#294">294</a>. +Obsession, + sexual, <a href="#476">476</a>; + subconscious, <a href="#476">476</a>. +Obsessions, <a href="#624">624</a>. +Obstacle sense, <a href="#214">214</a>. +Obstetrics, + posture in, <a href="#459">459</a>; + suggestion in, <a href="#452">452</a>; + sympathy harmful in, <a href="#452">452</a>. +Occupation, + alcohol and, <a href="#398">398</a>; + diversion of, <a href="#226">226</a>; + dual mental, <a href="#139">139</a>; + dusty, <a href="#172">172</a>; + feminine, <a href="#183">183</a>; + finding mental, <a href="#223">223</a>; + lack of, <a href="#219">219</a>; + mental condition in, <a href="#177">177</a>; + pleasant, <a href="#84">84</a>; + position during, <a href="#176">176</a>; + sedentary, <a href="#302">302</a>; + standing, sitting, intervals of rest in, <a href="#173">173</a>. +Occupation pains, <a href="#396">396</a>. +Ointment, + expensive, <a href="#59">59</a>; + weapon, <a href="#54">54</a>. +Old-maid, psychasthenic, <a href="#221">221</a>. +Olfactory acuity, <a href="#619">619</a>. +Operation, + idea of, <a href="#751">751</a>; + mental influence after, <a href="#759">759</a>; + suggestive, <a href="#306">306</a>, <a href="#431">431</a>; + visits after, <a href="#760">760</a>; + work after, <a href="#760">760</a>. +Operations on the abdomen, <a href="#303">303</a>; + series of, <a href="#304">304</a>. +Opium, + in hypnotism, <a href="#156">156</a>; + mind and, <a href="#192">192</a>. +Oppenheim, Prof., <a href="#323">323</a>, <a href="#511">511</a>, <a href="#512">512</a>, <a href="#527">527</a>, <a href="#660">660</a>. +Optic thalamus and dual dispositions, <a href="#151">151</a>. +Orchitis and epigastric reflex, <a href="#252">252</a>. +Ordure in therapy, <a href="#34">34</a>. +Organic disease, mental influence and, <a href="#190">190</a>. +Organic nervous diseases, <a href="#508">508</a>; + adventitious symptoms of, <a href="#509">509</a>; + compensation and, <a href="#508">508</a>; + incurable, <a href="#509">509</a>; + prophylaxis in, <a href="#509">509</a>; + unfavorable influence and, <a href="#508">508</a>. +Organs, feminine, out of pelvis, <a href="#430">430</a>. +Osler, Sir William, <a href="#11">11</a>, <a href="#323">323</a>. +Osteoarthritis, <a href="#424">424</a>. +Osteopath, <a href="#52">52</a>, <a href="#381">381</a>. +Osteopathy, success of, <a href="#207">207</a>, <a href="#385">385</a>, <a href="#386">386</a>. +Overcautiousness, <a href="#189">189</a>. +Overeating, habit of, <a href="#266">266</a>, <a href="#291">291</a>, <a href="#297">297</a>. +Oversensitiveness, neurotic, <a href="#239">239</a>. +Overseriousness, <a href="#218">218</a>. +Overweight, + prevention of, <a href="#295">295</a>; + short life and, <a href="#294">294</a>. +Ozena, <a href="#98">98</a>. + + +P + +Paget, Sir James, <a href="#589">589</a>; + on hysterical joint, <a href="#749">749</a>; + on neurotic joints, <a href="#386">386</a>. +Pain, + after operation, <a href="#761">761</a>; + a stimulus, <a href="#240">240</a>; + bearing, reconstructive, <a href="#235">235</a>; + character and, <a href="#238">238</a>; + consciousness of, <a href="#236">236</a>; + conservative, <a href="#240">240</a>; + contraindication to treatment, <a href="#394">394</a>; + deterrent, <a href="#68">68</a>; + differentiation of, <a href="#241">241</a>; + diffusion of, <a href="#238">238</a>; + discipline for, <a href="#238">238</a>; + dispelling, <a href="#130">130</a>; + distraction and, <a href="#754">754</a>; + diversion and, <a href="#225">225</a>, <a href="#754">754</a>; + equanimity in, <a href="#779">779</a>; + in life, <a href="#237">237</a>; + location of, difficult, <a href="#251">251</a>; + memory of, pleasant, <a href="#238">238</a>; <a href="#724">724</a>; + neurotic and organic, <a href="#240">240</a>; + on motion, <a href="#241">241</a>; + over healthy lung, <a href="#362">362</a>; + overattention and, <a href="#236">236</a>; + power to bear, and the individual, <a href="#441">441</a>; + preoccupation and, <a href="#235">235</a>; + psyche in, <a href="#761">761</a>; + radiation of, <a href="#240">240</a>; + relief of, in gynecology, <a href="#431">431</a>. +Pains, + barometer and, <a href="#382">382</a>; + company in, <a href="#10">10</a>; + in rainy weather, <a href="#382">382</a>; + muscular aches and, <a href="#389">389</a>; + occupation of mind in, <a href="#395">395</a>. +Paladino, Eusapia, <a href="#88">88</a>. +Palpitation from over-attention, <a href="#324">324</a>. +Palsies, + musculo-spiral, <a href="#401">401</a>; + neurotic, <a href="#589">589</a>. +Palsy, infantile, training for, <a href="#216">216</a>. +Panniculus, <a href="#299">299</a>. +Paracelsus, <a href="#15">15</a>, <a href="#688">688</a>. +Parallels, distortion of, <a href="#770">770</a>. +Paralysis agitans, <a href="#579">579</a>; + cord stretching in, <a href="#544">544</a>; + cures of, <a href="#544">544</a>; + drugs in, <a href="#544">544</a>; + Frenkel's method in, <a href="#544">544</a>; + mental control in, <a href="#542">542</a>; + mental influence and, <a href="#543">543</a>; + organo-therapeutics and, <a href="#544">544</a>; + psychic factors in, <a href="#542">542</a>; + psychotherapy and, <a href="#545">545</a>; + suspension and, <a href="#544">544</a>; + vibration and, <a href="#544">544</a>. +Paranoia and paresis, <a href="#532">532</a>. +Paraplegia, mimicry of, <a href="#590">590</a>. +Paresis, + alcohol and, <a href="#530">530</a>, <a href="#532">532</a>; + consoling hesitancy in diagnosis of, <a href="#533">533</a>; + difficulty of diagnosis of, <a href="#534">534</a>; + exciting life and, <a href="#530">530</a>; + hereditary factors in, <a href="#532">532</a>; + low grade nervous system and, <a href="#530">530</a>; + paranoia and, <a href="#532">532</a>; + parasyphilitic, <a href="#530">530</a>; + psychic influence in, <a href="#533">533</a>; + simulants of, <a href="#534">534</a>; + sparing relatives in, <a href="#533">533</a>; + syphilis and, <a href="#631">631</a>; + worry over syphilis in, <a href="#530">530</a>. +Paris, Dr., <a href="#16">16</a>. +Parry, old Dr., of Bath, <a href="#163">163</a>. +Parthenon, optical corrections, <a href="#772">772</a>. +Pâtés de foie gras, <a href="#291">291</a>. +Pathology, humoral, <a href="#57">57</a>. +Pathophobia, <a href="#612">612</a>. +Patient, + individual, <a href="#10">10</a>; + his disease and, <a href="#163">163</a>. +Patients, + objective and subjective history of, <a href="#164">164</a>; + no incurable, <a href="#184">184</a>. +Paul of AEgina, <a href="#13">13</a>. +Paul, St., <a href="#148">148</a>. +Pawlow on digestion, <a href="#269">269</a>. +Payot, M. Jules, on will, <a href="#220">220</a>. +Pelvic discomfort and attention, <a href="#430">430</a>. + +Peristalsis, + attention and, <a href="#270">270</a>; + experiments upon, <a href="#269">269</a>; + psychic influence and, <a href="#269">269</a>. +Perkins' tractors, <a href="#5">5</a>, <a href="#48">48</a>, <a href="#51">51</a>, <a href="#386">386</a>. +Perversions, sexual, <a href="#489">489</a>. +Personal influence, <a href="#69">69</a>; + place of, <a href="#77">77</a>; + relationship and, <a href="#77">77</a>. +Personality, + deeper levels in, <a href="#150">150</a>; + dual, hypnotism and, <a href="#150">150</a>; + dual, hysteria and, <a href="#149">149</a>; + human, <a href="#607">607</a>; + impressive, <a href="#70">70</a>, <a href="#147">147</a>; + in therapeutics, <a href="#69">69</a>; + other. <a href="#135">135</a>; + primary, <a href="#148">148</a>; + secondary, <a href="#149">149</a>; + supernumerary, <a href="#149">149</a>. +Pessimism, <a href="#233">233</a>. +Pets, fat, <a href="#291">291</a>. +Pettigrew, <a href="#61">61</a>. +Phantasms of the dying, <a href="#147">147</a>. +Pharmaceutics, father of modern, <a href="#15">15</a>. +Pharmocopeia, <a href="#1">1</a>. +Phenomena, + healing, <a href="#78">78</a>; + hysterical, <a href="#149">149</a>. +Philip Neri, St., <a href="#74">74</a>. +Phobophobia, <a href="#612">612</a>. +Phthisiophobia, <a href="#612">612</a>. +Phthisis, exaltation in, <a href="#642">642</a>. +Physicians, + abdominal discomfort and, <a href="#302">302</a>; + as patients, <a href="#191">191</a>; + family and, <a href="#729">729</a>; + old family, <a href="#714">714</a>; + personality of, <a href="#191">191</a>. +Physiognomy, <a href="#106">106</a>. +Pictet, <a href="#18">18</a>. +Pieta, <a href="#36">36</a>. +Pigmentation, + neurotic, <a href="#493">493</a>; + psyche and, <a href="#494">494</a>. +Pills, + bread, <a href="#88">88</a>, <a href="#281">281</a>; + ground biscuit. <a href="#281">281</a>. +Pinel, <a href="#8">8</a>. +Planes, intermuscular, <a href="#393">393</a>. +Plasters, + medicinal, <a href="#63">63</a>; + suggestion of, <a href="#34">34</a>. +Plato, <a href="#10">10</a>, <a href="#94">94</a>, <a href="#99">99</a>. +Play and exercise, <a href="#204">204</a>. +Pleasure, + joy and, <a href="#104">104</a>; + pain ingredient in, <a href="#240">240</a>. +Pleural adhesion, <a href="#401">401</a>. +Plexuses of nerve fibers, <a href="#109">109</a>. +Pliny, + on proprietaries, <a href="#59">59</a>; + the elder, <a href="#59">59</a>. +Plombières, <a href="#287">287</a>. +Plutarch on suicide, <a href="#719">719</a>. +Pneumogastric pressure, <a href="#315">315</a>. +Pneumonia, <a href="#3">3</a>, <a href="#22">22</a>; + depression in, <a href="#23">23</a>: + heart failure in, <a href="#23">23</a>; + hereditary, <a href="#383">383</a>; + in athletes, <a href="#202">202</a>; + nursing in, <a href="#23">23</a>; + suggestion in, <a href="#23">23</a>. +Podmore, <a href="#55">55</a>, <a href="#605">605</a>, <a href="#607">607</a>, <a href="#635">635</a>. +Polypharmacy, <a href="#41">41</a>. +Pomponatius, <a href="#14">14</a>. +Ponto, <a href="#68">68</a>. +Pope, <a href="#223">223</a>. +Pope Leo XIII, <a href="#223">223</a>. +Pork and cabbage, <a href="#249">249</a>. +Position, + after meals, <a href="#176">176</a>; + changes of, <a href="#210">210</a>; + in constipation, <a href="#276">276</a>; + in emptying the bladder, <a href="#472">472</a>; + in therapy, <a href="#207">207</a>; + post-operative, <a href="#763">763</a>; + relief and suggestion and, <a href="#213">213</a>. +Pott's disease, <a href="#68">68</a>. +Poultices, + of crushed lice, <a href="#34">34</a>; + of deterrent materials, <a href="#34">34</a>; + of insects, <a href="#34">34</a>; + of moss from mummy skull, <a href="#34">34</a>; + ordure, <a href="#34">34</a>; + signatures and, <a href="#34">34</a>. +Powder, sympathetic, <a href="#56">56</a>. +Power to choose, <a href="#149">149</a>; + will, <a href="#740">740</a>; + will, responsibility and, <a href="#738">738</a>. +Practice, metallic, <a href="#50">50</a>. +Precious stones, + signatures and, <a href="#36">36</a>; + suggestions and, <a href="#36">36</a>. +Precordia, pain in, <a href="#339">339</a>. +Predisposition to tuberculosis, <a href="#354">354</a>. +Pregnancy, <a href="#453">453</a>; + abortion for vomiting in, <a href="#455">455</a>; + air in, <a href="#453">453</a>; + exercise in, <a href="#453">453</a>; + habits of life in, <a href="#454">454</a>; + natural life in, <a href="#454">454</a>; + obesity in, <a href="#454">454</a>; + termination of, natural, <a href="#454">454</a>; + vomiting in, <a href="#455">455</a>; + vomiting of, remedies for, <a href="#455">455</a>. +Premonition, <a href="#78">78</a>, <a href="#634">634</a>, <a href="#675">675</a>; + fulfilled, <a href="#637">637</a>; + memory hallucinations and, <a href="#635">635</a>; + paralyzing, <a href="#611">611</a>; + suggestion and, <a href="#635">635</a>; + superstitions and, <a href="#638">638</a>; + unfulfilled, <a href="#637">637</a>. +Premonitions, + coincidence and, <a href="#638">638</a>; + telepathy and, <a href="#640">640</a>. +Prepuce, long, pathology in, <a href="#475">475</a>. +Preputial cleanliness, <a href="#485">485</a>. +Prescriptions, + earliest, <a href="#60">60</a>; + favorite, <a href="#3">3</a>; + Latin, <a href="#191">191</a>; + many ingrediented, <a href="#41">41</a>; + secret, <a href="#192">192</a>. +Pressure discomfort, abdominal, <a href="#252">252</a>. +Principles, + chemical and physical, <a href="#132">132</a>; + vitalistic, <a href="#132">132</a>. +Prognosis in Graves' Disease, <a href="#503">503</a>. +Prophylactic psychotherapeutics, <a href="#237">237</a>. +Prostate and self-abuse, <a href="#484">484</a>. +Prostatism, <a href="#468">468</a>; + castration and, <a href="#468">468</a>; + individual, <a href="#471">471</a>; + organotherapy and, <a href="#468">468</a>; + palliative treatment for, <a href="#471">471</a>; + position in, <a href="#471">471</a>; + seminal vesicle tissue for, <a href="#468">468</a>; + suggestion and, <a href="#270">270</a>; + vasectomy and, <a href="#469">469</a>. +Prostatitis and epigastric reflex, <a href="#252">252</a>. +Proteus, daughter of, <a href="#688">688</a>. +Providence, trust in, <a href="#775">775</a>. +Pruritus, + air bath and, <a href="#494">494</a>; + diversion of mind in, <a href="#495">495</a>; + mental factors in, <a href="#494">494</a>; + occupation and, <a href="#495">495</a>. +Pseudo-angina, <a href="#338">338</a>. +Pseudo-cyesis, <a href="#438">438</a>. +Pseudo-epilepsy, <a href="#538">538</a>; + auto suggestion and, <a href="#539">539</a>; + dread and, <a href="#539">539</a>; + menopause and, <a href="#540">540</a>; + mental cures of, <a href="#541">541</a>; + neuronic disturbance and, <a href="#539">539</a>, <a href="#597">597</a>, <a href="#693">693</a>. +Pseudo-Messiahs, <a href="#81">81</a>. +Pseudo-paresis, + memory disturbance in, <a href="#531">531</a>; + tremor in, <a href="#531">531</a>. +Pseudopods of neuroglia cells, <a href="#127">127</a>. +Pseudo-pregnancy, <a href="#438">438</a>. +Pseudo-presentiments, <a href="#635">635</a>. +Pseudo-rabies, <a href="#753">753</a>. +Pseudo-rheumatism, <a href="#379">379</a>. +Pseudo-science, <a href="#43">43</a>, <a href="#61">61</a>, <a href="#81">81</a>, <a href="#35">35</a>; + mental healing and, <a href="#38">38</a>. +Psychasthenia, + heredity and, <a href="#603">603</a>; + natural and acquired, <a href="#598">598</a>; + post-critical, <a href="#602">602</a>; + retirement and, <a href="#602">602</a>. +Psychic research, <a href="#144">144</a>. +Psychic states, neurons in, <a href="#117">117</a>. +Psycho-analysis, <a href="#77">77</a>, <a href="#595">595</a>, <a href="#625">625</a>; + dreams and, <a href="#595">595</a>; + hysteria and, <a href="#595">595</a>; + instruction in, <a href="#596">596</a>; + mesmerism, etc., and, <a href="#595">595</a>; + reversion and, <a href="#595">595</a>; + sex and, <a href="#595">595</a>. +Psychology + of advertising, <a href="#690">690</a>; + of the mob, <a href="#690">690</a>, <a href="#692">692</a>; + of patent medicines, <a href="#690">690</a>; + old and new, <a href="#58">58</a>; + principles of, <a href="#201">201</a>. +Psycho-neuroses, <a href="#239">239</a>, <a href="#281">281</a>; + after-treatment for, <a href="#591">591</a>; + appetite and, <a href="#592">592</a>; + asafetida and, <a href="#593">593</a>; + bread pills and, <a href="#593">593</a>; + business worries and, <a href="#593">593</a>; + children in, <a href="#592">592</a>; + disappointments and, <a href="#593">593</a>; + diversion and, <a href="#592">592</a>; + dominant ideas in, <a href="#593">593</a>; + drugs and, <a href="#593">593</a>; + love and, <a href="#593">593</a>; + lumbar, sciatica and, <a href="#406">406</a>; + mental impression and, <a href="#591">591</a>; + motor, <a href="#589">589</a>; + occupation and, <a href="#592">592</a>; + painful, <a href="#589">589</a>; + post-operative, <a href="#762">762</a>; + quinine and pepper for, <a href="#593">593</a>; + sorrow and, <a href="#594">594</a>; + subconsciousness and, <a href="#594">594</a>. +Psychotherapeutics, unconscious, <a href="#19">19</a>. +Psychotherapy, + abuse of, <a href="#6">6</a>; + Alexandrian, <a href="#11">11</a>; + at Rome, <a href="#12">12</a>; + concealed, <a href="#192">192</a>; + frank use of, <a href="#192">192</a>; + general principles of, <a href="#185">185</a>; + history of, <a href="#2">2</a>; + indeliberate, <a href="#3">3</a>; + individual patient and, <a href="#163">163</a>; + Münsterberg, Prof., on, <a href="#778">778</a>; + religion and, <a href="#775">775</a>; + skin diseases and, <a href="#491">491</a>; + surgical, <a href="#746">746</a>; + systematized, <a href="#192">192</a>; + tact and, <a href="#191">191</a>. +Pulse, intermission of the, <a href="#339">339</a>; + morning, <a href="#343">343</a>. +Pulse, rapid, hereditary, <a href="#340">340</a>; + paroxysmal, <a href="#340">340</a>; + persistent, <a href="#340">340</a>; + prognosis in, <a href="#340">340</a>. +Pulse, slow, athletes and, <a href="#344">344</a>; + congenital, <a href="#344">344</a>; + Napoleon and, <a href="#344">344</a>. +Punishment, + deters, <a href="#743">743</a>; + of sub-rational, <a href="#743">743</a>; + responsibility and, <a href="#740">740</a>. +Purgatives, abuse of, <a href="#287">287</a>. +Purgings, old time, <a href="#381">381</a>. +Purifiers, blood, <a href="#57">57</a>. +Pyramid, <a href="#7">7</a>, <a href="#112">112</a>. +Pythagoras, <a href="#26">26</a>. + + +Q + +Quack, <a href="#3">3</a>. +Quackery, + history of, <a href="#53">53</a>; + mind cures and, <a href="#46">46</a>. +Quakers, + color blindness in, <a href="#772">772</a>; + nervousness among, lack of, <a href="#778">778</a>. +Quinine, + as a febrifuge, <a href="#28">28</a>; + as prophylactic, <a href="#28">28</a>; + in fever, <a href="#28">28</a>; + suggestion and, <a href="#28">28</a>. + + +R + +Radiation of pain, <a href="#241">241</a>. +Radium, <a href="#5">5</a>, <a href="#45">45</a>. +Rainy weather pains, <a href="#382">382</a>. +Ramon y Cajal, <a href="#110">110</a>; + on attention, <a href="#126">126</a>. +Rattlesnake bite, <a href="#65">65</a>. +Raynaud's disease, <a href="#63">63</a>, <a href="#492">492</a>. +Rays, + actinic, <a href="#44">44</a>; + ultra-violet, <a href="#45">45</a>. +Razor, dread of, <a href="#195">195</a>. +Reaction, exaggerated, <a href="#360">360</a>. +Reading, + for insomnia, <a href="#139">139</a>; + in bed, <a href="#139">139</a>; + mind quiescent during, <a href="#139">139</a>; + muscles during, <a href="#195">195</a>; + of newspapers, <a href="#138">138</a>. +Recreations, <a href="#9">9</a>; + mental, <a href="#13">13</a>; + music and, <a href="#139">139</a>; + social, <a href="#139">139</a>; + theater and, <a href="#139">139</a>. +Re-creation, <a href="#124">124</a>, <a href="#138">138</a>. +Reduction in weight, + alcoholism and, <a href="#293">293</a>; + a life task, <a href="#293">293</a>; + without effort, <a href="#293">293</a>. +Reflexes, cardiac, <a href="#330">330</a>. +Regulation, monastic, <a href="#104">104</a>. +Reid, Dr. Archdall, on heredity, <a href="#230">230</a>, <a href="#699">699</a>. +Reil, Island of, <a href="#18">18</a>. +Relationship, personal, of physician and patient, <a href="#164">164</a>. +Relaxation, + abdominal, <a href="#209">209</a>; + mental, <a href="#140">140</a>; + of mind, <a href="#138">138</a>; + sessions of, <a href="#198">198</a>. +Relief, + in severe injuries, <a href="#85">85</a>; + natural, <a href="#188">188</a>. +Religion, + cheapening, <a href="#779">779</a>; + insanity and, <a href="#777">777</a>; + meaning of, <a href="#779">779</a>; + psychotherapy and, <a href="#775">775</a>. +Religious sense, disintegration of, <a href="#776">776</a>. +Remedies, + new, <a href="#19">19</a>; + plus suggestion, <a href="#19">19</a>, <a href="#197">197</a>; + proprietary, <a href="#59">59</a>; + repugnant, <a href="#66">66</a>; + secret, <a href="#53">53</a>; + secret, origin of, <a href="#53">53</a>; + specific, <a href="#186">186</a>; + various, <a href="#1">1</a>, <a href="#349">349</a>. +Reserve energy, law of, <a href="#18">18</a>, <a href="#92">92</a>, <a href="#93">93</a>, <a href="#310">310</a>. +Reservoir of energy, <a href="#93">93</a>. +Residue, intestinal, <a href="#274">274</a>. +Responsibility, <a href="#738">738</a>; + differing, <a href="#741">741</a>; + of defectives, <a href="#743">743</a>; + personal, <a href="#148">148</a>; + punishment and; <a href="#740">740</a>; + will power and, <a href="#742">742</a>. +Rest, + genuine, <a href="#224">224</a>, <a href="#237">237</a>; + pain and, <a href="#52">52</a>, <a href="#188">188</a>; + wear and, <a href="#602">602</a>. +Restlessness, conservative, <a href="#211">211</a>. +Retention, mental, <a href="#143">143</a>. +Reutergehem, <a href="#159">159</a>. +Rhazes, <a href="#13">13</a>. +Rheumatism, <a href="#44">44</a>, <a href="#98">98</a>; + acute, <a href="#382">382</a>; + anodynes for, <a href="#406">406</a>; + classic symptoms of, <a href="#406">406</a>; + derivation and relationship of, <a href="#380">380</a>; + foot troubles and, <a href="#414">414</a>; + heredity of, <a href="#382">382</a>; + muscular, <a href="#391">391</a>; + no lasting effects in, <a href="#379">379</a>; + old injuries and so-called, <a href="#387">387</a>; + recurrence of, <a href="#384">384</a>; + sequelae of, <a href="#384">384</a>; + so-called, <a href="#385">385</a>; + so-called chronic, <a href="#383">383</a>; + subacute, <a href="#384">384</a>; + treatment, abuse of, in, <a href="#381">381</a>; + unfavorable suggestion and, <a href="#385">385</a>. +Rhinitis <i>sympathetica</i>, <a href="#369">369</a>. +Rhythm, nodal, <a href="#342">342</a>. +Ribot, <a href="#138">138</a>. +Richardson, Benjamin Ward, <a href="#16">16</a>. +Riding, horseback, <a href="#204">204</a>. +Ring-worm, <a href="#61">61</a>. +Robert Boyle, <a href="#61">61</a>. +Roberti, S. J., Father, <a href="#65">65</a>. +Robertson, Dr., <a href="#16">16</a>. +Roger Bacon, <a href="#466">466</a>. +Roman life and manners, <a href="#58">58</a>. +Rome, <a href="#8">8</a>; + patent medicine men in, <a href="#58">58</a>. +Röntgen, <a href="#44">44</a>. +Rose, catarrh suggested by, <a href="#372">372</a>. +Rose cold, <a href="#369">369</a>, <a href="#375">375</a>. +Rose fever, artificial, <a href="#372">372</a>. +Rossetti's grief, <a href="#732">732</a>. +Routine, weekly, <a href="#183">183</a>. +Royal Society, <a href="#50">50</a>. +Royal touch, + Charles I and II and, <a href="#79">79</a>; + Edward the Confessor and, <a href="#79">79</a>; + James I and, <a href="#79">79</a>; + Queen Anne and, <a href="#79">79</a>; + Queen Elizabeth and, <a href="#79">79</a>; + William III and, <a href="#79">79</a>. +Royce on premonitions, <a href="#635">635</a>. +Rubber, <a href="#52">52</a>. +Rules, dietetic, <a href="#256">256</a>. +Rumbling, intestinal, <a href="#284">284</a>. + + +S + +St. Ives, R. L. Stevenson, <a href="#357">357</a>. +St. John Long's liniment, <a href="#29">29</a>, <a href="#381">381</a>, <a href="#402">402</a>. +St. Moritz, <a href="#357">357</a>. +St. Vitus' dance, <a href="#688">688</a>. +Sacrocoxalgia, <a href="#68">68</a>. +Sacro-iliac joint, tuberculosis of, <a href="#403">403</a>. +"Safe cure," <a href="#58">58</a>. +Saleeby on gymnastics, <a href="#203">203</a>. +Salicylates, + as specifics, <a href="#387">387</a>; + in old and young, elimination of, <a href="#387">387</a>. +Salivation, pregnancy and, <a href="#457">457</a>. +Salmon, not tortoise, <a href="#338">338</a>. +Salpêtrière, <a href="#154">154</a>, <a href="#159">159</a>. +Salt, + excess of, <a href="#283">283</a>; + mucous colitis and, <a href="#284">284</a>. +Sanatoria, modern and ancient, <a href="#10">10</a>. +Sardonyx and suggestion, <a href="#62">62</a>. +Sarsaparilla, <a href="#5">5</a>; + suggestive value of, <a href="#57">57</a>. +Sauerkraut, <a href="#248">248</a>. +Sausage, blood, <a href="#77">77</a>. +Scheidemantel on psychotherapy, <a href="#17">17</a>. +Schools, teaching of pathology and physiology in, <a href="#95">95</a>. +Schopenhauer, <a href="#648">648</a>. +Schrenk-Notzing and hypnotism, <a href="#159">159</a>. +Schurz, Carl, and failed premonition, <a href="#637">637</a>. +Sciatica, <a href="#402">402</a>; + acupuncture for, <a href="#408">408</a>; + etiology of, <a href="#404">404</a>; + hot needles for, <a href="#408">408</a>; + intra-pelvic causes of, <a href="#405">405</a>; + position at work and, <a href="#405">405</a>; + pressure and, <a href="#404">404</a>; + stretching and, <a href="#408">408</a>; + treatment for, <a href="#405">405</a>. +Science and a Creator, <a href="#776">776</a>. +Seasickness, <a href="#97">97</a>; + remedies and suggestion, <a href="#97">97</a>. +Secretions as remedies, <a href="#66">66</a>. +Sedentary life, preparation for, <a href="#200">200</a>. +Self, + over-attention to, <a href="#600">600</a>; + subliminal, <a href="#148">148</a>; + the other, <a href="#148">148</a>. +Self-abuse, + after-cure of, <a href="#487">487</a>; + air and, <a href="#487">487</a>; + breaking off the habit of, <a href="#486">486</a>; + cleanliness and, <a href="#488">488</a>; + confession and, <a href="#486">486</a>; + confidence and, <a href="#486">486</a>; + effect of, on prostate, <a href="#484">484</a>; + exaggerated effects of, <a href="#483">483</a>; + female, <a href="#488">488</a>; + habit of, <a href="#482">482</a>; + insanity and, <a href="#484">484</a>; + occupations and, <a href="#488">488</a>; + preputial concretions and, <a href="#485">485</a>; + reading and, <a href="#488">488</a>; + relapse into, <a href="#486">486</a>; + sleep and, <a href="#487">487</a>; + times of danger and relapses into, <a href="#487">487</a>. +Self-consciousness, + in clergymen, <a href="#582">582</a>; + in teachers, <a href="#582">582</a>. +Self-control, <a href="#148">148</a>; + for obesity, <a href="#294">294</a>. +Self-denial, <a href="#240">240</a>. +Self-discipline, <a href="#146">146</a>. +Self-hypnosis, <a href="#161">161</a>. +Self-indulgence, <a href="#148">148</a>. +Self-watching, <a href="#600">600</a>. +Sensations, + ideas and, <a href="#109">109</a>; + manifold, <a href="#560">560</a>; + missed, <a href="#129">129</a>; + over-attention to, <a href="#560">560</a>; + simple painful, <a href="#131">131</a>; + transfer of, <a href="#252">252</a>; + uncomfortable, <a href="#218">218</a>. +Sense of pressure, <a href="#262">262</a>. +Sepsis and alcohol in suggestion, <a href="#30">30</a>. +Serpents in therapeutics, <a href="#65">65</a>. +Sex, + cultivation of, <a href="#481">481</a>; + curiosity concerning, <a href="#489">489</a>; + exaggerated significance of, <a href="#479">479</a>; + expectorating, the, <a href="#346">346</a>; + in the background, <a href="#481">481</a>; + "mad," <a href="#480">480</a>; + on the mind, <a href="#479">479</a>; + perversion of, bathing and, <a href="#489">489</a>; + ugly habits and, <a href="#481">481</a>. +Sexual afflictions trivial, <a href="#473">473</a>. +Sexual neuroses, <a href="#472">472</a>. +Sexual perversions, <a href="#489">489</a>. +Sexual solicitude, <a href="#477">477</a>. +Sexual symptoms, exaggerated, <a href="#472">472</a>. +Sherrington on nerve mechanism, <a href="#123">123</a>. +Shilling, live on a, and earn it, <a href="#268">268</a>. +Shivering, <a href="#773">773</a>. +Shock, + anesthesia and, <a href="#754">754</a>; + the heart and, <a href="#314">314</a>. +Shoe-maker, + magic, <a href="#414">414</a>; + present day, <a href="#418">418</a>. +Shoes, + old-fashioned, <a href="#418">418</a>; + sloppy weather, <a href="#414">414</a>. +Short circuit, mental, <a href="#223">223</a>, <a href="#225">225</a>. +Shoulders and feelings, <a href="#103">103</a>. +Sidis, Boris, on psycho-analysis, <a href="#270">270</a>. +Sight, lapse of, <a href="#129">129</a>. +Signature, tremor in, <a href="#584">584</a>. +Signatures, + doctrine of, <a href="#21">21</a>, <a href="#34">34</a>, <a href="#35">35</a>; + psychotherapy and, <a href="#35">35</a>. +Simpson, Sir James, <a href="#147">147</a>. +Simulation, psycho-neurotic, <a href="#588">588</a>. +Sitophobia, <a href="#264">264</a>, <a href="#612">612</a>. +Sitting on foot, <a href="#405">405</a>. +Skin lesions, + artefact, <a href="#495">495</a>; + mind and, <a href="#493">493</a>. +Sleep, <a href="#111">111</a>, + <a href="#122">122</a>, + <a href="#123">123</a>; + amount of, <a href="#165">165</a>; + at sea, <a href="#658">658</a>; + communications during, <a href="#136">136</a>; + encroachment on, <a href="#183">183</a>; + habits and, <a href="#660">660</a>; + how much necessary, <a href="#653">653</a>; + Humboldt on, <a href="#653">653</a>; + hypnotic, <a href="#152">152</a>; + hypnotism and, <a href="#159">159</a>; + loss of, longevity and, <a href="#661">661</a>; + mental diversion and, <a href="#661">661</a>; + monastic rule and, <a href="#295">295</a>; + not dreamless, <a href="#672">672</a>; + noise and, <a href="#666">666</a>; + on trains, <a href="#666">666</a>; + prevention of, <a href="#653">653</a>; + solicitude over, <a href="#652">652</a>; + starting in, <a href="#664">664</a>; + troubles of, <a href="#663">663</a>; + troubles of, hunger and, <a href="#665">665</a>; + vibration and, <a href="#566">566</a>. +Sleeping in the light, <a href="#669">669</a>. +Sleeplessness, <a href="#651">651</a>. +Smaragdum and suggestion, <a href="#62">62</a>. +Snake, bite of, suggestion for, + prostration and, <a href="#32">32</a>; + in stomach, <a href="#13">13</a>; + skin of, in lichen, <a href="#25">25</a>. +Society, + Perkinean, <a href="#49">49</a>; + Psychic Research, <a href="#146">146</a>. +Socrates, <a href="#11">11</a>; + diversion and, <a href="#610">610</a>; + headache cures and, <a href="#554">554</a>. +Solicitude and prognosis, <a href="#237">237</a>. +Somnambulism, <a href="#138">138</a>; + hypnotic, <a href="#161">161</a>. +Somnambulistic, <a href="#137">137</a>. +Sound in hypnotism, <a href="#156">156</a>. +Sound reproduction, <a href="#610">610</a>. +Space, filled, illusion of, <a href="#768">768</a>. +Spasm, + expiratory, <a href="#364">364</a>; + inspiratory, <a href="#364">364</a>. +Specialist, advertising, <a href="#476">476</a>, + <a href="#482">482</a>. +Spectacles properly fitted, <a href="#258">258</a>. +Speech, tricks of, <a href="#566">566</a>. +<i>Spes pthisica</i>, <a href="#642">642</a>. +Spinal cell, <a href="#133">133</a>. +Spine, typhoid, <a href="#403">403</a>. +Spirit rapping through foot tendons, <a href="#419">419</a>. +Spiritualism, <a href="#78">78</a>. +Spitting, unnecessary, <a href="#346">346</a>. +Spleen as food, <a href="#244">244</a>. +Sport, <a href="#228">228</a>; + for its own sake, <a href="#229">229</a>; + indoor, <a href="#204">204</a>; + winning, <a href="#229">229</a>. +Sprain and fractures, <a href="#387">387</a>. +Sputum as a remedy, <a href="#67">67</a>. +Station, tremor in, <a href="#581">581</a>. +Steak, camel and elephant, <a href="#245">245</a>. +Steppes, <a href="#23">23</a>. +Stereoscopic vision, <a href="#766">766</a>. +Stevenson, Robert Louis, <a href="#356">356</a>. +Stew, + cat, <a href="#245">245</a>; + dog, <a href="#245">245</a>; + lion, <a href="#245">245</a>; + rat, <a href="#245">245</a>. +Stigmata, hysterical, <a href="#590">590</a>. +Stomach, + attention and the, <a href="#306">306</a>; + dilatation of the, <a href="#330">330</a>; + mental states and the, <a href="#243">243</a>; + motility of the, <a href="#261">261</a>; + not test tubes, <a href="#132">132</a>, + <a href="#242">242</a>; + resonance in, fifth interspace, <a href="#332">332</a>; + snake in the, <a href="#13">13</a>. +Stout people, constipated, <a href="#278">278</a>. +Stroke, "third fatal," <a href="#523">523</a>. +Stroking the forehead, <a href="#156">156</a>; + hypnotic, <a href="#153">153</a>. +Students, + medical, <a href="#99">99</a>; + symptoms in, <a href="#93">93</a>. +Study, <a href="#125">125</a>. +Stupidity, bodily conditions and, <a href="#106">106</a>. +Stuttering, <a href="#570">570</a>; + attention to, <a href="#577">577</a>; + breathing and, <a href="#578">578</a>; + correction of respiratory defects in, <a href="#573">573</a>; + cures of, <a href="#576">576</a>; + distraction of mind in, <a href="#79">79</a>; + forms of, <a href="#570">570</a>; + hindrances to speech and, <a href="#577">577</a>; + inserted letters in treatment for, <a href="#578">578</a>; + in the young, <a href="#573">573</a>; + in women, <a href="#573">573</a>; + Itard's fork and, <a href="#578">578</a>; + Kingsley's cork and, <a href="#578">578</a>; + Leigh methods and, <a href="#578">578</a>; + mental influence and, <a href="#572">572</a>; + practice in self-control for, <a href="#573">573</a>; + regulation of respiration in, <a href="#577">577</a>; + singing in treatment for, <a href="#577">577</a>; + state of mind in, <a href="#57">57</a>; + suggestion for, <a href="#579">579</a>; + tongue against teeth in, <a href="#578">578</a>; + tongue lowered in, <a href="#578">578</a>; + treatment for, <a href="#576">576</a>; + type of loss of control in, <a href="#570">570</a>; + walking and, <a href="#571">571</a>; + writing and, <a href="#571">571</a>. +Subconscious self, <a href="#145">145</a>, + <a href="#148">148</a>. +Südhoff, <a href="#38">38</a>. +Suffering, + a tonic, <a href="#723">723</a>; + real, <a href="#222">222</a>. +Sugars in constipation, <a href="#276">276</a>. +Suggestion, <a href="#2">2</a>; + antimony and, <a href="#25">25</a>; + as to symptoms, <a href="#360">360</a>; + coincidence and, <a href="#20">20</a>; + death and, <a href="#91">91</a>; + for colitis, <a href="#288">288</a>; + for surgical lesions, <a href="#748">748</a>; + in cold, <a href="#21">21</a>; + influence of, <a href="#76">76</a>; + in rheumatism, so-called, <a href="#385">385</a>; + in tuberculosis, <a href="#362">362</a>; + mechanism of, <a href="#109">109</a>; + neutralizing contrary, <a href="#186">186</a>; + not heredity, <a href="#251">251</a>; + pathological, <a href="#93">93</a>; + physiological, <a href="#260">260</a>; + seasickness and, <a href="#97">97</a>; + unfavorable, <a href="#186">186</a>. +Suggestions, optimistic, <a href="#511">511</a>. +Suggestive operation, <a href="#306">306</a>. +Suicide, <a href="#713">713</a>; + among children, <a href="#720">720</a>; + bureau of, <a href="#714">714</a>; + burial in disgrace and, <a href="#719">719</a>; + cataclysm and, <a href="#718">718</a>; + Chesterton on, <a href="#722">722</a>; + confession and, <a href="#714">714</a>; + contagious, <a href="#691">691</a>, + <a href="#720">720</a>; + cowardice of, <a href="#721">721</a>; + disgrace and, <a href="#719">719</a>; + dread of, <a href="#714">714</a>, + <a href="#726">726</a>; + earthquakes and, <a href="#718">718</a>; + epidemic of, <a href="#691">691</a>; + functional irrationality and, <a href="#714">714</a>; + Hamlet and, <a href="#722">722</a>; + headache and, <a href="#715">715</a>; + insomnia and, <a href="#715">715</a>; + justification of, <a href="#9">9</a>; + melancholia and, <a href="#556">556</a>; + mental factors in, <a href="#716">716</a>; + most frequent in June, <a href="#717">717</a>; + pain and, <a href="#723">723</a>; + prevention of, <a href="#713">713</a>; + problems of, <a href="#718">718</a>; + physician and, <a href="#726">726</a>; + prosperity and, <a href="#713">713</a>; + rarest in December, <a href="#717">717</a>; + reassurance and, <a href="#725">725</a>; + religion and, <a href="#718">718</a>; + social factors in, <a href="#717">717</a>; + suggestion and, <a href="#713">713</a>; + underweight and, <a href="#297">297</a>; + unexplained, <a href="#195">195</a>; + war reduces, <a href="#717">717</a>; + weather and, <a href="#715">715</a>; + women of Milesia and, <a href="#719">719</a>. +Supernatural, naturalizing the, <a href="#607">607</a>. +Superstition concerning "13," <a href="#639">639</a>. +Superstitions connected with medicine and surgery, <a href="#62">62</a>. +Suppression of reaction, <a href="#86">86</a>. +Supreme Being, <a href="#78">78</a>. +Surgery, + astrology in, <a href="#746">746</a>; + suggestion and, <a href="#748">748</a>. +Surveillance, + heart, <a href="#323">323</a>; + inhibitory, <a href="#600">600</a>; + insistent, <a href="#269">269</a>; + of function, <a href="#269">269</a>; + self, <a href="#600">600</a>. +Swallowing, <a href="#575">575</a>. +Sydenham, <a href="#16">16</a>, <a href="#71">71</a>. +Symonds, J. Addington, and consumption, <a href="#357">357</a>. +Sympathetic powder, <a href="#66">66</a>. +Sympathy, <a href="#188">188</a>; + as a remedy, <a href="#222">222</a>; + heart and, <a href="#319">319</a>. +Symptoms, hysterical, <a href="#590">590</a>. +Synapse theory of fatigue, <a href="#123">123</a>, + <a href="#124">124</a>. +Syncope, neurotic, <a href="#540">540</a>. +Syphilis, + curability of, <a href="#630">630</a>; + congenital contagion and, <a href="#630">630</a>; + heredity and, <a href="#629">629</a>, <a href="#631">631</a>; + imaginary, <a href="#753">753</a>; + maternal immunity from, <a href="#630">630</a>; + paresis and, <a href="#631">631</a>; + worry and, <a href="#509">509</a>. +System, sympathetic, <a href="#127">127</a>. +Systems of nerve fibers, <a href="#109">109</a>. +Systoles, extra, <a href="#333">333</a>. + + +T + +Tabes, + complications in, <a href="#527">527</a>; + "cures" of, <a href="#529">529</a>; + diphtheria serum in, <a href="#529">529</a>; + drugs in, <a href="#530">530</a>; + magic shoes and, <a href="#529">529</a>; + mental attitude and, <a href="#527">527</a>; + mild course in, <a href="#527">527</a>; + muscle control in, <a href="#528">528</a>; + normal lifetime and, <a href="#527">527</a>; + over-stretching the spinal cord in, <a href="#530">530</a>; + reassurance in, <a href="#528">528</a>; + relearning muscular movements in, <a href="#528">528</a>; + suspension in, <a href="#530">530</a>; + urethral treatment for, <a href="#529">529</a>. +Tabetic neuroses, <a href="#527">527</a>. +Table, leaving the, hungry, <a href="#299">299</a>. +Tachycardia, <a href="#340">340</a>; + essential, <a href="#342">342</a>; + Mackenzie on, <a href="#342">342</a>; + paroxysmal, <a href="#341">341</a>; + Wood's case of, <a href="#341">341</a>. +Tails, expressions in, <a href="#141">141</a>. +Talismans, <a href="#60">60</a>. +Talking, co-ordination and, <a href="#230">230</a>. +Tar water, <a href="#56">56</a>. +Taste, cloying, <a href="#131">131</a>. +Tea and abdominal distress, <a href="#307">307</a>. +Teaching, disease, <a href="#95">95</a>. +Tears, <a href="#66">66</a>; + grief and, <a href="#103">103</a>; + joy and, <a href="#103">103</a>; + relief of, <a href="#103">103</a>. +Telegraphy, wireless, telepathy and, <a href="#142">142</a>. +Telepathic premonition, <a href="#640">640</a>. +Telepathy, + accidents and, <a href="#145">145</a>; + in trade, in ordinary life, and in juries, <a href="#143">143</a>; + investigation of, by French Academy, <a href="#147">147</a>; + negation of, <a href="#144">144</a>; + negative tests of, <a href="#147">147</a>; + on the stage, <a href="#144">144</a>; + social life and, <a href="#143">143</a>; + supposed examples of, <a href="#144">144</a>; + twins and, <a href="#147">147</a>; + wireless telegraphy and, <a href="#142">142</a>. +Temper, + bad, <a href="#739">739</a>; + uncontrollable, <a href="#739">739</a>. +Temperature, variations of, <a href="#203">203</a>, + <a href="#354">354</a>. +Tennyson, <a href="#35">35</a>. +Tension, relaxation of, <a href="#197">197</a>. +Tenting in tuberculosis, <a href="#369">369</a>. +Thackeray, <a href="#35">35</a>. +Theater fires, <a href="#85">85</a>. +Theory, Duval, <a href="#123">123</a>. +Therapeutic persuasions, <a href="#26">26</a>. +Therapeutics of position, <a href="#208">208</a>; + popular, <a href="#186">186</a>. +Theriac, <a href="#20">20</a>; + Bernard's, <a href="#20">20</a>; + Galen's, <a href="#3">3</a>. +Thick lips, meaning of, <a href="#106">106</a>. +Thinness, physical disadvantage of, <a href="#298">298</a>. +Thompson, Francis, <a href="#357">357</a>. +Thompson, Prof. J. J., <a href="#139">139</a>. +Thompson, Sir Henry, <a href="#494">494</a>, + <a href="#657">657</a>. +Thomson, Dr. Wm. H., <a href="#505">505</a>. +Thoreau, <a href="#357">357</a>. +Thought, + for others, <a href="#221">221</a>; + New, <a href="#209">209</a>; + original, <a href="#135">135</a>; + pale cast of, <a href="#737">737</a>; + transference of, <a href="#141">141</a>. +Thunder, fear of, <a href="#612">612</a>. +Tics, <a href="#230">230</a>, <a href="#564">564</a>; + as types of nerve explosions, <a href="#564">564</a>; + children's, <a href="#568">568</a> + drumming with the fingers, <a href="#567">567</a> + emotional, <a href="#565">565</a>; + expletives and, <a href="#565">565</a> + facial, <a href="#565">565</a>; + familiar expressions and; <a href="#565">565</a>; + gestures and, <a href="#565">565</a>; + heredity and, <a href="#569">569</a>; + in games, <a href="#567">567</a>; + jerking, <a href="#565">565</a>; + mental treatment for, <a href="#569">569</a> + motor, <a href="#569">569</a>; + prophylaxis in, <a href="#569">569</a>; + shrugging, <a href="#565">565</a>; + speech, <a href="#565">565</a>, + <a href="#566">566</a> + squinting, <a href="#565">565</a>; + swearing, <a href="#568">568</a> + teachers' habits and; <a href="#566">566</a>; + winking, <a href="#565">565</a>; + writers', <a href="#567">567</a>. +Time is money, <a href="#179">179</a>. +Tissues, nervous, changes of, <a href="#89">89</a>. +Toes, + claw, <a href="#418">418</a>; + hammer, <a href="#418">418</a>. +Tolerance, intestinal, <a href="#217">217</a>. +"Tommyrotic" and erotic, <a href="#480">480</a>. +Torcular Herophili, <a href="#12">12</a>. +Torticollis, <a href="#393">393</a>. +Tortoise and salmon, lives of, <a href="#338">338</a>. +Touch and sight, <a href="#214">214</a>. +Tozzi twins, <a href="#229">229</a>. +Tractoration, <a href="#48">48</a>. +Tractors, + Perkins', <a href="#49">49</a>; + in yellow fever, <a href="#51">51</a>. +Training, <a href="#213">213</a>; + appetite, <a href="#216">216</a>; + equilibrium and, <a href="#215">215</a>; + facial muscles, <a href="#101">101</a>; + feeling and, <a href="#215">215</a>; + for pain, <a href="#217">217</a>; + for weight, <a href="#217">217</a>; + hearing, <a href="#215">215</a>, + <a href="#636">636</a>; + heart, <a href="#216">216</a>; + infantile palsy and, <a href="#216">216</a>; + in self-control, <a href="#745">745</a>; + intellectual, <a href="#218">218</a>; + memory, <a href="#686">686</a>; + movement, <a href="#686">686</a>; + muscles, <a href="#215">215</a>; + of defectives, <a href="#743">743</a>; + sight, <a href="#215">215</a>; + touch, <a href="#215">215</a>. +Trains and intestinal disturbances, <a href="#280">280</a>. +Treatment, absent, <a href="#5">5</a>, + <a href="#141">141</a>. +Tremor, + senile, longevity and, <a href="#580">580</a>; + premature, <a href="#580">580</a>; + prognosis of, <a href="#580">580</a>; + significance of, <a href="#580">580</a>. +Tremors, <a href="#579">579</a>; + actors and, <a href="#582">582</a>; + clergy and, <a href="#582">582</a>; + dread and, <a href="#581">581</a>; + fright and, <a href="#581">581</a>; + hypnotism and, <a href="#584">584</a>; + in intention, <a href="#581">581</a>, + <a href="#583">583</a>; + mental control and, <a href="#583">583</a>; + self-discipline and, <a href="#584">584</a>; + shaving, dread of, <a href="#581">581</a>; + standing, <a href="#581">581</a>; + suggestion waking, <a href="#584">584</a>; + teachers', <a href="#582">582</a>; + types of, <a href="#579">579</a>; + writing, <a href="#584">584</a>. +Treves, Sir Frederick, on alcohol, <a href="#30">30</a>. +Trifles, + fascination of, <a href="#651">651</a>; + in health, <a href="#164">164</a>. +Troubles that do not happen, <a href="#233">233</a>, + <a href="#612">612</a>. +Troy, <a href="#62">62</a>. +Trudeau, <a href="#359">359</a>. +Tuberculosis, + classes of, <a href="#188">188</a>; + contagion and, <a href="#353">353</a>, + <a href="#628">628</a>; + courage in, <a href="#356">356</a>; + "cures" for, <a href="#351">351</a>; + early diagnosis in, <a href="#354">354</a>; + early stage in, <a href="#353">353</a>; + heredity and, <a href="#352">352</a>; + heroes of, <a href="#356">356</a>; + immunity from, <a href="#629">629</a>; + incipient, <a href="#348">348</a>; + incurable, <a href="#352">352</a>; + predisposition to, <a href="#354">354</a>; + prevalence of, <a href="#351">351</a>; + protective, <a href="#629">629</a>; + pulse and, <a href="#354">354</a>; + quitters and, <a href="#355">355</a>; + remedies for, <a href="#351">351</a>; + slow, <a href="#352">352</a>; + stimulating, <a href="#356">356</a>; + suggestion and, <a href="#362">362</a>; + temperature range in, <a href="#354">354</a>; + unfavorable prognosis in, <a href="#352">352</a>; + vital resistance and, <a href="#351">351</a>; + whooping cough and, <a href="#346">346</a>. +Tumors, pelvic, sciatica and, <a href="#405">405</a>. +Twain, Mark, disappearance story of, <a href="#608">608</a>. +Types of expression, <a href="#102">102</a>. +Typewriters' fingers, <a href="#89">89</a>. +Typhoid fever, + antisepsis in, <a href="#24">24</a>; + in athletes, <a href="#202">202</a>; + mental symptoms in, <a href="#93">93</a>; + nurses in, <a href="#24">24</a>; + spine in, <a href="#403">403</a>; + suggestion in, <a href="#24">24</a>. + + +U + +Unconscious cerebration, <a href="#128">128</a>. +Unconsciousness, <a href="#119">119</a>, <a href="#123">123</a>. +Underclothing, variety in, <a href="#167">167</a>. +Undereating, <a href="#297">297</a>. +Underweight, correction of, <a href="#300">300</a>. +Unguentum <i>Armarium</i>, <a href="#54">54</a>. +Unknown, the, <a href="#189">189</a>, <a href="#607">607</a>. +Urbantschitsch, hearing training, <a href="#686">686</a>. +Uric acid diathesis, <a href="#270">270</a>. +Urinary worries, <a href="#470">470</a>. +Urination, position in, <a href="#459">459</a>, + <a href="#472">472</a>. +Urticaria, + diarrhea and, <a href="#281">281</a>, + <a href="#282">282</a>; + mind and, <a href="#491">491</a>. +Use and abuse, <a href="#196">196</a>. + + +V + +Vacuum cleaning, <a href="#174">174</a>. +Valerian, <a href="#68">68</a>. +Valerianate ammonium, <a href="#68">68</a>. +Van Eeden and hypnotism, <a href="#159">159</a>. +Van Helmont, <a href="#15">15</a>, + <a href="#55">55</a>, + <a href="#64">64</a>. +Van Swieten, <a href="#17">17</a>, + <a href="#71">71</a>. +Variation, <a href="#633">633</a>. +Varicocele, <a href="#473">473</a>; + depression, mental, and, <a href="#474">474</a>. +Varicose veins, <a href="#208">208</a>. +Varicosities, + feet elevated in, <a href="#208">208</a>; + occupations and, <a href="#208">208</a>. +Vascular pedicles, <a href="#126">126</a>. +Vaso-motor disturbance, <a href="#492">492</a>. +Vegetarianism, <a href="#256">256</a>. +Venesection, + for eye diseases, <a href="#28">28</a>; + for migrane, <a href="#28">28</a>; + mental influence and, <a href="#28">28</a>; + mind and, <a href="#14">14</a>; + suggestiveness of, <a href="#28">28</a>. +Version, + by heel in perineum, <a href="#459">459</a>; + natural, <a href="#459">459</a>. +Vertigo, + Menière's, <a href="#516">516</a>; + over-attention and, <a href="#512">512</a>; + significance of, <a href="#512">512</a>. +Vest, <a href="#168">168</a>. +Vibrations of cells, moments of, <a href="#142">142</a>. +Viper venom, <a href="#66">66</a>. +Virchow, <a href="#62">62</a>, + <a href="#226">226</a>, + <a href="#618">618</a>, + <a href="#647">647</a>; + on hobbies, <a href="#226">226</a>. +Virility, The Ages of Mental, <a href="#624">624</a>. +Viscera, sensitive nerves and, <a href="#560">560</a>. +Vision, + illusion of two-eyed, <a href="#764">764</a>; + stereoscopic, <a href="#766">766</a>. +Vitalism, <a href="#191">191</a>. +Vitality, resistive, and muscle, <a href="#108">108</a>, + <a href="#201">201</a>. +Volta, <a href="#48">48</a>. +Voltaic pile, <a href="#43">43</a>. +Vomiting, + abortion and, <a href="#456">456</a>; + after anaesthesia, <a href="#758">758</a>; + distraction of mind and, <a href="#456">456</a>; + frequency of, <a href="#456">456</a>; + neurotic, <a href="#455">455</a>; + non-suggestion of abortion and, <a href="#456">456</a>; + of live mice, <a href="#462">462</a>; + of snakes, <a href="#462">462</a>; + pernicious, <a href="#455">455</a>; + pregnancy and, <a href="#456">456</a>. +Von Bülow's case of headache, <a href="#550">550</a>. +Von Leyden crystals, <a href="#364">364</a>. +Von Moltke, <a href="#647">647</a>. +Von Monakow, <a href="#115">115</a>. +Von Retzius, <a href="#121">121</a>. + + +W + +Wakefulness, + matutinal, <a href="#662">662</a>; + persistent, <a href="#652">652</a>. +Waking, suggestion method for, <a href="#197">197</a>. +Walking, <a href="#205">205</a>; + complexity of, <a href="#229">229</a>; + coordination in, <a href="#3">3</a>. +Walks, morning, <a href="#169">169</a>. +Warming up, <a href="#92">92</a>. +Warning, coincidences and, <a href="#611">611</a> +Warts, + counting of, <a href="#493">493</a>; + Lord Bacon and, <a href="#493">493</a>; + mental influence and, <a href="#493">493</a>. +Wash water of little babies, <a href="#67">67</a>. +Water, + dread of, <a href="#62">62</a>; + drinking, <a href="#232">232</a>; + hypodermic, <a href="#88">88</a>. +Waters, mineral, <a href="#45">45</a>. +Waves of nervous energy, <a href="#110">110</a>. +Weak foot, <a href="#391">391</a>. +Weakness and discomfort, <a href="#299">299</a>. +Weapon ointment, <a href="#54">54</a>. +Weapon salve, <a href="#55">55</a>. +Weight, + abdominal distress and, <a href="#309">309</a>; + for height, <a href="#299">299</a>; + gain in, <a href="#301">301</a>; + good feeling and, <a href="#297">297</a>; + in intestinal neuroses, <a href="#285">285</a>. +Weir Mitchell's disease, <a href="#492">492</a>. +Wessex Tales, mental influence, instance of, <a href="#64">64</a>. +Whewell, <a href="#14">14</a>. +Which? (dream poem), <a href="#136">136</a>. +Whiskey, + in hypnotism, <a href="#156">156</a>; + in snake bites, <a href="#32">32</a>. +White hair and fright, <a href="#494">494</a>. +Whoop, habit, <a href="#25">25</a>. +Whooping cough, <a href="#24">24</a>; + diphtheria serum in, <a href="#25">25</a>; + mine air in, <a href="#25">25</a>; + more air in, <a href="#25">25</a>; + sea water in, <a href="#25">25</a>; + tuberculosis and, <a href="#25">25</a>. +Wiggs, Mrs., of the Cabbage Patch, <a href="#234">234</a>. +Will, + appetite and, <a href="#592">592</a>; + breaking the, <a href="#744">744</a>; + disorders of the, <a href="#694">694</a>; + education of the, <a href="#220">220</a>; + motion and the, <a href="#109">109</a>; + over the heart, <a href="#313">313</a>; + re-education of the, <a href="#737">737</a>; + to live, <a href="#90">90</a>; + training the, by punishment, <a href="#742">742</a>, + <a href="#744">744</a>. +Wimshurst machine, <a href="#43">43</a>. +Wind, + second, <a href="#92">92</a>; + third and fourth, <a href="#92">92</a>. +Wine and the doctrine of signatures, <a href="#36">36</a>. +Winkel on vomiting at pregnancy, <a href="#457">457</a>. +Witchcraft, <a href="#141">141</a>. +Woman, average normal, <a href="#433">433</a>. +Women, + feed hearts of, <a href="#221">221</a>; + home-keeping, <a href="#169">169</a>; + working, <a href="#169">169</a>. +Woodward, <a href="#286">286</a>. +Wordsworth, <a href="#135">135</a>. +Work, + at home, <a href="#182">182</a>; + latent intellectual, <a href="#134">134</a>; + monastic division of, <a href="#227">227</a>; + night, <a href="#175">175</a>; + six hours of, <a href="#182">182</a>; + social, <a href="#221">221</a>; + the day's, <a href="#165">165</a>, + <a href="#171">171</a>; + two-hour periods of, <a href="#227">227</a>. +Workers, night, <a href="#175">175</a>. +Working woman, <a href="#183">183</a>. +Worldliness, + this, <a href="#779">779</a>; + other, <a href="#779">779</a>. +Wraiths, <a href="#608">608</a>. +Writers' cramp, <a href="#396">396</a>, + <a href="#572">572</a>. +Writing rule, Gower's, <a href="#174">174</a>, + <a href="#396">396</a>. + + +X + +X-rays, <a href="#5">5</a>, <a href="#44">44</a>. + + +Y + +Yawning, contagious, <a href="#688">688</a>. + + +Z + +Zöllner's distortion of parallels, <a href="#771">771</a>, +Zoöphobia, <a href="#612">612</a>. +</pre> + + + + + + + + +<pre> + + + + + +End of the Project Gutenberg EBook of Psychotherapy, by James J. 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