Produced by Don Kostuch





[Transcriber's Notes]
  This book is derived from a copy on the Internet Archive:
    psychotherapy00walsgoog/psychotherapy00walsgoog_djvu.txt>

  A publication contemporary to this book is "Mother's Remedies"
  by Thomas Jefferson Ritter. It contains hundreds of suggestions
  that hindsight shows to be purely "mental" in their effect.
    http://www.gutenberg.org/ebooks/17439

  One of the author's favorite terms is "over-solicitous". The patient
  literally "worrys themselves sick" over trivial symptoms and makes
  serious cases worse than necessary. Most of his use of psychotherapy
  consists of informing, diverting and cheering the patient so that
  worry and its consequences are not piled on top of real or imagined
  disease.

  This book illustrates the general state of medicine in 1910.
  Psychotherapy was more important to medical care because so little
  was known of the complex physical mechanisms of the body. I
  particularly reacted to the discussion of hay fever because it
  plagued me for thirty years until experimental desensitization
  therapy successfully cured my case. Nonetheless, much of value has
  been lost with the decline of psychotherapy by the family physician.
  A personal relationship with the physician is often replaced with
  expensive impersonal technology that mostly tells what is not wrong.

  Many paragraphs have bold or italic titles. These are rendered
  by a extra blank line--a total of two blank lines.

  Obvious spelling or typographical errors have been corrected.
  Inconsistent spelling of names and inventive and alternative
  spelling is left as printed.

  The outline format of the book uses these conventions:
    Major Topics, [Upper Case title]
      Sections, [Upper Case, italic title]
        Chapters,
          Minor topics, denoted by bold face and an em-dash
            Topic subheads denoted by italics and and em-dash

  for example:
    SPECIAL PSYCHOTHERAPY
      SECTION VII. _Cardiotherapy_
        Chapter III. Cardiac Neuroses
          Varieties.-- [Bold]
           _Palpitation_.-- [italic]


  During the transcription of this book Dr. Michael Stewart of the
  Mayo Clinic, Jacksonville, FL., diagnosed me with a retinal
  condition that had deprived me of the ability to read with my left
  eye. His skilled surgery corrected the condition. I dedicate this
  transcription to Dr. Stewart and the skilled and thoughtful staff of
  Mayo.
[End Transcriber's Notes]


PSYCHOTHERAPY



PSYCHOTHERAPY



INCLUDING THE HISTORY OF THE USE OF MENTAL INFLUENCE,
DIRECTLY AND INDIRECTLY, IN HEALING AND THE
PRINCIPLES FOR THE APPLICATION OF ENERGIES
DERIVED FROM THE MIND TO THE
TREATMENT OF DISEASE.



BY

JAMES J. WALSH, M.D.. Ph.D.

DEAN AND PROFESSOR OF FUNCTIONAL NERVOUS DISEASE AND OF THE HISTORY
OF MEDICINE AT FORDHAM UNIVERSITY SCHOOL OF MEDICINE, AND OF PHYSIOLOGICAL
PSYCHOLOGY AT CATHEDRAL COLLEGE, NEW YORK; FELLOW OF NEW YORK ACADEMY OF
MEDICINE; MEMBER A.M.A., A.A.A.S., NEW YORK STATE MEDICAL SOCIETY,
GERMAN SOCIETY FOR THE HISTORY OF MEDICINE AND THE PHYSICAL SCIENCES,
NEW ORLEANS PARISH MEDICAL SOCIETY, ST. LOUIS MEDICAL HISTORY
CLUB, ETC.







  NEW YORK AND LONDON
  D. APPLETON AND COMPANY

  1912





COPYRIGHT, 1912, BY

D. APPLETON AND COMPANY



Printed in
New York, U. S. A.




TO THE JESUITS

TO WHOM THE AUTHOR OWES A HAPPY INTRODUCTION TO THE INTELLECTUAL LIFE
AND CONSTANTLY RENEWED INSPIRATION IN HIS WORK
THIS BOOK IS RESPECTFULLY AND AFFECTIONATELY DEDICATED



{vii}


PREFACE

"Prefaces are a great waste of time," said Francis Bacon, "and, though
they seem to proceed of modesty, they are bravery." In spite of this
deterring expression of the Lord Chancellor, the author ventures to
write a short _apologia pro libro suo_. Five years ago he began at
Fordham University School of Medicine a series of lectures on
Psychotherapy. This book consists of material gathered for these
lectures. It will be found in many ways to partake more of the nature
of a course of lectures than a true text-book. In this it follows
French rather than English or American precedent. Its relation to
lectures makes it more diffuse than the author would have wished, but
this is offered as an explanation, not an excuse. Addressed to medical
students and not specialists the language employed is as untechnical
as possible, and, indeed, was meant as a rule to be such as young
physicians might use to their patients for suggestion purposes.

The historical portion is probably longer than some may deem
necessary. The place of psychotherapy in the past seemed so important,
however, and psychotherapeutics masqueraded under so many forms that
an historical résumé of its many phases appeared the best kind of an
introduction to a book which pleads for more extensive and more
deliberate use of psychotherapy in our time. The historical portion
was developed for the lectures on the history of medicine at Fordham
and perhaps that fact helps to account for the space allotted to this
section of the book.

So far as the author knows, this is the first time in the history of
medicine that an attempt has been made to write a text-book of the
whole subject of psychotherapy. We have had many applications of
psychotherapeutics to functional and organic nervous and mental
disease and also indirectly to nutritional diseases; but no one
apparently has attempted to systematize the application of
psychotherapeutic principles, not only to functional diseases, but
specifically to all the organic diseases. A chapter on the use of
mental influence in anesthesia was, during the course of the
preparation of this volume, written for Dr. Taylor Gwathmey's
text-book on Anesthesia, which is to appear shortly (Appletons).

No one knows better than the author how difficult is the subject and
how liable to misunderstanding and abuse. He appreciates well, too,
how almost hopeless it would be to make a perfectly satisfactory
text-book of so large a subject at the first attempt. The present
volume is founded, however, on considerable experience, on wide
reading in the subject, and on much reflection on its problems. It is
offered to those who are interested in the old new department of
psychotherapy until a better one is available. The author's principal
idea in the book has been to help students and practitioners of {viii}
medicine to care for (_curare_) suffering men and women and not cases,
to treat individual human beings, not compounds in which various
chemical, physical and biological qualities have been observed,
diligently enough and with noteworthy success, but incompletely as
yet, and quite without the satisfying adequacy which it is to be hoped
will result from future investigations.

  James J. Walsh.
  110 West Seventy-fourth Street,
  New York City.


{ix}

CONTENTS

                                                    PAGE
Introduction                                          1


HISTORY OF PSYCHOTHERAPEUTICS

SECTION I

      _Psychotherapy in the History of Medicine_

   I. Great Physicians in Psychotherapy                  7

  II. Unconscious Psychotherapeutics                    19

 III. Genuine Remedies and Suggestive Exaggeration      25

  IV. Signatures And Psychotherapy                      35

   V. Pseudo-science and Mental Healing                 38

  VI. Quackery and Mind Cures                           46

 VII. Nostrums and the Healing Power of Suggestion      53

VIII. Amulets, Talismans, Charms                        60

  IX. Deterrent Therapeutics                            63

   X. Influence of the Personality in Therapeutics      69

  XI. Faith Cures                                       77



GENERAL PSYCHOTHERAPEUTICS

SECTION II

_General Considerations_

   I. Influence of Mind on Body                         84

  II. Unfavorable Mental Influence                      93

 III. The Influence of Body on Mind                    100

  IV. The Mechanism of the Influence of Mind on Body   108

   V. Brain Cells and Mental Operations                124

  VI. Unconscious Cerebration                          134

 VII. Distant Mental Influence                         140

VIII. Secondary Personality                            147

  IX. Hypnotism                                        151



SECTION III

_The Individual Patient_

   I. Psychotherapy and the Individual Patient         163

  II. The Morning Hours                                165

 III. The Day's Work                                   171

  IV. The Middle of the Day                            179

   V. The Leisure Hours                                181

{x}

SECTION IV

_General Psychotherapeutics_

   I. General Principles of Psychotherapy              186

SECTION V

_Adjuvants and Disturbing Factors_

   I. Suggestion                                       194

  II. Exercise                                         198

 III. Position                                         207

  IV. Training                                         213

   V. Occupation of Mind                               218

  VI. Diversion of Mind--Hobbies                       224

 VII. Habit                                            229

VIII. Pain                                             235


SPECIAL PSYCHOTHERAPY

SECTION VI

_The Digestive Tract_

   I. Influence of Mind on Food Digestion              242

  II. Indigestion and Unfavorable States of Mind       250

 III. Psychic Treatment of Digestive Conditions        254

  IV. Appetite                                         262

   V. Constipation                                     268

  VI. Neurotic Intestinal Affections                   278

 VII. Muco-Membranous Colitis                          286

VIII. Obesity                                          290

  IX. Weight and Good Feeling                          297

   X. Vague Abdominal Discomforts--Loose Kidney       302


SECTION VII

_Cardiotherapy_

   I. The Heart and Mental Influence                   310

  II. Diagnosis and Prognosis in Heart Disease         316

 III. Cardiac Neuroses                                 321

  IV. Cardiac Palpitation and
      Gastro-Intestinal Disturbance                    328

   V. Angina Pectoris                                  335

  VI. Tachycardia                                      340

 VII. Bradycardia                                      342


SECTION VIII

_Respiratory Diseases_

   I. Coughs and Colds                                 345

  II. Tuberculosis                                     350

 III. Neurotic Asthma and Cognate Conditions           364

  IV. Dust Asthma--Seasonal Catarrh, Hay Fever         368

   V. Dyspnea--Cat and Horse Asthma                    373

{xi}

CONTENTS xi

SECTION IX

_Psychotherapy in the Joint and Muscular System_

   I. Painful Joint Conditions--Pseudo-Rheumatism      379

  II. Old Injuries and So-called Rheumatism            387

 III. Muscular Pains and Aches                         389

  IV. Occupation Muscle and Joint Pains                395

   V. Painful Arm and Trunk Conditions                 400

  VI. Lumbago and Sciatica                             402

 VII. Painful Knee Conditions                          409

VIII. Foot Troubles                                    413

  IX. Arthritis Deformans                              421

   X. Coccygodynia                                     428


SECTION X

_Gynecological Psychotherapy_

   I. Mental Healing in Gynecology                     430

  II. Psychic States in Menstruation                   434

 III. Amenorrhea                                       437

  IV. Dysmenorrhea                                     440

   V. Menorrhagia                                      447

  VI. The Menopause                                    450


SECTION XI

_Psychotherapy in Obstetrics_

   I. Suggestion in Obstetrics                         453

  II. Maternal Impressions                             461


SECTION XII

_Genito-Urinary Diseases_

   I. Prostatism                                       468

  II. Sexual Neuroses                                  472

 III. Sexual Habits                                    482


SECTION XIII

_Skin Diseases_

   I. Psychotherapy in Skin Diseases                   491


SECTION XIV

_Diseases of Ductless Glands_

   I. Diabetes                                         496

  II. Graves' Disease                                  500


{xii}

xii CONTENTS

SECTION XV

_Organic Nervous Diseases_

   I. Psychotherapy of Organic Nervous Diseases        508

  II. Cerebral Apoplexy                                513

 III. Locomotor Ataxia                                 524

  IV. Paresis                                          530

   V. Epilepsy and Pseudo-Epilepsy                     534

  VI. Paralysis Agitans                                542

 VII. Headache                                         546


SECTION XVI

_Neuroses_

   I. Nervous Weakness (Neurasthenia)                  555

  II. Chorea                                           561

 III. Tics                                             564

  IV. Stuttering, Ataxia in Talking,
      Walking, Writing, Etc.                           570

   V. Tremors                                          580


DISORDERS OF THE PSYCHE

SECTION XVII

_Psycho-Neuroses_

   I. Psycho-Neuroses (Hysteria)                       585


SECTION XVIII

_Disorders of Mind_

   I. Mental Incapacity (Psychasthenia)                597

  II. Hallucinations                                   603

 III. Dreads                                           612

  IV. Heredity                                         627

   V. Premonitions                                     634

 VI. Periodical Depression                             641

 VII. Insomnia                                         651

VIII. Some Troubles of Sleep                           663

  IX. Dreams                                           669

   X. Disorders of Memory                              678

  XI. Psychic Contagion                                688


SECTION XIX

_Disorders of Will_

   I. Alcoholism                                      694

  II. Drug Addictions                                  707

 III. Suicide                                          713

  IV. Grief                                            727

   V. Doubting                                         732

  VI. Responsibility and Will Power                    738


{xiii}

SECTION XX

_Psychotherapy in Surgery_

   I. Psychotherapy in Old-Time Surgery                746

  II. Mental Influence Before Operation                749

 III. Mental Influence and Anesthesia                  753

  IV. Mental Influence After Operation                 759


APPENDICES

   I. Illusions                                        766

  II. Religion and Psychotherapy                       776


INDEX                                                  781

{xiv}

{xv}

LIST OF ILLUSTRATIONS

FIG.                                                   PAGE

The Temple of Epidaurus as a health resort    Facing page 9

 1.--Expressions of the mouth                           102

 2.--Cortex of human brain illustrating complexity
     of the systems and plexuses of nerve fibers        109

 3.--Small and medium-sized pyramidal cells of the
     visual cortex of a child twenty days old           110

 4.--Series of sections showing the fine nerve
     endings and branchings of the first and second
     layer of the visual cortex of a child
     fifteen days old.                                  111

 5.--First, second and third layer of the anterior
     central convolution of the brain of a child
     one month old                                      112

 6.--Layers of the posterior central or ascending
     parietal convolution of a new-born child           112

 7.--Diagram of cells of cerebral cortex                113

 8.--Scheme of lower motor neuron                       114

 9.--Scheme of the visual conduction paths              115

10.--Schematic frontal section through the occipital
     lobe illustrating manifold connections in a
     single lobe                                        116

11.--Isolated cell from human spinal cord               117

12.--Neuron from the optic lobe of the embryo chick     118

13.--Deep layer of giant pyramidal cells of the
     posterior central or ascending parietal
     convolution of a child thirty days old             119

14.--Pyramidal cell of cerebral cortex of mouse         119

15.--Neuroglia cells of the fascia dentata, in the
     new-born rabbit                                    121

16.--Neuroglia cell from the subcortical layer of
     the cerebrum from which two processes go to a
     blood vessel                                       122

17.--Neuroglia cells from the spinal cord               122

18.--An artery from the cerebral cortex                 125

19.--Neuroglia cells of the superficial layers of
     the brain from an infant aged two months           126

20.--Complexity of cell of the central nervous system   131

21.--Section through the cortex of the
     gyrus occipitalis superior                         132

22.--Motor cell of ventral horn of spinal cord from
     the human fetus                                    133

23.--Normal diaphragm curve in normal breathing         577

24.--Curve in diaphragm before and during talking
     by a stutterer                                     577

25.--Illusion of dual vision                            615

26.--Illusion of dual vision                            767

27.--Binocular vision                                   767

28.--Binocular vision                                   767

29.--The Müller-Lyer lines                              768

30.--Illusions of size                                  769

31.--Illusion of filled space (interrupted vision)      769

32.--Illusions of size and linear continuity            770

33.--Poggendorf's displacement of oblique lines         771

34.--Zöllner's distortion of parallel lines             772



{1}


PSYCHOTHERAPY


INTRODUCTION

To physicians who are students not alone of the manifestations of
disease but also of the workings of human nature, there are few
chapters in the history of medicine more interesting than those which
record the welcome by each generation of the supposed advances in the
treatment of disease. Each generation announced its cures for
diseases, provided its remedies to relieve symptoms, and invented
methods of treatment that seemed to put off the inevitable tendency
toward dissolution. Yet few of these inventions and discoveries
maintain their early reputations, and succeeding generations
invariably abandon most of this supposed medical progress in favor of
ideas of their own, which later suffer a like fate. Plausible theories
have not been lacking to support the successive remedies and methods
of treatment, but the general acceptance of them was always founded
far less upon theory than upon actual observation of their supposed
efficacy. Certain remedies were given and the patients began to
improve. Patients who did not have the remedies continued to suffer,
and sometimes the course of their disease led to a fatal termination.
Even with the best remedies death sometimes took place, but that was
easily accounted for on the ground that the disease had secured so
firm a hold that it could not be dislodged, even by a good remedy. The
connection of cause and effect between the administration of the
remedy and the improvement and eventual cure of the patient seemed to
be demonstrated.

The archives of old-time medicine disprove the notion that clinical
learning and teaching--that is, observation and demonstration at the
bedside--were not part of medical education until quite modern times.
The medical books of the thirteenth, fourteenth and fifteenth
centuries are full of descriptions of actual cases, while, over a
millenium before, one of Martial's epigrams tells of a patient who
dreaded the coming of his physician because he brought with him so
many students, whose cold hands gave chills to the poor victim.



Coincidence and Consequence.--In spite of the opportunities for
careful observation thus afforded and the facilities for training
clinical observers in medicine, many remedies came into vogue, were
enthusiastically applied, and then, after a time, went out of use and
were heard of no more. Sometimes they were subsequently revived and
had even a greater vogue than when originally brought out. But most of
these remedies eventually went forever into the lumber room of disused
treatments. Of the many thousands of remedies which had the approval
and the praise of past generations, two score at most hold a place in
the pharmacopeia of to-day.

There are many reasons for this initial success and eventual failure;
but the most important explanation lies not so much in reason as in
coincidence. In the majority of human ills there is a definite
tendency to get better, and almost anything that is given to the
patient will be followed by relief and {2} improvement. The recovery
is not, however, on account of the remedy, but occurs only after a
definite succession of events that would have taken place either with
or without the remedy.


Mental Influence.--What the old physicians did not, as a rule,
appreciate, or at least failed to value at its true significance, was
the effect upon the patient's mind of the taking of a remedy. Because
of the confidence with which it was given, the patient, having full
faith in the physician who gave it, became impressed with the idea
that now he must get well. The very presence of the physician and his
assurance that the illness was not serious and that many symptoms that
were sources of dread to the patient were only concomitant conditions
of the ailment, naturally to be expected under the circumstances,
relieved the patient from worry, and so gave his nervous energy a
chance to exert itself in bringing about improvement. In other words,
the suggestive elements of the presence of the physician and the
taking of his remedy were important therapeutic factors which enabled
what was an absolutely inefficient remedy, as the event proved when
closer observations of it had been made, to relieve even serious
symptoms, or helped a weak remedy to accomplish good results by
strengthening the patient's resistive vitality.

In recent years we have come to study much more closely this
suggestive element and to appreciate better its true value. Suggestion
has always been an important factor in therapeutics, but has been used
indeliberately and indirectly rather than with careful forethought.
Not that the great thinkers in medicine have not known its value and
have not used it deliberately on appropriate occasions, but that the
profession generally has been so much occupied with the merely
material means of curing that practitioners have not realized the
influence for good of the psychotherapeutic factors they were
unconsciously employing.

The history of the phases of psychotherapy brings out clearly how much
it has always meant in the curing of human ills.


Constancy of Psychotherapy in Medicine.--Though we are prone to think
of it as coming to attention in our time, psychotherapy has played an
important role in every phase of the history of medicine. It has
always been at work, though usually under other names, and has been
effectively used without conscious direction. Germs and their
pernicious activity were not recognized before our time, yet many
definite precautions against them, such as cooking of food and the
keeping of perishable goods on ice, which now seem to be the direct
result of our knowledge of bacteriology, were commonly practiced. The
influence of the mind on the body exerted itself quite apart from
man's recognition of its place or appreciation of its power. When
employed unconsciously it was in many ways even more effective than it
will be when a consciousness of the means by which it is applied
becomes more general. For most people are unwilling to confess that
their minds exercise as much influence as now proves to be the case,
and that over-solicitude means so much in inhibiting the curative
powers of nature, and that it is this which is favorably affected by
psychotherapy.

The great physicians employed psychotherapy very commonly, and on that
account many of their disciples were inclined to think that they were
neglectful of medication and other remedial measures. At all times
physicians have had to be large-minded and have had to recognize the
limitations of medicine in {3} their own time, to turn to other agents
and to appreciate how much their own influence on the patient and that
of the patient on himself meant for the relief of symptoms and the
increase of resistive vitality.

Some of the phases of indeliberate psychotherapy, however, are even
more interesting than this chapter of the history of genuine and
deliberate psycho-therapeutics. Not a few of the remedies recommended,
even by distinguished physicians, were utterly inert, yet accomplished
good through their effect upon the patient's mind. If we were to omit
all reference to certain favorite prescriptions that passed down from
generation to generation, sometimes for centuries, yet eventually
proved to be quite inefficient for the purpose for which they were
employed, what a large lacuna would be left in the history of medical
treatment! Galen's _theriac_ is a typical example of this. Still more
strikingly the role of psychotherapy is seen in the many remedies that
were recommended at various times for such self-limited diseases as
erysipelas, ordinary coughs and colds, pneumonia and typhoid fever.
Anything that was administered just before the change for the better
came in these diseases, or that was persistently taken until that
change came, was proclaimed as curative.

An even more interesting chapter in the positive history of
psychotherapy is that which shows how the value of genuine remedies
was exaggerated by suggestion, and how these remedies became
therapeutic fads, and sometimes almost seemed to be cure-alls. What a
large place antimony holds in medical history, though it is now
entirely discredited! How beneficent has venesection seemed, though it
is now frankly confessed that it has but a narrow usefulness for a
very circumscribed set of ills! Calomel in large doses has a history
very like that of antimony. Alcohol in various forms, now so
strikingly losing its hold in therapeutics, must also be placed in
this category.

Psychotherapy has perhaps had its most fruitful field of potency in
connection with discoveries in the physical sciences. Whenever a
discovery has been made in any science, an application of it to
medicine has been mooted by some fertile mind, though as a rule it
eventually proved to have no place in medicine. One might ordinarily
expect that the suggestion would be latent only when the discovery was
in one of the sciences allied to medicine, but this relation has not
been necessary. Discoveries in astronomy even, in light, in
electricity, in every department of physical science, have each been
given their opportunity to affect patients' minds favorably, and have
succeeded.


Irregular Phases of Psychotherapy.--The quack has always been a
psycho-therapeutist _par excellence_. His main stock in trade has been
his knowledge of men and his power to convince them that he was able
to do them good, so that he could tap all the sources of energy that
were in the patient, some of them quite latent, yet of great
efficiency. Often what the quack and the nostrum vender did for their
patients was calculated to do harm rather than good, yet the mental
energy aroused by the appeal to the patients' minds was sufficient not
only to neutralize the evil, but to release curative powers that
otherwise would not have been called out. The advertisements of the
nostrum maker have proved especially effective, and printer's ink,
properly administered, has been a most potent remedy.


Drug Therapeutics.--Many of the newer phases of mental healing pretend
to do away with drugs. Nothing is farther from my purpose than to
condemn drugs: I am simply pointing out how much supposed drug
efficacy has been {4} due to the mental influence on the patient of
the suggestion that went with the drugs. There has been no thought at
all of pushing drugs out of the extremely valuable place they occupy
in medicine, for I yield to no one in my thorough conviction of their
usefulness. But the efficacious element in the administration of many
drugs has been entirely the confidence of the physician in them, which
confidence was communicated to the patient's mind. Undoubtedly many
highly recommended drugs have in themselves tended to do harm rather
than good, and have been useful only because of this
psycho-therapeutic element. Dr. Oliver Wendell Holmes' famous
expression, that if all the drugs that had ever been used had been
thrown into the sea instead of put into patients' bodies the human
race might have been the better for it, should not be taken to mean
that a great many drugs are not efficacious. Above all, it leaves out
the most important consideration, that patients, while taking drugs
that are either inert or at times even slightly harmful, have had
their mental attitude towards themselves and their ills so favorably
modified by the repeated suggestion that the result has been
distinctly beneficial.

There are probably two score of drugs that are simply
invaluable--magnificent auxiliaries in times of physical and mental
distress. To realize and appreciate the place of these drugs, their
limitations, how they should be administered, and what they can do
under varying circumstances, has taken us centuries. When to these
drugs there is intelligently attached the influence that psychotherapy
has over the patient, their efficacy is probably doubled. Without that
influence nature often works against the drug and lowers its
efficiency. That is the reason why physicians, when themselves
patients, do not respond well to drugs. Familiarity has bred contempt
for some of the old-fashioned remedies, but the contempt that comes
from familiarity is often quite undeserved, and many of the things
that we thus undervalue because of accustomedness have a power that
should be respected. People in a dynamite factory become so familiar
with danger as to despise it at times, but that does not lessen the
energy of the dynamite when occasion arises. When the physician
himself is ill he is likely to remember his failures with drugs rather
than his successes. That is, however, only the tendency of human
nature to a certain pessimistic outlook where we ourselves are
concerned.

There is another class in whom familiarity with drugs has become a
serious matter. They are the patients who have made the rounds of
physicians, have learned to read prescriptions, have looked up the
significance of the various remedies that they have seen prescribed,
have heard doctors talk about them, and remember only what is
depreciatory, and who critically examine a prescription and conclude
that the remedies recommended are not likely to do them good. Every
physician knows the hopeless condition such patients are in. Mental
attitude will greatly help drugs, and it can utterly undo the effect
of all drugs except those which have certain drastic mechanical
effects. Drug failure in these cases is another illustration of how
much psychotherapy means in connection with drug treatment.

Not only is there no intent, then, to lessen respect for drugs in this
textbook of psychotherapeutics, but the one thing that the author
would like to emphasize is the necessity for giving drugs in
sufficient doses. Recommendations in text-books of medicine are often
vague in their indications as to dosage, and surprisingly small doses
are, in consequence, sometimes prescribed. {5} Practically the only
remedial element of such small doses is the mental effect on the
patient, whereas a combination of pharmaceutic and psychotherapeutic
factors would be much more efficacious. It is not unusual to find that
the patient who is supposed to be taking nux vomica as an appetizer or
a muscle tonic, or in order to produce heart equilibrium in the
cardiac neuroses, is getting five drops, two and a half minims, three
times a day, when he should be getting at least twenty drops with the
same frequency. I have known a physician to prescribe ten grains of
bromid where thirty to sixty grains should have been prescribed, and
such valuable pharmaceutic materials as bismuth and pepsin are often
given in doses so small that they preclude all possibility of benefit
except by mental influence.

With therapeutic nihilism or skepticism of the power of drugs I have
no sympathy. As a teacher of medicine I have for years emphasized the
necessity of the use not of conventional doses of drugs for every
patient, but of doses proportioned to the body weight. It seems to me
quite absurd to give the same amount of a drug to a woman who weighs a
hundred pounds and to a man who weighs two hundred and fifty pounds of
solid muscular tissue. I believe in using drugs well up to their
physiological effects if the drugs are really indicated.

With regard to other modes of treatment the same thing is true. Where
they are indicated, balneo-therapy, hydro-therapy, mechano-therapy,
electro-therapy, massage, and all the forms of external treatment,
should be used rationally and not merely conventionally. The
individual and not his affection must be treated. In all of these
methods there is a psychotherapeutic element, and for the benefit of
the patient this, too, must be recognized and used to its fullest
extent.


Supposed Novelties in Mind Healing.--We hear much of mental healing,
of absent treatment, of various phases of suggestion, and of the
marvelous therapeutic efficiency of complete denial of the existence
of evil, and sometimes we wonder whether all these things are not
offshoots of our recent growth in the knowledge of psychology. It is
possible, however, to find, masquerading under the head of the
efficacy of nostrums in the past, the equivalents for all the
activities of mental healing of the present. It all depends on what is
the scientific fad of the hour. If it is electricity, then some mode
of electrical treatment serves the purpose of suggesting cure, and
relief of symptoms follows. If drug treatment of any particular kind
is attracting much attention, then the suggestion is most effective
that is founded on this basis. Perkins' tractors or the Leyden jar are
effective at one time, radium or the X-rays at another, sarsaparilla
or dilute alcohol at another, while a generation that is much
interested in psychology may find, as ours does to a noteworthy
degree, quite sufficient favorable suggestion for the cure of many
ills in purely psychic influences, either direct or indirect,
deliberate or unconscious.

Men and women do not change, their ills are about the same, and except
for certain definite scientific remedies it is only the superficial
mode of treatment that differs very much. Psychotherapy has always
been an important element in most of the therapeutics of history. With
so much accomplished in the past by indirection, there can be no doubt
but that important advances in psychotherapeutics must result from the
extension of its deliberate use.

We have not yet reached a point in our knowledge of the mode of the
{6} influence of the mind on the body that will enable us to treat
this large subject in a scientific manner. What has been written is
set down rather as suggestive than conclusive. There is almost nothing
that the human mind cannot do, its power ranging from the ability to
delay death for hours or even days to causing sudden or unlooked for
death under strong emotional strain. But we are as yet without
definite data as to the possibilities of the immense power for good,
and also for ill, that lie unrevealed in this domain. Anything that
makes for observations by a large body of trained observers in a large
number of cases will almost surely serve to bring about a development
of this subject of valuable practical application.

Psychotherapy is open to large abuse. It will happen that men who are
not trained in diagnosis will occasionally try to use
psychotherapeutic means when what is needed is the knife, the actual
cautery, a good purge, some strong drug, or other efficient remedy
whose value has been demonstrated and which any trained physician can
use. It will also happen that men who lack tact will occasionally
disturb patients' minds still further by what they say to them in a
mistaken attempt at psychotherapy, and will sometimes suggest other
symptoms and make sufferers worse by their clumsy attempts to remove
symptoms that are already present. Every good thing, however, is open
to the same objection. Even good food is abused. The use of drugs has
been so abused that the abuse has done much to discredit medicine at
many periods. There is a Latin proverb which says: "From the abuse of
a thing no argument against its use can be drawn." We cannot prevent
liability to abuse, and psychotherapy is sure to meet that fate. It
has been abused in the past, and is abused now, and always will be
abused, but formal study of psychotherapy and its deliberate
employment will do more than anything else to limit the inevitable
abuse.

If its place in history and in medicine is definitely set forth, its
problems squarely faced and their solutions definitely suggested, it
is much less likely to be misused. At least, then, the whole subject
is open for free and frank discussion and for such additions and
subtractions as may make this department of therapeutics as important,
or at least in a measure as valuable, as climato-therapy or
balneo-therapy or mechano-therapy or electro-therapy. The development
of each of these subjects has proved helpful. It is true that each
specialist has, in the eyes of his colleagues in general practice,
exaggerated the significance of his own department. This is true in
all specialties, however, and psychotherapy deserves quite as much as
any of the subjects we have mentioned to have a place among the
text-books of medicine; and so this one is committed to the judgment
of clinical observers. Long ago Horace said:

  Si quid novisti rectius his candidus imperti
  Si non his utere mecum.


{7}

HISTORY OF PSYCHOTHERAPEUTICS

SECTION I

_PSYCHOTHERAPY IN THE HISTORY OP MEDICINE_


CHAPTER I

GREAT PHYSICIANS IN PSYCHOTHERAPY


"The real physician is the one who cures: the observation which does
not touch the art of healing is not that of a physician, it is that of
a naturalist."


Psychotherapy is as old as the history of medicine and may be traced
to the earliest ages. The great physicians of all time have recognized
its value, have used it themselves and commended its use to their
disciples, though realizing its mysterious side and appreciating its
limitations.


FIRST PHYSICIAN

The first physician of whom we have any record was I-em-Hetep, who
lived in the reign of King Tcsher of the third dynasty of Egypt,
probably before 4000 B. C. Among his titles, besides that of Master of
Secrets, was Bringer of Peace. He was looked up to as one who, when
not able to cure physical ailments, did succeed in consoling and
reassuring patients so as to make their condition much more bearable.
Like others of the great early physicians, he was after his death
worshiped as a god, a tribute which probably signifies that those who
had been benefited by his ministrations felt that he must have been
more than mortal.

The extent of the Egyptians' admiration for him will be appreciated
from the fact that the step pyramid at Sakkara is said to have been
built in his honor, though, as a rule, pyramids were erected only to
honor kings or the very highest nobility. The extant statue of
I-em-Hetep shows a placid-looking man with an air of beneficent
wisdom, seated with a scroll on his knees. It produces the distinct
impression, as may be seen from the illustration, that his patients
must have trusted him thoroughly, since this is the memory of his
personality that was transmitted to posterity. While he came to be
looked upon as the medical divinity of the Egyptians, he was never
represented with a beard, which is the token of the gods, or of
mortals who have been really apotheosized. Evidently his devotees felt
that it was the divine in his humanity which was the most prominent
feature that they wished to honor. Among the Greeks AEsculapius, who
had been merely a successful physician, came to be honored as a deity.
When we recall the condition of therapeutics at that {8} time, it is
evident that man's appreciation of his power to console, even though
he might not be able to heal, of his influence over men's minds in the
midst of their sufferings, and the confidence that his presence
inspired, were the real sources of their grateful recognition.


PSYCHOTHERAPY IN EGYPT

Among the Egyptians the first great development of medicine came among
the priests. The two professions, the medical and priesthood, were
one, and the temples were the hospitals of the time. We have stories
of people traveling long distances to certain temples in the early
days of Egypt and also of Greece. Often the sick slept in the temples
and dreamed of ways by which they would be cured. The stories make one
feel that somehow the sleep which came over them was not entirely
natural and spontaneous, but must have been something like hypnotic
sleep. As for the dreams, the suggestions of modern time given in the
hypnotic condition seem to be the best indication that we have of what
happened in those old days. Certain it is that the persuasion of the
patient that he would get better, the influence of the diversion of
mind consequent upon his journey and the regulation of life under new
circumstances in the temple, with the repeated suggestions of the
priests and of their various remedial measures, as well as those due
to the fact that other patients around him were improving, all plainly
show the place of psychotherapy at this time.

Much of the old-time therapy was in association with dreams supposed
to have been in some way inspired. This was true at Epidaurus, at Kos,
at Rome, at Lebene, at Athens, and at every place we know of where
cures were worked in the olden times. To the modern mind it seems
impossible that dreams should come so apropos unless they were in some
way directed. The only explanation seems to be the use of suggestion,
with the probable production of sleep resembling our modern hypnotic
trance. Apparently the patient's attention was little directed to the
origin of the suggestions received, but he remembered and benefited by
them.

The most explicit testimony that we have to the antiquity of
psychotherapeutics and to the employment of the influence of the minds
of patients over their ailments in the olden time is in Pinel's
"Nosographie philosophique" and in his "Traité médico-philosophique
sur l'alienation mentale."

Pinel himself will be remembered as the great French psychiatrist who,
confident that he could control most of them by mental influence,
first dared to strike the chains from the insane in the asylums of
Paris, at the end of the eighteenth century, when for more than a
century they had been treated more barbarously than ever before in
history. The passage makes clear that the writer himself, over a
hundred years ago, was persuaded of the significance of the patient's
mental attitude and of the value of mental treatment for many nervous
and mental diseases:

  An intimate acquaintance with human nature and with the character in
  general of melancholics must always point out the urgent necessity  of
  forcibly agitating the system, of interrupting the chain of their
  gloomy ideas, and of engaging their interest by powerful and
  continuous impressions on their external senses. Wise regulations of
  this nature are considered as having constituted in part the
  celebrity and utility of the priesthood of ancient Egypt. Efforts of
  industry and of art, scenes of magnificence and of grandeur, the
  varied pleasures of sense, and
{9}
the imposing influences of a pompous and mysterious superstition, were
perhaps never devoted to a more laudable purpose. At both extremities
of ancient Egypt, a country which was at that time exceedingly
populous and flourishing, were temples dedicated to Saturn, whither
melancholics resorted in crowds in quest of relief. The priests,
taking advantage of their credulous confidence, ascribed to miraculous
powers the effects of natural means exclusively. Games and recreations
of all kinds were instituted in these temples. Beautiful paintings and
images were everywhere exposed to public view. The most enchanting
songs, and sounds the most melodious "took prisoner the captive
sense." Flowery gardens and groves, disposed with taste and art,
invited them to refreshment and salubrious exercise. Gaily decorated
boats sometimes transported them to breathe, amidst rural concerts,
the pure breezes of the Nile. Sometimes they were conveyed to its
verdant Isles, where, under the symbols of some guardian deity, new
and ingeniously contrived entertainments were prepared for their
reception. Every moment was devoted to some pleasurable occupation, or
rather a system of diversified amusements, enhanced and sanctioned by
superstition. An appropriate and scrupulously observed regimen,
repeated excursions to the holy places, preconcerted fêtes at
different stages to excite and keep up their interest on the road,
with every other advantage of a similar nature that the experienced
priesthood could invent or command, were, in no small degree,
calculated to suspend the influence of pain, to calm the inquietudes
of a morbid mind, and to operate salutary changes in the various
functions of the system.

  [Illustration: The Temple at Epidaurus as a Health Resort]

  This gives some slight idea of the magnificent arrangement of this
  famous health resort of the Greeks in which every possible care was
  taken to influence the mind of the patient favorably and bring about
  his cure. The buildings of the Hieron or medical institution of
  Epidaurus were beautifully situated about six miles from the town of
  Epidaurus in picturesque scenery and the most healthful
  surroundings. There were a series of bathing houses for hydropathy.
  The abatons, lofty and airy sleeping chambers with their southern
  sides and open colonnade, are singularly like the open balconies of
  our tuberculosis sanatoria. Every occupation of mind was provided.
  There was a theatre that would seat over 10,000 people. Here the
  great classic Greek plays were given with fullest effect. There was
  a stadium seating about 12,000 people in which athletic events were
  witnessed, finally there was a hippodrome for alt sorts of
  amusements in which animals shared. Then there were the walks
  through the country, sheltered paths around the grounds for
  inclement weather, even tunnels for passage from one building to
  another and all the influence of religion, of suggestion, of contact
  with cultured priests thoroughly accustomed to dealing with all
  manner of patients. No wonder the place was popular and many cures
  effected.

  A, South Propylaea; B, Gymnasium; C, Temple of Esculapius; DD, East
  and West Abatons (temple enclosures); E, Pholos;  F, Temple of
  Artemis; G, Grove; H, Small Altar; I, Large Alter; J, South
  Boundary; K, Square (building); L, Baths of Esculapius; M, Gymnasium
  and Hostel; N, Four Quadrangles (for promenade and exercise); O,
  Roman Building; P, Roman Bath; Q, Portico of Cotys; R, Northeastern
  Colonnade; S, Northeastern Quadrangle; T, Temple of Aphrodite (?);
  U, Northern Propylaea, on the Road to Epidaurus; V, Roman Building;
  W, Northern Boundary; X, Stadium; Y, Goal or Starting Line; Z, Tunnel
  between Temple and Stadium. (Caton.)

  [End Illustration]


There are other phases of Egyptian medicine which serve to show us how
early many of the psychological ideas that we now are trying to adopt
and adapt in medicine had come to the thinkers in medicine of long
ago. There is, for instance, now in the Berlin museum an interesting
papyrus of the Middle Kingdom, the date of which is about 2500 B. C,
in which there are many modern ideas. It is a dialogue which attempts
the justification of suicide. The principal speaker, a man weary of
life, has made up his mind to suicide, but is hesitant. The others who
speak in the dialogue are his _secondary personalities_. The Egyptians
considered that there were several of these interior persons with whom
the man himself might have communication. A man could play draughts
with his _ba_ somewhat as we play solitaire. He could talk to and
exchange gifts with his _ka_. He could argue and remain at variance,
but more often come to an agreement, with his _khou_. This last was
his luminous immortal _ego_, which, according to the then generally
received Egyptian conception, formed a complete and independent
personality. The whole scene thus outlined is typically modern in
certain phases of its psychology, and presents the only known
treatment for the tendency to suicide. While we have but this
instance, there seems no doubt that the same system of persuasion must
have been employed for the cure of other mental conditions than that
which predisposes to suicide.

What is described in our quotation from Pinel as the most ancient form
of psychotherapy has all down the centuries been the rule of life for
patients at institutions similar to those of Egypt. We know more of
Greece than of other countries; there the shrines of AEsculapius were
in many ways what we now call sanatoria. They were spacious buildings
pleasantly situated, the hours of rising and of rest were definitely
regulated, the patients' minds were occupied with the details of the
cure, they met pleasant companions from distant places, they had all
the advantages of diversion of mind, simple diet, long hours in the
open air and abundance of rest away from the ordinary worries of life.
Besides, there had usually been some weeks or months of {10}
preparation during a lengthy journey and all the diversion of mind
which that implies. No wonder that these institutions acquired a
reputation for cures of symptoms which the physician had been unable
to accomplish while the patient was at home in the midst of his daily
cares and worries of life.

The temples in Egypt, in Assyria, in Greece, were much like the health
institutions--"cure houses," as the expressive German phrase calls
them--of our day. Pictures of the temple of AEsculapius at Epidaurus
show a magnificent building with beautiful grounds, ample bathing
facilities, and evidently many opportunities for a quiet, easy life
far from the worries and bustle of the world and with everything that
would suggest to the patient that he must get well. This phase of
psychotherapy in the olden time is not only interesting in itself, but
furnishes a valuable commentary on corresponding modern institutions,
since it shows that it is not so much the physical influences, which
have differed markedly at different periods, as the mental attitude so
constantly influenced at these institutions which was the real
therapeutic factor.

Now our sanatoria are nearly all founded on some special principle of
therapeutics. Some of them have dietetic fads and no food out of which
the life has been cooked is eaten. Some of them are absolutely
vegetarian. Some of them depend on wonderful springs in their
neighborhoods, others on certain forms of exercise, still others give
the rest cure. All succeed in relieving many symptoms. No one who has
analyzed the cures effected will think for a moment that it is the
special therapeutic fad of the institution that accomplishes all the
good done for patients suffering from so many different complaints.
Similar ills often are affected quite differently, and, while some are
relieved, others are not. Those who fail to be cured at one will,
however, often be relieved at another. It depends on how much
influence of mind is secured over the patient and how much diversion
from thoughts of self is provided.


MIND HEALING IN GREECE

When Greece awoke to the great literary and scientific discussion of
human thought that gave us such philosophic and scientific thinkers as
Hippocrates, Plato and Aristotle, then psychotherapy, in the formal
sense of caring for the mind of the patient as well as for his body,
came to be explicitly recognized as having therapeutic value.
Hippocrates insisted that medicine was an art rather than a science,
that personality had much to do with it, and that the patient must be
optimistically influenced in every way. The first of his aphorisms is
well known, but few realize all of its significance. Hippocrates
declares that "life is short and art long, the occasion fleeting,
experience fallacious and judgment difficult. The physician must not
only be prepared to do what is right himself, _but also to make the
patient, the attendants and externals coöperate."_ No one emphasized
more than he the necessity for differentiating the individual patient,
and to him we owe, in foundation at least, the aphorism that it is
more important to know what sort of an individual has a disease than
what sort of a disease the individual has, for the chances of cure
greatly depend on favorable individuality.

Perhaps Hippocrates' most striking direct contribution to
psychotherapy is his aphorism with regard to pain. He said: "Of two
pains occurring together in different parts of the body, the stronger
weakens the other." When {11} the attention is distracted from pain,
then it is lessened. Of two pains, then, only the one that attracts
the most attention is much felt, and, if a slight pain is succeeded by
a severe pain in another part of the body, the lesser pain will
apparently become trivial, or, indeed, not be felt at all.

In Plato we find the direct philosophic expression of the value of
psychotherapy. There had been during the preceding century a great
increase in information with regard to the facts of physical nature,
and especially the sciences relating to the human body, and so men had
come, as they are prone to at such eras--our own, for instance--to
think too much of the body and too little of the mind that rules it.
Accordingly, we have from Plato a deliberate, emphatic assertion of
this great truth under circumstances which make us realize how keenly
he appreciated its significance for the art of medicine and for
humanity.

Professor Osier, in his address, "Physic and Physicians as Depicted in
Plato," [Footnote 1] tells a story which shows clearly how much the
great Greek philosopher appreciated the place of psychotherapy.

  [Footnote 1: "AEquanimitas and Other Addresses."]

  Charmides had been complaining of a headache, and Critias had asked
  Socrates to make believe that he could cure him of it. Socrates said
  that he had a charm which he had learnt, when serving with the army,
  of one of the physicians of the Thracian king. Zamolxis. This
  physician had told Socrates that the cure of a part should not be
  attempted without treatment of the whole, and, also, that no attempt
  should be made to cure the body without the soul, "and, therefore, if
  the head and body are to be well, you must begin by curing the mind;
  that is the first thing. And he who taught me the cure and the charm
  added a special direction. 'Let no one,' he said, 'persuade you to
  cure the head until he has first given you his soul to be cured. _For
  this,'_ he said, _'is the great error of our day in the treatment of
  the human body, that physicians separate the soul from the body._'"

Because it anticipates so much that is thought to be recent in the
treatment of certain affections this paragraph is interesting from
many standpoints. Headache is typically one of the ills that in the
modern time has often been cured by suggestion. Critias knew how much
confidence Charmides had in Socrates, whom he looked upon as his
master, and that, therefore, Socrates' declaration of his power to
cure would probably be sufficient to relieve his disciple. Critias
shrewdly suggests, however, that Socrates possessed a charm which he
had learned from a distinguished royal physician. Cures in the modern
time of any kind are likely to be much more effective if they come
from a distance and, above all, if they have some connection with
royalty, or have been tried with favorable results upon distinguished
personages.


ALEXANDRIAN PSYCHOTHERAPY

When the center of interest in Greek medicine was transferred from
Greece itself to Egypt, and the Alexandrian school represented what
was best in medical thinking and investigation, we find evidence once
more of wise physicians realizing the influence of the mind on the
body and of what seemed to physicians of lesser experience the cure of
physical ills by mental means. One of the most distinguished
physicians of all time is Erasistratos, who, with Herophilus, made the
fame of the great medical school at Alexandria, {12} the first
university medical school in the world's history. Both practiced
dissection with assiduity, and, while it is Herophilus' name that is
associated with the _torcular_ within the skull, and it was he who
gave the name _calamus scriptorius_ to certain appearances in the
fourth ventricle, and otherwise stamped his personality on the study
of the brain, it is to Erasistratos that we have to turn for a typical
example of the mental physician. Erasistratos, about 300 B. C,
recognized the valves of the heart, gave them the names tricuspid and
sigmoid, and, like his great colleague, studied particularly the
nervous system. He seems to have distinguished the nerves of motion
from those of sensation, recognized their different functions and the
different directions in which they carried impulses, and thought the
brain the most important organ in the body.

The story is told that he was summoned in consultation to see the son
of Seleukos, surnamed Nikator, the Macedonian general of Alexander the
Great, who became ruler of Babylonia. The illness of this son,
Antiochos, had baffled the skill of the court physicians. While
Erasistratos was feeling his patient's pulse, the stepmother of the
young prince entered the room. She, the second wife of his father, was
young and handsome, and Erasistratos noted that there was great
perturbation of the pulse as soon as the stepmother came in. He
correctly surmised that the young man was in love with the lady and
that his illness had been occasioned by the feeling that his love was
hopeless. The very sharing of his secret seems to have started the
young man's cure, and Erasistratos' wisdom and medical skill became a
proverb throughout the East.


PSYCHOTHERAPY AT ROME

Galen.--Galen, whom we are prone to think of as a Latin because so
much of his work was done at Rome, but whose works have come to us in
Greek, and who was a disciple of the Greek school of medicine, brought
up under Greek influence in his native town of Pergamos, re-echoed
Hippocrates' expressions as to the necessity for securing the
patient's confidence and setting his mind at ease. The story in the
"Arabian Nights" of his experience with the quack, which is known to
most people, shows clearly how the place of mental influence in the
relief of human ills must have been brought home to him. For nearly
fifteen centuries his works continued to be the most read of medical
documents. Nine tenths of all the physicians of education and
influence, confidently looking to him as their master, kept copies of
his works constantly near them, and turned to them for medical
guidance as they would to the Bible for spiritual aid.

The book of Galen which is usually placed first among his collected
works shows how much more important is the mind than the body for
human happiness, and insists on mental interests as making life worth
while. In it he describes the good physician, and says that to be a
good physician a man must also be a good philosopher. When he comes to
talk of the different sects in medicine--for even in his time there
were groups of men who founded their medical practice on very
different principles--he points out that the members of the different
medical sects, while all employing practically the same remedies, do
so on quite different principles, and yet get about the same {13}
results. This concept comes as near to being a conscious reflection as
to the place that the patient's mental reaction had in therapeutics as
might well be expected at that early date.


Alexander of Tralles.--After Galen, medicine suffered an eclipse
because the Romans became too devoted to luxury to permit of its
development, and later the descent of the barbarians from the North
disturbed silence and culture. In spite of the disturbance, however,
there is evidence during the succeeding centuries of the deliberate
use of mental influence and even of direct suggestion in the cure of
disease.

Alexander of Tralles (sixth century A. D.) was not judiciously
critical in his selection of remedies. Often he has quite ridiculous
therapeutic suggestions, and yet we have at least two stories with
regard to him which clearly indicate his employment of mental
influence. One of his patients is said to have been suffering from the
delusion that his head had been cut off by order of the tyrant, but he
was cured as soon as the doctor hit on the interesting expedient of
making him wear a leaden hat, which eradicated his delusion and made
him think his head had been restored.

It is also in Alexander Trallianus, as he is sometimes called, that we
have the original of the story which has been often told, many writers
giving it as an experience of their own. A woman was sure that she had
swallowed a snake, and that it continued to exist in her stomach,
devouring much of her food and causing acute pain whenever large
quantities of food were not provided for it. All sorts of remedies had
been tried without result. At last Alexander gave her an emetic and
then slipped into the basin into which she was vomiting a snake
resembling as closely as possible that which she thought she had
swallowed. The ruse effected a complete cure. Usually in latter-day
variants of this story the cure is only temporary, for the patient
after a time has the same symptoms as before and then is sure that
during the time of its residence in the stomach the snake has given
birth to young.


Paul of AEgina.--In the seventh century Paul of AEgina collected all
that had been written on insanity by physicians of olden times, and
many of his directions and prescriptions for treatment show that he
appreciated the value of mental influence. He recommends that those
who are suffering from mental disease should be placed in a quiet
institution, should be given baths, and that an important portion of
the treatment should consist of mental recreations.


ARABIAN MENTAL MEDICINE

The Arabian physicians who succeeded to the traditions of Greek
medicine preserved also those relating to psychotherapy. Rhazes, the
first of the great Arabian physicians, has a number of aphorisms that
show his interest in and recognition of the value of mental healing.
He insisted that "doctors ought to console their patients even though
the signs of death are impending. For the bodies of men follow their
spirits." He believed that the most important function of the
physician was "to strengthen the natural vitality for, if you add to
that you will remove a great many ills, but if you lessen it by the
drugs which you employ you add to the patient's danger." "Truth in
medicine," he said, "is a goal which cannot be absolutely reached, and
the art of {14} healing, as it is described in books, is far beneath
the practical experience of a skillful, thoughtful physician."
Manifestly he realized the importance of the influence of the
physician over the individual patient.

His greatest successor among the Arab physicians, Avicenna (eleventh
century), "the Hippocrates and the Galen of the Arabians," as Whewell
called him, has some striking tributes to what he recognized as the
influence of the mind on the body. He appreciated that not only might
the mind heal or injure its own body, but that it might influence
other bodies, through their minds, for weal or woe. He says: "The
imagination of man can act not only on his own body, but even on other
and very distinct bodies. It can fascinate and modify them, make them
ill or restore them to health." In this, of course, he is yielding to
the dominant mystical belief that man can work harm to others, which
subsequently, under the name of witchcraft, came to occupy so
prominent a place for ill in European history. But at the same time it
is evident that his opinions are founded on his knowledge of the
influence of mind on body, as he had seen its action in medicine. From
him we have the expression: "At times the confidence of the patient in
the physician has more influence over the disease than the medicine
given for it."


MEDIEVAL MIND-HEALING

During the Middle Ages faith was one of the things most frequently
appealed to, and even the physicians made use of religious belief to
secure a favorable attitude of the patient's mind toward the remedies.
One of the men who particularly realized the importance of this was
Mondeville, the great French surgeon.

Pagel has called attention to Mondeville's insistence on preparing the
patient's mind properly for venesection. The patient should be made to
feel that this procedure was sure to do him good, and various reasons
should be given him why the removal of a certain amount of blood
carried with it poisons from the body, and so gave a better
opportunity to nature to conquer the disease. If the patients were
unfavorably disposed towards venesection, Mondeville thought that it
should not be performed, as it was not likely to do good. It was not
that he felt that the mental influence was the more important of the
two therapeutic factors, but that a combination of the remedial force
of blood-letting with a favorable state of the patient's mind meant so
much more than could be accomplished by venesection alone that it was
worth while to take pains to have the combination of the two. We in
modern times realize that in most cases blood-letting rather did
physical harm than good. It continued to hold a place in medicine
because patients were so much impressed by it that they were given
renewed vigor after its use.


MENTAL HEALING IN THE RENAISSANCE

What is exemplified in medieval medicine in this matter remains true
during the Renaissance. In the fifteenth century Petrus Pomponatius,
well known as a thinker and writer on borderland subjects related to
medicine, came to the conclusion that men might very well be cured of
certain ailments {15} by influence from the minds of others, and that
such treatment, undertaken by physicians appropriately endowed,
produced wonderful effects. He said:

  Some men are specially endowed with eminently curative faculties;
  the effects produced by their touch are wonderful: but even touch is
  not always necessary; their glances, their mere intention of doing
  good are efficient for the restoration of health. The results,
  however, are due to natural causes.


PSYCHOTHERAPY AND MODERN MEDICINE

Paracelsus.--Paracelsus, the great physician of the first half of the
sixteenth century, who may well be considered the father of modern
pharmaceutics, had no illusions with regard to the exclusive power of
drugs over disease. He recognized that mental influence was extremely
important, and often lent a power not otherwise possessed to many
remedies. He said:

  Imagination and faith can cause and remove diseases. Confidence in
  the virtue of amulets is the whole secret of their efficacy. It is
  from faith that imagination draws its power. Anyone who believes in
  the secret resources of Nature receives from Nature according to his
  own faith; let the object of your faith be real or imaginary, you
  will in an equal degree obtain the same results.

Personal magnetism, in the sense in which we now use it, a
transference of the idea from the science of magnetics as related to
the phenomena of the magnet, seems to have originated with Paracelsus.
He was sure that the influence exerted over certain patients by
certain physicians was due to a force very like that exerted by the
magnet over iron. He was even inclined to think that magnets
themselves might exert a strong potency over diseased conditions, and
he found them to be useful in epilepsy. Doubtless in many cases of
supposed epilepsy successfully treated the ailment was really of an
hysterical nature. In these cases the strong suggestion which the use
of the magnets gave for many centuries acted favorably.


Agrippa.--The writings of Cornelius Agrippa, a contemporary of
Paracelsus, and, like him, a student of alchemy and of the secrets of
nature, contain corresponding passages which serve to show how much of
interest there was in mental influence during the Renaissance. All of
these men were, of course, a little outside of the ordinary medical
tradition, intent on getting to realities, not being satisfied either
with words or assumptions, refusing to accept many thing that the
physicians of their time completely credited. Agrippa in a
characteristic passage said:

  Our mind doth effect divers things by faith (which is a firm
  adhesion, a fixed intention, and a vehement application of the
  worker or receiver) in him that coöperates in anything, and gives
  power to the work which we intend to do. So that there is made in
  us, as it were, the image of the virtue to be received, and the
  thing to be done in us, or by us. We must, therefore, in every work
  and application of things, affect vehemently, imagine, hope and
  believe strongly, for that will be a great help.


Van Helmont.--At the end of the sixteenth century Van Helmont, who
carried on the work in pharmaceutics begun by Paracelsus, and to whom
we owe the discovery of a number of substances commonly used, as well
as the invention of the word "gas," was a thorough believer in the
influence of mind over body and, indeed, in the existence in human
beings of storehouses {16} of latent energy ordinarily unemployed, but
that might under special circumstances be tapped to produce wonderful
effects. Indeed, some passages remind us of Prof. James' expressions
in his discussion of the law of human energy. Van Helmont said:

  All magical power lies dormant in man, and requires to be excited.
  (Compare Prof. James's "Law of Mental Energy" in the chapter on
  Mental Influence). This (need for excitation) is particularly the
  case if the subject upon whom we wish to operate is not in the
  most favorable disposition; if his internal imagination does not
  abandon itself entirely to the impression we wish to make upon him;
  or if he towards whom the action is directed possesses more energy
  than he who operates. But when the patient is well disposed or
  weak, he readily yields to the magnetic influence of him who
  operates upon him through the medium of his imagination. In order to
  operate powerfully, it is necessary to employ some medium; but this
  medium is nothing unless accompanied by internal action.


Sydenham.--In the more modern period the deliberate use of the
influence of the mind on the body is quite as clear. Undoubtedly the
greatest of modern physicians, who well deserves the name of the
English Hippocrates, is Sydenham. How much Sydenham realized that many
of his patients' ailments could only be cured by occupying their minds
with other things is seen in his writings. There is a characteristic
story told by Dr. Paris in his "Pharmacologia" which illustrates this
well and is a striking anticipation of what we are prone to think of
as very modern views in these matters:

  This great physician, Sydenham, having long attended a gentleman of
  fortune with little or no advantage, frankly avowed his inability to
  render him any further service, at the same time adding, that there
  was a physician of the name of Robertson, at Inverness, who had
  distinguished himself by the performance of many remarkable cures of
  the same complaint as that under which his patient labored, and
  expressing a conviction that, if he applied to him, he would come
  back cured. This was too encouraging a proposal to be rejected; the
  gentleman received from Sydenham a statement of his case, with the
  necessary letter of introduction, and proceeded without delay to the
  place in question. On arriving at Inverness, and anxiously inquiring
  for the residence of Dr. Robertson, he found, to his utter dismay
  and disappointment, that there was no physician of that name, nor
  ever had been in the memory of any person there. The gentleman
  returned, vowing eternal hostility to the peace of Sydenham, and on
  his arrival, at home indignantly expressed his indignation at having
  been sent on a journey of so many hundred miles for no purpose.
  "Well," replied Sydenham, "are you better in health?" "Yes, I am now
  quite well; but no thanks to you." "No," says Sydenham, "but you may
  thank Dr. Robertson for curing you. I wished to send you on a
  journey with some object of interest in view; I knew it would be of
  service to you: in going, you had Dr. Robertson and his wonderful
  cures in contemplation; and in returning, you were equally engaged
  in thinking of scolding me."


Morgagni.--In the century following Sydenham we have a number of
examples cited by Morgagni, the father of pathology, in which his
recognition of the value of the mind as a curative agent and of the
harm that may be done by over-occupation of the mind is set forth at
its proper value. Benjamin Ward Richardson in his "Disciples of
AEsculapius" [Footnote 2] tells of two incidents in which this phase
of Morgagni's very practical application of knowledge to medical
practice is exemplified:

  [Footnote 2: London, 1901]

{17}

  In other examples, where the symptoms are due to mental oppression,
  he pursued a course of treatment that was of soothing nature. A
  distinguished professor of physic at Bologna happened to discover
  that his pulse was intermittent, and being extremely anxious about
  it was incessantly feeling his pulse, to discover that the evil was
  daily increasing. Morgagni's advice to his patient was to take his
  finger off his wrist and not to inquire too anxiously about his
  condition. The advice was followed, and the result was a complete
  removal of the disturbance.

  It is a very singular truth that in describing the action of the
  nervous system on the circulation Morgagni shows that he was
  cognizant of the fact that the circulation may be disturbed by two
  sets of nervous irritations, one inflicted through the
  pneumogastrics, the other "through those nerves which are
  subservient to the arteries"--the vaso-motor system which is readily
  disturbed by the mind. In one patient he observed great
  perturbations of the pulse in both wrists as the result of mental
  anxiety. But a day or two later the pulse derangement was confined
  to the left side altogether. The pulse of the right arm was quite
  regular, while that of the left arm still showed the inequality.
  When the mental distress was relieved, this pulse also became equal.

Morgagni cites Sydenham's contemporary, Lancisi, the great Italian
physician, as recognizing the influence of the emotions on the heart.
Examples of similar convictions as to mental influence in medicine are
also found in the works of Morgagni's great contemporaries, Boerhaave
and Van Swieten, and the great physicians of the seventeenth and
eighteenth centuries were closely imitated in their recognition of the
value of the influence of mind over body in medicine by their
successors in the profession.


John Hunter.--Wise old John Hunter recognized the influence of the
mind on the body very clearly. He said, for instance, "There is not a
natural action in the body, whether voluntary or involuntary, that may
not be influenced by the peculiar state of mind at the time." He lays
it down as a law that "every part of the body sympathizes with the
mind, for whatever affects the mind, the body is affected in
proportion." He said further, "as a state of the mind is capable of
producing a disease, another state of it may affect a cure." He called
attention to the fact that the touch of a corpse produced wonderful
effects upon the minds of patients. He said, "Even tumors have yielded
to the stroke of a dead man's hand." He observes that "while we should
naturally expect that diseases connected with the nerves--and those in
which their alteration is in the action of parts not in their
structure--would be most affected by the imagination, we find that
there are other diseases in which they appear to have little
connection that are much affected by the state of mind."


German Mind Healing.--In his monograph on "Psychotherapy in Its
Scientific Aspects" [Footnote 3] Dr. Berthold Kern calls attention to
a forgotten book of the German physician Scheidemantel, published in
1787. Its title was "The Emotions as Remedies." It seems to be very
rare since even our Surgeon General's Library has no copy of it. The
author treated psychotherapy systematically. He insisted that man was
a unit in which body and soul mutually influenced each other.
Scheidemantel blamed the moralists for considering the soul
exclusively and the physicians for thinking only of the body. He
thought that this was a serious mistake for both sides and he seems to
have anticipated much of our recent discussion on the influence of the
body and {18} of things physical generally in what is called crime and
various divagations from law. On the other hand, he thought that the
influence of the mind on the body was one of the most important
elements in therapeutics.

  [Footnote 3: "Die Psychische Krankenbehandlung im Ihren
  Wissenschaftlichen Grundlagen." Berlin 1910.]

Reil, after whom the Island of Reil is named, and who taught us much
with regard to brain anatomy, was also interested in the influence of
mind on body. He was the professor of anatomy at Berlin in the early
part of the nineteenth century and had great influence over the
medical science of the time. He insisted on the recognition and
development of psychotherapy and hoped to give it a place beside the
medical and surgical treatment of human ills. He did much to create a
current of thought in German medicine which culminated in Johann
Müller's very definite expressions with regard to the power of the
mind over the body.

Very probably the most striking expression of the influence of mind
upon body is in that wonderful old book, Johann Müller's text-book of
physiology, issued in an English edition (London, 1842) under the
title "Elements of Physiology." The subject, a favorite study, is set
forth very clearly, and evidently from personal knowledge. He
recognized that the mind might influence every organ and function of
the body. The influence of expectancy he emphasized particularly:

  The influence of ideas upon the body gives rise to a very great
  variety of phenomena which border on the marvelous. It may be stated
  as a general fact that any state of the body, which is conceived to
  be approaching and which is expected with perfect confidence and
  certainty of its occurrence, will be very prone to ensue as the mere
  result of that idea, if it do not lie without the bounds of
  possibility. The case mentioned by Pictet, in his observations on
  nitrous oxide, may be adduced as an illustration of such phenomena.
  A young lady, Miss B., wished to inspire this intoxicating gas; but
  in order to test the power of the imagination, common atmospheric
  air was given to her, instead of the nitrous oxide. She had scarcely
  taken two or three inspirations of it, when she fell into a state of
  syncope, which she had never suffered previously; she soon
  recovered. The influence of the ideas, when they are combined with a
  state of emotion, generally extends in all directions, affecting the
  senses, motions and secretions. But even simple ideas, unattended
  with a disturbed state of the passions, produce most marked organic
  effects in the body.

With regard to the influence of the mind over the body in the matter
of fatigue Müller is especially emphatic. He states just as clearly
two generations ago the Law of Reserve Energy as James stated it in
recent years. Of course, Müller was far beyond his time in everything,
but then men who really think always are, and even Müller's accurate
expression only represents what had been in the minds of thinking men
in many previous generations. He says:

  The idea of our own strength gives added strength to our movements.
  A person who is confident of effecting anything by muscular efforts,
  will do it more easily than one not so confident in his own power.
  The idea that a change is certainly about to take place in the
  actions of the nervous system, may produce such a change in the
  nervous energy, that exertions hitherto impossible become possible.
  This is still more likely to be the case, if the individual is at
  the time in a state of mental emotion.

Even this necessarily fragmentary and rather disjointed sketch of the
main features of psychotherapeutics, as we see them recognized by the
great {19} physicians of the past, serve to show that mental influence
has always been appreciated as an important element in the care of the
individual patient.

The times when special attention has been paid to psychotherapy have
certain special characteristics. Usually the periods have come just
after a signal advance in medicine made through devotion to physical
science. Great attention is given to the advances and for a time the
individual patient is forgotten in the hope that at last physical
science is going to solve the problems of the physical man. With the
disappointment that always follows there is a reversion of feeling and
men realize once more how important is the mental state of the
patient, even in physical diseases. Then there comes an emphatic
expression of the value of psychotherapy. We are at present in the
midst of one of these periods, hence the widespread interest in the
subject.


CHAPTER II

UNCONSCIOUS PSYCHOTHERAPEUTICS

The great authorities in medicine, the men whose thought counted for
most in the development of not only the science but the art of
medicine, the men to whom we look back as having been great practicing
physicians, have always used this remedial measure deliberately and
have suggested to others that it should be so used. But the smaller
minds have been satisfied to think that their drugs, their external
remedies and applications, have been the sole sources of the benefit
that accrued to the patient. Such smaller men are prone to think that
they have specifics for disease, while the larger men hesitate and
recognize that coincidence plays a large role and that the suggestive
factors in therapeutics often deceive us as to the real efficacy of
drugs and remedies.

All physicians have at all times used, though often unconsciously, the
suggestive factor in therapeutics, and mental influence has had
everywhere a large role in the treatment of disease. Only in recent
years have we come to appreciate how many diseases are self-limited.
In the treatment of these self-limited diseases all sorts of drugs and
therapeutic methods achieved a reputation. Some of them were looked
upon by generations as specifics, though we know now that they are
almost, if not completely, useless so far as any direct influence upon
the disease is concerned. Indeed, at times they were, _per se_,
harmful rather than beneficial, and the patient literally got well in
spite of the treatment, though the repeated suggestion of betterment
often more than overcame the ill effect and helped in recovery.


REMEDIES PLUS SUGGESTION

Prof. Richet, the head of the department of physiology, University of
Paris, quotes the expression of a French critic of medicine: "Hurry up
and take the new remedy while it still cures. After a time it will
lose its power." The power that is lost as remedies grow familiar is
the suggestive element that accompanied them at the beginning. They
were announced with a flourish of trumpets as a discovery in
therapeutics, a number of cases treated with them {20} were much
benefited (because of the feeling that they must do good), and it was
only after a great many cases had been treated, many of them under
circumstances where patients knew nothing of the claims made for the
remedies, and where physicians had little or no previous confidence in
them, that their true place in therapeutics was revealed. Every
physician of experience has seen the popularity of remedies wax and
wane as a consequence of the attention called to them. We have new
therapeutic discoveries every week. Enthusiastic articles are written
about them, many of them in perfect good faith, and then after a time
no more is heard of them, or they sink back into the long list of
dubious remedies that may be tried when others have failed, but have
no special claim upon us, in spite of the fact that some physicians
continue to think them wonder-working.

"Time is short and art is long, the occasion is fleeting, experience
fallacious and judgment difficult," as Hippocrates bemoaned 2400 years
ago, and conditions in medicine continue the same. With suggestions
and coincidence ever at work, it is still practically impossible to
determine the intrinsic value of any remedy until after a prolonged
trial. In the olden time it was still more difficult because there had
been no such accumulation of experience as we have to guide us, and so
it is not surprising to find striking examples of even great
physicians recommending remedies whose main therapeutic influence must
have been the element of suggestion.


Galen's Theriac.--Perhaps the most striking instance of suggestive
therapeutics is Galen's famous _theriac_, various prescriptions for
which have come down to us, some of them much more complex than
others, so Galen is probably not responsible for all its absurdities.
This remedy contained a host of ingredients, some of which neutralized
others, and all of which taken together could have had but little
effect save by a strong suggestion to the patient that as he was
taking so many drugs he surely must be benefited.


Bernard's Theriac.--Almost in our own time another _theriac_ came
prominently before the public. In his younger years Claude Bernard,
the French physiologist, worked in a little drug store in a country
place not far from the farm on which he was born. There he found that
the most called for remedy was a _theriac_. It was good for most of
the ills that flesh is heir to and was bought in quantities by the old
women of the neighborhood, who administered it on every occasion. The
remedy was made in large quantities, but the secret of its composition
in this particular pharmacy was what interested Bernard. Whenever any
compound was for any reason spoiled in the drug store, the rule was,
"Put that aside for the _theriac_." This much sold remedy then
consisted of the most heterogeneous drugs. It was so diluted that it
could do no harm, though it had quite sufficient taste and odor to
make every one who took it realize that without doubt they were taking
a strong medicine.

The effect of the knowledge of the composition of this wonderful
remedy on Claude Bernard was the best that could have been
anticipated. He resolved to study the physiological effects of drugs
so that they could be given scientifically, and not in the hit or miss
fashion that made possible the success of the _theriac_.

The custom of Bernard's country drug store, however, was not different
from that of most country drug stores of the time. Unconscious
psychotherapeutics we may well call it, because the main therapeutic
factor was {21} suggestion, renewed as often as the mixture was taken,
that the patient ought to feel better, until finally whatever symptoms
were due to over-attention and to concentration of mind on feelings of
discomfort were diverted. Just as soon as the inhibition exercised by
this over-attention ceased its hampering effect nature completed the
cure.


Suggestion in Colds.--Many remedies acquired a reputation for breaking
up coughs and colds. It is, however, extremely doubtful whether any
one has ever aborted a cold, or any other infection, that had gained a
hold on the patient. We now know that this common affliction is not
due to cold but to absorption of infectious material. Nansen spent two
winters near the North Pole without catching any cold, and his men
were as healthy as himself. He had been back in civilization scarcely
a week before he and his men were confined to bed with a grippy cold.
In the far north, and high on mountains where the temperature is low,
colds are not as common as they are in crowded cities and especially
among those who are much in crowds. Cold weather only predisposes to
the infection, and after it has occurred it is sure to run its course.
That course may be longer or shorter. The cold is usually preceded by
chilly feelings. Every one knows it is possible to have chilly
feelings that seem to portend a cold, yet be well the next day. If in
the meantime any remedy is taken, credit will be given to the remedy.
When a cold was supposed to be merely a disturbance of circulation or
a congestion, one might expect to break it up. Now that we know that
it is a microbic infection, and know further that microbic diseases
are usually cured by a definite reaction on the part of the body, we
are not so likely to think of breaking them up. There are still
physicians who think they can abort a threatened pneumonia or
abbreviate typhoid fever, but they are not those who know most about
the science of medicine.

We have the story, then, of a series of remedies used with great
confidence in coughs and colds, some of them physically beneficial,
many of them, especially those containing opium, often physically
harmful, yet taken with such confidence that undoubtedly the patient
was helped through his mind if not otherwise. What is thus true for
this class of diseases can also be said of other minor affections.
Many internal remedies have been used for boils and styes and other
external infections and have often had wide vogue. The reason for
their acceptance as remedies has been that the giving of anything
produces a more hopeful attitude in the mind of the patient and this,
by bettering the general health, sometimes overcomes the tendency that
may exist to a repetition of such infectious processes.


Erysipelas.--The medical history of erysipelas is just a succession of
remedies recommended, each claimed to be almost infallible, yet
abandoned after a time for another for which like exaggerated claims
were made. The doctrine of signatures played a large rôle in the
treatment of erysipelas, and, strange as it may seem, still survives.
According to the doctrine of signatures, erysipelas, being a disease
involving intense redness of the skin, red things in nature would be
likely to do it good. Red pepper, for instance, was suggested for it
over and over again, both internally and externally. Various red
remedies have been favorites at different times in history. At
present, in many country places, a poultice made of cranberries is
supposed to be most efficacious. For many years I lived in a small
town where one of the grocers {22} put in a large stock of cranberries
each fall, though the people of the neighborhood used them but little
on the table, because during the winter there were many calls for them
for the making of poultices for erysipelas. People who have had
erysipelas, especially if it has occurred on unexposed portions of the
body, are supposed to be protected against its recurrence--for there
is a distinct liability to its recurrence--by the wearing of red
flannels!

There is scarcely any drug that has not at some time been recommended
as almost a specific for erysipelas. Anything that was given on the
third or fourth day, and it was only at this time as a rule that
patients came to physicians to be treated, seemed to bring about the
alleviation of symptoms that occurred on the fifth or sixth day.

Erysipelas, because of the sudden irruption of fever which accompanies
it, the intense redness which characterizes it, and the discomfort
which is often present, is an affection that disturbs patients very
much. For them, then, the presence of the physician and his assurance
that their affection is not likely to be severe, and his prompt relief
of certain conditions, all act by suggestion on the patient's mind and
strengthen the natural curative reaction.

In country places where physicians were not near, erysipelas was one
of the affections that continued almost down to our own day to be
treated by incantations. I have known in a little American country
town of a woman making a "charm," as it was called, for erysipelas.


Pneumonia.--Pneumonia is another of these sharply self-limited
diseases that give opportunity to many remedies for the acquisition of
a reputation as cures. Croupous pneumonia is so disturbing in its
onset, so rapid in its progress, yet so strictly self-limited in the
previously strong and healthy, that in the old days there were many
remedies that were supposed to bring about the crisis. The old
text-books contain so many cures that it is surprising pneumonia
should have continued to be the fatal disease it has been at all
times. Almost any remedy that is used for three or four days in
pneumonia will be followed by the crisis with, in most cases, a
favorable termination. The crisis takes place some time from the
seventh to the tenth or eleventh day, and often we do not see a
pneumonia patient until the second or third day of the disease. Just
before the crisis the patient runs into a series of acute and more or
less alarming symptoms. Often there is much restlessness, difficulty
of breathing with complaint of heaviness, and perhaps prostration. The
pulse and temperature are high, the skin hot and dry. Then in the
midst of this the patient sleeps, there is a critical sweat, the
temperature drops, the patient wakes up feeling quite well, there is
little difficulty in breathing, and he feels that recovery is sure to
come. The change is so great that it is natural that it should have
been attributed to all sorts of remedies which had been used
immediately preceding the crisis.

I once heard an old physician declare at a meeting of a large and
important medical society that calomel in divided doses was
practically a specific for pneumonia. He said he waited forty-eight
hours to be sure that the affection was pneumonia, and also that it
had reached that diffusion in the lungs beyond which it was not likely
to go, then he gave the calomel. He said that, almost as a rule,
during the next forty-eight hours the crisis came--and he attributed
it to the calomel. We have had other remedies just as curious as this
recommended and taken quite seriously. Some years ago a {23} Russian
physician, who had been treating soldiers in the Russian army for the
pneumonia which occurs so commonly after exposure on the Steppes,
announced that he had found in digitalis almost a specific. He pushed
the tincture up to twenty drops three times a day, beginning it just
as soon as the pneumonia was detected, and the rate of mortality among
his patients was about one per cent. According to his theory, it was
the failure of the heart in pneumonia that made the disease fatal.

Apparently the character of the patients in whom his pneumonias
occurred was forgotten. They were absolutely the most favorable cases
that could be selected. Most of them were young men between twenty and
twenty-five. At this age no one who is given a reasonable amount of
fresh air should die of pneumonia. If the patient had a serious heart
lesion, or a crippled kidney from nephritis after scarlet fever, or
crippled lungs because of a previous attack of tuberculosis, then the
pneumonia might be fatal--indeed, almost inevitably would be, or, in
the last-mentioned case, would end by lysis and not crisis. It really
matters little what remedy is given to young, otherwise healthy,
adults; they will get better, barring serious complications. The use
of digitalis lessened the chances of recovery by stimulating too early
in the case the heart that later had to bear one of the most serious
strains that the organ can stand. But doubtless this harm was more
than overcome by the patient's knowledge that he was taking a new and
powerful remedy, supposed to be particularly calculated to cure him.

Moreover, the special interest of the physician in these cases, and
his administration of a remedy with confidence which inspired the
patient, undoubtedly did much good. Pneumonia is one of those diseases
in which the patient is likely to be greatly depressed unless he is
surrounded by favorable mental influences, and is encouraged to
believe that he is going to get well. Every physician has probably had
cases in which patients died, not because of the severity of the
disease, but because they gave up the struggle in fright. If several
of a man's friends have died of pneumonia during the year or two
before he gets it, he is likely to conclude, especially if he is of
the worrying kind, that his doom is sealed as soon as the diagnosis of
pneumonia is made. If this thought persists hardly anything will save
him. He must be assured that pneumonia is not necessarily serious,
that there are remedies that influence it, and that his own case is
particularly likely to respond favorably to them.

We now realize that nursing is the most important element in the
treatment of pneumonia. Such attention to the patient as will treat
symptoms so as to prevent them from disturbing him, will secure him
against discouragement, will arouse his resistive vitality by assuring
him of a favorable termination. This will above all prevent the
patient from feeling that he is attacked by a fatal disease. The
presence of the doctor and his general directions make the patient
realize how thoroughly the course of the disease is understood and
therefore how likely it is that a favorable termination will be
brought about. We know how much the mind may interfere with the
breathing if allowed to dwell on it, and therefore if the patient
becomes over-solicitous about the condition of his lungs he seriously
hampers his recovery. In pneumonia the physician has always brought
relief, and he has usually attributed his success to his drugs, though
he has felt, too, that the confidence inspired {24} by him meant much
for his patient. It would have been better had he exaggerated the
mental influence rather than the drug power.


Typhoid Fever.--Typhoid fever is another affection for which we have
many therapeutic suggestions, with wide vogue, that are nevertheless
almost directly opposed to what we know about the pathology and
etiology of the disease. Typhoid fever runs its course in from between
twenty to thirty days. The majority of people who take the affection
and who give in to it early enough, so as not to wear themselves out,
come through successfully. Complications may carry them off, but we
expect uncomplicated cases to recover. The longer course of typhoid
has made the action of drugs appear less striking than in pneumonia
and erysipelas, but a number of remedies have been proclaimed to
shorten its course, to make it less dangerous, to cure, and sometimes
actually to abort it. So often have these come and gone that the
physician who knows the history of therapeutics is likely to be
suspicious of them. Even at present there are certain remedies
supposed to have this effect, but one does not find them used in
hospitals where large numbers of cases are seen and where there are
opportunities for comparative observation. They are used only by
physicians who see a few cases every year, and to whom coincidences
may mean much more than they are likely to when extensive statistics
of the disease are made.

As a rule, these remedies are founded on some real or supposed
scientific principle. The antiseptic treatment of typhoid, for
instance, was based on the supposition that if one can kill the
microbes in the intestine the disease will run a shorter course. The
principle apparently fails to note that any remedy likely to kill
microbes is still more likely to kill cells of other kinds, and above
all human cells lessened in their resistive vitality by disease. The
advocates of this remedy also forget that typhoid is now recognized as
a general disease with only a local manifestation in the intestines,
and that the treatment of this local manifestation is no more likely
to affect the course of the disease than the treatment of the symptoms
of typhoid would be likely to do. But the giving of remedies with the
thoroughgoing confidence that awakens trust is in itself an excellent
therapeutic agent, and patients thus treated are sure to be benefited
in so far as they share the physician's confidence. Just the same
effect, however, can be produced by careful nursing and by making the
patient realize that even though typhoid fever runs a definite course,
which we cannot abbreviate nor probably influence, we can by nursing
so prevent complications as to make a fatal termination almost
impossible.


Whooping Cough.--Perhaps none of the common affections illustrate the
influence of psychotherapy better than it is exemplified in the
history of the therapeutics of whooping cough. We have had all sorts
of remedies suggested for it, and most of them have been introduced by
those who had found them of great service in shortening the course of
the disease, and in making the "whoop" disappear much sooner than
would otherwise be the case. There have been internal and external
remedies, inhalations and inunctions, as well as many less likely
methods of treatment. Practically none has maintained itself. Whooping
cough is likely to run a rather long course. We know now that as a
consequence of the strain upon the lungs tuberculosis not infrequently
develops. Whenever this is true the tendency to cough is likely to be
{25} prolonged far beyond the natural period, and from habit ingrained
upon the nervous system the "whoop" is likely to continue, though
there is no necessity for it. It is this secondary period of the
affection that the remedies have succeeded in shortening either
apparently or in fact.

Practically anything that is done for children is likely to instil the
persuasion that the "whoop" should disappear. Anything impressive will
arouse this favorable attitude of mind toward the affection, and hence
the remedies have obtained a reputation. In the interior of many
countries draughts of sea water are a popular remedy for whooping
cough. Sea water, it is said, loses its efficacy if carried long
distances from the shore, so the children must be brought to the
seaside. In mining regions children are taken down into the mines. The
experience is enough of itself, especially when talked over a good
deal in the family, and when the occasion is often the first outing
that the child has had for months, to bring with it such improvement
in health as will enable it to suppress the whoop. If the exposure to
the mine air does not bring improvement, it is said to be either
because the child was not taken deep enough, or because there was no
gas in the air, or the wrong sort of mine was chosen, or some other
plausible excuse is advanced.

The development of scientific medicine, or at least what we are
pleased to think of as more scientific therapeutics than they had in
the past, has not kept us from having many and varied remedies for
whooping cough, which, after being introduced on apparently good
authority and apparently accomplishing many good results, have
eventually been allowed to drop into innocuous desuetude. Whenever the
administration of any such remedy was accompanied by strong
suggestion--when the internal remedies were particularly distasteful,
or the inhalations rather trying or at least sure to attract the
attention of the sufferers--then good results followed. But the cures
were due to the mental influences at work. In recent years various
serums, including diphtheria serum, have been tried with reported good
results. The giving of the injection is one of those little operations
that is likely to impress itself forcibly upon the child's mind, and
when given in connection with the promise, implied or explicit, of
improvement it is easy to understand that there will be a tendency to
lessening the frequency of the whoop, at least during the secondary
periods of the disease.



CHAPTER III

GENUINE REMEDIES AND SUGGESTIVE EXAGGERATION

The story of the suggestive use of drugs shows us many suggestions
employed even by distinguished physicians, men whose work is eminently
rational and has lived long after their time. In fact, very few, even
of the most distinguished physicians, have failed to extol remedies
which later proved to be quite ineffectual. Hippocrates felt quite
sure that an external application of snake skin was a cure for all
forms of that chronic skin manifestation, lichen. Pythagoras declared
that anise seed held in the hand was an excellent remedy for epilepsy.
These are only examples which serve to show how much suggestion has
been used unconsciously by the medical profession. The sensation {26}
produced by the touch of the viper's skin was sufficient in some
patients to bring about a change in the circulation in the skin, or
perhaps a distinct modification of the nerve impulses on which trophic
conditions in the skin depend, and this may have produced some cures
on which Hippocrates founded his recommendation. We know that the skin
can be unfavorably affected directly through the nervous system, and
there is no good reason for thinking that it may not also be affected
favorably. In our own day we have seen the suggestive influence of an
operation act as a remedy in epilepsy and have lauded it for a time.
It is, therefore, not surprising that Pythagoras saw, as he thought,
the strong scent of the anise seed act favorably. Both of these
conclusions as to the causative agency at work were wrong, because it
was suggestion and not the operation in most cases, nor the anise in
any case, which caused the improvement.


THERAPEUTIC PERSUASION

It is not only in the distant past, however, but also in quite modern
times that these therapeutic persuasions have existed among
physicians, and as a result physicians have frequently recommended and
employed remedies that we now know not only to have been quite
useless, but sometimes even harmful. A typical example of this is the
use of antimony, originally discovered and studied by Basil Valentine,
an alchemist who had busied himself much with the nature of
substances, vegetable and mineral, and with their action as remedies
for disease. Sir Michael Foster hailed him as the first of
pharmacologists, and said: "The old monk did not care for the problem
of the body; all he sought to understand was how the constituents of
the soil and of plants might be treated so as to be available for
healing the sick and how they produced their effect."


Suggestion and Antimony.--This was an eminently scientific research.
It brought the father of pharmacology to certain supposed discoveries
which continued to occupy men's minds for centuries, yet ultimately
proved to be utter misunderstandings of drug action, because
suggestion played so large a role that it vitiated all the
conclusions. The best known of Basil Valentine's books is the
"Triumphal Chariot of Antimony," which contains many interesting
scientific observations that were probably new at the time and which
show their author's investigating spirit and his interest in
scientific research.

In spite of his scientific advances, however, Valentine was wholly
mistaken with regard to antimony. He used it in various diseases, and,
of course, it always produced very definite effects on the bowels.
These effects the physician could easily foretell. It was for the
patient a proof that the physician knew much, both about his disease
and his remedies, since he could prophesy the results. After the
antimony had exerted its influence the patient was much more ready to
think that he must get better, and the influence of this suggestion
worked strongly in all cases where the affection was not serious, and
undoubtedly helped the patient's resistive vitality to throw off
disease. In weak patients its physical effect was lamentable. It still
further reduced vitality, and when used by thoughtless physicians must
have done great harm. In spite of this, however, antimony continued to
be used for centuries. Shortly {27} after the middle of the
seventeenth century, when it was beginning to be neglected, antimony
received a new lease of life as a consequence of its employment in a
lingering illness of Louis XIV. The French king was attacked by what
has since been recognized as typhoid fever. Many remedies were tried,
but all in vain; the fever continued. When the fever had nearly run
its course and the physicians were on the point of acknowledging that
they could do nothing, and when a fatal termination seemed near, it
was decided at a consultation to follow the advice of an old
practitioner and use the old-fashioned remedy, antimony. Almost
immediately the king began to get better. His improvement was quite
naturally attributed to the last drug that he had taken, and antimony
regained and held its remedial reputation for the next two centuries.

Such stories have always worked wonders in producing popular faith and
even professional confidence in drugs. When great personages seem to
be cured by certain remedies, ordinary logic ceases to act, and the
strong power of suggestion comes in to strengthen whatever remedial
influence there may be.


Calomel and Suggestion.--Such mistaken notions as to therapeutic
efficiency are not confined to centuries before our own. During much
of the nineteenth century calomel was employed as extensively as
antimony had been in preceding centuries. Calomel was often given in
doses which produced effects resembling those of antimony. Even in the
small doses we now employ, it is apt to be a thorough purgative. In
the twenty and forty grain doses, commonly administered by the country
doctors of two generations ago at the beginning of practically every
ailment, it was purgative--and worse. Its effects could, of course, be
very strikingly seen, and what patients wanted were just such visible
results of the doctor's prescription. Undoubtedly, then, the calomel
did good, but not by its effect upon the patients' bodies, but upon
their minds. Calomel is still used in ways that partake more of the
old-fashioned ideas than we care to confess. Some of its supposed
effects in stimulating the flow of bile have been placed in doubt by
modern investigation, but we still use it empirically, and undoubtedly
its effectiveness is partly due to the fact that many patients see the
results in the purgation in dark coloration of the stools and are
confident that improvement must follow--and it does. Perhaps at a
subsequent operation we find the bile ducts effectively blocked and
then learn for certain that the stool coloration observed was not
biliary but due to a chemical reaction of the calomel itself.


Venesection and Its Suggestiveness.--Between the periods of antimony
and calomel popularity venesection was the favorite remedy of
physicians. It is hard to understand now the extent to which this
practice was carried by the medical profession. People were bled for
nearly every combination of symptoms. In severe cases the amount of
bleeding practiced was almost incredible. Mirabeau, the great French
orator, suffering from angina pectoris, was bled some eighty ounces in
the course of forty-eight hours. In spite of this heroic treatment,
which his physicians thought ought to have cured him, he died. We find
it hard to understand how he lived so long. This, of course, was an
exceptional case at the very height of the venesection furor, but it
helps us to realize how convinced physicians were of the curative
power of the practice.

{28}

Thoughtful physicians like Morgagni did not accredit it, or at least
refused to allow it to be practiced on themselves, but its acceptance
was practically universal. Probably no remedial measure ever generally
used was calculated to be so effective as bleeding in producing a
strong mental influence. The rather sacrificial preparations for it,
the sight and the prick of the lancet, then the sight of the blood,
the languor that followed, the reaction on nature's part to reproduce
the lost material, all united to impress the patient's mind so deeply
that it is easy to understand that all the reserve of mental force was
now directed toward helping nature in the cure of whatever disease was
present. Venesection itself in nine out of ten cases probably did more
physical harm than good, but all the good came from its suggestion.

We are now apt to think of venesection as consisting only in the
removal of some blood from a favorably situated vein, but we must not
forget that in the olden time they bled from many veins, and that a
particular vein was picked out because it was supposed to be connected
in some way with the seat of the special trouble under treatment, and
as a result there was a particular appeal to mental influence. A vein
on the forehead was opened for the treatment of migraine and diseases
of the eyes, on the nose in case of discharge from the eyes, back of
the ears in chronic headache and in stuporous conditions, or beneath
the chin when there was pain in the eyes, or in the nose, or in the
jaws. The cephalic vein was opened for headache and for certain
affections of the eyes and ears. Altogether there were thirty
different veins opened for as many maladies. It was thought extremely
important in the drawing of blood from the arm that that arm should be
chosen which, for some anatomical or other reason, was supposed to be
the more intimately connected with the affected part of the trunk or
head. The psychotherapeutic factors at work in these cases are easy to
understand, and their beneficial effects gave the practice a firm
foothold in medicine.


Quinine and Suggestion.--Whenever any drug has secured a reputation
its use has always been extended to many other diseases besides that
for which it was definitely indicated. Quinine is a typical example.
It is a specific for malaria and, properly administered in suitable
doses, breaks up the fever--not because of any action upon the febrile
condition itself, but because it kills the _Plasmodium malariae_ whose
reproduction in the blood brings about the paroxysms of fever. It was
argued, however, that since quinine was good for one kind of fever it
would probably be good in others, and all sorts of theories were
invented and supported by supposed observations of the effect of
quinine on various organs and tissues, even on the white blood cells,
by which its efficacy in fever was supposed to be explained. Quinine
was used in all sorts and conditions of fever, and acquired a
reputation as a remedy that had the power even to abort conditions
leading to all fevers. It was used in large doses for such conditions
as cold, incipient pneumonia, or indeed any disease with a chill at
the beginning, and was supposed to be a powerful prophylactic.

Now it is settled that while quinine in small doses is an excellent
tonic, it has no effect at all upon fevers in themselves nor upon
fever-producing conditions. Yet it is still administered by many who
have not quite abandoned the old teachings as if it were a general
febrifuge. In the meantime, the use of quinine as a prophylactic of
colds and other minor febrile conditions has {29} spread so that many
people make themselves very uncomfortable by taking a large dose of
quinine and whiskey whenever they fear they are going to have a cold.
As a consequence they feel dull and heavy the next day, but assume
that they would have been much worse than they are had they not taken
the potent remedy the night before. Undoubtedly some of them are
enabled by the suggestive value of the remedy and the continued
suggestion of its unpleasant effects to throw off the lassitude that
comes from some minor infection and are encouraged to get out into the
air, when they might otherwise have stayed in the house. This enables
them to get rid of their colds sooner than would be the case if they
allowed themselves to be confined. Most of them, however, are harmed
rather than benefited, and the cold runs its course, unaffected except
that the patient is more miserable and depressed for the first day or
two than he would otherwise have been. There are physicians who still
use quinine as a febrifuge in typhoid and other essential fevers, and
doubtless its bitter taste helps their patients because of the
suggestive value of an unpleasant medicine.


St. John Long's Liniment.--An interesting exemplification of the power
of mystery in adding to the curative value of a commonplace remedy is
found in the story of the famous St. John Long liniment. St. John Long
was a well-known quack in London in the early part of the nineteenth
century. Like all quacks at all times, his specialty was chronic
diseases. He claimed to be able by means of external applications to
cure the pains and aches to which the old are so likely to be subject.
St. John soon acquired an immense reputation. He gave a liniment with
a secret formula that was literally a miracle worker. People who used
it found after a few times that they were free from, or at least
greatly relieved of, aches that had bothered them for years. It was
good for sprains and for internal pains of all kinds, as well as for
the so-called chronic rheumatisms, which have as their principal
symptom pains and aches around joints. So great a reputation, indeed,
was acquired by the remedy that an agitation was begun to have
Parliament buy the secret from its inventor in order to present it to
the British nation. The proposition was actually carried through the
legislative chambers and a considerable amount of money, still larger
in those days because of the comparatively greater value of money, was
voted to St. John Long.

His liniment had a place in the British Pharmacopeia under his name
for many years afterwards. It proved to be only a simple old-fashioned
remedy, the basis of which was turpentine, and one of the principal
ingredients was the white of egg. Just as soon as the secret was known
the power of the remedy began to decline. So long as it remained
mysterious and unknown, discovered by a man who supposedly had made a
special study for many years of these conditions, and had finally
worked out the external applications necessary for them, it
accomplished wonders. Just as soon as it was known to be a combination
of familiar turpentine and egg it lost its power. The remedy is, of
course, an excellent counter-irritant, and the gentle rubbing
undoubtedly did much good. The most important element, however, was
the mental influence, the feeling that now things must be better,
which thought distracted attention from the aches and pains and caused
the unfavorable influence of over-concentration of mind on the part to
cease, for the vaso-motor system is particularly under mental
influence. Every now and then since that time some {30} liniment or
oil containing nearly the same ingredients as that of St. John Long's
acquires a reputation as a consequence of a campaign of advertising.
It is the printers ink that counts, however, and just as soon as the
advertising ceases to attract attention the remedy fails in
efficiency.


Alcohol Plus Suggestion.--Alcohol has been employed in medicine with
the persuasion that it is a remedy for many states of exhaustion,
though we have gradually gotten away from its use to a great extent,
because we realize that subsequent physical ill consequences outweigh,
in most cases, the physical good it may do. Its use was undoubtedly
due to the confidence of physicians communicated to patients, and the
sense of good feeling which it gives and which proves a further strong
suggestion to the patient. This sense of well-being is illusory, for
it is sure to be followed by a longer period of dejection, which more
than counteracts it unless the dose of alcohol can be maintained for
some time.

A generation ago few physicians would have cared to treat exhausting
diseases, the continued fevers for instance, without liberal doses of
alcohol. Practically the only treatment for pyemia and septicemia on
which any stress was laid, and in which there was any general
confidence, was the administration of alcohol in large quantities. In
the septicemia consequent upon puerperal infection it was the common
teaching to give alcohol by the tablespoonful or more every hour, or
oftener, until its effects began to be noticed, and ordinarily large
quantities were required, so that sometimes nearly a quart was taken
in the twenty-four hours. Undoubtedly these septic conditions were
accompanied by great mental prostration, and this was emphasized by
the knowledge that they are often fatal. So patients were usually
depressed into a state of mind in which their resistive vitality was
much lowered. Alcohol, then, by producing a sense of well-being as
well as by stimulating hope in other ways and suggesting possibilities
of recovery, undoubtedly exerted a powerful and favorable influence on
the mind. Its use in these cases nearly always did good, in spite of
its inevitable depressive reaction, for the course of these infections
was rapid and the dosage of alcohol could be maintained until there
was a change for the better or the fatal termination was in sight.

Alcohol was frequently used in many other conditions of a similar
nature, and above all in the septic conditions so common in hospitals
before the days of antisepsis and asepsis. When it is recalled that
amputations yielded a mortality from sepsis of at least one in four,
the extensive use of alcohol in hospital practice two generations ago
will be readily understood. We have changed that, however, and Sir
Frederick Treves, at a meeting of the British Medical Association at
Toronto, five years ago, called particular attention to the statistics
of the use of alcohol in British hospitals. During the last forty
years milk and alcohol have exactly changed places in the London
hospitals. Between 1860 and 1870 about four times as much was spent
for alcohol as for milk in these hospitals; during the last decade
about four times as much was spent for milk as for alcohol.

A corresponding change has taken place in many other phases of
treatment in which alcohol was commonly used. The physician of fifty
years ago would have thought that one of his most efficient remedies
had been taken from him if he could not use alcohol freely in
tuberculosis. There are practically no well-known specialists in
tuberculosis now who recommend the use {31} of alcohol. On the
contrary, most of them point out the dangers from its use and consider
that the depression which follows even a moderate dose is likely to do
much more harm than the temporary and fleeting stimulation which it
gives can do good. In the treatment of phthisis in recent years milk
has done much more than take the place of alcohol: it has displaced it
entirely. The medical profession realizes now that what the
consumptive needs is not more stimulation--for more of that than is
good for him is forced upon him by the toxins of the disease--but more
nutrition to enable him to resist the progress of the disease and
raise his resistive vitality against its toxemia. The one stimulant
that is of service in the affection is oxygen, and even that should be
given in nature's dosage rather than by artificial means.


_Alcohol in Pneumonia_.--A corresponding change has taken place in the
professional attitude towards the use of alcohol in pneumonia. There
was a time not so very long ago when alcohol was considered the sheet
anchor of our therapeutics for pneumonic conditions, especially those
in which from the beginning a fatal termination seemed inevitable,
because of the age of the patient or some complication. There were
physicians who said that if they had to choose between all the drugs
of the pharmacopeia on the one hand without whiskey and whiskey
without all drugs whatsoever, for the treatment of pneumonia, they
would make the latter choice. We are not as yet entirely away from the
point of view that attributes a certain value to alcohol in pneumonia,
though even those who still employ alcohol are less emphatic in their
advocacy of it. Any one who has seen the result of the fresh air for
pneumonia patients will think less and less of alcohol. One well-known
clinical authority declares that the very best place to treat
pneumonia in our cities would be beneath the trees in the parks. Our
patients are being treated at the ends of wards with the windows up,
on the balconies, and on the roofs, and the death rate is much reduced
and the necessity for any other than oxygen stimulation seems much
less.


_Alcohol in Vague Affections_.--The suggestive influence of the effect
of alcohol is unconsciously obtained in a number of vague and rather
chronic affections. Among these the most noteworthy are women's
diseases. Various alcoholic home remedies, gin and whiskey, usually
disguised by some bitter, used to be popular. But the known presence
of alcohol in these discredited them. Then the nostrum vendors
proceeded to supply something just as good. They were, in fact, the
same things under another name. Many of the much-advertised remedies
that are supposed to cure the ills the weaker sex is liable to, have
been found to be little more than dilute whiskey, for in alcoholic
strength they were about equal to whiskey diluted once with water, and
the other substances were added only to disguise the taste and the
odor of this principal ingredient. Many of these remedies have
elicited innumerable flattering testimonials and not all of these were
fraudulent or obtained by questionable means, but many of them were
given because of results secured through the remedies. The alcohol
gave the well-known sense of well-being, and the suggestive influence
of this increased the appetite, tempted the patient to move around
more, and to get more into the air than before, and the consequence
was an improvement in the general health, in the midst of which many
symptoms that seemed to the excited imaginations of run-down
individuals to be serious were relieved. In a great many cases,
however, the result was the {32} formation of a whiskey habit; hence
the crusade which has discredited these remedies.

Other patent medicines, and, indeed, some of the proprietary
preparations, commonly recommended as nutrients and the like, and
supposed to be ethical, are found to owe whatever efficiency they have
to their alcoholic content. Here once more the suggestive elements
were the more important, and enabled substances of little physical
efficiency to produce effects that seemed to indicate the presence of
powerful energizing materials.


_Whiskey in Snake-Bites_.--A typical example of a remedy which owes
its efficacy to mental influence over the patient is the use of
whiskey for snake-bites. It is generally recognized that whiskey is
not only of no special beneficial effect for snake-bite, but that when
taken in the large quantities usual in such cases it probably produces
an ill effect by disturbing the patient's general condition and
lowering his resistive vitality. I have no doubt, however, that its
use in considerable quantities has in these cases proved of value
because of the mental effect upon the patient. Ordinarily a snake-bite
is followed by a sense of extreme terror and prostration that lowers
the resistive vitality. This is overcome by the temporary stimulation
of the alcohol. The generally accepted idea that whiskey is almost a
specific remedy for snake-bite takes away from most people this dread
and consequent depression, and does this especially at a time when the
acuter symptoms of the venom are making themselves felt. Only about
one in six even of those bitten by large rattlesnakes are likely to
die. Many circumstances are in their favor. The bite is not likely to
be fatal unless the full contents of the poison sac is injected--which
will not be done if the sac has been emptied in the preceding
twenty-four hours--and if there are any obstacles, such as clothing or
even hair, on the part struck by the snake. Most people, however,
would almost die from fright, and such a thing is quite possible, if
they thought there was no remedy. The fact that they understand that
alcohol is an almost infallible remedy gives them courage, and as soon
as they receive some whiskey and it begins to take effect this intense
depression is relieved.

It would be better if the knowledge we now have as to snake-bites were
more generally used, and if people understood that only rarely is such
an accident fatal. In this way there would be no necessity for an
appeal to mental influence through whiskey. It is probable, however,
that alcohol will still be used for many years, at least in the
country districts, because the supposed knowledge is too widely
diffused for a correction to come soon, and then other modes of
treatment have not that persuasive mental influence which whiskey has
as the result of the long tradition. There are many other popular
remedies for snake-bite not quite so inefficient as whiskey, but that
will continue to enjoy a reputation and really have a certain
efficacious result as a consequence of the expectant attitude evoked
by the fact that for as long as the patient has heard anything about
these things this particular remedy has been mentioned always as the
one thing sure to do good.


Other Cures.--Fontana, toward the end of the eighteenth century, was
sure that he had discovered in caustic potash an absolute specific for
snake poisoning. He had had a series of cases, and felt that he had
actually observed this substance following the snake poison into the
system and neutralizing it. Its active effect on the external tissues
proved eminently suggestive for {33} the patient and good results
followed. We have had many specifics since, and yet we are not quite
sure how much any of them avail unless recent biological remedies
prove lasting in their effects and are really of therapeutic
efficiency.


Antidotes and Suggestion.--For many other poisons beside snake venom
there have been announced supposed antidotes of all kinds. The
literature of the antidotes used for opium is extremely interesting
and even in recent times contains many disillusions. Twenty years ago
our medical journals contained any number of cases in which a solution
of potassium permanganate seemed to have proved effective in
neutralizing not only opium itself but its alkaloids and derivatives.
Not only was it efficacious, then, if taken while the opium was still
in the stomach but, just as with Fontana's caustic potash and the
snake venom, it followed the opium into the tissues and at least
blunted its action. Numbers of cases were reported in which potassium
permanganate was supposed to have had this desirable effect. The
effect of alcohol in neutralizing carbolic acid attracted as much
attention as did potassium permanganate for opium. Here there was no
doubt that alcohol immediately after the external application of
carbolic acid did prevent its corrosive action. It was supposed to do
the same thing in the stomach and even, as some enthusiastic observers
thought, followed the carbolic acid into the tissues. Here once more
the claim is not proven and it is evident that the influence on
patients' minds when small doses of carbolic acid were taken, was the
real therapeutic factor at work.


Poultices in Suggestive Therapeutics.--Poultices represent another
phase of the value of suggestion in medicine and surgery, though for
many centuries those who used them were sure that the reasons for
their employment were entirely physical and not psychic. All sorts of
poultices have been used and each was supposed to do specific curative
work. New forms of poultice material have been introduced, and
physicians and patients have been certain that each worked wonders of
its own. The drawing power of the poultice was extolled until patients
dwelt on the idea that this external application was literally engaged
in extracting from them, even from distant portions of their anatomy,
virulent material that would do harm if allowed to remain in them.
Poultices in suitable cases, because they represent moist heat, do
good by counter irritation, by bringing about the expulsion of gas, by
diverting internal hyperemia to external tissues, but most of their
supposed efficacy has been really due to the bother required to
prepare and apply them, the discomfort of having them on, and the
feeling that now something had been done and the aches and pains must
get better. They are still used, but to a much less degree than
before. Now the ordinary teaching is that a hot water bag wrapped in
dry flannel, if dry heat is the agent desired, and in moist flannel,
if moist heat is the desideratum, is much more efficient. It takes but
a few minutes for a poultice, no matter how hot when applied--and
occasionally in the olden time they were applied so warm as to burn or
scald--to decrease in temperature to that of the body. After that they
represent only a moist compress.

It is easy to understand that the suggestive influence of poultices
might serve for an age that knew less about the realities of the
efficacy of external applications than ours. As a matter of fact, we
have, nevertheless, shown ourselves to be quite as credulous and ready
to receive analogous remedies as the past generation. With the waning
of the popularity of the poultice, not {34} only among the profession,
but also among the people generally, there came into use various
plasters which were supposed to have even more wonderful efficacy than
the poultice of the olden time. These required a good deal of trouble
to apply and once applied remained on for hours, and so continued to
produce a definite curative effect on patients' minds. When first
introduced, exaggerated claims were made for their therapeutic value
and a regular crusade to diffuse correct information regarding them
had to be made, in order to set them in their proper place as mere wet
compresses, without any therapeutic efficiency beyond that of cloths
wrung out in water and kept in touch with the skin.


_Poultices and the Doctrine of Signatures_.--There was a general
impression in the past that the indication of the ailment for which
substances are medically useful has been set on them by nature, either
through the color, or the form of the plant, or other qualities. In
general, the law of similars is supposed to hold in the doctrine of
signatures--like cures like. Hence the cornmeal poultice for light
jaundice, the flax-seed meal poultice for darker jaundiced conditions
and for tendencies to gangrene. The charcoal poultice was employed for
this same purpose with no better reason, though some of its efficacy
may have been due to oxygen present in the pores of the charcoal. I
have already spoken of the appeal to the patient's mind in the use of
the cranberry for erysipelas, and various other berries were used in
like manner on the doctrine of signatures.


_Deterrent Materials and Suggestion_.--Another basic principle in the
making of poultices was the use of deterrent, repulsive materials,
because these were more effective on the patient's mind. All the
ordures were so employed. Goose and chicken excrement was supposed to
be particularly efficacious for many of the purposes for which we now
use iodine. It was applied over sprains and bruises on the unbroken
skin. Cow-dung was employed as a poultice for sprains of the larger
joints, especially on the feet and legs, but to be efficacious it had
to be applied fresh. I have known, within twenty years, of physicians
in two so supposedly cultured parts of the country as Pennsylvania and
Maryland, to employ such ordure poultices for the cure of sprains and
dislocations, and these physicians had a great reputation among the
people of their countryside. They were known especially as good bone
doctors, and their use of such deterrent materials instead of
decreasing their practices rather added to them.


Ointments.--In the Middle Ages ointments made of the most far-fetched
materials were employed even by distinguished surgeons. That, indeed,
is the one serious flaw in the surgery of the thirteenth and
fourteenth centuries, when they did everything else so well. These
ointments contained all manner of materials that were likely to
impress patients and make them feel that something wonderful was being
done for them. Crushed insects of all kinds were employed for external
lesions. Here the doctrine of similars seems once more to have been in
play. Insects gave creepy feelings, and whenever such feelings, or the
paresthesiae generally, were complained of, a poultice or ointment
made of insects seemed to be the natural remedy. The more repellent
the materials, the more efficient they were likely to be. Many of the
paresthesiae are due to neurotic conditions and it is not surprising
that when an ointment of crushed lice--these insects being collected
from barnyard {35} fowls or from hogs--was used, the suggestive
influence was strong. Another important ingredient in ointments were
portions of dead bodies. A bit of a mummy from the East was supposed
to be particularly efficacious. Portions of the bodies of men who had
been hanged, or of the moss that grew on the skulls of malefactors
whose bodies had been long exposed in chains to the air, were also
favorite ingredients. Plants and shrubs gathered in graveyards,
especially in the dark of the moon, because on account of the terror
of the place they were then harder to get, also had a great
reputation.



CHAPTER IV

SIGNATURES AND PSYCHOTHERAPY

_Similia similibus curantur_, like is cured by like, is a very old
idea. According to the doctrine of signatures nature had put an
external natural marking or a symbolical appearance or characteristic
upon a plant, mineral or other object, to indicate its special
usefulness for the treatment of certain diseases or for affections of
certain organs. Sir Robert Boyle, sometimes spoken of as the father of
chemistry, said, "Chymists observe in the book of nature that those
simples that wear the figure or resemblance, by them termed signature,
of a distempered part, are medicinal for that part or that infirmity
whose signature they bear." On this principle yellow flowered plants
were good for jaundice, because they resembled it in color. The blood
stone was good for hemorrhage, and plants of certain forms were good
for the organs or parts of man which they resembled. Certain plants
were named with this idea. Kidneywort, liverwort, are typical
examples. Scorpion grass, our familiar forget-me-not of the _genus
myosotis_, was so-called because its spike resembled a scorpion's tail
and was, therefore, good against the scorpion's sting, or against
pains similar to that produced by such a sting. Some of the
resemblances were extremely far-fetched, but in spite of the defect of
nature's signature on them, they seem to have been effective in
therapeutics. The plant, sometimes called Jew's ear, which can by an
effort of the imagination be made to bear resemblance to the human
ear, was, for instance, supposed to be a successful cure for diseases
of that organ.

We know now that there is no significance in this doctrine of
signatures. It represented one phase of pseudo-science. But the idea
of itself was enough to help people to throw off many symptoms, to
relieve discouragement, to encourage them with the thought that they
ought to get better; accordingly they took new heart, ate better, went
out more, and as a result naturally slept better, and then nature did
the rest. Signatures are an exquisite example of pure psychotherapy,
as the initial agent and natural curative methods accomplishing the
cure.


Signature Details.--Some of the details of the doctrine of signatures
are amusing. For a considerable period nuts were supposed to be a good
brain food, and some traces of this idea are still extant, although
there does not seem to be any better reason for it than the fact that
many nuts have an arrangement of their lobes which resembles the
conformation of the brain. On the same principle the Chinese use
ginseng-root as a general tonic. The extract is not {36} of any
special significance in medicine, though it has come to be much
advertised in recent years, and the Chinese continue to pay high
prices for it. The reason is that the root of the ginseng plant often
resembles the human body. The more nearly this resemblance can be
traced, the more virtue there is for the Chinese in the particular
specimen of ginseng. The signature is on the roots. It is good for man
because it looks like man, just as the nuts are good for the brain
because they look like the brain. In modern times we are likely to
think that we are far away from any such self-deception. But our
deceptions have a more appealing pseudo scientific element in them.
Fish was for some time considered a good brain food because fish has
phosphorus in it and so has the brain. The two reasons have as much
connection as that between nuts and the brain; or ginseng and man.

Astrological ideas came in to help out ignorance and foster supposed
knowledge. The sun and the stars were favorable planets and the moon
unfavorable. If anything about a plant reminded the gatherer of the
sun or the stars, then that plant was sure to be beneficial,
especially in chronic diseases. If anything reminded him of the moon,
however, then it could be expected to be maleficent in influence.
Though childish, this had yet its power to help.

The use of nitrate of silver, which in the old days was called lunar
caustic, because it had, in a fresh state, a silvery, moon-like sheen,
was largely a matter of signatures. The signature went both by
similitude and by contrary. Since the lunar caustic supposedly had a
moon quantity, therefore it would be good for moon-struck people--the
lunatics of the old time and of our own time. As a consequence nitrate
of silver was used in many obscure nervous and mental diseases. In
epilepsy it was commonly employed. Even in our own times, entirely on
empiric grounds, it was used for such severe organic nervous diseases
as locomotor ataxia and sometimes to such an extent as to produce
argyria. Undoubtedly, its use, with confidence on the part of the
physician and suggestion and persuasion on the part of the patient,
did much to relieve sufferers from discouragement and from such
psychic disturbance of their general health as would have made their
condition seem worse.


Wines as Remedies.--How much suggestibility means in the choice of
remedies that of themselves are more or less indifferent, may be well
judged from the recommendations with regard to various wines that have
been made by physicians. At one time and place it is red wine, at
another it is white wine that is particularly effective. For certain
nations the stronger wines, as Port or some of the Hungarian wines,
have appeared to exercise specific effects. Except for the tastiness
of these various brands or for other trivial accessories, it is
probable that the therapeutic efficacy of the wine depends entirely on
the alcohol and the effect of this upon the patient. In his "Memories
of My Life," Francis Galton relates that Robert Frere, one of his
fellow pupils with Prof. Partridge, who became through marriage in
later years a managing partner in a very old and eminent firm of wine
merchants, told him that the books of the firm for one hundred and
fifty years showed that every class of wine had in its turn been
favored by the doctors.

In prescribing wine the doctrine of signatures probably had more to do
with the special choice than anything else. Red wines were recommended
for anemic people, because somehow the coloring was supposed to affect
the {37} patient in such a way as to make up for the lack of coloring
in the blood. On the other hand, the light, and especially the
straw-colored wines, were recommended for liver troubles, because of
their relation in color to the yellow of bile. Light wines were best
for people who had more color than normal. Some wines are much
stronger than others, and the alcohol, as in so many of our patent
medicines, had a stimulating tonic effect, but in olden times this was
supposed to constitute only the smallest portion of the efficiency of
the wine, while the ingredients that made its color and taste were
extremely important. The taking of red wine by anemic patients often
proved suggestively valuable, and the alcoholic stimulation led them
to eat more freely and look at things more hopefully and,
consequently, to improve in health more rapidly than would have been
the case had they not had the feeling that somehow they were actually
consuming elements that would make their blood red.


Precious Stones.--The doctrine of signatures applied particularly to
precious stones, and many of the popular medical superstitions with
regard to precious stones were founded on it. The blood stone was said
to be efficient as a tonic: it stimulated people: it made the anemic
stronger and ruddier if it were worn on the fingers. The torquise
turned pale when its owner was in poor health. It was the stone that
was an index of what has been called "the blues" or what one modern
writer has dignified by the title "splanchnic neurasthenia." Dr. Donne
wrote of:

  A compassionate turquoise that doth tell
  By looking pale, the owner is not well.

It is probable that the pallor of the patient's hands as the
background to the stone made the difference in its appearance thus
noted. It became deeper in hue, as it were, when people were in ruddy
health. The suggestive influence of such beliefs is easy to
understand. It is even possible that the wearing of an amethyst did
help to keep people from indulging in liquor to excess, for that is
the traditional effect of the wearing of this stone, though its virtue
seems to be founded on nothing better than the supposed derivation of
the name from the Greek _a_ privative and _methuo_, "I get drunk,"
suggesting strongly to the wearer that he should not get drunk.

The jacinth superinduced sleep and doubtless the strong suggestion of
this supposed influence helped many sufferers from so-called insomnia
to get sleep. The single fixed idea that now they must get to sleep
would greatly help them. Pillows in the olden time were occasionally
set with bits of jacinth, and there is even the record of bed-linen
embroidered with it. This would probably be quite as effective as are
hop-pillows in the modern time, for their main influence, as is also
true of pine pillows, seems to be through suggestion. Some other
traditions with regard to precious stones are harder to understand,
yet may be explained. The owner of a diamond was supposed to be
invincible. Diamonds represented money and money meant power. It is
harder to explain the tradition that the possession of an agate made a
man able and eloquent.

The wide acceptance of the doctrine of signatures, and of allied
ideas, as to the effect of precious stones and metal and jewelry upon
disease, makes {38} it clear that the acceptance of a mental
persuasion with the changes in habits that follow, may serve as the
basis of a successful system of therapeutics. The materials associated
with the idea had absolutely no more physical influence than does the
carrying of a horse chestnut or a potato in the pocket serve to keep
off rheumatism.



CHAPTER V

PSEUDO-SCIENCE AND MENTAL HEALING

An interesting phase of psychotherapy is found in the history of the
applications of new scientific discoveries to medicine. The
development of every physical science has been followed by an attempt
to apply its new principles and discoveries to the treatment of
disease. Such applications have nearly always been followed by
excellent results at the beginning. But almost without exception, the
medical significance of these discoveries has, after a time, been
found to be _nil_. When these discoveries were made they became the
center of public attention. The announcement of their application to
medicine then seemed natural and produced a feeling that another great
therapeutic principle had been discovered. Sometimes wonderful
therapeutic effects were noted. The chronic diseases particularly were
helped for some time, at least, and practically all the affections
that have mainly subjective symptoms were greatly relieved, or
actually cured. After a time, however, when the novelty of the
discovery wore off, its suggestive power was lessened and then the
remedy lost its therapeutic power.


ASTROLOGY

Astrology is the typical example of pseudo-science in medicine. The
stars, and particularly the planets and the moon, were supposed to
have great influence on human destiny, human health, and human
constitutions. Astrology was an organized body of knowledge over 3,000
years ago. Mr. Campbell Thompson has recently translated a series of
300 inscriptions from the cuneiform tablets in the British Museum, and
Professor Südhoff of Leipzig has compiled all the references to
medicine in these. The latter's studies show the extent which star
influence was supposed to have over human health. A halo round the
moon, an obscuration of the constellation of Cancer, the pallor of a
planet in opposition to the moon, the conjunction of Mars and Jupiter,
and other movements and phenomena of heavenly bodies were supposed to
foretell the approach of disease for man and beast.

As a consequence of this application of astrological knowledge to
medicine, operations were performed only on certain favorable days or
under favorable conjunctions of planets. An ailment that occurred at
an unfavorable time, because of an unpropitious state of the heavens,
would not be relieved until the motions of the stars brought a more
benign conjunction. Observations seemed clearly to indicate that the
stars actually had such influences. Even Hippocrates, though he
insisted that "the medical art requires no basis of vain presumption,
such as the existence of distant and doubtful factors, the {39}
discussion of which, if it should be attempted, necessitates a
hypothetic science of supra-terrestrial of subterrestrial belief,"
could not entirely get away from astrology. In his treatise on "Air,
Water and Locality" he writes: "Attention must be paid to the rise of
the stars, especially to that of Sirus as well as the rise of
Arcturus, and after these to the setting of the Pleiades, for most
diseases in which crises occur develop during these periods." In the
second chapter he writes: "If anyone would be of the opinion that
these questions belong solely in the realm of astrology, he will soon
change his opinion as he learns that astrology is not of slight, but
of very essential importance in medical art." (Personally I doubt the
Hippocratean authorship of these passages, but they are surely very
old.)

The influence of the suggestions derived from astrology on human
patients continued until almost the nineteenth century. There were
many protests, especially from the Doctors of the Church, that the
applications of astrology to medicine were false, but the practice
continued. Both Kepler and Galileo drew horoscopes for patrons, and
while Kepler doubted their value, he felt that in making them he was
justified by custom. Galileo drew up the horoscope of the Grand Duke
of Tuscany during an illness, and declared that the stars foretold a
long life, but the Duke died two weeks later. But incidents of this
kind did not disturb either popular faith or medical confidence in
astrology as helpful, in prognosis, at least, if not also in
diagnosis. Even so late as 1766 Mesmer was graduated at the University
of Vienna, when it was doing the best medical work in Europe, with a
thesis on "The Influence of the Stars on Human Constitutions."


Later Astrology.--Few now realize that the curious figure printed at
the beginning of most of our almanacs down to the present day is a
relic of the time when physicians believed in the influence of the
constellations over the various portions of the body. Even yet this
idea has not entirely gone out of the popular mind, and hence its
retention as something more than a symbol in our little weather books.
Man was considered as a little world, a microcosm, and the universe,
as men knew it--the sun, the moon and the planets
together--constituted a macrocosm. It was observed that the bodies
constituting the universe were circumscribed in their movements and
never went out of a particular zone in the heavens which was called
the zodiac. This zodiac was divided into twelve equal parts called
signs or constellations. Similarly man's body was divided into twelve
parts, of which each one was governed by a sign of the zodiac or by
the corresponding constellation. The ram governed the head; the bull
the neck; the twins the paired portions, shoulders, arms and hands;
the crab the chest; the lion the stomach, and so on. The old surgical
rule, as quoted by Nicaise in his edition of Guy de Chauliac's "Grande
Chururgie," was that the surgeon ought not make an incision, or even a
cauterization, of a part of the body governed by a particular sign or
constellation on the day when the moon was in that particular portion
of the heavens, for the moon was supposed to be the bringer of
ill-luck and to have untoward influences. The incision should not be
made at these unfavorable periods for fear of too great effusion of
blood which might then ensue. Neither should an incision be made when
the sun was in the constellation governing a particular member,
because of the danger and peril that might be occasioned thereby.

{40}

Such rules were supposed to be founded on observation. Patients were
influenced by them mainly because they were assured that the surgical
treatment was undertaken under the most favorable influence of the
stars and that all unfavorable influences had been carefully observed
and eliminated. It is hard for us to understand how such ideas could
have been maintained for so long in the minds of men whose other
attainments clearly show how thorough they were in observing and how
profoundly intelligent in reaching conclusions. We should, however,
have very little censure for them, since from some other standpoint we
find every generation, down to and including our own, jumping at
conclusions just as absurd and just as inconsequential. And the
practice of astrology was not without its value, for the reassurance
given patients by the consciousness that the stars were favorable did
much to relieve their anxiety as to the consequences of surgery,
lessened shocks, hastened convalescence, and favored recovery.


HERBAL MEDICINE

What is thus exemplified in astronomy and astrology can be found in
the story of every other science. After the knowledge of the stars,
the next organized branch of information that might deserve the name
of science related to plants. This, too, was introduced into medicine,
and with more justification than astrology. Most of what was
accomplished by early herbal medicine was, however, due to the
influence produced on the mind rather than to any physical influence
tending to correct pathological conditions. The shape and color of
plants, their form, the appearance of their leaves, were all supposed
to indicate medical applications for human ailments. The reason for
their acceptance was entirely the ideas associated with the plants and
not any definite therapeutic effect. Whatever good nine-tenths of all
the herbal medication accomplished certainly was by means of the
influence on the mind. We have abandoned the use of most herbal
remedies in recent years, even many that are still retained in the
pharmacopeia, because we have realized their physical incapacity for
good.



ALCHEMY

When chemistry, under the old name of alchemy, began to develop, its
first study was of minerals, and just as soon as a body of knowledge
was acquired chemistry was applied to medicine. All the investigators
were engaged in searching for the philosopher's stone, the substance
by means of which it was hoped to change base metals into precious. It
was generally believed that when this substance was found, it would
have wonderful applications to human diseases and would transmute
diseased tissues into healthy tissues in the same way that it
transformed metals. It was felt that the philosopher's stone would be
an elixir of life as well as a master of secrets for wealth. This
would seem amusingly childish to us were it not for the fact that in
radium we, too, seem to have discovered a philosopher's stone--a
substance that transmutes elements. For some years after its discovery
{41} we were inclined to think that it must have some wonderful
application in medicine and in surgery, and we actually secured many
good results until its suggestive value wore off.

The fact that much had been learned about chemicals persuaded men that
they must be beneficial to human beings. Thus they were taken with
confidence and produced good results. When our modern chemistry
developed out of alchemy a great variety of drugs began to be used,
and long, complex, many-ingrediented prescriptions were written.
Polypharmacy became such an abuse that the time was ripe for
Hahnemann, whose principles, if carried to their legitimate
conclusions, would require his disciples to give practically nothing
to patients and treat them entirely by suggestion.



MATHEMATICAL MEDICINE

When mathematics developed, applications of that science were made to
physiology and to medicine. Under the influence of Borelli, the school
of Iatro-Mathematical medicine developed and it flourished long after
him. Foster, in his "History of Physiology," says:

  Borelli was so successful in his mechanical solutions of
  physiological problems that many coming after him readily rushed to
  the conclusion that all such problems could be solved by the same
  methods. Some of his disciples proposed to explain all physiological
  phenomena by mathematical formulas and hypotheses concerning forces
  and the shapes and sizes of particles.



MAGNETISM

Magnetism occupied a large place in the minds of the great thinkers of
the sixteenth and seventeenth centuries. There is no doubt that
Paracelsus accepted, quite literally, what we embody in figurative
expressions with regard to magnetism. To him the attraction of sex was
magnetic. People had personal magnetism because they possessed
physical powers by which they attracted others. He considered that
these powers of attraction were expressions in human beings of the
power of the magnet in the physical world, and that the two were
literally equivalents. Kepler, one of the deepest thinkers of his
time, evidently entertained the idea that the magnet represented the
soul of the physical world, and that the planets were held in
connection with the sun and their satellites with the planets, by
magnetic attraction. We now call it the attraction of gravitation. We
understand the force no better than before, but have changed the
terms. Descartes theorized much along magnetic lines, and felt that by
the use of certain expressions he was adding to knowledge, though he
was really only multiplying terms.


Human Magnetism.--How seriously the question of human magnetism was
taken will perhaps be best appreciated from one old fallacy. For a
long period it was supposed that human beings were so highly magnetic
that if a man were exposed in an open boat, in perfectly calm weather,
in the open sea, where no currents would disturb him, his face would
turn to the north, under the same magnetic influences as caused the
needle to point to the north! Many studies of magnetism were made at
this time, so that the subject {42} attracted widespread attention.
Columbus had made some rather startling observations on his voyage to
America with regard to the declination of the magnetic needle, and,
during the century following, Norman and Gilbert made interesting
studies in the same subject. Father Kircher wrote two books on
magnetism and there were a number of others written by university
professors. Advantage was taken of this thoroughly scientific interest
in magnetism to erect a whole body of pseudo-scientific medicine
supposed to be founded on magnetic principles. The same theories were
also applied to supposed explanations of various psychological
phenomena.

During the sixteenth and seventeenth centuries the application of
magnets was a favorite treatment for a great many diseases. Especially
were they useful in the treatment of muscular pains and aches and the
chronic diseases which so disturbed men's minds. Many of the joint
troubles of the aged, the muscular pains and aches that develop from
the wrong use of muscles, and the vague internal discomforts which
often disturb men so seriously, were cured by the application of
magnets. Perkins' success with his tractors shows how much can be
accomplished in this way.



ELECTROTHERAPY

The great development of pseudo-science in medicine remained for the
era following the scientific investigation of electricity. With the
discovery of the Leyden jar and its startling spark, a new and
marvelous healing agent seemed to be at hand. It is quite amusing to
read the accounts of the influence of the spark of the Leyden jar on
the well and on the ailing. In my "Catholic Churchmen in Science"
(Dolphin Press, Phila., 1909) I summed up the situation.

  Winckler of Leipzig said that the first time he tried the jar, he
  found great convulsions by it in his body; it put his blood into
  great agitation; he was afraid of an ardent fever, and was obliged
  to use refrigerating medicines. He felt a heaviness in his head as
  if a stone lay upon it. Twice it gave him a bleeding at the nose.
  After the second shock his wife could scarcely walk, and, though a
  week later, her curiosity stronger than her fears, she tried it once
  more, it caused her to bleed at the nose after taking it only once.
  Many men were terrified by it, and even serious professors describe
  entirely imaginary symptoms. The jar was taken around Europe for
  exhibition purposes, and did more to awaken popular interest than
  all the publications of the learned with regard to electricity, in
  all the preceding centuries.

The extent to which the curative power of electric sparks from the
Leyden jar was supposed to go is best appreciated from a list of the
affections that one distinguished electro-therapeutist claimed could
be not only benefited, but absolutely cured by its employment. It
included pulmonic fever, under which title practically all the more or
less acute diseases of the chest were included, and some at least of
the sub acute; dropsy, by which was meant every effusion into the
abdominal cavity no matter what its cause; dysentery, under which was
included at that time not only the specific dysenteries but many of
the summer complaints and some typhoid fevers; diarrhea, including all
the intestinal diseases not already grouped under dysentery; putrid
and bilious fever, under which category were assembled the worst cases
of typhoid; typhus {43} fever, and all the other continued fevers, and
any febrile condition reasonably severe for which no other term could
be used; epidemic diseases, pest, anthrax, small-pox, cancer, gravel,
diseases of the bladder and of the brain and spinal cord. The Leyden
jar had no real effect on any of these affections, but doubtless the
mental effect of this new remedy was quite sufficient to be of
distinct therapeutic value in the milder forms of many of them.

With Galvani's discovery of the twitching of the muscles of the frog
there came a new impetus to the exploitation of electricity in
medicine. Many felt that now it was beyond doubt that electrical
energy bore some definite relation to vital energy--that one might be
made to replace the other if indeed they were not more or less the
same thing. This led to many applications of electricity in medicine.
Students of physiology were convinced that they were getting close to
the solution of the mystery of life, and their persuasion was readily
carried over to the people of the time, so that electricity literally
worked wonders on them.

When the various electrical machines were invented and their use
popularized, pseudo-science proceeded to exploit them, and succeeded,
because the mechanical shock of the electric current proved a
suggestive therapeutic stimulant. Gordon in the eighteenth century
made the first practical frictional electrical machine, and soon some
men were observing wonderful effects with it, though the charge was so
small that it could actually accomplish little. Just after the
invention of the voltaic pile in 1800 it came to be used in medicine
with wonderful results. We are prone to think that electrotherapy is
modern, but when electrical machines were quite crude, current
strength small and potential low, old-time electro-therapeutists were
recording their wonderful results and were getting just as marvelous
effects as are reported now by enthusiasts. Considerable
electro-medical literature existed a century ago when next to nothing
was known of electricity. When, later, high potency currents came in
and the Wimshurst and other powerful machines were invented, there was
revealed at each novel invention a new horizon in electro-therapy and
wondrous cures were reported. These continue to occur in the practice
of a few favored individuals, though the general profession secures
only some ordinary mechanico-muscular effects, which demand much time
for real good to be accomplished and have nothing at all of the
marvelous about them.

The power of the pseudo-scientific aspect of electricity to influence
patients, far from being lost in our time, has rather been increased.
Our newspapers make their readers eminently suggestible because they
constantly furnish suggestions, and nothing so strengthens a function
of any kind as exercise of it. All sorts of electrical contrivances
and apparatuses are advertised to cure various pains and aches. Many
of them actually seem to relieve long-standing discomfort, though it
is not through any electrical power that they do so, but entirely
through their influence on the patient's mind. A museum of the
electrical contrivances of various kinds for which absurdly high
prices are paid at the present time and which people recommend to
others because of having been benefited by them would be interesting.
There are belts of many kinds, and rings, and medallions, and plates
to be worn on the back and on the chest, and curiously shaped poles or
"polar plates" resembling various organs, and pendants and armlets and
anklets and insoles of many, many kinds, usually {44} going in pairs,
one made in zinc and the other in copper, and worth exactly as much as
the weight of copper and zinc in them, yet curing chronic ailments by
suggestion, or at least bringing relief from many pains and aches
complained of.



LIGHT AND PSYCHOTHERAPY

Just as electricity has always been therapeutically abused by those
who have taken advantage of the suggestive influence of its marvelous
energy, so each new discovery in light has been the source of
pseudo-scientific applications to medicine. When the explanation of
photography was first made, shortly after the middle of the nineteenth
century, and it was demonstrated that it was the blue light, or at
least that end of the spectrum, and even some of the rays beyond the
visible violet, which were the most active in this regard,
applications of this fact to popular medicine became the order of the
day. We had a wave of "blue light therapy" that wandered over this
country and sold tons of blue glass. People simply sat beneath the
blue glass as the sun shone through it and were supposed to absorb the
actinic rays and acquire new life. According to many who had tried
them, the ultra-violet rays were quite equal in their power to heal
and restore new vigor to old frames to the fabled elixir of life of
the olden time. "Rheumatism (that universal ill of the unthinking) in
all its hydra-headed forms disappeared," as one enthusiast declared,
"before the blue light, like the mists of the morning before the sun."
All this, though it is said that the movement had no more serious
foundation than the desire of a manager of a glass factory, who found
himself stocked up with blue glass through a mistake, to dispose of
his surplus stock. He not only did so, but many other manufacturers
turned special attention to the new product because of the demand for
it. The newspaper advertising was through the reading columns. The
results were heard of on every side.



THE X-RAY

That happened two generations ago, and it might be supposed that in
the meantime there had been so much advance in popular education, and
particularly in the diffusion of scientific knowledge, that such a
self-deception on the part of scientists, and blind following by the
people, could not take place in our time. Just as soon as Roentgen
discovered the X-ray, however, we began to have applications of that
wonderful agent to curative purposes. About 1900, scarcely five years
after Roentgen's discovery, there was hardly an ailment that some one
did not claim to have seen treated successfully by the X-rays.
Especially was this true for the chronic and hitherto supposedly
incurable diseases. All the forms of malignant disease were treated by
the new agent, and some supposedly marvelous cures were reported.
Everything chronic was favorably affected--lupus, rodent ulcer,
eczema, acne rosacea, even tuberculosis of the lungs. At the time I
was on the staff of a medical journal, and the favorable reports came
in so thick and fast that it really looked for a time as though the
surgery of the future was to be much simplified. It took but a year or
two to show us how little of lasting therapeutic benefit there was
{45} in the X-ray, in spite of the fact that it is a marvelous agent
in its action upon living tissues. At the present moment it is used
comparatively little, and its use is gradually diminishing, except for
very special limited affections.



RADIUM AND RADIO-ACTIVITY

When radium was discovered, though it came so soon after the discovery
of the X-ray and our disappointment with it, the old story of another
pseudo-scientific medical application was told. For a time it looked
as though radium might accomplish all that had been promised for the
X-ray, though that promise had been so lamentably broken. Then,
besides radium, we had brought home to us the whole class of
radio-active substances, and their possibilities. The internal
administration of radio-active liquids was one of the hopes of
therapeutics. We had found it difficult to explain how many of the
mineral waters produced the beneficial action credited to them when
taken at the spring. We knew that artificially made waters of exactly
the same chemical composition, so far as we could determine, did not
have the same effect, nor even the waters themselves when taken at a
distance from the spring.

With the discovery of the radio-active principle there came the
suggestion that possibly the main virtue of mineral waters at the
spring was due to radio-activity. This would not be present in
artificial water and would disappear from the natural water during
shipment. This new idea was alluring, and it captured many. Radium
seemed to be the new panacea. But we are discovering its limitations.
It is of little avail in surgery; it is probably of less avail in
medicine. As yet, however, we cannot say absolutely and must wait
until results are determined. In the mean time many zealous advocates
of the marvelous power of radio-activity to cure are exploiting it,
apparently getting results and certainly making money. In the case of
the mineral waters, also, the most important therapeutic element is
probably the mental influence, which is strongest at the spring
itself, where the suggestion of efficiency is repeated many times a
day, and where the very atmosphere breathes confidence in the results
to be obtained.



SUGGESTION AND PSEUDO-SCIENCE

These applications of science, or rather of supposed science,
illustrate the influence of suggestion. The succession of events in
each case is about as follows: The definite attitude of mental
expectancy is created in the popular mind. As a consequence, with the
application of the new scientific principle, patients cease inhibiting
the recovery that would have come spontaneously before, only that they
were self-centered and had their nervous energies short-circuited.
Some are benefited by the habits of life that are established as a
consequence of the belief that they are about to be cured, while
before this they had been largely confining themselves to their
houses, and had been refusing to take recreation or get diversion
because of the conviction that they were ill. Finally, many of them
had no real physical ills, but were suffering from mental ailments
brought on by dreads and by a concentration {46} of attention on
certain portions of the body which interfered with the normal
physiologic action of those parts. Whenever strong mental impressions
are produced, from any cause, results will surely follow, some of them
marvelous. The supposed causes of these results will seem quite absurd
to those who study them afterwards, but they were living realities to
the sufferers. Nothing is more calculated to produce a strong mental
impression than a newly discovered scientific fact with some
supposedly wonderful application to humanity. The subsequent history
of the application of scientific discoveries to medicine has been as
invariably the same as the primary enthusiasm over each new
therapeutic agent. After a time some people were not benefited.
Physicians lost confidence in the power of the new remedial measure,
whatever it might be. Patients were no longer impressed by the
assurance that they would be benefited, and then the new application
has either completely disappeared from our list of remedies, or has
remained only to be used by a few, who still report good results from
it. In spite of the constancy of this succession of events, we are
still quite ready to take up with enthusiasm new discoveries in
science and their applications to medicine. We have not yet lost the
feeling, common in earlier centuries, that all science was meant for
man and that every new scientific development must have some special
reference to him.



CHAPTER VI

QUACKERY AND MIND CURES

Not less interesting than the therapeutic results obtained by men who
in good faith were using inert remedies that they thought effective,
are the cures obtained by men who had good reason to know that the
therapeutic methods they were using were quite inefficient. Their good
results, often loudly proclaimed by healed patients, are obtained
entirely through the patients' minds. Usually these men are supposed
to possess some wonderful therapeutic secret, which they have obtained
by a fortunate discovery, or by long years of study, though usually
their discovery is a myth and their long years of study a fable. So
long as people can be brought to believe in their powers many cures
are sure to follow their ministrations. The real secret is their
knowledge of human nature. They induce people to tap new sources of
vital energy in themselves, and somehow they succeed in bringing to
their aid this law of reserve energy. Besides, in many cases the real
reasons why patients continue to have certain symptoms once they have
been initiated, is that their worry about themselves inhibits their
natural curative power. This inhibition is prevented or obliterated by
the change of mind produced by the quack, and then the _vis medicatrix
naturae_ brings about a cure.

Probably the oldest story that we have of a quack in our modern sense
of the word is found in the Arabian Nights, some of the stories of
which were old even in the time of Herodotus. One day Galen, famous
for his work at Rome in the second century after Christ, found a
wandering healer pursuing his avocation in his front yard. He found
also that this man succeeded in relieving certain patients for whom he
had been unable to do anything. He {47} found that the medicines
prescribed were likely to do harm rather than good, yet many of the
patients were benefited.

Galen succeeded in winning the man's confidence, who told him his
story. He had been a weaver, but his wife thought he was not making
money enough to support her properly, so she had advised him to become
a leech. After taking lessons from a wandering quack, he set up for
himself. When Galen inquired as to his method of making a diagnosis,
he found that he did it entirely by his knowledge of human nature. He
was even able to tell what was the matter with patients at a distance
when friends came to demand medicine for them.

We think that such ready deception was possible only in earlier times,
when education was not widely diffused and when belief in
superstitions was fostered. Any such idea completely ignores the
modern status of the quack and the success that he meets among even
the more intelligent members of the community. Indeed, with the
diffusion of information in modern times the quack has secured a wider
audience. Superficial ideas of science are disseminated by the
newspapers and by the magazines, people think that they understand all
about it, and then these ideas are turned to their own advantage by
the irregular practitioners of medicine. We have quacks by the score
in all the centers of population, making a livelihood by exploiting
the ailing, and serving to no small extent to create a feeling of
popular discontent towards the physician, because that serves the
purpose of quackery. Indeed, it is during the past century or a little
more that some of the most striking examples of quackery have
occurred.


Cagliostro.--Cagliostro, whose story is told in Dumas' "Memoirs of a
Physician," and an excellent account of whose life may be found in
Carlyle's "Miscellanies," is one of the great quacks and humbugs of
history. He began his supposed medical work at Strasburg by the modest
claim that during his travels in the East he had found a series of
remedies which made old people young. In proof of his power to do this
he exhibited his wife. She was a handsome young woman of very shady
reputation whom he had married on his travels. She professed to be
sixty years of age, though she was really under thirty and looked it,
but she claimed that she had a son who had served for many years in
the Dutch army. This imposition was so effective that in Strasburg,
and subsequently in Paris, the charming pair collected large sums from
wealthy old persons, especially from women on whom the marks of time
had begun to show, and who expected, as the result of the treatment,
to be shortly as young and as handsome-looking as Madame Cagliostro
herself.

We might think that it is quite impossible for any such a deception as
this supposed renewal of youth to be practiced in our more enlightened
day when popular education is so widely diffused. We must not forget,
however, that the newspapers bring us evidence every month of some old
person who is quite sure that something that was being done for him
was, if not renewing his youth, at least giving him back much of his
pristine vigor, healing his aches and pains, and enabling him to take
up his work once more. In treating the ravages of old age, which would
seem to be altogether beyond any influence of psychotherapy, some of
the most striking results are obtained. New therapeutic methods for
the old come into vogue every year. As they grow older, {48} people
become discouraged and so do not exert even the natural energy that
they have for the maintenance of health and the keeping up of
strength. Their discouragement keeps them from exercising enough, and
this decreases appetite and sleep, and as a consequence there are many
disturbances of function. All of this disappears as soon as they feel
encouraged. Brown Sequard and his extract of testicular tissues is a
typical example of how strong suggestion may influence the old and
make them think that they are renewing their vigor and strength, and
even their youth.


Perkins, Prince of Quacks.--Shortly after Cagliostro an American
succeeded in using a very simple idea to gain world fame and at the
same time to make an immense amount of money. He was a Connecticut
Yankee with the typical name, Elisha Perkins. Dr. Perkins must have
been born under a lucky star; at least he lived in fortunate
circumstances for his purposes. Galvani's discovery of the twitchings
that occur in the frog's legs when a nerve-muscle preparation or its
equivalent was touched by metals in contact, had aroused world-wide
discussion as to the place of electricity and magnetism in biology.
Volta's brilliant experiments, which led to the invention of the
Voltaic Pile, still further increased men's interest in this subject.
It was then that Dr. Perkins came to exploit these electrical and
magnetic ideas in medicine by means of a very simple invention. It was
indeed the simplicity of his apparatus that made its appeal even more
wide than would otherwise have been the case, and, be it said, left a
larger measure of profit for the inventor.

Oliver Wendell Holmes in his "Medical Essays" [Footnote 4] has told
the story of what may be called the rise and fall of tractoration. Any
physician who wants to appreciate the real significance of cured cases
should read Holmes' essay. We quote:

    [Footnote 4: Houghton, Mifflin Co., Boston.]

  Dr. Elisha Perkins was born at Norwich, Connecticut, in the year
  1740. He had practiced his profession with a good local reputation
  for many years, when he fell upon a course of experiments, as it is
  related, which led to his great discovery. He conceived the idea
  that metallic substances might have the effect of removing diseases,
  if applied in a certain manner; a notion probably suggested by the
  then recent experiments of Galvani, in which muscular contractions
  were found to be produced by the contact of two metals with the
  living fiber. It was in 1796 that Perkins' discovery was promulgated
  in the shape of the Metallic Tractors, two pieces of metal, one
  apparently iron and the other brass, about three inches long, blunt
  at one end and pointed at the other. These instruments were applied
  for the cure of different complaints, such as rheumatism, local
  pains, inflammations, and even tumors, by drawing them over the
  affected parts very lightly for about twenty minutes. Dr. Perkins
  took out a patent for his discovery, and traveled about the country
  to diffuse the new practice.

    [Footnote 5: (Transcriber: This footnote is not numbered in the
    text but appears to refer to the preceding paragraph.): In one of
    Plautus' plays there is a curiously interesting expression that is
    recalled by this subject. The dramatist described one of his
    characters, Sosia, as thrown into a sleep by the manipulations of
    Mercury. These manipulations are described as _tractim
    tangere_--that is, to touch strokingly. It would remind one very
    much of Perkins' Tractors, and in this regard the fact that
    Mercury was to the Romans, besides being the messenger of the
    gods, the divinity of thieves, seems not without interest.]

Just what the tractors were composed of may be found in the
description of them filed with an application for a patent in the
Rolls Chapel Office in London. They were not simply two different
metals, but a combination of many metals, with even a little of the
precious metals in them, partly because {49} of the appeal that this
would make to the multitude, as chloride of gold did to our own
generation, but doubtless mainly because the claim of precious metals
entering into the composition enabled the inventor to sell his
tractors at a better price.

Dr. Holmes continues:

  Perkins soon found numerous advocates of his discovery, many of them
  of high standing and influence. In 1798 the tractors had crossed the
  Atlantic, and were publicly employed in the Royal Hospital at
  Copenhagen. About the same time the son of the inventor, Mr.
  Benjamin Douglass Perkins, carried them to London where they soon
  attracted attention. The Danish physicians published an account of
  their cases in a respectable octavo volume, containing numerous
  instances of alleged success. In 1804 an establishment, honored with
  the name of the Perkinean Institution, was founded in London. The
  transactions of this institution were published in pamphlets, the
  Perkinean Society had public dinners at the Crown and Anchor, and a
  poet celebrated their medical triumphs. [Footnote 6]

    [Footnote 6:
      "See pointed metals, blest with power t' appease
       The ruthless rage of merciless disease,
       O'er the frail part a subtle fluid pour,
       Drenched with the invisible galvanic shower,
       Till the arthritic staff and crutch forego
       And leap exulting like the bounding roe!"]

Miss Watterson [Footnote 7] tells how he attracted attention. Like all
successful quacks, he had an inborn genius for advertising.

    [Footnote 7: "Mesmer and Perkins's Tractors,"
      _International Clinics_, Vol. III, Series 19. 1909.]

  He lived in the house once occupied by John Hunter [how
  characteristic this is--the first quack we mentioned in this
  chapter, took up his work in Galen's front yard], and in 1804 the
  Perkinean Institute was opened, but by the end of 1802, 5,000 cases
  had already been treated. Lord Rivers was president. Sir William
  Barker, Vice-President [Prominent legislators, lawyers, bankers
  always lend their names.] Twenty-one physicians, nineteen surgeons,
  and the leading veterinaries succumbed to the influence of the magic
  tractors. One "eminent physician" who had had 30 guineas from a
  country patient and had done him no good was very angry when the
  sick man took to Perkinism.

  "Why, I could have cured you in the same way with my old brick-bat
  or tobacco pipe, or even my fingers."

  "Then why, sir," answered the patient in a stern voice (Perkins
  quotes this), "did you dishonorably pick my pocket when you had the
  means of restoring me to health?"

  In some 176 pages young Perkins gives us the pick of 2,000 cases who
  had, of course, been foolish enough at first to put faith in the
  ordinary physician and his drugs.

  In Bath, particularly, where aristocratic London went, as they do
  to-day, to repair the damage wrought by a season in town, the
  Tractor Cure was the talk of the place. But an enemy dwelt there, a
  Dr. Haygarth, an unbeliever. He, with a certain Dr. Falconer,
  fabricated a pair of false tractors. Five cases of gout and
  rheumatism were operated on by the conspirators, who discussed in a
  light tone the wonders of magnetism as they described circles,
  squares and triangles with the sham tractors. "We were almost afraid
  to look each other in the face lest an involuntary smile should
  remove the mask from our faces," says Haygarth, but the two
  assistant doctors, unaware of what was being done, were almost
  converted to Perkinism when they saw the five patients slowly
  mending under the treatment. One man experienced such burning pain
  that he begged to wait till the next day. [Footnote 8]

    [Footnote 8: Compare the first effects of the Leyden Jar, related
    in the chapter on Pseudo-Science.]

  So rapid, and so many were the hospital cures wrought by these two
  doctors, that patients crowded to them and they could hardly spare
  five minutes to eat. They amused themselves inventing other
  instruments made of common nails and sealing wax, and effected with
  them cures, while they sent a pair of false tractors {50} to Sir
  William Watson in London and Dr. Moncriffe in Bristol, who operated
  with them with wonderful results.

It must not, however, be thought that the uneducated, or the
unskilled, or even merely unoccupied, were the only ones taken in by
the supposed power of Perkins' Tractors. As we have seen, many
physicians did not hesitate to avow themselves publicly as believers
in this new and marvelous application of magnetism to human healing.
It is true that the only thing we know about the men who became
advocates of this new instrumental therapeusis, is their connection
with it. The attention of the scientific world was rather cleverly
managed. Dr. Perkins presented a pair of his tractors and the book
that he had written about their use to the Royal Society. The custom
of that learned body was to accept such presentations by a formal
letter of thanks and place the objects and books on their shelves. No
formal investigation of the claims to scientific consideration of such
presentations was made. All possible advantage was taken of the fact
that the Royal Society had accepted the new invention and had publicly
thanked the discoverer for it.

How characteristically recent this old story is; it is renewed on
every possible occasion and wears all the familiar aspect of modern
devices for securing recognition and obtaining the apparent
approbation or recommendation of some scientific society or
institution. We had an example of it a few years ago when a nostrum
exploiter signed the register of an International Congress immediately
after a great medical investigator and then used a photograph of the
names for advertising purposes.

How did the tractors secure the vogue they enjoyed? Those who believed
in them did so not because of the scientific theory that animal
magnetism or magnetic influence was behind them, nor because of the
plausible ways of the Connecticut Yankee, but because of the
unquestioned and unquestionable facts of actual healing that they saw
in connection with the use of the tractors. Every one of these
applications of science to medicine that has proved to be
pseudo-scientific after enthusiasm subsides has made its appeal
through the cures effected by it. Cures are what Eddyism advances to
support its claims, cured patients are presented as their most
effective argument by the osteopaths, cured symptoms are the proofs
for Hahnemannism, but none of these systems of treatment ever cured as
many cases in a corresponding time as did Perkins' tractors. They
cured all sorts of physical ills, but their only effect was exerted
through the mind.

Holmes wrote:

  Let us now look at the general tenor of the arguments addressed by
  believers to sceptics and opponents. Foremost of all, blazoned at
  the head of every column, loudest shouted by every triumphant
  disputant, held up as paramount to all other considerations,
  stretched like an impenetrable shield to protect the weakest advocate
  of the great cause against the weapons of the adversary, was
  that omnipotent monosyllable which has been the patrimony of cheats
  and the currency of dupes from time Immemorial--Facts! Facts! FACTS!
  First came the published cases of the American clergymen,
  brigadier-generals, almshouse governors, representatives,
  attorneys and esquires. Then came the published cases of the
  surgeons of Copenhagen. Then followed reports of about one hundred
  and fifty cases, published in England, "demonstrating the efficacy
  of the metallic practice" in a variety of complaints, both upon
  the human body and on horses, etc. But the progress of facts in
  Great Britain did not stop here. Let those who rely upon the numbers
  {51} of their testimonials, as being alone sufficient to prove the
  soundness and stability of a medical novelty digest the following
  from the report of the Perkinistic Committee. "The cases published
  (in Great Britain) amounted, in March last, the date of Mr. Perkins'
  last publication, to about five thousand. Supposing that not more
  than one cure in three hundred, which the tractors have performed,
  has been published, and the proportion is probably much greater,
  it will be seen that the number, to March last, will have exceeded
  one million five hundred thousand!"

It is not surprising that with such "facts" behind them the tractors
attracted deep and wide attention. A contemporary tells of it and the
fate of the inventor:

  A gentleman in Virginia sold a plantation and took the pay for it in
  tractors. Nothing was more common than to sell horses and carriages
  to buy them. But the worst (or the best) of it was, yellow fever was
  raging in New York, and Perkins thought he could cure the fever with
  the tractors and fell a victim to the fever himself.


Success of Quackery.--Always in the history of quackery and, indeed,
in the history of all therapeutics, the appeal is to the cures that
have been effected. This is the only evidence, of course, that can be
adduced for the development of therapeutics, and yet the history of
medicine makes it clear how carefully supposed cures must be analyzed
if they are really to mean anything. Mesmer could adduce thousands of
cured cases. Perkins could do the same. Every quack in history, from
Galen's weaver, who became a leech, down to the last street corner
nostrum vendor, does the same thing. When on the strength of supposed
cures, then, a new system of therapeutics is introduced, it is much
more likely than not that there is no foundation for the claims made.
We have had ever so many more experiences of disappointment after the
introduction of remedies which cured at the beginning of their
history, than we have had of remedies that maintain themselves after
prolonged experience. It is the attitude of scepticism and suspended
judgment until after a remedy or method of treatment has been tried on
many different kinds of cases in varying circumstances that
constitutes the only efficient safeguard against repeating the
unfortunate errors of old times in the matter of drugs and remedial
measures. If the public could be made to realize this, they would be
much less easily taken in.

What the quacks cure are not always imaginary ills, but often ills
that are very real, at least to the patients, and the symptoms of
which are relieved by the confidence aroused in the new remedy and the
representations of the supposed discoverer, who, in spite of the
exaggerated claims which he makes, somehow succeeds in catching the
trust of patients. Very often this process initiated by the quack is
really only the beginning of the cure.

In most people a vicious circle of pathological subsidiary causes is
formed when anything becomes the matter. Patients are persuaded that a
serious illness is ahead of them. This keeps them from exercising as
much as before. Becoming overcareful of their diet, they reduce it
below the normal limit for healthy activity. This causes them to have
less energy for work and disturbs their sleep. Then a host of minor
symptoms, supposed to be due to the disease, whatever it is or they
think it is, but really consequent upon the unhealthy habits that have
formed, begin to develop. Just as soon as confidence in their power to
regain health is restored to these people, a virtuous circle, {52} to
use the Latin word virtue in its etymological sense, of strength and
courage, is formed. Everything conspires to stimulate the patients;
they live more naturally, the subsidiary symptoms consequent upon
their bad habits disappear and the disappearance of each one of them
means for the patients a new assurance of triumph over disease. They
attribute every improvement to the remedy they happen to be taking,
though most of them are due to the changes in their habits, their
diversion of mind, and the new energy released by their sense of
encouragement.

An excellent example of how some of these mental persuasions in
quackery act, and of how the cure is often really due to the physician
who previously treated the case, though it is credited to the quack,
may be found in the story that Hilton tells in his "Rest and Pain":

  When this patient was first seen by a surgeon, he was thought to be
  laboring under some disease of the bladder and kidneys, for he had
  severe lumbago, pain over the bladder, and offensive urine. There
  had been no suspicion of anything wrong as regards the spine. He was
  a master painter and a house decorator, and was monstrously
  conceited, thinking himself right and everybody else wrong. When I
  explained to him, after careful examination, that the spine was the
  cause of the symptoms, he was not satisfied with my opinion and
  without my knowledge consulted Sir Benjamin Brodie, who also assured
  him that his spine was diseased and told him that he must rest it by
  lying down. To this he then assented. As he could not be controlled
  in his own house, I persuaded him to go to Guy's Hospital, where he
  had got nearly well; but he was very impatient, and would not remain
  long enough under my care to be quite cured. He returned home,
  gradually improved, and was getting quite well when some pseudo
  friend advised hydropathy and homeopathy--it did not matter which
  of the two--as "the thing" to cure him. After a few months he was
  perfectly restored, not by either hydropathy or homeopathy, but,
  no doubt, by nature. The man, however, feels convinced that
  hydropathy and homeopathy cured him. It so happens, gentlemen, that
  sometimes we do not get the degree of credit which perhaps belongs
  to us.

To Mr. Hilton's reflections one is tempted to add that many of these
patients, after having been seriously ill, cannot bring themselves to
think that they will gradually get well by the forces of nature. Even
after they have improved very much they are still inclined to think
that that improvement is illusory or will relapse because they have
not been "cured," that is, actively treated, in some way so that a
"cure" should result. When they are nearly well, because of properly
directed rest and nursing, someone recommends some irregular form of
treatment. They take it up and this gives them confidence that they
are being cured. This state of mind makes the ultimate steps of their
recovery more rapid than it otherwise would be. As a consequence, the
irregular gets the credit. Immediately after this case Mr. Hilton
tells the story of another case in which a "rubber" got all the credit
for the cure. It is evident that the modern osteopath has only
somewhat systematized what had been in existence generations ago.

All this tendency of human nature to respond to anything that is done
for it, provided the promise of cure goes with it, is taken advantage
of by the quack, sometimes unconsciously, for his own purposes.
Results, as a rule, are secured, in spite of the remedies that he
suggests, which in most cases do harm rather than good. Of the
thousands of remedies that have been introduced by quacks, not one now
remains, though every one of them produced {53} wonderful cures on a
great many patients at some time or other. It is the duty of the
physician to secure just as good results honestly. He must influence
the patient's mind favorably so as to bring about a modification of
habits and a hopeful outlook on life, in spite of whatever ailment
there may be. If he can do so he will have in his hands the best
therapeutic measure that has been employed in all the history of
medicine. It is the most universally applicable. It will cure, that is
help, all forms of disease. It will relieve many of the symptoms of
even incurable diseases. It will occasionally arouse the resistive
vitality of the patient to such an extent that even apparently
incurable diseases will be overcome. This is the lesson that the
modern student of medicine must draw from the history of quackery.



CHAPTER VII

NOSTRUMS AND THE HEALING POWER OF SUGGESTION

A striking illustration of the power of the mind to bring about the
cure of ailments and symptoms of every sort is found in the history of
the many nostrums and remedies that have worked wonders for a time and
later proved to be inert or even harmful. The ordinary definition of a
nostrum includes the idea of secrecy. At all times in the world's
history fortunes have been made out of such remedies. They appeal not
only to the uneducated, but also to those who are supposed to be well
informed, and this in spite of the fact that generally the remedies
are claimed to do good for nearly every form of disease, and it must
be evident to anyone, after a moment's serious thought, that the one
idea of their inventor is not to benefit patients, but to make money.

With the multiplication of newspapers and magazines, there has been a
great increase in these secret remedies and of their users. Apparently
all that is needed for many people who are ailing, or think they are
ailing, is to be told in a more or less impressive way that some
remedy will cure, and then it proceeds to do them good. There is a
general impression abroad that some of these remedies represent great
discoveries in medicine, and the feeling of most of those who take
them is that the inventor has found a new and wonderful remedy. During
all the centuries such secret remedies have come and gone, and not one
of them has proved to be of lasting value. Just as soon as its
composition is no longer a secret it begins to fail. It is, therefore,
evident that its effect was entirely due to influence on the mind and
not at all to any influence on the body.

The stories of the origin of these remedies bear a striking
similarity. There are two variants on the theme: either the inventor
is supposed to be an earnest student of science, devoting himself to
profound research for many years and finally finding some wonderful
secret of nature hitherto hidden from men; or else the remedy has been
discovered by happy accident, and some chronic sufferer pronounced by
the most eminent physicians to be hopelessly incurable has in despair
turned to the now method, caring little really, so discouraged is he,
whether it does good or ill, and wakes up to find that he is on the
high road to recovery, apparently having been directed by Providence
in the use of the remedy in question. Overflowing with gratitude, he
{54} wants to share the heaven-sent blessing with all mankind--for a
valuable consideration.


The Weapon Ointment.--Among the most famous nostrums, and a striking
example of the great rôle played in therapeutics by mental influence
and coincidence, is the Unguentum Armariam or Weapon Ointment. This
famous remedy would cure any wound made by a weapon, if it could only
be employed before the fatal effects were absolutely manifest. There
was an abundance of evidence that it stopped the pain, checked the
bleeding and initiated the restoration of the patient to health. We
know the remedy not from traditions of its use among the uneducated,
but from descriptions that we have by men who were among the best
educated of their time, and that by no means an era of dullards. The
story of this infallible remedy is all the more surprising because it
was not applied to the wound itself, nor indeed to the sufferer at
all, but _to the weapon which inflicted the wound_. Nay, it was well
authenticated that, where the weapon could not be secured for
inunction, if the ointment were applied to a wooden model of the
weapon, the cure followed with almost, though, it was confessed by
some, not quite so much assurance as in the fortunate case of the
weapon being available.

The story has been so well told by Oliver Wendell Holmes in his
"Medical Essays" [Footnote 9] that it seems best to retell it in
abstracts from his "Homeopathy and Its Kindred Delusions." He says:

    [Footnote 9: Houghton Mifflin Co., Boston.]

  Fabricius Hildanus, whose name is familiar to every surgical
  scholar, and Lord Bacon, who frequently dipped a little into
  medicine, are my principal authorities for the few circumstances I
  shall mention regarding it. The Weapon Ointment was a preparation
  used for the healing of wounds, but instead of its being applied to
  them, the injured part was washed and bandaged, and the weapon with
  which the wound was inflicted was carefully anointed with the
  unguent. Empirics, ignorant barbers, and men of that sort are said
  to have especially employed it. _Still there was not wanting some
  among the more respectable members of the medical profession who
  supported its claims_. [Italics ours.] The composition of this
  ointment was complicated, in the different formulas given by
  different authorities; but some substances addressed to the
  imagination, rather than the wound or weapon, entered into all. Such
  were portions of mummy, of human blood and of moss from the skull of
  a thief hung in chains.

  Hildanus was a wise and learned man, one of the best surgeons of his
  time. He was fully aware that a part of the real secret of the
  Unguentum Armarium consisted in the washing and bandaging the wound
  and then letting it alone. But he could not resist the solemn
  assertions respecting its efficacy; he gave way before the outcry of
  facts (!), and therefore, instead of denying all their pretensions,
  he admitted and tried to account for them upon supernatural grounds.

Holmes says further:

  Lord Bacon speaks of the weapon ointment, in his Natural History, as
  having in its favor the testimony of men of credit, though, in his
  own language, he himself "as yet is not fully inclined to believe
  it." His remarks upon the asserted facts respecting it show a
  mixture of wise suspicion and partial belief. He does not like the
  precise directions given as to the circumstances under which the
  animals from which some of the materials were obtained were to be
  killed, for he thought it looked like a provision for an excuse in
  case of failure, by laying the fault to the omission of some of
  these circumstances. But he likes well that "they do not observe the
  confecting of the Ointment under any certain constellation; which
  is commonly the excuse of magical medicines, when they fail, that
  they {55} were not made under a fit figure of heaven." It was
  pretended that if the offending weapon should not he had, it would
  serve the purpose to anoint a wooden one made like it. "This," says
  Lord Bacon, "I should doubt to be a device to keep this strange form
  of cure in request and use, because many times you cannot come by
  the weapon itself." And in closing his remarks on the statements of
  the advocates of the ointment, he says, "Lastly, it will cure a
  beast as well as a man, which I like best of all the rest, because
  it subjecteth the matter to an easy trial." It is worth remembering
  that more than 200 years ago, when an absurd and fantastic remedy
  was asserted to possess wonderful power, and when sensible persons
  ascribe its pretended influence to imagination, it was boldly
  answered that the cure took place when the wounded party did not
  know of the application made to the weapon, and even when the brute
  animal was the subject of the experiment, and that this assertion,
  lie as we all know it was, came in such a shape as to shake the
  incredulity of the keenest thinker of his time.

It is interesting to follow up some of the controversies among
scientific men with regard to the weapon ointment, for they serve to
show how the remedy came to maintain its prominence for so long.
Podmore, in his "Mesmerism and Christian Science" (London, 1909),
tells the story of the controversy between Goclenius, a professor of
medicine at the University of Marburg, who published as the Inaugural
Thesis for his professorship, a treatise on the "Weapon Salve," and
Father Roberti, a Jesuit scientist and philosopher, whose final
treatise in the controversy was entitled after the lengthy fashion of
titles in that day, "Goclenius Corrected Out of His Own Mouth; or, The
Downfall of the Magnetic Cure and the Weapon Salve." The decision of
the controversy was eventually referred to the great physician of the
time. Van Helmont, who decided that both disputants were partly wrong,
the Jesuit erring most, but that above all Goclenius should
distinguish between the cases when the weapon had blood on it and when
it had not. When there is blood on the weapon, he held, then the salve
is always effective; when there is not, then much stronger remedies
were required. In both cases, of course, the salve or ointment was
applied to the weapon.

In the midst of this discussion of the points at issue, it is
interesting to note Van Helmont's opinion with regard to many curious
things used in medicine at that time. He insists that Goclenius makes
a mistake in attributing therapeutic power alone to the moss taken
from the skull of a condemned criminal who had been hung in chains.
This material, under the name of _usnea_, was apparently quite popular
in prescriptions for various chronic ills, and especially those that
we now recognize as prolonged neurotic affections. Van Helmont
emphasizes the fact that the experience of all physicians shows that
material taken from the heads of condemned criminals executed in other
ways, as, for instance, those broken on the wheel, may be just as
effective. Van Helmont conceived of the magnetic and sympathetic
feeling as a natural process. All the force of the stars might be
concentrated in objects that had been beneath their beams for a long
time, and this might be communicated in some wonderful way to patients
so as to supply defects of vitality. Such defects of vitality Van
Helmont's prescriptions actually were compensating, but the source was
in the patients themselves--that reservoir of surplus energy which
remains unused unless some strong suggestion brings it out.


Sympathetic Powder.--After the weapon ointment, the best known of the
nostrums of older times is probably Sir Kenelm Digby's famous
Sympathetic {56} Powder, which Dr. Holmes talks of as even better
known than its great therapeutic predecessor. This, too, was a
wonderworker. Unlike the Unguentum Armarium, however, its composition
was simple. It was nothing else than copper sulphate which had been
allowed to deliquesce to a white powder. This powder would cure any
injury as infallibly as the weapon ointment. It, too, was not applied
to the wound, but to the _bloodstained_ garments (Van Helmont's
distinctions between the bloody and the bright weapon should be
recalled) of the wounded person. The patient did not need to be
present at the time the application was made. He might be far away and
yet its efficacy was, according to many very intelligent and highly
educated persons, quite assured.

For the sympathetic powder we have one of the stories of far-fetched
discovery that have since become so familiar. A missionary, traveling
in the East, was said to have brought the recipe to Europe about the
middle of the seventeenth century. The Grand Duke of Tuscany, in whose
dominions the missionary took up his residence, heard of the cures
performed by him and tried by offers of money and favor to obtain the
missionary's secret, but without success. Sir Kenelm Digby, however,
who was traveling in Italy, happened by good fortune to do a favor for
the missionary, and put him under such deep obligations that he felt
the only way he could properly repay his benefactor was to confide to
him the composition of this wonderful remedy. Sir Kenelm Digby was at
this time one of the best known of English scholars. After having
reached distinction in the English navy, he had devoted himself to
literature, to philosophy, and to politics. He had devoted much time
to the old books of alchemy. Therefore, the offer of this precious
piece of information especially appealed to him. On his return to
England he proceeded to use it for the benefit of his friends, and it
created a sensation. The French dictionary of the Medical Sciences
tells the story of the application of the powder for the first time in
England and of the subsequent use of it, especially on the nobility of
England:

  An opportunity soon presented itself to try the powers of the famous
  powder. A certain Mr. Howell, having been wounded in endeavoring to
  part two of his friends who were fighting a duel, submitted himself
  to a trial of the sympathetic powder. Four days after he received
  his wounds, Sir Kenelm dipped one of Mr. Howell's garters in a
  solution of the powder, and immediately, it is said, the wounds,
  which were very painful, grew easy, although the patient, who was
  conversing in a corner of the chamber, had not the least idea of
  what was doing with his garter. He then returned home leaving his
  garter in the hands of Sir Kenelm, who had hung it up to dry, when
  Mr. Howell sent his servant in a great hurry to tell him that his
  wounds were paining him horribly; the garter was therefore replaced
  in the solution of the Powder, and the patient got well after five
  or six days of its continued immersion.

  King James I, his son, afterwards Charles I, the Duke of Buckingham,
  then Prime Minister, and all the principal personages of the time
  were cognizant of this fact; and James himself, being curious to
  know the secret of this remedy, asked it of Sir Kenelm, who revealed
  it to him, and his majesty had the opportunity of making several
  trials of its efficacy, _which all succeeded in a surprising manner_.


Tar Water and Therapeutic Faith.--One further story of an old nostrum
deserves to be told because of the distinction of its chief promoter,
who did not, however, as do most of the nostrum promoters, make a
fortune by it. {57} This is the incident of Bishop Berkeley and his
tar water. Berkeley was one of the leaders of thought of the
eighteenth century. At one time he came to America with the idea of
enlightening the ignorance of the colonists and of founding a school
of philosophy. Besides being one of the most learned men of his time,
he was one of the best. He was known for his gentleness, his
unselfishness, and his lack of pretension. Yet all of these virtues
were unable to save him from falling a victim to a medical delusion.
One of his essays is on the value of tar water in medicine, and is
entitled "Siris, a Chain of Philosophical Reflections and Inquiries
Concerning the Virtues of Tar Water," etc.

Tar water was prepared by stirring a gallon of water with a quart of
tar, letting it stand for several days, and then pouring off the clear
water. It, in fact, retained scarcely more of the tar than the odor.
According to the great philosopher, this not only cured, but prevented
diseases. The list is, indeed, so long that it is hard to understand
how the claims for it could have received any credence. They did,
however, and Berkeley himself, and many of his friends, were cured of
many and various ills, and were protected from many more by its
frequent use. The odor was the factor that proved of suggestive value
and set free the springs of vital energy.


Sarsaparilla.--It might be thought that such deception of self and
others as has been illustrated in the weapon salve and sympathetic
powder would be impossible in our enlightened day. Anyone who thinks
so forgets certain incidents of recent times. The story of
sarsaparilla is a striking illustration. Few drugs have been more
popular in the last half century, and it is even yet popularly
supposed to be a wonderful tonic, a cure for many diseases. During the
first half of the nineteenth century, when the humoral theory of the
causation of diseases was generally accepted, certain German
physicians thought they observed that a decoction of sarsaparilla was
a sovereign remedy for various ailments having their origin in the
blood. The blood was at that time supposed to become impure for many
reasons, and the possibility of neutralizing such impurity by medical
measures was seriously attempted. As Virchow used to insist, the
humoral pathology still holds its ground in popular estimation, and so
blood purifiers are favorite remedies, and will doubtless continue to
be for at least another generation, until cellular pathology secures a
hold on the popular mind.

Sarsaparilla came in, then, as a great blood purifier, and was used
for ten years by many of the physicians of the world, confident that
they were obtaining excellent results from its use. After a time,
however, further study of the drug showed that it was inert. Gradually
the employment of sarsaparilla as a remedial agent ceased, though it
continued to be used as an elegant vehicle in the prescription of
nauseating remedies.

Only after it had been thus abandoned by the regular profession, was
it taken up extensively by others who advertised its virtues widely
and secured a great clientele for it. Probably more money has been
spent on sarsaparilla during the last fifty years than on any other
single drug. Many millions were every year appropriated by rival
concerns to advertise its virtues. It has been possible at any time
during the last half century to secure any number of people who were
willing and ready to declare--and most of them convinced of the truth
of what they said--that various preparations of {58} sarsaparilla had
cured them of long-standing ills, and that they considered it a
life-saving remedy.

The efficient ingredient in the sarsaparilla, so far as any of its
various preparations have seemed to do good, has not been anything
that was in the bottle, but the printer's ink that was absorbed from
the outside of it. People were persuaded that they would get better,
and, as far as most of them were concerned, this was of itself quite
sufficient to turn the scale in favor of improvement that led to the
obliteration of symptoms. So long as these symptoms were a source of
worry and trouble to them, they continued to be quite incurable. Just
as soon as the inhibition of nervous energy, due to worry and
over-attention to their sensations, stopped, then the natural force of
the body was sufficient to remove the sources of complaint.


Psychology, Old and New, of Remedies.--Men have always known how to
take advantage of the possibility of influencing patients' minds by
wondrous claims for remedies. Anyone is sadly deceived who thinks that
it is only in recent times that men have learned to make their
advertisements of nostrums suggestive by the promises made or that we
have developed the psychology of advertising to such a degree as to
appeal to the ailing more forcibly and surely than was done in the
past. Here is the announcement that went with a remedy in old Irish
medicine more than 1,000 years ago. It was, according to its inventor,
"a preservative from death, a restorative for the want of sinews
(strength), for the tongue-tied, a cure for swelling in the head, and
of wounds from iron and of burning by fire, and of the bite of the
hound; it preventeth the lassitude of old age, cures the decline, the
rupture of the blood vessels, takes away the virulence of the
festering sore, the fever of the blood, the poignancy of grief--he to
whom it shall be applied shall be made whole." The announcement ended
up with the panegyric "extolled be the elixir of life bequeathed by
Diancecht to his people; by which everything to which it is applied is
made whole." When it is noted that, besides death and loss of muscle
power and aphasia and wounds and burns and bites, it also cures old
age and consumption (for that is what is meant by decline) and
hemorrhages, and probably aneurysms, and fevers and also grief, there
are not many modern panaceas that exceed it in power.

Always, as in this Irish announcement of the olden time, the climax of
the advertisement is a note of exultant praise for the inventor who
has brought such a magnificent blessing to mankind. The ways of the
nostrum vender are ever the same.


Roman Nostrums.--How old are all these methods, and how little human
nature has changed through all the centuries! The patent medicine men
of Rome in the early Christian eras made use of just the same methods
that are employed to-day. Friedländer, in his "Roman Life and Manners
Under the Early Roman Empire," tells the story well. Many remedies
were known by special arbitrary names, instead of descriptive names
recalling the ingredients. Sometimes they were named after famous
physicians who had used them, or were said to have done so; again, the
preparations were named after persons of distinction who actually, or
supposedly, were cured thereby, much as, in our own day, cigars are
named after poets, statesmen and pugilists. The titles of some of
these preparations, for instance, were "Ointment for Gout, Made for
Patroculus, Imperial Freedman--Safe Cure"; "Ointment for {59} Aburnius
Valens" (probably the famous jurist) called the "Expensive Ointment";
"Eye Salve with Which Florus Cured Antonia, the Wife of Drusus (the
Emperor's son) After the Other Doctors had Nearly Blinded Her." Many
of these remedies were labeled "instantaneous," "safe," "sure cure,"
"Harmless remedy," and the like. Frequently euphonious names,
sometimes from the Greek, were chosen: Ambrosia, Anicetum, Nectarium,
for the promoters evidently knew the satisfying effect, on both
patient and physician, of a mystifying foreign name.


_Proprietary Remedies_.--A corresponding abuse very like that of our
own time was with reference to proprietary medicines. Physicians,
instead of compounding their own, accepted those made by others with
the exaggerated claims for them, used them on patients, transferring
their own confidence in them to the patients, thus producing cures
which, after a time, proved to be due entirely to the influence on the
patient's mind. Pliny, the elder, complains that physicians of his
time (the first century after Christ) often bought their remedies so
as to avoid the trouble of preparation. He evidently refers to
compounds supposed to be curative for various affections; for
Friedländer says that "often the physicians did not know the exact
ingredients of the compounds that they used and should they desire to
make up written prescriptions, would be cheated by the salesmen." Both
Galen and Pliny complain that physicians used ready-made medicines,
instead of original prescriptions carefully prepared by or under the
supervision of the physicians themselves. It is evident that the
proprietary remedy had come into existence thus early, and that
various drug manufacturers made specialties which physicians,
following the line of least resistance, found it easy to prescribe,
though men like Pliny and Galen realized that this was an abdication
of one of the most important functions of their profession, which was
bound to work harm in the end both to themselves and to their
patients.

How curious it is to find exactly the same state of affairs recurring
in our time, with absolutely similar results. Simple remedies that are
well known combinations of ordinary drugs receive high-sounding names,
usually derivatives from the Greek or the like, and are claimed to
work just as many wonders as the old-fashioned nostrums. Even
imitations of the old-fashioned poultices, when thus exploited, give a
new lease of life to the exploded idea of the drawing-out power of
external applications.


Common Ailments and Nostrums.--Certain ailments are particularly the
subject of exploitation by the manufacturers of remedies. Rheumatism
is one of these, neuralgia is another, catarrh is a third, and
headache a fourth. Then there are various forms of indigestion and all
the pains and aches associated with it. All of these ailments are
rather vague and are in some cases at least, due to the insistent
dwelling of the patient's mind on some symptom of very little
significance. Others are real pains and aches, relieved by some simple
anodyne drugs, doubly efficient when taken with the suggestion that
they represent a wonderful discovery, which came only after long years
of study and investigation, and are said to represent a new departure
in medicine. Another favorite field for the nostrum vender is the
series of pains and aches associated with the menstrual condition.
Many of these nostrums are used by hundreds of thousands, and yet an
analysis shows that probably the only active substance in them is the
alcohol in which certain of the drug {60} principles are dissolved.
This makes the patient feel better by the exaltation that comes from
the dose of alcohol and the rest is merely suggestion, though there is
no doubt that symptoms which have failed to be cured by physicians are
sometimes relieved by these remedies. It is a cure by faith, not by
medicine.


Cured Cases as Evidence.--As all of the nostrums, and indeed all the
therapeutic movements supposedly medical or physical or religious,
secure their vogue on the strength of reported cures, this would seem
to be the best possible evidence for the efficacy of a remedy. But
unless the cases supposed to be cured are critically examined and
analyzed, and above all, followed for some time afterwards, such
evidence is open to all sorts of errors. Is it any wonder, then, that
the physician, familiar with the history of medicine in this regard,
asks for the careful study and analysis of these cases. We know that
it was on the strength of cures effected by it, that the weapon
ointment became possible throughout Europe. We know that portions of
the body of executed criminals and the touch of the hanged cured as
many cases as, let us say, osteopathy or Eddyism. The sympathetic
powder and its advocates appealed to the many cures that followed its
use. Every other nostrum from the beginning of time has made this same
appeal.



CHAPTER VIII

AMULETS, TALISMANS, CHARMS

Amulets, talismans, charms--these words are commonly used with
something of the same significance, and for our purpose all three may
be treated in common.


Prophylactic Objects.--From the earliest ages men have worn amulets,
that is, objects often resembling jewelry, though sometimes the
remains of animals or even of men, [Footnote 10] with the idea that
they would ward off illness, or cure it when present. Rings of many
sorts, brooches, various objects suspended around the neck, ear-rings,
head-bands, belts for the waist, and rings for the wrists and the
ankles, ornamented bracelets and anklets, have at all times had a
medicinal power attached to them in some minds. Earrings are still
worn by many with the idea that they are helpful in affections of the
eyes. I have known children's ears to be pierced and earrings inserted
because the little ones were suffering from headache. Precious stones
were supposed to have this power when worn. The amethyst protected its
wearer from drunkenness; the bloodstone cured anemia; while the opal
was supposed to portend evil. Occasionally such gems were ground up
and used as internal or external remedies, because of the power
supposed to be attached to them. Their influence upon the mind, at
least, can be readily understood. The earliest prescription we have in
America is at the Metropolitan Museum, New York, among the curiosities
from Egypt (about 1500 B.C.). It calls for the use of ground up
precious stones in fumigations, probably for an hysterical person.

  [Footnote 10: A king of Italy of the later nineteenth century used
  to send the parings of his toe-nails to friends to be worn in rings
  for luck and protection against disease.]

The precious metals were used also as powerful cures. Chaucer says,
"for {61} gold in physick is a cordial." Some think that our own use
of chloride of gold a few years ago for many chronic ills had little
more reason than the preciousness of gold impressing itself on
patients. Inscriptions were made on the metals, and these were
supposed to add to their healing or preservative quality. Famous among
these was the abracadabra. It had to be written in a particular
triangular form, and was then very powerful. Here the amulet invades
the sphere of the charm. Prayers were written on parchment, or on
paper, or on papyrus, in the old time in Egypt, Babylon and Assyria,
and when worn about the body were supposed to do great good. It is
surprising to us now how many physicians and scientists placed
confidence in these things because they thought that they had seen
good results. Alexander of Tralles recommends a number of them. Robert
Boyle, the father of chemistry, says that he was cured of a severe
ague, that the doctors could not benefit, by the application of an
amulet to his wrists. Burton, in the "Anatomy of Melancholy," has a
series of references that show how much he, himself, and the educated
men of his time, believed in the power of amulets to help in illnesses
and Boyle, particularly, has a number of references to precious stones
and their curative virtue.


Rings in Therapy.--Under Faith Cures I mention the cramp rings blest
by the Queen of England and effective against abdominal pains. Other
kinds of therapeutic rings were used rather commonly. All through the
Middle Ages iron rings were worn, which were good for colic and
biliousness and also for rheumatic pains. There are literally
thousands of such rings worn now, here in the United States, and by
quite intelligent people. Personally, I know of more than a dozen
cases where they have been worn for years. The wearers faithfully take
them off each day, rub off the rust which collects on the inside, call
their own and others' attention to the fact that all this material has
been drawn out of the body through the supposed electrical power of
the ring, and then they replace them. Here is pseudo science obtruding
itself. Usually these rings are of polished steel and look a little
like silver. They may, however, be obtained in gold plate, and then
are supposed to be quite as efficacious. The iron or steel rings cost
two dollars each; gold-plated rings cost five to ten dollars,
according to the ability of the patient to pay, for metallotherapy has
as one of its effects the lessening of congestion of the purse. Those
who wear them would not part with them, because they feel the benefits
derived. These rings are supposed to be particularly good for vague,
painful conditions in the joints, especially the so-called rheumatic
pains.

In old times these rings were sometimes engraved with a legend that
was itself a strong suggestive element. The rings of the Middle Ages
that were supposed to be a cure for biliousness were engraved with a
command to the bile to go and take possession of a bird. Occasionally
rings were supposed to be valuable because of their origin. Epileptic
fits, for instance, were rendered much less frequent and less severe
if a ring made of money that had been given in the church were worn.
The condition was that the sufferer should stand at the church door
asking a penny from every unmarried man who passed in or out. After
sufficient alms had been thus collected the money was exchanged for
silver money that had been contributed to the church, and from this
the ring was made. It was to have a cross and sometimes a verselet
from Scripture, or an exorcism, or a prayer, engraved on it. It is
{62} easy to understand that all of this represents strong suggestive
influence and that the standing at the church door begging alms might
well represent an enforced prolonged opportunity to get rest and air,
for many unmarried men do not go to church, and so there were also
physical factors at work in the cure noted.


Precious Stones as Preservatives.--Pettigrew, in his "Superstitions
Connected with Medicine and Surgery," mentions a number of the
precious stones and their power to heal. Garnet hung about the neck
relieves sorrow and refreshes the heart; chrysolite is the wisdom
stone, the enemy of folly; heliotrope staunches blood and acts as an
antidote; sapphire is good for ague and gout, and also gives its
wearer courage; it also stops bleeding at the nose and was an
antidote; the topaz was good for lunatics; the carnelian cured bloody
fluxes and also fluxes of anger and passion. Jasper, hematite and
similar stones had certain general powers of doing good. The Bezoar
stone had a great reputation against melancholy; the smaragdum was
infallible against epilepsy; the onyx was good for sleep; the sardonyx
prevented bad dreams. The most wonderful stone, however, was the
agate; taken in liquid it was good for any disease. It made the skin
healthy. It preserved against snakebite, and against all poisons, and
it prevented the devil from injuring one who wore it or drank it, and
also preserved him from being struck by lightning. Considering how
common agates were and how readily they could be obtained, it is
rather surprising that we should have so many stories of illness and
deaths by lightning and from poison and from venomous serpents in the
old days when its curative value was rated so high.


Amulets.--The coin given by the kings of England when they healed the
scrofulus or epileptic came to be, in one sense, an amulet. The sight
and the touch of this acted as an ever recurrent suggestion tending to
make these patients better, and undoubtedly the coin was of great
service by its renewal of the mental influence of the touch of the
king. There are traditions, also, that these coins healed others who
touched them, and sometimes for generations they were kept in families
as representing a fountain of healing and of preservation of health.
Any object that thus became invested with reverence produced healing
effects. Virchow, in the introduction to Schliemann's "Troas," tells
of going to a long distance for water, during the time when he was
present at the excavations, in order to be sure that the water would
be absolutely pure. The natives had heard that he was a great
physician from the West. They concluded that the reason why he went to
this particular distant spring for water, in spite of the trouble
involved, was that it must have some wonderful healing virtues.
Accordingly a tradition of healing grew up around it, and people came
from long distances, drank from it and were cured.

There are still people who carry horse chestnuts for rheumatism, and
occasionally a farmer carries a potato for the same purpose. The
feeling is, if they do no good, at least they can do no harm.
Doubtless in the Middle Ages the same feeling prevailed as to other
favorite objects. At present, among the better informed classes,
various pendants supposed to have some connection with electricity are
popular. I have seen a medal made of alternate discs of copper and
zinc, and confidently believed to be strongly electrical, worn even by
an otherwise sensible merchant in a country town. Electric belts still
are {63} extremely common--and expensive. Supposed electric insoles,
one made of copper, the other of zinc, are sold in great numbers and
at good prices, though, quite needless to say, they are absolutely
inert electrically. Various electric contrivances, small batteries,
and the like, really are of the nature of amulets. People have a faith
in them that is not justified by anything in science, but that faith
helps them in their ills. Most of the supposed medicinal plasters are
in the same class. As a rule, sufficient curative material cannot be
incorporated in a plaster to be of any service, and most of them,
though widely advertised, are scarcely more than rubber adhesive
plaster. They do good partly by their mechanical effect, because they
actually support muscles, but mainly because of faith in their
efficacy. Whenever a particular discomfort occurs the feeling that a
plaster is covering the spot gives the patient assurance that he or
she must soon be better. In all of these effects there is no
manifestation of any physical or marvelous supernormal power, but
simply and solely of the influence of the mind on the body.



CHAPTER IX

DETERRENT THERAPEUTICS

In the history of therapy a peculiar phase was the use of all sorts of
materials, intensely repugnant to human nature and deterrent to all
the finer feelings, but which, nevertheless, proved curative of many
ills. We know now that there was absolutely nothing remedial in these
substances or methods of treatment, but only the effect produced upon
the patient's mind. If the patient makes sufficient effort to overcome
the intense repugnance, that enables him to release hitherto latent
vital energies, or to correct hampering inhibitions which have
prevented curative reactions. The more the patient had to conquer
himself, or herself, the more surely did the remedy produce a good
effect. It was effective, however, not only among the poor and the
uneducated, but often also among the better informed, provided the
patients became persuaded of its efficiency. Persuasion in these
matters is usually best secured by the reports of cured cases. It is
easy to obtain "cures" from almost anything. They are set up as
confident proofs of the remedial virtue of methods of treatment. They
have been, in the history of medicine, more often the indexes of
action upon mind than upon body. Real remedies help patients to get
better. Supposed remedies, that afterwards prove quite inert, _cure_.


Portions of Corpses.--One of the ingredients of the famous Unguentum
Armarium (see chapter on Nostrums) was, as has been said, moss scraped
from the skull of a man who had been hanged. It was declared to be
particularly efficacious against so-called dead members, such as the
blanched fingers of Raynaud's disease, or the hysterical palsies, and
other functional paralytic conditions of the limbs. The real
therapeutic factor was not the gruesome material itself, but the
potent suggestions awakened by it. It is probable that the quacks and
witch doctors who gave out the formula of their remedies as containing
such material often did not take the trouble to collect them, and that
their salves and ointments were really quite inoffensive preparations.

{64}

Touch of the Hanged.--Some of the traditions which gather round the
effect of contact with the body of a hanged person are curiously
interesting from the standpoint of psychotherapy. This form of
execution seems to have had a much more potent influence in producing
therapeutic elements in the bodies of the victims than any other. We
do not hear much of the touch of a beheaded person's body nor of any
place in medicine for portions of the victims of execution by
shooting, though Van Helmont claims curative properties for these in
lesser degree. All sorts of ailments were, however, supposed to be
cured by the touch of a hanged person. Thomas Hardy in his "Wessex
Tales" tells of a young woman in his time suffering from a paralyzed
arm, apparently a form of paralysis due to a functional nervous
condition, who was recommended by an old "conjure" doctor to touch her
bared arm, as soon after the execution as possible, to the purple mark
of the rope around the neck of a man who had been hanged. The doctor
assured her this was the only means by which she could be cured. We
would not be surprised to hear of her cure under such circumstances.

Hardy has carefully collected his material regarding the traditions of
the southern part of England, and he makes the hangman say, when the
woman applies to him for permission to touch the body of the victim,
that such a request had not been made for some years, but that there
used to be many applicants when he was a younger man. He adds,
moreover, that it was the custom to apply to the governor of the
prison and that usually this application was made by the physician of
the patient who accompanied him or her on the visit to the corpse.
There is no doubt that physicians did, in many cases, have recourse to
such methods, and that the reasons for their belief in the efficacy of
the touch of the dead was that they had seen the cure in this way of
many puzzling diseased conditions, which their skill in wortcraft and
herbal medicines had not enabled them to relieve. The touch of the
corpse was supposed to bring about a "turning of the blood," and this
produced the good effects. Occasionally the patients fainted from
terror, yet afterwards were found to be able to use limbs that had
been quite beyond their control before. The story is typical of what
happened in country districts all over Europe for centuries.


Mummies.--How little distant we are from the use of such material for
therapeutic purposes will be appreciated from the fact that mummy was
used in medicine down nearly to the end of the eighteenth century. The
first edition of the "Encyclopedia Brittanica" (1768) said:

  We have two different substances preserved for medicinal use under
  the name of mummy, though both in some degree of the same origin.
  The one is the dried and preserved flesh of human bodies, embalmed
  with myrrh and spices; the other is the liquor running from such
  mummies, when newly prepared, or when affected by great heat or
  damps. The latter is sometimes in a liquid, sometimes of a solid
  form, as it is preserved in vials well stopped, or suffered to dry
  and harden in the air. The first kind of mummy is brought to us in
  large pieces, of a lax and friable texture, light and spongy, of a
  blackish brown color, and often damp and clammy on the surface: it
  is of a strong but disagreeable smell. The second kind of mummy, in
  its liquid state, is a thick, opaque, and viscous fluid, of a
  blackish color, but not disagreeable smell. In its indurated state,
  it is a dry solid substance, of a fine shining black color, and
  close texture, easily broken, and of a good smell; very inflammable,
  and yielding a scent of myrrh and aromatic ingredients while
  burning. This, if we cannot be content without medicines from our own
  bodies, ought
{65}
  to be the mummy used in the shops; but it is very scarce and dear;
  while the other is so cheap, that it will always be most in use.

  All these kinds of mummy are brought from Egypt. But we are not to
  imagine, that anybody breaks up the real Egyptian mummies, to sell
  them in pieces to the druggists, as they may make a much better
  market of them in Europe whole, when they can contrive to get them.
  What our druggists are supplied with, is the flesh of executed
  criminals, or of any other bodies the Jews can get, who fill them
  with the common bitumen so plentiful in that part of the world; and
  adding a little aloes, and two or three other cheap ingredients,
  send them to be baked in an oven, till the juices are exhaled, and
  the embalming matter has penetrated so thoroughly that the flesh
  will keep and bear transportation into Europe. Mummy has been
  esteemed resolvent and balsamic: but whatever virtues have been
  attributed to it, seem to be such as depend more upon the
  ingredients used in preparing the flesh, than in the flesh itself;
  and it would surely be better to give those ingredients without so
  shocking an addition.


Serpents in Therapeutics.--Snakes and portions of snakes have been
prominent features of deterrent therapeutics at all times. Headaches
were cured by wrapping a dead snake around the head, or by the touch
of a snake's skin, and sore throat by wearing a snake's skin around
the throat at night. This seems one degree better than the custom,
still common, of wrapping the stocking, that has been worn during the
day, around the neck. In the chapter on Graves Disease, the use of the
touch of a snake, or of a snake's skin worn around the neck, is
mentioned. Girdles made of snake's skin or snakes themselves, were
supposed to be good for colic and for various internal troubles, and
were sometimes, among barbarous peoples, a sovereign remedy for the
ills of pregnancy and assured the woman a safe delivery and an easy
labor. Undoubtedly they lessened dreads by suggestion and the effort
necessary to overcome repugnance. Some of the symptoms of the
menopause have been cured in the same way. Rattlesnake oil has had a
special reputation among mountainous people, where the snakes
abounded, for the pains and aches of the old, and the vague joint
discomfort, sometimes spoken of as rheumatic, but really due to
various individual conditions. It is probable that in most cases the
oil thus employed was not extracted from the rattlesnake, but was some
ordinary oil palmed off under that name, and having its special
effectiveness because of the thought associated with it.

Various portions of serpents are still in use, sometimes in the hands
of physicians, though usually in popular medicine. I knew a physician
in a small inland city who had a great local reputation for curing
external eye troubles, and who owed not a little of it to the fact
that the people in his neighborhood thought that he used rattlesnake
oil as one of the ingredients for his strongest prescriptions. He was
supposed to be able to dissolve even cataract by his remedies, and
there is no doubt that in many cases of chronic indolent ulcer of the
eye he was able to bring about a cure sooner, and have it last longer,
than those of the regular profession who had not the advantage of this
popular faith. He was careful to buy rattlesnakes from certain of the
mountain people, who killed and brought them to him and who advertised
the fact that they had such commissions from him. The stories were
made all the more interesting by the fact that the doctor would not
purchase dead rattlesnakes. They must be brought to him alive, since
the therapeutic virtues can only be extracted immediately after death.
A mountaineer with a couple of live rattlesnakes with him is always an
interesting object and a fine {66} advertisement. One would like to
know what the doctor did with the snakes--that is, how he disposed of
them without suspicion. Homeopathic physicians still have
lachesis-viper venom in their pharmacopeia. Their remedies, however,
if they really follow the dilution principle of their founder, can
have an effect only on the mind, so that the use of lachesis is not
surprising.


Repugnant Remedial Measures.--Quite in keeping with the use of
deterrent remedies of various kinds are the recommendations to do
certain things that involve great self-control, and the overcoming of
repugnance, or fright, or the like. A favorite mode of preparing
remedies in the Middle Ages was to gather the particular herbs for the
prescription in a graveyard in the dark of the moon. The patient
himself was supposed to gather them and to be alone when doing so, if
they were to be effective. How much occupation of mind and diversion
of thought would be afforded for timid people by the effort to
overcome themselves to this extent! The occupation of mind alone and
the concentration of thought necessary for the ordeal would be quite
sufficient to divert many people from the centralization of attention
on themselves, which is responsible for so many of their symptoms, or
for that exaggeration of symptoms that aggravates the ailment.


_Ordures as Remedies_.--Among all primitive peoples we have the story
of the use, as remedies, of ordures of various kinds, of repugnant
portions of animals, of ground insects, of animal excrement and urine,
and even of human excretions, of the blood of serpents, or eels, or
carrion feeding birds, and the like. Ground lice and insects of
various kinds are very common as prescriptions in the history of
primitive medicine. They turn up here and there through the Middle
Ages, and they are said to be still used in China. The more one knows
about side-tracks in medicine, the more does one find of far-fetched
repugnant materials vaunted as wonderful cures. Some of the substances
employed are so disgusting that one does not care to mention, much
less discuss, them. I have had a man tell me that, in a severe
epidemic of diphtheria, he saved his children's lives when they were
attacked by the disease, and the children of others were dying all
around him, by blowing the dried excrement of dog down their throats.

There are certain popular medical practices that are related to these
old traditions of deterrent therapeutics. In many manufacturing
establishments, in spite of progress with regard to sepsis and
antisepsis and the diffusion of information as to first aid to the
injured, it is still the custom to put spittle on wounds. I am sure
that every doctor has seen quids of tobacco used in this way. Even
native-born Americans, who are not illiterate, are sometimes found
using some deterrent material. I have known such a man use his own
urine as an eye-wash for sore eyes, and the use of children's urine
for such purposes is much commoner than might be thought. After all,
it is only a generation since physicians used to taste urine in order
to determine whether it contained sugar or not, and I have seen a
country doctor even take between his finger and his thumb a little of
the excrement of a child and apply his tongue to it, pretending of
course that he obtained very valuable information this way.


_Excretions and Secretions_.--All the human excretions have formed the
basis of vaunted remedies. Tears, on the principle that like cures
like, were used for melancholia; nasal secretion to lessen respiratory
difficulty through {67} the nose; sputum for various mouth affections,
but also as an application to external abrasions, and to the eyes, the
ears, and the like. Undoubtedly patients were helped by many of these,
not because of any physical effect, but because they felt easier as a
consequence of the satisfaction of having something done for them, and
the consequent freedom from solicitude which allowed nature to produce
her curative reaction without interference. The greater the effort he
has to make, apparently the more efficiently does he control this
disturbing state of mind. This is the secret of many cures now as well
as in the olden time.

Whatever good effect is produced in such cases comes, of course, from
the persuasion that these substances will do good, and there must be a
strong suggestion to that effect before the repugnance can be
overcome. While we are prone to think the older peoples who used such
materials commonly are to be condemned for ignorance and superstition,
it is well to recall that human nature has not changed, and is still
ready to be influenced in the same way. Brown Sequard's extract of
testicular substance came in this category. We had a wave of
organotherapy a few years ago, and we know now that whatever benefits
patients derived from taking heart substance for heart troubles, and
brain substance for brain troubles, and kidney for renal diseases, was
entirely due to mental influence. The cannibal who eats the heart of
his enemy, thinking that the vigor and courage of the other will pass
into him, undoubtedly has for a time a power of accomplishment greater
than before. Nothing acts so powerfully as suggestion of this kind to
give renewed vigor and to enable us to tap sources of energy that we
were not aware of in ourselves, and that enable us to accomplish what
before seemed quite impossible, and even to bring about curative
reactions.


Diseases Benefited.--Observe the classes of disease that were
particularly relieved by deterrent therapeutics. Headache was one of
these. All sorts of things were cures for headaches--the touch of the
hangman's rope, or of an executed criminal, or some herb gathered in
the graveyard in the dark of the moon, or pills made of the excrement
of various animals. The forms of headache thus relieved would be those
in which over-attention to self, rather than real headache, produced
queer feelings in the head, though concentration of attention might
exaggerate this into an ache. Foot troubles were cured by deterrent
therapeutics. To wear the shoes of a dead person, especially of a
murderer who had been hanged, would cure them. Colic was cured by
pills of excrementitious materials, and by all sorts of other
deterrent remedies. For instance, one well-known remedy was to wash
the feet and drink the wash-water. The wash-water of little babies was
a favorite remedy for the vague abdominal pains of old maids, and for
the symptoms due to the menopause.


Deterrent Pain.--A striking illustration of a strong mental influence
helping out a slight amount of therapeutic efficiency is found in the
use of the actual cautery for medical affections. At a number of times
in history most of the chronic pains and aches, the arthritises, the
so-called gouty tendencies when localized, the rheumatic affections
and especially the chronic rheumatisms, have been treated by means of
the cautery. All of the neuralgias, many of the neuroses, all of the
neuritises and a certain number of so-called palsies and paralyses,
were treated successfully by this means. It is a very suggestive
remedy producing a deep impression that now relief must be in sight.
It {68} became popular over and over again, though after a time it
always lost its influence, and ceased to have the beneficial effects
that it had at the beginning of its reintroduction.

During the second half of the eighteenth and the beginning of the
nineteenth century the cautery became very popular. It was applied
particularly in the form of the moxa. A cylinder of cotton was
employed for this purpose, being set on fire and allowed to burn on
the skin of the patient, producing a deep wound. The mental effect of
this can be readily understood. Baron Larrey, one of the most eminent
surgeons of the time, thought the moxa one of the best aids that he
had in the treatment of many affections where the knife was not
indicated. There were large groups of diseases in which it was almost
a specific. Larrey employed it in affections of vision, of smell, of
taste, of hearing and of speech. In many paralytic affections of the
muscular system, in all chronic affections of the head, among which he
enumerates non-traumatic affections, hydrocephalus, chronic headaches
and many other affections supposed to be seated in the cranium. In
asthma he was particularly successful with the moxa. Old catarrhal
affections yielded to it. Consumption was frequently benefited by it.
Most of the chronic affections of the uterus were benefited, as were
also similar affections of the stomach. He considered that the moxa
must be admitted, without contradiction, to be the remedy _par
excellence_ against rachitis. In Pott's disease, which he called
dorsal consumption, it worked wonders. In sacrocoxalgia, in
cocygodynia and femero-coxalgia he had excellent results with the
moxa.

A glance at this list shows exactly the class of cases in which
suggestion has always played a large role, and for which there has
been, at various times, a series of specific remedies, medicinal,
manipulative and surgical. Others extended the value of the moxa
beyond these affections. Ponto found it valuable in gout, and in the
various chronic affections which are sometimes grouped under the name
chronic rheumatism. He insisted that the moxa could be placed on
almost any part of the body, though the contra indications he suggests
show how far the men of his time went with its use. Only these
portions named might not have a moxa applied to them. It must not be
used on the skull, on the eyelids, on the ears, on the mamme, on the
larynx and on the genitals, though it might be applied to the perineum
or the perineal body.


Deterrent Taste and Smell.--The disturbing effects produced by other
senses besides those of sight have been used in the same way for the
production of definite therapeutic suggestive effects. A number of the
ill-tasting, almost nauseating drugs of the olden time prove to have
very little real therapeutic efficiency in the light of modern
clinical careful observation. This is particularly true of the herbs
and simples. Many a disgusting preparation apparently owed all of its'
good effects on the patient to the effort that was required to swallow
it, producing such a favorable influence upon the mind, by
_contrecoup_ as it were, that the patient got better. A little girl
said that cough medicines were nasty things they gave you in order to
keep you from catching cold again. The sense of smell has been used in
the same way. Valerian is probably an efficient drug in certain
respects, but undoubtedly its efficiency is materially increased by
its intensely repulsive odor. For many of the psycho-neuroses and
neurotic conditions generally the ammonium valerianate is likely to be
much more efficient than the strychnin valerianate, though probably
the {69} latter should be considered as more physically efficacious in
its tonic properties. Asafetida, musk and some preparations of the
genital organs of animals that used to be in the pharmacopeia, owed
most, if not all, of their power, whatever it was, to the mental
effect of their odor and the feeling of deterrence that had to be
overcome before they were taken.

There is a precious therapeutic secret in this use of deterrent,
repugnant, frightful materials which patients use to advantage under
certain circumstances. It illustrates the influence of the mind over
the body, and emphasizes the fact that such influence can be exerted
in the full only when a deep impression is produced upon the patient.
Whether this can be imitated without deceit, and without the use of
undignified methods, must depend on the physician himself and his
personality. There can be no doubt that there is a wonderful power
here to be employed. It must be the physician's business to find out
in each individual case, according to his own personal equation, just
how he may be able to use at least some of it. It is well worth
studying and striving for, because nothing is more potent for
psychoneurotic conditions, and for neuroses on the borderland of the
physical, than which no ailments are more obstinate to treatment.



CHAPTER X

INFLUENCE OF THE PERSONALITY IN THERAPEUTICS

Though it has seldom been fully realized and has probably never been
appreciated as in our time, one of the most important factors in
therapeutics, in every period of the history of medicine, has been the
personal influence of the physician. Therapeutic fashions have come
and gone, new drugs have been introduced, have had their day and then
been relegated to the limbo of worn-out ideas. At all times, however,
physicians have succeeded in doing good, or at least using, with
apparent success, the therapeutic means of their own time, however
crude and inadequate these afterwards proved to be. They have
succeeded in shortening the progress of disease as well as increasing
the patient's resistive vitality and thus enabled him not infrequently
to survive where otherwise a fatal termination might have occurred.
All unsuspected during most of the time, it was the personal influence
of the physician that counted for most in all of the historical
vicissitudes of therapeusis. It mattered not that the means he
employed might seem absurd to the second succeeding generation, as was
so often, indeed almost invariably, the case, his personal influence
has at all times overshadowed his available therapeutic auxiliaries.
In spite of all our advance in scientific medicine, to a considerable
degree this remains true even at the present time, and to fail
properly to use this important auxiliary is to cripple medical
practice.


Place of Personal Influence.--When the antitoxins and directly
curative serums seemed about to make for themselves a place in
therapeusis, it looked for a time as though this personal element
might be entirely superseded. It seemed that all other therapeutic
factors must give way to definitely accurate doses of antitoxic
principles, directly opposed to the toxins of disease and {70} capable
of conquering it. With the success of diphtheria serum, the prospects
for scientific therapeutics from the biological standpoint became very
promising. Unfortunately, our further experience with antitoxins and
therapeutic sera of various kinds has not been satisfactory, and now
the medical world is looking elsewhere for progress in therapeutics.

This throws us back once more on the old-time therapeutics, and we
have to learn to use all their elements. One of the most important of
these, if not, as we have suggested, absolutely the most important,
the one that in all the many variations of therapeusis has maintained
itself, is the personal influence of the physician by which he is able
to soothe the patient's fears, allay his anxieties, make him face the
situation calmly so that he may not use up any of his vital force in
useless worry, but on the contrary employ all his available psychic
energy in helping nature to overcome whatever disturbance there is
within the organism. This personal influence was for several centuries
spoken of as personal magnetism, not merely in the figurative sense in
which we now employ that term, but in a literal sense. The implication
was that some men possessed within themselves a reservoir of
superfluous energy, vital in character, but thought to be related to
the force exhibited by the magnet, when it attracted bodies to itself,
and made metals for a time magnetic like itself, and which actually
passed over from the physician to his patient. We have gotten away
from the idea of any physical force flowing from physician to patient,
but we know very well that certain physicians are much more capable
than others of arousing the vital energies of the patient, sometimes
to the extent of making him feel, after treatment, that he has more
force than before. The patient feels that something must have been
added to his natural powers, though he has only been brought into a
state of mind where he can better use his own powers.

It is the men whose presence created this impression in patients, an
impression that is justified by the fact that somehow he enabled them
to vitalize themselves better than before, who have been most
successful in the treatment of patients. In all ages the men of
reputation for healing have had this. A careful study of their lives
shows that this counted for more in many of the experiences of their
healing than the drugs and remedies which they employed. The men who
have been the most sought by patients have not as a rule left us great
therapeutic secrets; on the contrary, they have only employed the
conventional remedies of their times with reasonable common-sense and
have added to them their own personal influences. On the other hand,
the men who have made discoveries in therapeutics, and in medicine,
have not always been popular as physicians. They have known too much
of their own lack of knowledge to be quite confident in their use of
remedies, and this has hurt something of their personal influence over
patients.



IMPRESSIVE PERSONALITY

As a matter of fact, it is easy to comprehend, even from the
comparatively scanty details that we have of habits and methods of the
great physicians, that their effect upon their patients was always
largely a matter of impressive personality. Any one who, from a
pharmaceutical standpoint, knows how {71} inefficient were many of the
remedies that great physicians depended on, yet how effective they
seemed to be to their patients, and even to themselves, will
appreciate the factor of personal magnetism that entered into their
employment. It is not alone in the olden time that great physicians
have been almost worshiped. For their patients they have at all times
been men of exalted knowledge, masters of secrets and comforters of
the afflicted, just as was the first great physician of whom we have
any account, I-em-Hetep, in Egypt nearly six thousand years ago. Such
men as Hippocrates, as Galen, as Sydenham and Boerhaave, and Van
Swieten, accomplished curative results far beyond the therapeutics of
their time. The loving admiration of patients and of their disciples
shows how strong were their personalities and gives us, almost better
than the writings they have left to us, the secret of their successes
as practitioners of medicine.

A Great Modern Physician's Influence.--It is interesting to study in
the lives of great physicians the details which illustrate their
personal influence, their consciousness of it and how deliberately
they used it. A typical example very close to us, whose reputation was
still fresh while I was at the University of Paris, was Professor
Charcot. He had made great discoveries in nervous pathology. To a
great extent he had revolutionized our knowledge of nervous diseases
and added many new chapters to this rather obscure department of
medicine. Far from making the treatment of nervous diseases easier
than before, or giving more assurance to the physician who dealt with
them, his discoveries, however, had just the opposite effect. His work
emphasized that practically all of the so-called nervous diseases were
due to degenerations in the central nervous system, which no medicine
could be expected to relieve in any way, and which nothing short of
the impossible re-creation of damaged parts could ever cure. His
studies included organic degenerations of other organs, and in his
treatise on "Diseases of the Old" it is made clear that many of the
symptoms of old age are due to organic lesions for which no cure can
ever be expected. This would seem to discourage treatment, yet somehow
Charcot became a great practicing physician as well as a medical
scientist and pathologist.

His success was due to his personal influence over his patients. In
spite of the unfavorable prognosis that he had to give in so many
cases, he was able by suggestion to help many patients with regard to
their course of life, and to reassure them, so that many adventitious
neurotic symptoms not due to their underlying nervous disease, but to
their solicitude about themselves, disappeared. Very few people who
came to him went away without feeling that his advice had been very
valuable to them and without experiencing, as a rule, after they had
followed his advice, that they were much better than they had been
before. It was for the neurotic conditions associated with nervous
affections that Charcot's personal influence over patients was of the
greatest therapeutic significance.

He himself recognized this and did not hesitate to use it to its
fullest extent. Towards the end of his life, the method by which his
patients were presented to him was calculated to make their relation
to him, above all, a very personal one, and to give his influence the
fullest weight. Nervous patients who came to see him, were each in his
turn invited from the general waiting-room into a small ante-room just
outside of Charcot's office and {72} there, in silence and dim light,
asked to await the summons of the physician himself. When the time
came for him to call them in, the folding doors between the rooms
opened and he stood in a blaze of light inviting them to enter. Many a
neurotic patient despairing of relief for symptoms that had lasted
long in spite of the treatment of many other physicians, felt at once
that here, in this kindly, gentle-voiced man standing so prominently
in the light, was surely the long looked-for physician who would heal
whatever ills there were. They came fully impressed with his power to
heal, and all the valuable influence of auto-suggestion was enlisted
on the side of their physician.

What is true in the regular practice of medicine can be seen much more
clearly in the history of those who were not physicians, but who,
nevertheless, by personal magnetism, succeeded in curing various ills,
or at least in lifting up patients so that they used their own natural
powers of recovery to much better advantage than would have been
possible if left unaided.

Every successful healer has had this same personal influence, personal
magnetism, call it what we will, which his patients have thought
helpful to them through some direct communication, but which he
himself, if he seriously studied it, and which every other thorough
student of the question must realize, was due only to his power to
call out the latent vitality of his patients. The mystery is not one
of teledynamics, a transfer of energy from the operator, but one of
awakening dormant faculties in the subject. Just why they should be
dormant, since the patient so much wants to use them if he only could,
is hard to understand. They do, however, lie dormant until the call of
another strong personality wakens them to activity. Many people are so
constituted that they cannot do effective work except under the
direction of others. They lack initiative, though they may fill
secondary places very well, indeed, much better often than the man of
initiative who so frequently lacks capacity for details. In the same
way many people are not able to bring out to the full all their own
energies, even for their own bodily needs, unless under the guidance
and influence of others; hence the stories of the healers that we have
all down the centuries, and who have a definite place in the history
of humanity and of medicine.


A Modern Healer.--A typical instance of the really marvelous power of
mental influence over the minds of sufferers from many kinds of ills,
is found in the career of the well-known Father Kneipp. For more than
twenty-five years he had attracted the attention of Europe, and had
made the little town of Woerishofen well known all over the world
because of the cures effected there by him. The exactly proper phrase
is effected _by him_ because it is clear to anyone who has studied the
therapeutic methods he employed, that it was not these, or at least
not these alone, that enabled him to cure so many ailments which had
resisted the efforts of some of the best physicians in Europe. It was
his magnetic personality which won patients to the persuasion that
they must get better because he said so, and then to the following out
of certain very simple natural rules of life, and certain quite as
simple remedial measures, which acted as alteratives and enabled
patients to tap reservoirs of vitality, of which they themselves were
unconscious, but which, supplying energies to overcome tendencies to
various symptomatic conditions, brought about cures.

{73}

Pfarrer Kneipp had himself suffered from consumption, had been
practically given up and then, as is the case of many another, had
taken himself in hand, had secured much more outdoor air than before,
and more abundant nutrition, until gradually his ailment was overcome.
It is true that he used various hydrotherapeutic measures, some of
them, as he confessed afterwards, to an excess, both as regards the
temperature of water and the length of the application of it, that
might have seriously hurt him if he had been less robust, but it was
not so much his hydrotherapy as his own determination to get better
and to live a little closer to nature that led to his cure. Then he
became the apostle of cold water and of many natural remedial
measures, and as a consequence, healer of all forms of ills in the
many thousands who flocked to consult him in the little South German
town. He made his patients get up early in the morning, get out in the
air shortly after rising, the excuse, or, as he declared it, the
reason being that they were to walk with bare feet in the dewy grass.
After this he had them eat heartily of simple food, of such variety
and in such quantity as relieved them of constipation, made them use
water, internally and externally, in abundance, and after a time, sent
most of them on their way rejoicing that they had been cured from
chronic ills.

Some of the highest in Europe came to him; the Empress of Austria was
his patient, and he was asked to prescribe for the Pope; reigning
princes and all the lesser order of the nobility were included among
his patients. Several of the Rothschild family went to him and where
they went, of course, others flocked. Very few failed to be benefited.
People less educated, and less rich in the world's goods than these,
came also, and went away relieved. After a time Kneipp societies were
founded all over Europe and even spread through America. These
consisted of organizations of men and women who encouraged each other
to keep up the Kneipp practices. With his death there has come a
decline in interest in Kneipp methods. He, himself, was sure that his
remedies and recommendations were the important curative factors. Now
it has become clear that it was mainly his forceful personality, his
power to lift patients above their ills, and enable them to use mental
resources or vital forces that they could not use until encouraged by
him with the thought that they would surely get better. In the
atmosphere he thus created, they seemed to borrow something of his
overmastering personality. It can not be too often repeated that this
is the secret of the success of the great world healers. They do not
transfer force to others, but they enable others to use their _own_
forces more successfully.


An Ancient Healer.--Let us compare some of the details of the career
of Father Kneipp with the story we have of one Aristides, who, as the
result of dreams that came to him while practicing the cult of
AEsculapius and the injunctions contained in these dreams, was cured
of many ills, and afterward delivered a series of sacred orations.
Aristides is one of the first of the large group of literary men, much
interested in their own health and their own ills, whose writings have
been preserved for us. He was intensely proud of the number and
variety of his ills, and he was perhaps conceited about the curious
ways in which some of them had been cured. Traveling in the winter
time he caught a chill; then he suffered from earache and in the midst
of a storm developed fever, asthma and toothache. Arrived in Rome, he
had severe internal sufferings, shivering fits and want of breath.
Treatment by the Roman {74} doctor only aggravated his sufferings. A
stormy voyage home made him worse. When, at last, he arrived in
Smyrna, the doctors gathered round him, and were astonished at the
manifold nature of the disease. They could do nothing for him.

Suffering from all these ills (which remind one of a modern literary
man who has got his mind on his stomach and his body on his mind),
Aristides went to a number of the old temple hospitals and received
suggestions in sleep from AEsculapius. These he has described in what
are called his sacred orations. In them we have every phase of modern
therapy that has the strong element of suggestion in it. Like Pfarrer
Kneipp, he tried very cold baths and was benefited by them. Walking in
the dewy grass in his bare feet was another recommendation that had
come to him in a dream. Occasionally he would run rapidly for a
considerable distance, and then when heated plunge into a cold bath.
We have many complaints of his fever and stomach troubles. Mud-baths
were also recommended to him and, of course, tried with benefit for a
time. Sand baths later proved to be beneficial. For rheumatism a cold
bath, after running almost naked in the cold north wind, proved
successful when other remedies failed. Aristides wrote out his
experiences, and his writings had great influence over generations of
patients and maintained the influence of the old Greek temples as cure
houses long after the general acceptance of Christianity. As the
result of his writings, no matter how bizarre a dream might be, some
interpretation of a therapeutic nature was found from it.


Constancy of the Law of Personal Influence.--Indeed, there has
apparently never been a time when some strong character, full of
religious enthusiasm and of high purpose, strong in the confidence of
men, has not succeeded in accomplishing wonderful curative results by
the reassurance that comes from a renewal of faith in the goodness of
Providence. There are, for instance, a number of stories which show
John Wesley's power to help men to tap the reservoir of surplus energy
that all of us have within us, but that somehow we do not succeed in
making use of, unless some strong mental influence is brought to bear
on us. Practically every religious man who has had the love and the
veneration and the respect of those around him has succeeded in
accomplishing the cures that many people in recent years have been
prone to regard as rather novel phenomena in the history of
psychology. Men like St. Philip Neri, St. Francis Xavier, and St.
Francis of Assisi, and St. Bernard, have many stories told of them
which show how much they were able to help fellow mortals by enabling
them to make use, even in a physical way, of their own highest and
best powers. Their lives show how much more they did.

Nor is this power confined to men. In nearly every century we have the
story, also, of wonderfully strong women, leaders of their time, who
inspired the profound confidence and veneration of those around them,
and who were enabled, by their own strength of character, to help
people physically as well as morally. The Life of St. Catherine of
Siena is full of such instances. She spent her life mainly in caring
for the sick and the distressed at the hospital in Siena, and the
beautiful hospital there was completed largely as a monument to her.
During her lifetime marvelous cures occurred that in many cases were
evidently due to her power over the minds of people. The {75} life of
St. Teresa has a number of similar examples, and Joan of Arc, in her
lifetime, lifted many a dispirited man into vigorous strength because
of her own abounding personality and the physical reaction which
contact with her enthusiasm brought.


Modern Examples.--Nor did such occurrences come only in older and less
sophisticated centuries than ours. John Wesley is close enough to our
time to negative any such impression, but there are many other
examples. There is Pastor Gassner, whose cures remind Prof.
Münsterberg of the Emanuel movement at the present time, but there are
also a number of strong, religious characters whose influence was
exercised in the alleviation of physical ills during the nineteenth
century. The name of Father Matthew, the Irish "Apostle of
Temperance," as he was called, is mainly connected with wonderful
cures of the worst forms of alcoholic addiction. Physicians know how
difficult such cases are to cure, yet there are many thousands of what
were apparently hopeless cases to Father Matthew's credit. It may be
remarked that this is one of the ills that modern mental treatment
claims most success with. Besides these morbid habits there are,
however, other cases, told in detail, in which Father Matthew's
influence enabled people to shake off headaches, to get rid of
illusions, to overcome hysteria, and even to relieve other and much
more physical affections. Animal magnetism was the subject of much
thought in his lifetime (nineteenth century), so that it is not
surprising that Mr. John Francis McGuire, a member of the English
Parliament, who wrote Father Matthew's life in 1864, declared that
"Father Matthew possessed in a large degree the power of animal
magnetism, and great relief was afforded by him to people suffering
from various affections; and in some cases I was satisfied that
permanent good was effected by his administrations."

Another strong man of this same kind was Prince Alexander of
Hohenlohe. Though a prince he had become a clergyman and spent his
life in the service of the poor. Shortly after he became a priest he
went through a great epidemic, fearlessly caring for his poor people,
and as a consequence inspired them with so much confidence that ever
after they came to him with all their ills. He was able to help, not
only the poor, but also many of the nobility. Some of the things
reported as accomplished through his influence show extraordinary
power. His usual method was to endeavor to inspire in the people who
came to him a faith in their cure, and then after a time the cure was
actually accomplished.

During the recent troubles in Russia, attention was called to the fact
that the famous Father John of Cronstadt, the hero of Bloody Sunday,
was looked up to with so much respect and veneration that many people
found themselves helped physically by contact with him. There are a
number of interesting stories of cures of ills of various kinds, some
of them exclusively mental, but many of them fundamentally physical,
which took place as a consequence of the new spirit of hope infused
into people because of their confidence in Father John. His subsequent
history seems to indicate that this was evidently due to the forceful
personality of the man rather than to any special religious influence.
His influence was not limited to the ignorant masses in Russia, for
some of the cures reported occurred in families of the better class,
thoroughly capable of judging the character of the man apart from his
religion.

{76}


SUCCESS IN HEALING

We have any number of examples, then, of this power of the healer in
history. Over and over again we find that it was the personality of
the man and the suggestive value of the means that he employed that
enabled patients to cure themselves, that is, to use all the vital
force which they had for curative purposes. This force had hitherto
been inhibited by their own doubts of themselves and their doubts of
the value of all ordinary means of cure which had been previously
employed in their cases. This is the secret of the success of the
healer, and this secret is much more valuable for therapeusis than any
remedy which has come down to us from the olden time. It has,
unfortunately, been neglected, and thus an important benefit to
humanity has been lost. Now that we are able to review frankly and
deliberately the conditions that obtained in the past, it is time to
set about making use of this oldest secret in medicine, now no longer
a secret, as a strong factor in the treatment not of disease but of
patients.

Healers are at all times strong characters who are helpful to others
because of their own superabundant strength. The world is made up of
two classes of people, lifters and leaners, and the leaners constitute
by far the larger class. Most men and women are the subjects of doubts
and dreads and difficulties with regard to their health, and the more
time they have for introspection, the more are they likely to suffer.
Unable to overcome them by themselves, they need the help of others.
What they need, above all, is the reassurance that a trained strong
mind can give them. The exercise of this mental influence over them,
is only what corresponds to leadership in all the affairs of life.
Most people need to be led and to be guided. The place of the
physician is that of guide and director. The family physician of the
olden time had a precious amount of influence that accrued to him from
his character, and it was used to magnificent purpose. Most of his
drug treatment would be looked upon as quite absurd at the present
time, yet he did a great good work by lifting people up to their own
highest possibilities of resistive vitality. That means more for the
conquest of disease, even now, in most cases, than any remedies we
possess.

Often men do not realize how much their personal influence counts for.
They think it is their method of treatment, or some new discovery in
drugs or remedial measures, or some new phase of psychology they have
hit upon, that is producing results. This makes it difficult to
determine, in given cases, just what are the actual influences at
work. Many men supposing themselves to be discoverers of some novel
force, are merely exploiting that old-time influence of one mind over
another that can be observed all down the centuries.

It is interesting to study the careers of men who thought they were
employing on their patients some new psychological method, when all
they were exploiting was the old-fashioned influence of suggestion
from a stronger personality to a weaker. A dozen times in history
hypnotism has been announced as a wonderful curative agent. At present
no one thinks it so, but, on the contrary, if used frequently, we
think that it is much more likely to do harm than good. We went
through a phase of interest in hypnotism a quarter of {77} a century
ago and there are now signs of the possibility of its return in
another form. In recent years we have heard much of psycho-analysis,
of dominant ideas, of the auto-suggestion that comes from this, and
how much benefit can be conferred on the patient by removing such
ideas or revealing their unfavorable influence and so neutralizing
them.

The patients that come for treatment and to whom psychotherapy is of
special benefit, are not, as a rule, those suffering from acute
diseases or injuries, though even in these cases the attitude of mind
is always an important therapeutic factor. The patients are mainly
those suffering from chronic ailments, and from minor affections
which, while they do not confine them to bed, often prove the source
of such serious disturbance as makes them very miserable. The
suffering in the world is out of all proportion to the actual disease.
Many people who have little disease suffer a great deal, partly from
over-sensitiveness, partly from concentration of mind on their
ailments, and partly from such ignorance of whatever pathological
condition is present that they grow discouraged and morbid over it.
The rôle of psychotherapy is particularly to help patients of this
kind. This does not mean that its main purpose is to treat imaginary
disease, or disease which exists only in the mind of patients, for in
nearly all of these cases there is a definite physical element in the
affection. Even where the disease is quite imaginary, though that term
has been so sadly abused that it is perhaps better to speak of
affections as purely mental in origin, psychotherapy is important. As
has been well said, a patient not having something physical the matter
who thinks that there is something the matter, is in a worse state
than one who really has something the matter. There are a great many
such cases. If the principles of psychotherapy can relieve them and
cure many of them, then it has a large place in human life.

In order that the individual patient may be benefited, a thorough
understanding must be established between physician and patient. This
must take on the character of a personal relationship. The patient
must feel that the physician has a personal interest in him--that
there are certain individual features in his ailment which make his
case mean something much more than ordinary to his physician. Some
physicians have the power to make their patients feel this personal
relationship to a marked degree. They are the eminently successful
practitioners of medicine. Their patients sound their praises, and
even though they may not be distinguished scientists, they acquire a
large practice. Some of them are thoroughly scientific men. All of us
know them and, while we may not be able to understand just how it is
done, we recognize their power.



CHAPTER XI

FAITH CURES

The series of phenomena that may be grouped under the term "faith
cures" represent the oldest, the most frequent, universal, and
constantly recurring examples of the influence of the mind over the
body for the healing of ills. Whenever men have believed deeply and
with conviction that some other being {78} was able to help them, many
of their ills, or at least the conditions from which they suffered
severely, have dropped from them and their complaints, real or
imaginary have disappeared. This was true whether it was the touch of
another human being supposed to have some wonderful power that was the
agent, or some persuasion of the interference of the supernatural that
appealed to them. Religions of all kinds have always had their cures,
and one of the main reasons why men have accepted the various
religions has nearly always been because of the weight of these
healing phenomena. Apparently it does not matter how debased the form
of religion may be, whether it is exercised by the medicine man of a
savage tribe with methods that appeal only to barbarous instincts, or
by a highly cultured priest of a form of religion appealing to the
loftiest feeling and the profoundest intellectuality, cures take place
whenever devotees have complete and absolute faith in the possibility
of divine or supernatural interference in their behalf. The very
earliest history that we have tells us of such cures, and the daily
papers bring us reports of them from all quarters among the high and
the low, the educated and the uneducated.

The phenomenon is universal and we come logically to the belief that
the Supreme Being intended that confidence in Him, and above all
recognition of the fact that somehow the world with all its ills has a
meaning for good, should be rewarded. The argument that religion is a
natural revelation should then apparently be extended to include also
the thought of a healing power in connection with it. Many of the
founders of religions that have meant much for uplift to mankind, have
made healing a principal portion of their message to man--the proof of
their missions. Indeed, there actually seems to be an extension of
power, above what is natural, to those who in profound confidence in
Divinity, turn to this source of strength for relief from the ills
that flesh is heir to. In any of these cases, definite inquiry as to
the significance of the particular incident is needed, and not any
general principle of either acceptance or rejection. Faith healing is
a fact, its meaning is of the greatest importance for psychotherapy
and its phenomena deserve that specific study which alone can give any
certainty in the matter.


Accessories of Faith Cures.--From the earliest dawn of history we have
definite records of faith cures. It is true that they were usually
associated with certain physical factors besides the mere act of the
mind. In ancient Egypt the physicians were also priests, and while
they administered various remedies, these had the added advantage of
being supposed to be the result of divine inspiration, or suggestion,
or to be in some way connected with religion. Among these men there
were many strong personalities, contact with whom brought healing.
Dreams and premonitions and hallucinations all had a definite place in
their therapeutics because of their supposed connection with religion,
or at least with the beings of another world. Spiritualism, itself a
form of religion, is very old, and communications from spirits, real
or supposed, were easily thought to have therapeutic significance.


Miracles.--In most cases of faith healing, faith acts through the
definite conviction that there is to be a direct interference with the
ordinary course of nature in the patient's behalf. Some of the
evidence for such direct interference on the part of Providence is so
strong as to carry conviction even to serious and judicious and
judicial minds. When the circumstances are such {79} that an exception
to the laws of nature would not involve an absurdity, there is no good
reason why its occurrence should be absolutely put out of the
question. It may well be urged that we know so little about the laws
of nature that we cannot determine absolutely what are and what are
not exceptions to those laws. There is in itself, however, no
absurdity in what is called a miracle, and unless one is ready to
reject Christianity entirely, or to declare it absolutely impossible
that the God who made the universe should have any personal care for
it, or above all any interest in particular individuals in it, their
possibility must be admitted. The attitude of utter negation and
incredulity often assumed at the present day is only a reflection of a
certain ignorance of philosophy, and too great dependence on a
superficial knowledge of physical science, so characteristic of
narrowly trained minds. After a visit to Lourdes and careful study of
_"La clinique de Lourdes,"_ I am convinced that miracles happen there.
There is more than natural power manifest.

In a great many cases it is easy to see that the agents involved in
the faith cures, and the circumstances surrounding them, are quite
unworthy of any supposition that the Deity should have interfered.
Where there is anything irrational, or sordid, or eminently selfish
about the faith-healing, then any appeal to a supposed interference
from on high is absurd. Horace said in another matter, but it will
bear application here: "Nec deus intersit nisi dignus vindice nodus."
Do not let a god intervene unless there is a set of circumstances
worthy of him. In many of the faith-healing phenomena claimed to be
connected with religion there are a number of absurdities. It may be
suggested that any one person must not set himself up as the judge of
such absurdity. When it is evident, however, that the ailing are being
exploited for the benefit of one or of a few persons, or when there
are certain manifestly irrational conditions in the circumstances of
healing, then it is fair to conclude that what we have to do with are
only examples of healing by means of strong mental influence. But it
would be quite wrong on account of these abuses to dismiss the whole
subject of miracle healing as all imposture or merely mental
influence.


The Royal Touch.--Probably the most interesting chapter in the history
of faith cures is that of the touch of the King of England for
scrofula, or, as it was known, the King's Evil. His touch was also
supposed to be efficacious in epilepsy. English historians usually
trace the origin of the custom to Edward the Confessor. Aubrey remarks
that "the curing of the King's Evil by the touch of the King does much
puzzle our philosophers, for whether our Kings were of the house of
York or Lancaster, it did the cure for the most part."

Even the change of religion in the time of Henry VIII and Elizabeth
made no difference. Some people who hesitated about submitting to
Elizabeth as queen lost their hesitancy when they heard that the
queen's touch was successful in curing. James I wanted to drop it, but
was warned not to, as it was a prerogative of the crown with which he
had no right to interfere. Charles I was particularly successful.
Charles II, whose licentious life apparently would quite unfit him for
the exercise of any such power, was perhaps the English king who
devoted most time to healing. While he was in exile in the
Netherlands, many people crossed over to the Low Countries in order to
be touched by him, and they returned cured of many different diseases.
{80} This effectively prepared the minds of many for his return. Under
scrofula were included most of the wasting diseases, and under
epilepsy many neurotic conditions as well as many organic
disturbances. It is easy to understand how great was the room for the
successful employment here of mental influence.

Queen Anne continued the practice, and many cures were reported in her
time as late as the eighteenth century. William of Orange, when he
ascended the throne with Mary, refused to believe that there was any
special power for good in his touch. On one occasion he touched a
person who came to him, saying as he did so: "God give you better
health and more sense." In spite of this skeptical attitude his touch
is said to have healed that particular person. In the next reign,
however. Queen Anne resumed the practice, and Dr. Samuel Johnson, as a
boy of five, was touched by her with some hundreds of others in 1712.
No cure was effected in his case, but as the gruff old doctor lived to
a round age in rather sturdy health, doubtless some would raise the
question as to whether, if he had early scrofula, it was not greatly
modified for the better.

The circumstances connected with the royal touch were all calculated
to be curative of the affections for which this practice had a
therapeutic reputation. There were certain times in the year,
particularly in the spring after Easter, when the king touched people
for their ills. Ordinarily preparations would be made for some time
before, and the patients would have all the benefit of expectancy.
Then there came the journey to London to the king's presence, and as
it was usually known that these ailing folks were on their way to the
king, they received particular care from the people of the towns
through which they passed. Then came the day of the touch itself, and
the presentation of a coin, the so-called coin of the king's touch,
which the patient was supposed to preserve. On the way home they were
once more subjects of solicitude, and they had the royal coin to
assure them every now and then that they had been touched by the
king's hand, and that they ought to get well--for had not many others
been thus cured? All this favorable suggestion, with the outing and
the better food, was eminently calculated to cure the so-called
scrofular conditions, under which term was grouped many vague forms of
malnutrition and the milder epilepsies and pseudo epilepsies, for the
cure of which the touch was famous.


Cramp Rings.--Scarcely less famous than the king's touch for
nutritional and neurotic conditions were the "cramp rings," which were
blessed by the Queens of England and were supposed to cure all sorts
of cramps. The power attached to them for this form of ailment was
similar to that which the king's touch had for scrofula or the king's
evil. Cramps seemed to be the "queen's evil." Whenever a queen died
there was a great demand for these rings, because no more could be
obtained until a new queen was crowned. The efficiency of these and
the cures which they performed can be readily understood. Many of the
hysterical conditions within the abdomen are cramplike in character.
Hysteria will imitate nearly every form of cramp, including even those
due to gallstone and kidney calculus. Any strong mental influence will
do more for hysterical pain than our strongest medicines. On the other
hand, many of the cramplike conditions within the abdomen may be
relieved by concentration of mind on some distracting thought, and
feelings of discomfort in the intestines may thus be relieved.

{81}

Mental Healers.--When the king was absent from England during
Cromwell's time, the touching for the king's evil was sadly missed. If
Cromwell himself had announced that he would touch for the diseases
that used to come to the king, a number of cures would undoubtedly
have been reported. As it was, Greatrakes, the Irish soldier
adventurer, dreamt that he was commissioned from on high to touch for
the same diseases as formerly had gone to the king, and, having begun
it, cures followed until probably many more came to him every year
than usually went to the sovereign in the olden times. He worked at
least as great a proportion of cures. Greatrakes had many imitators,
some of them doubtless quite sincere, but they were people of more or
less deranged intellect, the kind who easily get the idea that they
are commissioned for some purpose that sets them above the common
people. Indeed, the story of the mental healers is probably, more than
anything else, a chapter in the history of insanity, and the power of
those with delusions to lead others to share their delusions. This is
not a slur upon human nature, and especially upon some of the
inspirations and aspirations that lift it up to do great things, but a
literal statement of the view of these phenomena that seems forced
upon us by modern advances in the knowledge of the psychology of
mental influence and of psychic contagion.

Most of the influence that was acquired by men who in the course of
history claimed to have a heavenly mission has been due, as with
healers heretofore referred to, to reputed cures made by them. Trace
the story of this among the Eastern nations in the old time. The
pseudo-Messiahs of the Jews always advanced as one evidence their
healing power, but so did the founders of religions among all the
other nations of antiquity. It must be borne in mind, however, that
many of the queer religions of after times were founded by men who
claimed to have a Messiahship, and put forth, as the evidence of a
divine commission, their power to cure the afflicted. Sometimes the
men who made these claims were good men. In many cases they were
apparently self-deceived. Very often, however, they had no claim to
goodness in the commonly accepted meaning of that term, for they
counseled the violation of moral precepts, made exceptions, for their
own benefit, to general laws, and exploited their followers for
selfish reasons. Provided their followers had confidence in them,
however, they continued to work cures, so that even reasonable people
were likely to be led to the thought that there must be something
supernatural about their activities. In every century there have been
two or three men who have thus secured a following, and apparently
healed many diseases.

The phenomena of faith-healing as the result of belief in the heavenly
mission of special men, are as common now as at any time. Dr. Cutten
in his "Three Thousand Years of Mental Healing" (_Scribners_, 1911)
has a chapter on "Healers of the Nineteenth Century," which shows how
many phenomena of faith-healing can be studied in recent generations.
Some of the men and the women who are mentioned secured wide
reputations throughout our own country.

These faith-healing movements have particularly affected the New
England portion of our population, and many of our most prominent
healers have been born in the New England States. Wherever the new
cults flourished, it is usually found that some of the most prominent
members are descendants of {82} the old New Englanders. It has been
suggested that this is due to the gradual loss of belief in great
religious truths by New Englanders, and a definite tendency toward
reaction against this loss of the religious sense, which, as is usual
with reactions, easily becomes exaggerated. From lack of belief they
jump to excess of belief. Men without trust in Providence find the
trials of life hard to bear, and they dread the development of
physical ill so much that they exaggerate their feelings, or even
create symptoms. Men are happier with the feeling that the
supernatural powers surrounding them are interested in them directly
and personally, and that somehow things, even in an incomprehensible
world, are arranged, if not for the best, at least for such good as
makes ills stepping-stones to new benefits. Whenever they are led far
away from that thought, there is likely to be an exaggerated reaction
back to it. The stronger minded apparently can get on without
religion, but to the great mass of men a strong religious sense is
needed to enable them to overcome the lack of self-confidence that is
the root of dreads, doubts, difficulties of many kinds, and which is
also the source of many symptoms as well as the cause of the
exaggeration of many ailments.

As a rule, modern healers have been founders of new religions, or at
least they have broken away from old-established sects, and have
formed congregations for themselves. They have sprung up in every part
of the country. East, North, South, West, and among all the differing
nationalities of our population. We cannot console ourselves with the
idea that they affect especially the foreigners, for the native-born
people have proved to be quite as susceptible to them. These healers
have, as a rule, abused the medical profession and the use of drugs,
and have taught that disease, if it really existed at all, was from
the devil: that what one needed, in order to secure relief from pains
and ills, was faith in God--but always through _them_. Many of these
men and women have probably been serious and earnest and have deceived
themselves first. Most of them have undoubtedly been more or less
disequilibrated, though they have practically all exhibited the power
to accumulate large amounts of money from their followers. The people
who have gone to them have not been the ignorant among our population,
but particularly those who read the newspapers, and who look upon
themselves as well informed. The intelligence of the disciples of
these healers, as we ordinarily estimate intelligence, has been a
little above the average, rather than below it.


_Schlatter and Dowie._--Probably the most disillusioning phenomena
with regard to the complacent idea that the diffusion of information
prevents manifestations of superstition are stories of the healers
Schlatter and Dowie. At the end of the nineteenth century both of them
attracted widespread attention. Schlatter was probably not quite sane.
He wandered through the deserted portions of the Southwest, hatless,
unkempt, with clothing torn and without shoes. In July, 1895, he first
attracted attention as a public healer in New Mexico. After a reputed
forty-day fast he went to Denver, where people flocked from all parts
of the country to him. Files of people formed--sometimes five or six
thousand--to be touched, and healed, by him. His reputation was due to
the cures that were reported. Dowie was another of these healers. Just
at the beginning of the twentieth century he organized a great new
church of his own, and announced himself as Elijah, the prophet,
returned to life. {83} Nearly 20,000 persons are claimed to have been
healed during the first ten years of his healing career. Toward the
end of his life he declared that he treated, and cured, over 50,000 a
year. An abundance of crutches, canes and every form of surgical
appliance for the ailing hung on the walls of his church at Zion City,
Chicago, left by people who, having been healed, had no further use
for them.


{84}

GENERAL PSYCHOTHERAPEUTICS


SECTION II


_GENERAL CONSIDERATIONS_


CHAPTER I


INFLUENCE OF MIND ON BODY


The power of mind over body for the relief of symptoms has been
recognized, not only by physicians, but by the generality of men at
all times. Every one has had experiences of aches, or actual pains, or
discomfort quite annoying while one is alone, but that disappear while
in pleasant company or occupied in some absorbing occupation. Many a
headache that was painful enough to disturb us seriously while we
tried to apply ourselves to something of little interest, and became
almost unbearable if we tried to do something disagreeable, and
actually intolerable if the occupation of the moment was a drudgery,
disappeared, at least for the time, when we turned to a pleasant game
of cards or indulged in some other favorite pastime. Our relief was
not, however, from an imaginary ill, for the symptoms usually
reasserted themselves when we got through with the pleasant
occupation, showing that they have been there all the time and that we
have only turned our mind away from them, and hence have ceased to
feel them. This is so familiar it seems almost too commonplace to
repeat, yet it constitutes the special phenomenon that lies at the
base of psychotherapeutics, or the mental healing of physical ills.

It is not alone the slighter, more or less negligible aches or pains,
nor the vague discomforts that thus disappear when our attention is
occupied, but even quite severe and otherwise unbearable pain may be
modified to a great extent. A toothache that is bearable, though it
nags at us constantly and never lets us forget its presence while we
are occupied with many other things during the evening, may become a
positive torture when we get to bed. This is not only because of
physical conditions modifying the pain, for there seems no doubt that
the warmth induced by the preliminaries for sleep and the bed-covering
have a tendency to increase congestion, but it is mainly because as we
doze off we are able, less and less, to inhibit our attention, or
divert it from the pain that is present, and so this is emphasized
until we have to do something for it or lose hours of sleep. This lack
of inhibition, which characterizes the dozing hours, represents the
state of mind in which people are who have no interest in their
occupations, and who have ceased to find recreation in the ordinary
pleasures of life, when pain of any kind comes to them.

Cabanis, at the beginning of the nineteenth century, under the title
of {85} "The Influence of the Moral on the Physical," discusses what
we would now call mental influence on the body. He says:

  The great influence of what one may call the moral or mental on what
  may be called the physical is an incontestible fact. Examples
  without end confirm it every day. Every man capable of making
  observations finds proofs of it thousands of times in himself. Many
  physiologists and psychologists as well as moralists, have collected
  the evidence that brings out clearly this power of the intellectual
  operations and emotions on the different organs and the diverse
  functions of the living body. All of us could add new illustrations
  to these collections. Men who are rude and credulous talk of the
  effect of the imagination, and if they are not themselves its
  playthings and its victims, at least they know how to observe its
  effects In others.

  As a matter of fact, the action of our organs can be in turn
  excited, suspended, or totally inhibited, according to the state of
  mind, the change of ideas, the affections and the emotions.

  A vigorous, healthy man has just made a good meal. In the midst of
  the feeling of satisfaction which diffuses itself over all his body,
  his food is digested with energy and without any bother. The
  digestive juices perform their work steadily and without causing any
  annoyance. But let such a man receive some bad news; let some sudden
  emotion come to excite him, and especially to shock him into
  profound sadness, and at once his stomach and intestines cease to
  act upon the food which they inclose, or they at best perform their
  functions badly. The digestive juices, by which the food materials
  were gradually being dissolved, are suddenly stricken with
  inactivity. What might seem to be a stupor comes over the digestive
  tract, and while the nervous influence which determines digestion
  ceases entirely, that which tends to bring about the expulsion of
  material from the digestive tract may become more active and all the
  material contained in the digestive viscera may, in a short time, be
  expelled.


Relief in Severe Injuries.--Even extremely severe injuries, which
inflict serious organic lesions that ordinarily would produce shock
and collapse, quite apart from the pain induced, may at moments of
excitement pass unnoticed. A soldier often does not know that he is
wounded until the flow of blood calls his attention to it, or perhaps
a friend points it out to him, or loss of blood causes him to faint.
The prostrating effects of even fatal wounds may thus be overcome for
a considerable time in the excitement of battle, or because of a
supreme occupation by a surpassing sense of duty. There is the
well-known story of the young corporal detailed to make a report to
Napoleon at a very important crisis of one of his great battles, who
made the report with such minute accuracy that it called forth a
compliment from Bonaparte, for it involved a very special exercise of
memory for details, yet who was actually on the verge of death when he
delivered the message. As his duty was accomplished the Emperor,
noticing his extreme pallor, said: "But you are wounded, my lad." The
young soldier replied, as if, now that duty was done, the
consciousness of his wound had just come to him, "No, Sire, I am
killed," dropping dead at the Emperor's feet as he uttered the words.

In all of the great theater fires examples of this kind are recorded.
A woman who barely escaped with her life from a theater fire some
years ago had an ear torn off, very probably by some one grasping it
in the crowd. She knew nothing of this until it was called to her
attention after she got out of the theater, and then she promptly
fainted from the pain and shock. Under such circumstances men walk
with broken legs or limp even with dislocations, utterly unconscious
that anything serious has happened to them. Men have been known to be
unaware of a broken bone or even more serious conditions, {86}
ordinarily quite painful and disabling, while laboring to help others
in an accident.


Suppression of Reaction.--This side of the influence of the mind on
the body is so interesting that its effects have often been noted and
studied. While we do not quite understand the mechanism by which it
accomplishes its marvels of anesthesia and even of motility under
apparently impossible conditions, there is no doubt that severe pain
may utterly fail to reach the consciousness, though the nervous system
is uninterruptedly carrying the messages just as it did before. The
lack of attention suppresses the ordinary effect upon the personality.
Evidently the messages originate and are carried to the nerve centers,
but find no attention available for them, and so pass unnoticed. The
study of phases of this phenomenon of suppression of reaction forms a
good basis for the use of mental influence, and shows its marvelous
power to overcome disturbing physical factors.


Amputation Stump Aches.--An interesting example of the influence of
mind over body, when circumstances favor its exercise or emphasize it,
and at the same time a striking illustration of the potency of
suggestion in the cure of discomfort, is found in the stories that are
so common of cases of pains in amputation stumps. Any number of weird
tales are told of men who complain of feeling cramps in the toes of an
amputated limb after this portion of their body had been buried. The
discomfort is common enough. In the special stories, however, the
limbs have been dug up, the toes straightened out--according to the
story, they were always found cramped in some way--and then the
patient is at once restored to ease. In the good old times they
probably believed in some direct connection between the straightening
out of the toes of the amputated member and subsequent relief of pain.
For us it is but an example of the power of suggestion. It is not the
sort of suggestion that one likes to think of employing, though it has
a certain dramatic quality which adds efficiency to suggestion.


The Mind and Motility.--We have spoken thus far almost exclusively of
painful conditions as relieved by suggestion or mental influence, but
disturbance of motor function may also be favorably affected. There
are any number of cases on record in which patients who had been
utterly unable to walk were restored to motility by a shock. Many such
patients have, in the midst of the excitement of a fire, or the scare
caused by the presence of a burglar, got up and walked quite as well
as ever, though sometimes they have been for years previously confined
to bed. The San Francisco earthquake is said to have exerted such an
effect on a number of patients, and, while such unusual disturbances
cannot often be provided for the cure of these ailments, there can be
no doubt at all of the power of a shock to the mind to overcome
functional incapacity that has resisted every possible form of
treatment.

Ailments of this kind, which involve inability of the will to control,
or rather to initiate, movements of the body, receive their best
explanation on the neuron or neuroglia theory. (See the chapter on the
Mechanism of Suggestion.) The central neurons become either quite
separated from certain of the peripheral neurons, or at least the
connections are not made with that nice adjustment necessary for the
proper passage of nerve impulses. The shock communicated to the
nervous system by fright is sufficient, however, to restore these
connections, and consequently to enable the patient once more to
exercise motor functions that have been in abeyance for some time.

{87}

_Astasia-abasia._--Any one who has had to deal with the cases for
which the French have invented the rather impressive Greek name of
astasia-abasia--how much better it would be to call the condition
simply what we know it to be, nervous inability to stand or
walk!--appreciates how almost a miracle is needed to improve them. The
incapacity for station or movement to which the disease owes its name
is so complete in many cases, and the patients' lack of confidence in
self so absolute, that no ordinary remedial measure is capable of
doing any good. These cases are usually a severe trial to the
patients' friends. Indeed, the patients themselves maintain their
nutrition so well and, as a rule, enjoy such good health, or, as has
been said, enjoy their bad health so well, that it is for their
attendants the physician feels most commiseration. Yet generally he is
quite unable to do anything. It is certain, however, that with care
and authoritative suggestion there would not need to be an earthquake,
or a fire, or even a burglary, as a therapeutic measure in these
cases. As a matter of fact, their cure when it occurs is always
brought about by some strong mental influence.


Mental Influence on Organs.--_The Heart_.--The influence of mind can
be noted on practically every organ of the body in a concrete way. It
might be thought that the heart, the first living thing in the animal
being, the pulsations of which begin before there is any sign of the
nervous system, might be free from this influence. On the contrary,
the heart is so readily affected by mental states that, taking effect
for cause, the old popular, and even scientific idea with regard to
it, was that it was the organ of the emotions. The heart is stimulated
more by favoring circumstances, and suffers more from depression, than
almost any other organ. In the melancholic states it usually beats
less frequently and is sluggish. When individuals are tired out and
the heart has become weakened in its action, new courage will first be
noted as having its effect upon the heart action. As the whole
muscular system is much influenced by the mental state and, as the
control of the arterial system depends on the muscles in the arteries,
it is easy to understand how much the general bodily condition may by
mental influence be modified for good and ill.


_Digestive Tract_.--The stomach and intestines, though their functions
might be presumed to be dependent entirely on physical conditions, are
almost completely under the control of the mental state. At moments of
depression, just after bad news has been received, the appetite is
absent, or is very slight and digestion itself proceeds slowly and
unsatisfactorily. On the other hand, when there is mental good feeling
appetite is vigorous and digestion is usually quite capable of
disposing of all that is eaten. If after a period of rejoicing in the
midst of which food is taken abundantly bad news is brought, the
mental influence on digestion can be seen very well. It is not alone
that depression interferes with digestive processes, but apparently
some favorable factors for digestion consequent upon the previous
state of mind are withdrawn, and now what would have been a proper
amount of food proves to be an excess and the digestive organs find it
difficult to deal with it..


Nervous Inhibition.--The mind can actually inhibit certain of the
involuntary processes of the body by thinking about them, and, above
all, by dwelling on the thought that they are going wrong. This
becomes easier to understand when we recall how, in the same way, we
may disturb many habitual and more or less unconscious actions that we
have grown accustomed to. There {88} are any number of actions
requiring careful attention to details which become so habitual that
we do not have to think of them at all. Not infrequently it happens
when we try to explain to others how we do them, we disturb the
facility of performance and have to repeat the acts several times
before we succeed in performing successfully what a moment before we
did without any thought. The story of the centipede who was asked how
he walked with all his hundred legs, and who tried to describe how
easy it was and got so mixed up that he was unable to move at all, is
a whimsical symbol of conscious attention disturbing actions which go
on quite well of themselves if only we do not allow ourselves to think
consciously of each and every phase of them.

How much the mind may influence the body under certain conditions when
trance-like states either assert themselves or are brought on, has
often been noted. Lombroso in his book "After Death What?" [Footnote
11] says of Eusapia Paladino the "medium," that "when she is about to
enter the trance state the frequency of the respiratory movements is
lessened just as is the case with the Indian fakirs. Before the trance
she will have been breathing eighteen to twenty times a minute; as the
trance begins the number of respirations is gradually reduced to
fifteen; when the trance is fully developed she breathes twelve times
a minute or less. On the other hand, at the same time the heart beats
increase. Normally her pulse is about seventy, but during the early
trance stage it rises to ninety, while during the course of a deep
trance, it may go as high even as one hundred and twenty. The passing
from a more or less rigid state to that of active somnambulism is
marked by yawns and sobs and spontaneous perspiration on the
forehead." The observation of these phenomena is, of course, entirely
apart from any theory one may hold with regard to mediumistic
manifestations, and it provides evidence of mental influence that is
very striking.

  [Footnote 11: Small, Maynard & Co.. Boston, 1909.]

Imaginary Drug Effects.--Drug effects may be produced through the
imagination. Physicians know that when patients are persuaded that
certain effects are to be expected from a particular medicine, the
effects may follow all the same in sensitive, imaginative people, if
that medicine is replaced by some inert compound. Many a physician who
has used bread pills or other placebos to replace a drug that he did
not want the patient to acquire a habit for, has thus been able to
allow good effects to go on without interruption, where the stoppage
of medicine had previously interfered with the continuance of the good
habit that had been formed. Very few physicians have not seen the
effect of a hypodermic of pure water when a hypodermic of morphine is
demanded, and when the patient would not sleep without having the
hypodermic injection. Sleeping powders of various kinds can sometimes
with distinct advantage be replaced by inert materials, because the
patient's mind is fixed upon the idea of sleep coming after a certain
time and they, in consequence, compose themselves to rest.


The Nerves and Tissues.--Cases occur where disturbances of vitality
are noted as a consequence of nervous affections, though no gross
lesion of the nervous system is demonstrated. Certain nervous people
suffer from ulcerative conditions of their hands, and it is evident
that in some the nervous impulses {89} that would ordinarily keep the
skin surface in good, healthy condition are insufficient. Some people
who use a typewriter have no difficulty at all with the ends of their
fingers, while others are subject even to loss of skin or ulcerative
conditions that make it almost impossible for them to go on with their
work. In some this is true in the winter, in others in the summer.
There are a number of skin conditions which are due to nervous factors
and these evidently point to the influence of the central nervous
system in keeping the forces of our body in such health, and resistive
vitality, as will enable us to carry on whatever work we may wish to.
This is, of course, a very individual matter. Some people chap very
easily, some suffer from chilblains, or are frost-bitten even on
slight exposure, and these peculiarities are evidently dependent on
the intensity of the nervous impulses as well as the tone of the
circulation, which itself depends on the nerves to a great extent.

It is evident that some of these disturbances are not enduring, but
are only temporary and therefore are due to functional disturbances of
the nervous system. Physicians often see hysterical patients suffering
from intense pain that requires an injection of morphine, yet after a
series of such incidents, the physician is able to give an injection
of plain water and produce just as good an anodyne effect. In these
cases some influence of the will is enough to correct the painful
disturbances. Occasionally a single member loses sensation, or motion,
or both, yet the fact that its nutrition does not suffer shows that
there is only disturbance in the motor connections between it and the
central nervous system and not in the sensory nor trophic tracts, and
that this functional defect may be restored by some favorable
influence.


_Nerve Supply and Health_.--We know now that when a part of the body
is cut off from its connections with the central nervous system, it
begins at once to be lowered in vitality and gradually tends to
dissolution. This will be true in spite of the fact that the
circulation continues as actively as before. It is not necessary,
indeed, that the nerve trunk to a part should be cut, if it is
sufficiently compressed its function is stopped and various
disturbances begin to appear in the vitality of the part which it
supplies. A typical example is to be seen in certain fractures of the
clavicle, where a fragment presses on one of the nerves leading to the
arm. After a time pains develop in the arm, a burning feeling is
noticed in the skin, which becomes shiny and cold and of distinctly
lowered vitality. Even a slight injury to the arm will now produce a
serious ulcerative condition. There are evidently important influences
for life that flow down through the nerves from the central nervous
system, quite as important in their way as the nutritional elements
which flow through the blood.

How these influences of the mind on the body are accomplished is a
portion of that larger mystery of the influence of mind, or soul, or
principle of life, on the material elements of which our body is
composed. Why a man receives a shock of lightning or a charge of
electricity at high voltage, and without a mark on his body or a
change in any cell that we can make out, be dead, though he was living
an instant before, is another of these mysteries too familiar for
discussion. There is no change in the weight of the body, nothing
physical has happened, but what was living matter with the power to
accomplish the functions of living things is now simply dead material,
unable to resist the invasion of saprophytic micro-organisms which
will at once, {90} unhampered, proceed to tear it down, though the
preceding moment resistive vitality was completely victorious. The
mystery remains, but the mechanism of the influence can now at least
be studied with much more satisfaction than was the case a few years
ago.


Death and the Mind.--The extent to which the mind can be made to
influence the body is apparently without limit. While the doctor is
frequently disturbed by the fact that death occurs when there is no
adequate physical reason for it, just because the patient has looked
forward to it with complete preoccupation of mind, there is no doubt
that occasionally death may be put off in the same way. We talk about
people living on their wills. This is a literal expression of what
actually occurs in certain cases. On the other hand, without the will
to live, it is sometimes extremely difficult to keep alive patients
who are in a run down condition. If one of an old married couple dies
when the other is ill, we conceal the sad news very carefully from the
survivor. This is done not alone to put off the shock and sorrow for a
time, but because often, under such circumstances, there will be no
will to live.

When the vital forces have run down to such a degree that it seems
impossible, so far as ordinary medical reason goes, to look for
anything but dissolution, patients still cling to life if there is
some reason why they want to live until a definite time. It does not
happen so much with the acute diseases but is quite common in chronic
cases. Patients will live on expectant of seeing a friend who is known
to be hurrying to them, or for some other purpose on which they very
strongly set their minds. In the life of Professor William Stokes, the
Irish physician, to whom we owe the introduction of the stethoscope to
the English medical world, and many other important contributions to
medicine, there is a striking story that illustrates this power of the
will to maintain life until a definite moment.

  An old pensioner, a patient of Stokes' in the Meath Hospital whose
  life was despaired of, and whose death was hourly expected, was one
  morning distressed and disappointed at observing that Stokes, who
  believing that the man was unconscious at the time, and that it was
  useless to attempt anything further as his condition was hopeless,
  was passing by his bed. The patient cried out: "Don't pass me by,
  your honor, you must keep me alive for four days." "We will keep you
  as long as we can, my poor fellow," answered Stokes; "but why for
  four days particularly?" "Because," said the other, "my pension will
  be due then, and I want the money for my wife and children; don't
  give me anything to sleep for if I sleep I'll die." On the third day
  after this, to the amazement of Stokes and all the class, the
  patient was still breathing. On the morning of the fourth day he was
  found still breathing and quite conscious, and on Stokes' coming
  into the ward, he saw the patient holding the certificate which
  required the physician's signature in his hand. On Stokes
  approaching him, the dying man gasped out. "Sign, sign!" This was
  done, the man sank back exhausted, and in a few minutes after
  crossed both hands over his breast and said, "The Lord have mercy on
  my soul," and then passed quietly away.


_Dread and Death_.--Dr. Laurent in his little book, "La Médecine des
Âmes," [Footnote 12] has a story of similar kind but from a very
different motive:

    [Footnote 12: Paris, Maloine, 1804.]

  They brought to the prison infirmary one day an old burglar, an
  incorrigible offender, who was undergoing a long sentence. He was
  suffering from cancer of the stomach, and was already in a very
  advanced stage of the affection. The poor devil seemed to realize
  his condition very well, and felt that it was only a question of a
  short time until he should die. He had made up his mind to that with
  the {91} resignation which so often characterizes people of this
  kind. Only one thing put him out very much, and that was the fear of
  dying in prison.

  "I know well that I have to pass in my checks," he said over and
  over again; "but I do not want to die here. I do not want to be cut
  up after I am dead."

  He still had two months of his sentence to undergo. Every day the
  disease made notable progress. His cachexia became more profound.
  Life was passing from him drop by drop. At the end of five weeks he
  was scarcely more than a living skeleton. Every morning we expected
  to find him dead, or at least in his last agony. Nevertheless, every
  morning, by an effort, he was able to recognize me and a little life
  shone out of his sharp, small eyes that seemed like those of a bird
  of prey.

  One morning he said to me: "Oh! you need not watch me. You shall not
  have my carcass. I do not want to die in prison. I shall not die
  here." He lived on till the end of his sentence. The morning of his
  freedom he said to me, "I told you that I did not want to die here,
  and that I would not die here."

  By an effort of his will he aroused himself enough so that his
  friends were able to take him out of the prison. It was the last bit
  of energy he had, however. His will power was at an end. A few hours
  after his arrival in the house of his son he went off into a
  profound depression, and would not talk even to his own. Then his
  death agony came on, and he died that same evening. The strange and
  surprising struggle of this man against death, the marvelous force
  of physiological resistance which the fear of autopsy, if he died,
  gave him, struck me vividly at the time. What intimate and
  mysterious bond connects mind and matter that the one is able to
  react in so much energy upon the other. How wonderful to think that
  the fear, lest his abandoned body should be cut up, should actually
  keep body and mind together until after the danger of that dreaded
  event was passed.


_Suggestion and Death._--On the other hand, there are many stories
that show us how the giving up of hope of life seems to even hasten
death. We have many stories of the death on the same day of husband
and wife, or of brothers and sisters who thought very much of each
other. Some of these are mere coincidences, but there are too many to
be all explained on the score of coincidence. It seems clear that the
living one, on hearing of the death of the other, feels that now there
is nothing more to live for, and gives up the struggle. Hence the
important rule in medical practice that a seriously ill patient should
not be told of an accident, and, above all, of the death of a near
relative.

On the other hand, strong expectation of death at a definite time,
especially if accompanied by suggestions with some physical signs, may
bring about actual dissolution. We have a number of well authenticated
stories to illustrate this.


_Renewal of Hope._--How much energy even the slightest hope may
furnish, when apparently all power of effort is exhausted, is well
illustrated by what happens to men who are lost at sea or in a desert.
After the lapse of a certain length of time human nature seems utterly
incapable of further effort and they sink down exhausted. The
appearance of a light at a distance, a hail, any communication that
gives them even the slightest hope will renew their energy and enable
them to draw on unsuspected stores of vitality after the end seemed
inevitable. It may be said that the exhaustion in these cases is more
apparent than real, that discouragement prevents the release of even
the energy that is present, and might be used under more favorable
circumstances, but that is exactly the argument which favors the
deliberate employment of psychotherapeutic motives to enable patients
to use the energies which they possess. In the midst of disease, or
the struggle for life, when vitality is {92} being sapped, hope is
lost or obscured, just as it is when a man is alone in the desert or
struggling far from help on the ocean. If we can prevent this
discouragement from sapping his powers there will always be a
prolongation of life, and often this will be sufficient to enable
vital resistance to overcome exhausting disease.


Law of Reserve Energy.--Prof. William James [Footnote 13] called
particular attention to the law of reserve energy which recent studies
in psychology have emphasized. This law of reserve energy is a
conclusion from certain facts which are very familiar to men and have
been observed as long as the memory of man runs, yet the full
significance of which has never been read quite aright. Applied to a
very limited range of actions, it has been applied only half-heartedly
in ordinary life, and to its full extent only under the pressure of
absolute necessity. This law holds out the best promise to
psychotherapy. It shows that there are reservoirs of surplus energy in
man which, if they can be successfully tapped, present possibilities
of resistance to fatigue--and fatigue in many more ways than we used
to think resembles disease. Besides, this law represents a very
wonderful capacity for withstanding pains and aches and conquering
disinclination that would otherwise seem impossible. If it can be made
to apply to ordinary life as well as it does to extraordinary events,
then the conscious deliberate use of psychotherapy or mental
suggestion should prove to have wonderful remedial power. Prof. James
said:

    [Footnote 13: _American Magazine_, Sept., 1908.]

  Everyone knows what it is to start a piece of work, either
  intellectual or muscular, feeling stale--or "cold," as an Adirondack
  guide once put it to me. And everybody knows what it is to warm up
  to his job. The process of warming up gets particularly striking in
  the phenomena known as second wind. On usual occasions we make a
  practice of stopping an occupation as soon as we meet the first
  effective layer (so to call it) of fatigue. We have then walked,
  played, or worked enough, so we desist. That amount of fatigue is an
  efficacious obstruction on this side of which our usual life is
  cast.

  But if an unusual necessity forces us to press onward, a surprising
  thing occurs. The fatigue gets worse up to a certain critical point,
  when gradually it passes away, and we are fresher than before. We
  have evidently tapped a level of new energy, masked until then by
  the fatigue obstacle usually obeyed. There may be layer after layer
  of this experience. A third and fourth wind may supervene. Mental
  activity shows the phenomenon as well as physical, and in
  exceptional cases we may find, beyond the very extremity of fatigue
  distress, amounts of ease and power that we never dreamed ourselves
  to own--sources of strength habitually not taxed at all, because
  habitually we never push through the obstruction, never pass those
  early critical points.

He then states what has come to be called the law of reserve energy.

  _It is evident that our organism has stored up reserves of energy
  that are ordinarily not called upon, but that may be called upon;
  deeper and deeper strata of combustion or explosible material,
  discontinuously arranged, but ready for use for any one who probes
  so deep, and repairing themselves by rest as well as do the
  superficial strata_.

There is, then, a marvelous reserve power in men and women which can
be used in emergencies and in times of severe strain, to enable men
and women to accomplish what looks impossible and which has often
contradicted the prognosis of the physician. History is full of
applications of this law which, however, does not come into action,
unless especially called. Men and women {93} may die simply because
they give up the struggle. Men and women who _will not give up_ seem
able to overcome severe illness that would take away ordinary people.
It has often been said that tuberculosis takes only the quitters and
that men of character constitute the typically favorable patients for
tuberculosis sanatoria. Psychology is now getting at the explanation
of many events that were formerly quite inexplicable. The science has
come to recognize the reservoir of reserve energy in human nature
which may be tapped under special favoring circumstances. The
physicians of the past have often succeeded in tapping it deliberately
as well as unconsciously. There is large room, however, for the
further development of medicine along this line, to the great
advantage of therapeutics and probably the most promising field at the
present time in view in therapy lies in this direction. Hence the
necessity for more deliberate conscious use of it in every possible
suitable form.



CHAPTER II

UNFAVORABLE MENTAL INFLUENCE

Much as may be accomplished by psychotherapeutics through favorable
mental influence--the modifying of the mental attitude towards
disease, diversions of mind from aches and pains, concentration of
attention on subjects apart from ailments--much more may be done by
removing any unfavorable mental influence. This of itself produces
symptoms either by interfering with normal processes through
surveillance of them, or by so exaggerating, through attention to
them, slight symptoms that may be present that patients are made quite
miserable, though there is no adequate physical cause for their
condition. Perhaps the most striking example that we have of
unfavorable mental influence as productive of the persuasion that
disease is present, is familiar to every physician who is close to
medical students when they are first introduced to the symptoms of
disease. It is almost a rule that certain members of the class
immediately conclude that they are suffering from one or more of the
symptoms which they are studying, and that, therefore, they must have
the diseases with which the symptoms are associated. If at this time
they walk on the shady side of a street on an autumn day and have a
little shivery feeling, or when they get into the sun they feel a
glow, these two very normal feelings are exaggerated into chilliness
and fever, and the student has to go to his professor to have his
mental malaria or typhoid treated. To the student, his symptoms are
for the moment very real, and unless someone in whom he has confidence
reassures him, his discomfort will probably continue for some time.


Pathological Suggestion.--In a word, suggestions of disease are much
easier to take than is usually imagined, and if people read or hear
much about diseases they are likely to jump to the conclusion that
they are sufferers. Under present conditions there are many more such
sinister suggestions put before people than used to be the case. The
newspapers are constantly reporting curious cases and rare diseases,
and usually those of absolutely unfavorable prognosis and inevitably
fatal termination are particularly dilated on. Pathology has become a
source of many sensations, until the community {94} generally has come
to eke out the thrills of the day's news by reading about fatal
diseases and fatal injuries, whenever murder and suicide sensations
fail. As a consequence, many become persuaded that they are suffering
from forms of disease of which they have not a symptom, and, not
infrequently, the wonderful cures that are reported in the newspapers
consist of nothing more than recoveries from these imaginary ills into
which people have suggested themselves as the result of reading about
morbid states.

A typical illustration of the power of the mind to influence the body
unfavorably is recognized in many of the comic stories that have had a
vogue in recent years. Their underlying thought is that if a man is
only told often enough, and by a number of different people, that he
does not look well, or if he is even asked a little solicitously as to
whether he feels well or not, he will almost invariably begin to
persuade himself that there must be something the matter with him.
After a time, under the influence of this unfavorable suggestion, he
begins to feel tired and is likely to think that he cannot go on with
his work. When meal time comes his appetite fails him. A victim has
been even known to go home and send for the doctor, persuaded that
there is something the matter, simply because a series of friends, for
a joke, or sometimes through a mistake, have insisted on asking him
questions that called attention to his state of health. Few men are
strong enough to stand the influence of unfavorable suggestion of this
kind, if it is frequently repeated. More direct forms of suggestion of
disease have, of course, even greater effects. Many a man goes to a
quack only feeling a little out of sorts and wanting to reassure
himself, but easily becomes persuaded that there is something serious
the matter with him.


Unfavorable Suggestion in Ancient Times.--This unfavorable influence
of the mind on the body, even to the extent of the production of
disease by means of suggestion, was recognized by the ancients. They
knew and wrote of hypochondriasis and, indeed, they invented the term.
In many of these cases the seat of auto-suggestion is supposed to be
the digestive organs and the localization of the discomfort is in the
hypochondria, that is, in the upper abdominal region. The Grecian
writers seemed to recognize clearly that the symptoms were the result
of thinking over much about self and concentration of attention upon
unfavorable suggestions.

Plato, in the "Republic," says:

  In former days the guild of Asclepius did not practice our present
  system of medicine, which may be said, he declares, to educate
  diseases. He cites the example of Herodicus who, "being a trainer
  (of gymnasts) and himself of a sickly constitution, by a happy
  combination of training and doctoring, came to the invention of
  lingering death; for he had a mortal disease, which he perpetually
  tended, and, as recovery was out of question, he passed his entire
  life as a valetudinarian." Plato, finishing the description, makes
  us recognize the hypochondriac when he says: "He could do nothing
  but attend upon himself, and he was in constant torment whenever he
  departed in anything from his usual regimen, and so dying hard, by
  the help of science he struggled on to old age."

The picture of the neurasthenic, or hypochondriac, who has educated
himself, as Plato says, into disease, is an interesting parallel to
modern conditions in this matter.

Nowhere more than in this matter of knowledge of disease, can weight
{95} be attached to Pope's dictum that a little knowledge is a
dangerous thing, and that one must drink deep or touch not the Pierian
Spring of medical information. The teaching of pathology under the
guise of physiology, now so common in our schools, is likely to do
more harm than good. Various pathological conditions, such as those
produced by alcohol and tobacco, have been emphasized to such an
extent as to produce unfavorable suggestions in the pupils' minds with
regard to the untoward events that may happen in their insides, and
the serious lasting pathological changes that may occur, though all
unconsciously, to the sufferer as the result of indiscretions. The
study of the morbid changes produced in the mucous membranes of the
digestive tract by the use of stimulants, impresses ideas on the mind
that are readily transferred to other abuses in eating or drinking.
The rather vivid pictures and descriptions of the pathological
conditions that may develop, become a portion of the acquired
consciousness as to internal conditions, and this consciousness acts
as an unfavorable suggestive factor whenever there are any digestive
symptoms.


Bacteriphobia.--The development of bacteriology has had a similar
effect, especially because periodicals and newspapers like to take up
only the sensational side of biological discoveries. Most physicians
who have had anything to do with nervous diseases have seen cases of
misophobia, the fear of dirt, which in our day has taken on the
special character of fear of microbes. Those who are sensitive to the
possibility of contamination learn of the almost sacrificial
precautions that surgeons take to avoid wound infection, and conclude
that practically everything they handle must fairly reek with
microbes. They hesitate about touching the door knob or latch, and
invent all sorts of excuses to wait for a moment outside the door in
order to have someone else open it. Especially are they timorous about
touching the door knobs of a physician's residence, or the chairs in
his waiting room, or even to shake hands with him. Hospital walls and
doors become an abomination to them. These cases emphasize how much of
unfavorable suggestion there has been in the present spread of popular
knowledge with regard to microbes.

A writer on popular science once said that every time we spread a
piece of bread of the size of the hand with butter, we scatter over
its surface as many microbes as there are inhabitants in the United
States. The expression has gone the rounds, producing its effect on
sensitive people, occasionally causing even a disgust for so important
an article of diet as butter, more often giving rise to an extreme
sensitiveness with regard to any special savor that butter may have,
and it may have many according to the prevailing food of the cow.
There has been much emphasis laid on the potentialities for harm of
the microbes, and very little on the important part which they play in
the production of many forms of food materials. Most people know and
dread the fact that microbes produce disease. Very few seem to realize
that while we know many thousands of different kinds of microbes,
scarcely more than a score of them are known to be seriously
pathogenic, while all the others are either indifferent or, as we know
of very many, are actually benefactors of mankind.

People have heard much of the flora of the digestive tract, until they
have come to think with anxiety of the almost infinite number and
multitudinous variety of the minute plant life that finds a habitat in
the human intestine. Most people think that all of these are, in
tendency at least, {96} harmful, and are only kept from being
positively dangerous by the overwhelming vital activity of the mucous
membrane and the secretions which keep them from exerting their malign
activity. Very few appreciate the fact that the intestinal flora, far
from being a disturbing factor, are often an aid to digestion, and
that the equilibrium established among them favors many biological and
chemical processes which help in the preparation of food and in the
breaking up of waste products that might be dangerous if reabsorbed
during their stay in the intestinal tract. Microbes we have always
with us and always will have, and men have lived to round old age, not
only in spite of them, but very probably partially because of them.
They are part of that beneficent mystery of nature of which as yet, in
spite of scientific progress, we know comparatively little.


_Opposing Favorable Suggestion_,--A recent striking change of
sentiment with regard to one form of food material furnishes a good
example of how little we know about the real effect of bacterial life
within the digestive tract. There was a time, not so long since, when
sour milk was supposed to be especially harmful, or at least only
likely to do good to those of particularly strong digestive vitality.
Metchnikoff's work on the influence of sour milk on the digestive
tract, however, has brought a complete reversal of opinion in this
matter. Now most physicians are convinced that the bacillus of sour
milk, acts in the intestinal tract to inhibit the reproduction and
growth of other, and possibly more disturbing, bacterial agents. Sour
milk is looked upon as one of the things that, by neutralizing certain
unfortunate bacterial processes in the digestive tract, lead to
longevity. There seems no doubt at all, that those who consume a great
deal of it, live longer lives than the average, and many old men have
taken to its use with a consequent amelioration of digestive
annoyances.

The popularization of bacteriology, then, has been one of those
moments of unfavorable suggestion that have affected a large number of
people. Such influences do not mean much for people of phlegmatic
temperament. For others, however, they have a weighty significance and
make every symptom, or more properly every sensation, that is at all
unusual in the digestive tract, seem of ominous import. Certain
sensations inevitably accompany digestion. The peristaltic movements
are usually said to be unfelt, but even a slight exaggeration brings
them into the sphere of sensation. Where attention is given to the
abdominal region and its contents, feelings that ordinarily are not
noticed at all come to be perceived. With the unfavorable suggestion
derived from the unfortunate diffusion of a superficial knowledge of
pathology and of bacteriology instead of hygiene and the science of
beneficent microbiology, these feelings produce a bad effect upon the
individual.


Familiar Examples of Unfavorable Suggestion.--There are many familiar
examples of the discomfort that may be produced by the mental
persuasion that something will disagree with us, or that certain
feelings have a significance quite beyond that which ought to be
attributed to them. Everyone knows how qualmy may be the feeling
produced by being told that something eaten with a relish contained
some unusual material, or was cooked under unclean conditions. Food
that agrees quite well with people, so long as they do not know too
much about it, often fails to be beneficial after they see how it has
been prepared. It is often said that people would not relish the food
{97} placed before them if they were aware how lacking in cleanliness
was the place of its preparation, and how negligent those who had
charge of it. Occasionally a peep at the kitchen of a boarding house
effectually takes away appetite, or disturbs the equanimity with which
food must be taken, if there is to be that undisturbed digestion which
makes for healthy nutrition.

It is, indeed, with regard to digestion that the influence of the mind
on the body, favorable as well as unfavorable is, perhaps, most
effectively exercised. Unfortunately the unfavorable influence is even
more pronounced than its opposite. Some people are much more sensitive
than others in this respect, and even the thought of certain defects
in the preparation of their food seriously disturbs them. Everyone has
had the experience of seeing sensitive persons leave the table because
some one insisted on telling a nauseating tale. Anyone who has seen
the effect of talking of blood sausage or fried brains with black
butter sauce at a table on shipboard, when some practical joker was
exercising his supposed wit, knows how much the imagination can
disturb, not only appetite but digestion. The attitude of mind means
much, and especially are such unfavorable suggestions likely to
produce serious effects in inhibiting digestion.


_Suggestion and Seasickness_.--Seasickness illustrates the place of
unfavorable suggestion in digestion. The nausea, consequent upon the
movement of a vessel at sea, is due to a disturbance of the
circulation within the skull, and particularly of the circulation in
the semi-circular canals. The organ of direction of the body is
disturbed by the over-function demanded of it, consequent upon the
continuous movement of the vessel. This is, however, only a
predisposing element. A strong additional factor is the firm
persuasion many people have that they will suffer from nausea and
seasickness, and the unfavorable expectancy thus aroused. Most people
have to give their dole to Neptune. Those who for weeks before have
been expecting and dreading it usually pay a heavy tribute. Probably
the best remedy for seasickness is the suggestion that there is no
necessity for losing more than a meal or two, if even that much,
provided there is simplicity of diet and proper predisposition of body
by gentle opening of the bowels, and lack of the over-feeding that
sometimes comes from dinners given before departure. I have known many
people who, after suffering severely not in one but in many voyages,
have, by means as simple as this, been saved from days of seasickness
even in rough weather.

Most of the cures for seasickness that have been suggested have
depended principally on the suggestive element. For instance, there is
no doubt that many people are relieved by wearing dark glasses, and
this remedy does good for train sickness and other afflictions of a
similar kind. There is, however, no good physical reason why wearing
dark glasses should help except through their constant physical
suggestion. A simple remedy that has helped many through seasickness
is the wearing of a sheet of glazed paper, usually some heavy
writing-paper, immediately over the skin of the abdominal region. This
of itself has no physical effect, but the sensation of its presence
constantly obtrudes itself, and by making people feel that they must
be better because a great many other people have declared that they
were bettered by this remedy, they actually suffer less from nausea
and vomiting. Many of the internal remedies employed for seasickness
are directed to the stomach and intestines. {98} As the seat of the
difficulty is not here but within the skull, the reputation which
these remedies have acquired has been due largely to the suggestive
effect of taking them rather than to any physical qualities they
possessed, though of course they have served to set at rest stomachs
disturbed by unfavorable expectancy.


Disease Groups and Suggestion.--Labeling groups of ailments with a
single term gives rise to many unfortunate conclusions and dreads with
regard to what a particular condition really is. The word
"indigestion" is commonly used for any stomach discomfort or
disturbance, especially that occurring after eating, from the slight
distress because too much has been eaten, or the uncomfortable feeling
of fullness because too much liquid has been taken, or the discomfort
due to an unsuitable mixture of food materials, to such serious
conditions as develop when there is motor insufficiency of the
stomach, followed by dilatation, with delay of the food for long
periods and with consequent fermentation, distress and bad breath.
Whenever the word "indigestion" is mentioned, the patient may think of
the worst cases that he has seen or heard of with this label, and
concludes that while his ailment may not be very serious just now, it
is only a question of time until it becomes so, and that unless he can
get rid of his uncomfortable feeling he is destined to have one of the
forms of "indigestion" that are productive of such serious discomfort,
with probably ever increasing torment, until some fatal complication
develops. The initial symptoms of gastric ulcer and cancer have been
labeled indigestion, and people, often recalling the serious
consequences that followed in such cases, fear for themselves.


_Fearing the Worst_.--This looseness of terms is noted with regard to
many other forms of disease. Rheumatism calls up the picture of
advanced arthritis deformans, with the awful deformed joints and
bed-riddenness, which should not bear the term rheumatism at all, but
which the patient has heard called so. Catarrh is the simplest of
inflammatory processes, meaning merely an increase of secretion,
functional in character and without any serious disturbance of an
organic character beneath it, but many people have heard the
foul-smelling ozena called catarrh, at least popularly, and so the
mental picture of such a repulsive progressive process as beginning in
them is suggested. It is important, therefore, when using words that
have such wide connotation as these, to explain exactly what is meant,
and perhaps, better still, not to use the words, but to employ some
more specific term that does not carry a cloud of dreads with it.
Indigestion can be a very simple passing set of symptoms, but once
certain people get the notion that they are troubled with indigestion,
their minds dwell on it to such an extent that they are likely to
limit their eating more than they should, and to disturb digestive
processes by thinking about them and using up in worry nervous energy
that should be allowed to flow down to actuate digestion.


So-called Incurability.--Patients are likely to hear entirely too much
of the incurability of disease. To the doctor and patient this word,
incurability, often has an entirely different meaning. The doctor
means only that the diseased tissues cannot be restored to their
previous condition by any of our known remedies, and that the effects
of the deterioration are likely to be felt to some degree for the rest
of the patient's life. To the patient it means, as a rule, not only
that the doctor can do nothing for him, which is usually {99} quite
untrue, for much can be done for his symptoms even though the
underlying disease may be intractable, but also that the symptoms are
to grow constantly worse. This is often quite without foundation, for
nature's compensatory powers are very wonderful and seldom fail to
afford relief. In a great many cases fatal termination comes, not from
the original affection, but through intercurrent disease. Above all,
incurable means to many patients that finally the victim is to become
more and more subject to the pains and ills of his "incurable" ailment
until he becomes perhaps a pitiable object. Incurability, when we
recall that patients are so likely to mistranslate this term in the
way indicated, must be a word little used. Etymologically it is never
true, for _cura_ means care, and we can always care for and relieve
the patient. In every chronic case there is room for hope of much
relief through accustomedness, various remedies, nature's compensatory
methods, and, above all, the modification of the state of mind.

There is probably no incurable disease that is ever quite as serious
as it is pictured by its victim when he first hears this word
pronounced. When we recall the chances of life, and that in any given
case, almost as a rule, the patient will live to hear of the deaths of
men and women who were in perfect good health when his ailment was
pronounced incurable, there is much of consolation to be derived from
conditions as they are. It seldom happens that a physician sees a
sufferer from tuberculosis, whose affection is running a somewhat
chronic course, without being able to find out that since the first
symptoms of the disease manifested itself, one or more of the
patient's near relatives have died because of exposure incident to
their abounding health. Pneumonia, appendicitis, typhoid fever,
accidents of various kinds, take off the healthy relatives, while the
tuberculous patient, constantly obliged to care for his health, lives
on, and often is able to accomplish a good deal of work. It is
important to impress facts of this kind upon these "incurable" cases,
for they represent the light in the desert, or the shout, or the
whistle at sea, that give renewed energy when nature seems about to
give up the struggle.


Thinking Health.--Hudson in "The Law of Mental Medicine" [Footnote 14]
suggests that we should think health and talk health on all suitable
occasions, remembering that under the law of suggestion health, as
well as disease, may be made contagious. This expression probably
represents an important element for the prophylaxis of disease under
all conditions. Under present conditions people talk entirely too much
about disease and have too many suggestions of pathological
possibilities constantly thrown around them by our newspapers, our
magazines and by popular lecturers as well as by our free public
libraries. People have learned to think and talk disease rather than
health. This predisposes them to exaggerate the significance of their
feelings, if it does not actually, on occasion, lower their resistive
vitality because of solicitude. The medical student torments himself
with the thought that he is suffering from the diseases that he
studies, and we cannot expect that the general public will be even as
sensible as he is in this matter. On the contrary, people generally
are much more liable to exaggerate the significance of their feelings,
hence the necessity for healthy suggestions rather than innuendoes of
disease.

  [Footnote 14: McClurg, Chicago, 1903.]

In recent years, to paraphrase Plato's expression, people are much
more {100} inclined to educate themselves in disease than in health.
The result has been a storehouse of unfavorable suggestion, from which
ideas are constantly being taken to make whatever symptoms that may be
present seem unduly important. Consequently people look for the worst,
and suggest themselves into conditions where not only are they
exaggerating their symptoms, but they are absolutely preventing the
flowing down of such nervous impulses as will enable them to overcome
affections that are present. Whenever anything turns up that lessens
their tendency to unfavorable auto-suggestion, their health improves.
Hence the taking, with confidence, of any quack medicine, no matter
what its constituents, cures them; hence the success of the numerous
and very varied forms of mental treatment. New Thought, Eddyism,
osteopathy, and the like, attain most of their successes because of
the removal of unfavorable suggestions, and the setting up in their
stead of favorable suggestion. In psychotherapy the first duty of the
physician is to undo all the unfavorable suggestion at work, and, if
successful in that, great therapeutic triumphs are possible.



CHAPTER III

THE INFLUENCE OF BODY ON MIND

While trying to take advantage of the influence of the mind on the
body for therapeutics, it is important to remember that the body has a
great influence on the mind. There are many states of mind that are
dependent on states of body, and that can be modified only by first
modifying the body. Body changes can at least greatly help. In order
to use the mind in the therapeutics of conditions in which it would
help in the awakening of such vitality as is necessary for the cure,
particularly of many of the chronic affections, it is necessary first
to dispose the body so that it will not constantly be adding to, or at
least emphasizing, an unfavorable state of mind. For this purpose it
is important to study definitely and practically the influence that
various attitudes, expressions and external manifestations may have in
changing the internal feelings. This factor seems trivial when viewed
from the standpoint of health, but it is one of the trifles that are
very helpful in the predisposition of the patient to get better.
Alteratives in medicine, while we have not been able to say just what
their effect was, have done much for us, and the influence of body on
mind is just such an alterative.

Even those who have insisted most strenuously on the independence of
mind from body have always recognized not only the influence of the
mind on the body, but also of the body on the mind. Perhaps the most
familiar example of this is the well-known liability to dream after
eating things that disturb digestion and seem to interfere, probably
by congestive tendencies, with the circulation of the brain during
sleep. It has always been recognized that mental operations are
sluggish for some time after eating, and that a period of depression
is likely to follow any excess. The Romans feared the consequences of
indigestion so much that, occasionally after they had surfeited
themselves with rich food, they took such direct mechanical means as a
feather or a finger in the throat to relieve their overloaded stomach,
in order that they {101} might not suffer the after consequences, but
especially the depression and irritability of mind.


Disposition and Digestion.--The relation of the body to the mind in
many other besides the purely animal digestive functions has always
been realized. It has always been felt that the disposition of an
individual depended to a great extent on his nutrition. Men were not
usually approached for favors before their meals, and especially after
a long fast, but, as far as possible, requests were made shortly after
meals. It has always been recognized that the best time for men to get
together in council is, at least so far as amiability goes, shortly
after meals. Tiredness was also felt to be an important element in
affecting the mind. The tired man, even though he may be hungry, can
only eat a hearty meal at the risk of serious disturbance of
digestion, for, as a consequence of the fatigue of the body being
communicated to the mind, the mental influence which predisposes to
good digestion is lacking, and it is easy for serious digestive
disturbances to be set up. In a word, body and mind are inextricably
involved in all that concerns not only health but good feeling, and
these two terms are practically convertible.


Feeling and Expression.--In nothing is the influence of the body on
the mind more clear than in the influence of expression upon the
disposition. Actors know that if they want to well express a certain
feeling, they must arouse that feeling deeply, and the easiest, surest
and most direct method of doing so is to fix the features in the
expressions that would ordinarily indicate the presence within of
these feelings. If we insist on putting our features into the shape
which ordinarily expresses sadness, that will be reflected internally,
and we shall become as sad as our expression. On the other hand, if
the features are drawn, even by force of will, into the state that
ordinarily expresses joy or lightness of heart, we shall be tempted
more and more to feel that way, until at last even internal melancholy
may be dissipated. In the oldest book in the world, "The Instruction
of Ptah Hotep," written about 3,000 years before Christ, the old
father giving advice to his sons says: "Let thy face be bright what
time thou livest," and the literature of every time since then
emphasizes the same idea.

This influence of the expression on the mind is an extremely important
element in psychotherapy. Men and women must be taught to shake off
inner sadness, and over-occupation of mind, by training their facial
muscles of expression as far as possible to occupy positions
expressive of good feeling, but above all not to let them be fixed in
positions indicative of ill feeling. It makes a great difference for
the mental state whether a man has the corners of his mouth drawn down
or up, or whether they are pulled straight across the face to give the
severe, austere expression that some people seem to cultivate. If the
corners of the mouth are allowed to droop the glumness and depression
is likely to grow deeper. If the lips are curled upward and smile,
even though it may be a forced smile, the inner feeling will soon
yield to it. Actors are able to counterfeit the reality, but much more
than this, as we have said, they realize that, by imitating the
externals of the feeling, they awaken the feeling itself within them.
This is true for anger and loathing, and for many of the more serious
dispositions as well as for those that might be thought more
superficial, and hence more controlled by the external muscles.

{102}

_The Mouth_.--It is interesting to realize how different are the
expressions of the face as a consequence merely of control of the
sphincter of the mouth and its associated muscles. Physiological
psychologists have often called attention to the fact that only a few
lines are necessary to picture the characteristic human expressions of
sadness, joy and severity. If a little droop is given to the line that
represents the lips, melancholy is at once expressed, while the upward
curve expresses joy, and the straight line severity. These types of
human expression are easy to control, and the internal effect of each
is soon felt where there is deliberate, or indeliberate, perseverance
in its maintenance.


  [Illustration: Fig. 1.  Three abstract faces.]


_The Eyes_.--A typical example of the influence of the mind on the
body is to be found in the use of the eye muscles, especially the
oblique muscles. Of definite and important use for many purposes, they
are especially employed to attract attention by means of the eyes.
Coquetry has used them to express various phases of sex attraction. We
all know the picture of the young woman who "makes eyes." It is
interesting, however, to set solemn people imitating these exercises
of the oblique eye muscles. For most people it is practically
impossible to use these muscles without a corresponding quasi-demure
setting of the features, commonly associated with those who use them
most. There is even likely to be a certain attitude of mind aroused
corresponding to the setting of the features in a particular way.
While this is true for almost any other expressive state of the
countenance, it is not so easy to demonstrate as is this.

The use of the superior recti muscles has also a definite effect upon
the disposition. One of the pleasures of walking in a well-kept forest
where the trees meet high overhead, is that the eyes are inevitably
attracted upward to range among them, and there is a corresponding
elevation of feeling. Bernard Shaw once said that it was impossible to
enter a Gothic church without an elevation of the spirit, because the
eyes were surely attracted upward by the height of the nave, and a
corresponding uplift of feeling ensued. During a period of glumness it
is apparently impossible to keep the eyes raised. People who are
depressed and "cast down," as the expression is, invariably keep their
eyes downward, and just as soon as a man "looks up and not down" there
is a lifting of the depression. Even such apparently trivial muscular
actions as this may influence the mind, and thus react upon the
physical system generally.


_Wrinkles_.--Many influences of the body on the mind group themselves
in the muscles of expression around the eyes. Wrinkles, for instance,
are originally a habit of mind, and then the emphasis of this, in the
muscles of the face, is reflected back to deepen still further the
dejection or nervous unrest that originally causes them. It is
surprising to see what an influence it has on patients who go round
much with wrinkled foreheads, to have them give over the practice and
discipline themselves to appear with uncorrugated superciliary
muscles. St. Ignatius Loyola, the founder of the Jesuits, and one of
{103} the wisest managers of men that ever lived, has emphasized in
one of his rules that "wrinkles on the forehead and still more on the
nose" are a sign of interior disquiet and must not be seen. He
realized that the interior feelings could be influenced by suggestion
at least, by having those who indulged in wrinkles keep their
foreheads and noses smooth. Most of the expression of the face is
concerned with the eyebrows and neighboring regions, and people should
occasionally be asked to look at themselves in the glass, so as to rid
themselves of habits of expression indicative of a disturbed mind, for
this will do much to help to relieve the mental disturbance.


Attitudes and the Mind.--With regard to the influence of the body on
the mind, and the stimulating mental reaction that follows even a pose
of well-being and good feeling, perhaps nothing affords more striking
evidence than the effect of assuming the expressions and attitudes
usually associated with various states of mind and then noting the
results. If a man throws his shoulders back, and takes in long breaths
of air, expanding his chest and stimulating his circulation, his whole
body as well as his mind feels the effect. A slow walk with bowed
shoulders and head, while one moodily turns over all the possibilities
for ill in the life around, does very little good, while a brisk walk
with head thrown back, shoulders erect, brings a man home with mind
and body both ready to throw off temporary obstacles of all kinds, and
in addition to the fact that the mental depression has disappeared, to
some extent at least, all the physical functions will be accomplished
better than before.


Tears and Feeling.--Some of the usual translations of the meaning of
external expressions are not justified by what we know of their actual
purpose and effects. For instance, tears are supposed to be a sign of
deep grief. Except in the very young they are not, as a rule, to be
thus understood. As we grow older they are much more frequently a sign
of deep feeling that is usually quite pleasurable. It is almost
impossible for a human being to be touched deeply without a glistening
of the eyes that readily runs over into tears. A mother who is proud
of something that her children have done is quite sure to have tears
in her eyes. If she is present at a successful musical or dramatic
performance given by a son or a daughter, especially where there is
something of a triumph for them, she is sure to have tears in her
eyes. There are few mothers who fail to be moved in this way when
their children take prizes, or when some one writes to tell them how
well their children are doing. Tears, indeed, far from being a sign of
sadness, usually in adults indicate profound joy.

Tears, then, instead of being discouraged, should rather be
encouraged, unless when indulged in to excess. We realize how trying
to health and strength is the stony grief that does not melt into
tears. The mother who faints over the sudden death of her child, and
who wakes to silent consciousness, is in a dangerous condition until
the solace of tears comes to her. Until there are tears, we fear for
the effect upon her mind of the grief. The sufferer from melancholia
is sad, but a good outburst of tears will, indeed, often mean the end
of a prolonged period of melancholia. In the trials of life tears are
a consolation rather than an addition to sorrow. In the olden times
men wept as well as women, and Homer's heroes thought it not at all
beneath their dignity to be seen in tears. Over and over again, the
physician learns that while people have been going to "shows" that
were supposed to make them {104} laugh and so divert their minds, the
best possible effect is derived not from trivial laughter, but from a
serious play that touches the heart deeply and makes all who go to it
melt a little. Many nervous patients never feel better than after they
have had a good quiet cry.

The influence of the serious things of life in producing favorable
states of mind is not sufficiently appreciated, or at least has come
to be neglected in our day. There is a seeking far and wide for
pleasure and diversion that should be obtained near home, through the
simple joys of domestic life or intimate contact with others who need
us in some way. As has been well said, it is not far-fetched pleasure,
but simple joys that are more needed in our time. Nothing so enables
the patient to get his, and above all her, mind off self as care for
others. This must be expressed, however, in external acts accomplished
by ourselves for others to have any deep effect. Doing things for
other people deepens the feeling of sympathy, and so makes the mind
much more ready to respond to increase of these feelings so profoundly
as to displace selfish considerations. Exercise is valuable, but
exercise undertaken for a worthy motive, constantly before the mind
during the time it is taken, means ever so much more in awakening all
the sources of energy that there are in men and women to make life
worth living for themselves and others.


Application of Principles.--The best possible source of relief from
that combination of mental despondency, and the lack of bodily
vitality which so often accompanies it, and which, if not interrupted,
may lead to a serious breakdown of mental health, is the discipline of
work; above all, work for the benefit, of others, to which one forces
one's self gradually but persistently, not with, long intervals, but
day after day. The discipline of the asylum and the sanatorium is
probably the most efficient curative agent when these cases are at
their worst. When the symptoms are beginning, a discipline of a milder
character, yet resembling that of the institution, but appealing to
higher motives and leading to frequently repeated actions for the
benefit of others, will undoubtedly do much to prevent worse
developments or make the future condition of the patient less serious
than it would otherwise be. Undoubtedly some of the old monastic
regulations were efficient in preventing the more serious developments
of despondency when the danger to himself and others of the
melancholic was not so well recognized as at present.


_Laughing Cures_.--Every now and then the newspapers announce that
some physician has invented a laughing cure, or a smiling cure, or
something of the kind. Sometimes these reports are founded on actual
occurrences; oftener, perhaps, they are the invention of a reporter
suffering from a dearth of news. There is, however, no doubt that a
smiling cure will do much to make people, even those who have serious
reasons to be depressed, feel better. Every physician knows that if
melancholic patients of the milder type can be amused quietly, their
depression is modified for the better. Accordingly, we advise them to
see farces or lively comedy, and we try to pick out cheerful nurses
for them. The depression consequent upon some serious illness can be
better relieved in this way than by any tonics or stimulants. For the
depression, for instance, that so often follows a stroke of apoplexy,
the employment of a nurse with a good human sense of humor and a large
sympathy with the humorous side of things in life will do more to
arouse a man from the lethargy into which he settles than almost
anything else.

{105}

With regard to laughing, there is, of course, another element that
must be remembered. A hearty laugh moves the diaphragm up and down
vigorously, empties and ventilates the lungs, stimulates the heart
mechanically by its action upon the intra-thoracic viscera, and is one
of the best tonics that we have for the circulation in the abdominal
cavity, and probably also for the important nervous mechanisms
centered there. Its action upon the lungs is readily recognized. Its
influence upon the heart is usually not so much thought of, but
deserves even a more prominent place. It is now well known that when
patients have gone into coma or the apneic condition that sometimes
follows shock, or the administration of an anesthetic, when the heart
ceases to beat, the only effectual means of resuscitation is by
directly irritating the organ. It has been suggested that if the
abdominal cavity is open the surgeon's hands should be passed up and
should squeeze the heart through the diaphragm. It has even been
proclaimed that tapping on the chest vigorously over the precordium
may arouse a heart that has for the moment stopped beating. It is easy
to understand, then, that a hearty laugh, by stirring up all the
intra-thoracic viscera, stimulates the heart mechanically and sets it
beating more vigorously than before. This is one of the reasons why
people feel so well after a hearty laugh.

Even slight swallows of water act as a distinct heart stimulant. When
people have fainted, a succession of swallows of water, each of them
acting as a heart tonic, is one of the best methods that we have of
stimulating the heart's action. It is usually said that this action is
a consequence of the reflex from the terminal filaments of the vagus
nerve running back and reflected down again to the heart. To me it has
always seemed that the swallowing action had a direct mechanical
effect upon the heart, because the esophagus passes so close to it in
the thoracic cavity.

Man is the only animal that laughs, and, as the old philosophers point
out, he might very well be defined as _animal risibile_ with just as
much truth as by the words _animal rationale_. It requires reason in
order to have a sense of humor. The higher the reason, the more the
humor. Peasants and the uneducated have, as a rule, a very undeveloped
sense of humor. It is the highly educated man of deep intellectual
powers who catches all the humor of a situation, and, though his
expression of it may not be loud, it is deep and helpful at moments of
depression. Humor is, of course, very different from wit, which is
biting and which seems almost to be shared by the animals, if we can
judge from the fact that they appear, occasionally, to play practical
jokes upon one another.

It seems almost absurd that a physician should tell patients that it
will do them good to practice smiling, to take every possible
opportunity to laugh, and even to take frequent glances into a looking
glass, to see that they are not pulling long faces. The difference
between a feeling of melancholy and one of gladness consists mainly in
the position of the outer angles of the mouth. The putting into
practice of the maxim, not to let the sad lines dominate the
countenance, but to insist on keeping the others there as far as
possible, means much for the correction of internal feelings of
depression and discouragement that may be badly interfering with the
flow of nerve impulses from the brain to the body.


Mouth Breathing.--Since Meyer's discovery of the overgrowth of the
{106} lymphoid tissue in the pharynx, we have learned to appreciate
how important is mouth breathing, even for the intellectual life. We
all knew before, and indeed from time immemorial it was well
understood, that, as a rule, people who went around with their mouths
open were of low grade intelligence. All sorts of methods were used to
teach these young people to keep their mouths shut. They were reminded
of it at home, they were told about it at school, and, if they
married, their wives tried to keep them from this apparent
manifestation of lack of intelligence. Of course, they were not, as a
rule, able to carry out the well-meant intentions of their friends and
advisors. The mouths were kept open because they could not breathe
normally through their noses, and so respiration had to be
accomplished by the only other available avenue. As a consequence of
the open mouth, the lips were inclined to roll out somewhat, and
certain indications of the human physiognomy were supposed to be
associated with these thick lips.

Now we know the real meaning of the condition. Mouth breathing is
possible, but it is inadequate. Insufficient respiration leads to
insufficient oxidation of tissues, and to lowered vitality in all
structures, and this is particularly notable in the brain, as well as
in certain other higher structures. It is not because the individuals
are lacking in intelligence that their mouths are open, but because
the same reason that compels the open mouth also affects their
intellectual activity. The blocking of nasal respiration lowers vital
activity of all kinds. Hence the lowered intellectual vitality. The
thick lips, which are supposed to be characteristic of a certain
passionateness of nature, and which usually are associated with a lack
of thorough control over animal inclinations, probably owe their
significance to the fact that this special peculiarity of feature
usually accompanies mouth breathing, and that the individual who
labors under this deficient respiration, is likely to lack control to
at least some degree. There is even a question whether the deficient
oxidation is not likely to be much more notable in its effect upon the
higher faculties than on the lower, and as a consequence the latter
develop somewhat to the detriment of the former.

These studies in physiognomy may, indeed, be correlated in many ways
with distinct physical conditions instead of as formerly with the
general constitution of the individual. For instance, large protruding
eyes used to be said to be characteristic of nervous, timid, sensitive
individuals, easily scared, and not well able to take up the harder
parts of the battle of life. Now we know that this feature is usually
associated with an excess of secretion of the thyroid gland, and that
the nervousness is not a matter of character so much as it is due to
the disturbance of internal metabolism consequent upon this
interference with the proper function of an important organ. It might
well be called a slight thyroid intoxication. In large amounts it
produces all the symptoms of Graves' disease.


Bodily Conditions and Stupidity.--We have many illustrations of the
influence of the body on the mind, when purely physical causes work
rather serious results on disposition and character and energy. A
typical example was the so-called tropical anemia which existed in
Porto Rico when the Americans took possession of the island. There
were so many cases of it that out of about 25,000 deaths reported in
1903, nearly 6,000 were from so-called anemia. Investigation of the
conditions soon revealed the real cause. It had been {107} thought to
be due to a combination of the climate, malaria and the lack of
nutrition on the part of the country people. The people were
absolutely without ambition, they had no energy, they seemed scarcely
able to keep body and soul together, and they cared for nothing except
to get just enough to supply them with a meager sustenance. Of
incentive to lift themselves up, there was none. This was largely
attributed by the first Americans who went to the island to the
conditions which had existed under Spanish rule, as the Spaniards had
not encouraged manufactures or industries in the island, and had left
the people without any incentives to the awakening of enterprise or
initiative.


_Hook-Worm Disease_.--Before long it was found that the real reason
for the anemia of the Porto Ricans was the presence in their
intestines in large numbers of the so-called hook-worm. These worms
exhausted the vitality of the sufferers and left them without surplus
energy and, indeed, with scarcely enough life to care whether or not
life itself continued. It was not a moral condition, but a very
definite physical cause that was at work. Shortly afterwards it was
found that the same disease existed in our Southern states among the
so-called "poor whites." Before this, these people had been supposed
to be a characterless, unambitious, lazy people, who cared not to get
on, who had sunk to about the lowest depths possible for civilized
people, and who were quite satisfied to remain there. The discovery of
hook-worm disease among them, however, soon made it clear that their
laziness was the result of the drain upon their systems due to the
presence of thousands of hook-worms. When these were removed, if
nature was not already exhausted, the "poor whites" became normal
human beings once more with ambition and initiative.

This story of pathology influencing racial qualities is not new in the
history of the world. It is not improbable that even certain periods
of decadence in Egyptian history which have ordinarily been attributed
to the so-called running out of particular ruling races or families,
or to the degeneration of the people consequent upon luxury, were
really the result of the spread of the hook-worm disease through
certain portions of Egypt. Dr. Sandwith, who has studied the disease
very carefully in Egypt, is sure that it has existed there for at
least four thousand years, and that the descriptions of certain
affections which occurred in Egypt in historic times were really due
to the same cause as now is known to produce the so-called Egyptian
chlorosis, the name that was used for hook-worm disease in Egypt.
Workers in soil, and in mines and in tunnels, are especially likely to
be affected by it, and whenever it is neglected it spreads rather
widely, as is seen in the mines of Germany and Hungary at the present
time. As the cause was unrecognized in the olden time, it is possible
that periods of supposed lassitude among the people were really due to
infection by this parasite.


_Malaria and Degeneration_.--In recent years it has come to be
generally recognized that the decadence of Greece, for instance, was
not due to moral causes so much, perhaps, as to physical reasons.
During the classic periods in Greece there are no traces of malaria.
After the invasion of Sicily, the expedition against Syracuse and
other attempts on the part of the cities of Greece to spread their
dominion, malaria seems to have been introduced among her people, and
as the _anopheles_ mosquito was already there, the malaria spread
widely, and in the course of a century affected so many of the people
that their energy and ambition and initiative were to a great extent
destroyed. {108} It is well known that these effects often occur as a
consequence of malaria, and as generation after generation is affected
by the disease, are emphasized more and more. The relaxing effect of
tropical climates, of which we have heard so much, and which is
supposed after a time to bring about the inevitable production of a
race eminently lazy and careless of the future, is probably much more
due to certain affections, such as malaria and those consequent upon
animal parasites, than to any constitutional change that has taken
place in the body, or any profound corresponding change in the mind.
It is a case of the body influencing the mind and producing an
apparently different race from that which existed before, though all
this may be changed for the better by some even slight amelioration of
bodily conditions.

In any attempt, then, to influence the human mind in order to use its
power and its reserve energy for therapeutic purposes, the place of
the body and its influence upon the mind must always be remembered. It
is quite impossible to lift people up to enable them to use their
mental reserve force if they are living in discouraging physical
conditions, which use up so much of energy as to make it impossible to
have any to spare. Many of the phases of mental discouragement and
lack of initiative which are reflected in what we call lowered
resistive vitality and lack of immunity to infection, are really
consequent upon physical states representing a drain upon the system
that can be removed, or at least greatly improved, if they are
discovered and properly treated. Victims of chronic malaria and of
hook-worm disease cannot be lifted up by psychotherapy. Neither can
sufferers from other forms of chronic physical debility. After the
removal of the debilitating cause, however, mental influence may be
brought to bear to encourage them to rise to their opportunities, to
literally take on new life, and gradually accumulate reserve energy
that will enable them to accomplish, not only the average work of
mankind, but even better, in the reaction that comes with the new
feeling of physical energy. And what is thus true in these extreme
cases is even more true of minor ailments and conditions.



CHAPTER IV

THE MECHANISM OF THE INFLUENCE OF MIND ON BODY

The question as to how mind influences body, and body mind, has always
proved a riddle to all but those with a special theory in the matter.
The facts of the mutual influence of mind on body are so obtruded on
observation that they could never be missed, but it is quite another
thing to reach a satisfactory explanation of them. How the will
initiates motion continues in spite of all our advance in psychology,
to be as much a mystery as ever. Just how sensation is transformed
into ideas is a parallel mystery. Since the mind is able to influence
motion, it is not surprising that it should be capable of modifying
secretion or inhibiting other kinds of functions. Any of these various
activities is scarcely more mysterious than the other. Since the
transformation of sensation into thought takes place, it is
comparatively easy to conclude that the mental processes are able to
exclude, or to some extent inhibit, sensation. All these activities
have actually been observed. How does this mutual influence of mind on
body take place? What principles underlie it?

{109}

At present, it would be futile to hope to outline the absolute
principles on which the mechanism of mental influence or suggestion
depends, but we can discuss recent explanations that have been
offered, and this will help us to understand, not the mystery itself,
but just where the mystery lies and what the physical mechanism
connected with it is.


  [Illustration: Fig. 2.--CORTEX OF HUMAN BRAIN ILLUSTRATING
  COMPLEXITY OF THE SYSTEMS AND PLEXUSES OF NERVE FIBERS (Combination
  of the methods of Weigert and Golgi--after Andriezen). _c, z.,_
  clear zone free from nerve fibers; _M.P.,_ Exner's plexus in the
  molecular layer; _A. str.,_ ambiguous cell stratum; _Subm, P.,_
  sub-molecular plexus; _Gt. P. P.,_ great pyramidal plexus; _Pol.
  P.,_ polymorphic plexus; _W.,_ white matter. (Barker.) ]


{110}

These explanations are as yet only theoretic, but theories have often
helped students in science to make their thoughts more concrete and
their investigations more practical. It would be a mistake to conclude
that because some of the theories advanced are very plausible, we
have, therefore, reached definite truth with regard to the mechanics
of the brain that underlie suggestion and mental influence.


Brain Complexity.--The most interesting feature of the discoveries in
brain anatomy during the past generation, has been that the central
nervous system is of even greater complexity than had been thought.
Because of this, these new discoveries, instead of solving the
biological mystery they subtend, or even helping very much to solve
it, have made it still harder to understand just how we succeed in
controlling and directing this immensely complex machine, of whose
details we are utterly unconscious, yet which we learn to use with
such discriminating nicety of adjustment and accomplishment. The
discoveries of Golgi and of Ramon y Cajal show us that the brain
consists of nerve cells with a number of ramifying fibers connecting
each cell and each group of cells with other simple and compound
elements of the brain, and sending down connecting fibers to every
organ and every part of the body. Dr. Ford Robertson calculates that
in an average human brain there are at least three billions of cells.
Without knowing anything of their existence, much less anything of the
infinite detail of their structure and mode of operation, we have
learned to use these for many purposes.


  [Illustration: FIG. 3.--SMALL AND MEDIUM-SIZED PYRAMIDAL CELLS OF
  THE VISUAL CORTEX OF A CHILD TWENTY DAYS OLD. Section taken from the
  neighborhood of the calcarine fissure. A. plexiform layer; B, layer
  of the little pyramid; C, layer of the medium-sized pyramid; a,
  descending axis cylinders; b, ascending or centripetal collaterals;
  c, stems of the giant pyramidal cells. (Ramon y Cajal.)

  (This and the next three illustrations illustrate the complexity of
  the central nervous system as observed in the very young child where
  the development does not as yet obscure the interesting details of
  dentritic branching. They serve to emphasize the much more
  pronounced condition which develops in the adult.)]


Nerve Impulses.--We do not know even how nerve impulses travel.
Probably they do so by a mode of vibration, just as heat and light and
electricity are transmitted as modes of motion. The similarity that
used to be thought to exist between the transmission of nerve impulses
and of electrical energy is now known definitely to be only an
analogy, and not to represent anything closer. Waves of nervous energy
travel at a different rate of speed from electrical waves, and there
are other notable differences. Such phases as molecular action, or
motion, or vibration are only cloaks for our ignorance, A generation
ago Huxley declared that "the forces exerted by living matter are
either identical with those existing in the inorganic world or are
convertible into them." He instanced nervous energy as the most
recondite of all, and {111} yet as being in some way or other
associated with the electrical processes of living beings. As Prof,
Forel said in his "Hygiene of the Nerves," "the neurokym cannot be a
simple physical wave, such as electricity, light or sound; if it were
its exceedingly fine weak waves would soon exhaust themselves without
causing the tremendous discharges which they actually call forth in
the brain."


Law of Avalanche.--How great is the power of the nervous system or the
energy of it that may be set loose by some very simple reflex, as
suggested by Forel, is illustrated by what Ramon y Cajal calls the Law
of Avalanche. A single peripheral nerve ending is represented in many
different portions of the brain. An ocular nerve ending, for instance,
probably has direct connection with four or more portions of each
hemisphere. Each of these portions of the brain has association fibers
connecting it with other parts and so the stirring of a single nerve
ending may disturb many thousands, perhaps hundreds of thousands, of
brain cells; at least it affects them in some way or other. The older
psychologists used to insist on the similarity, or analogy, between
the cosmos ol the universe and the microcosmos that man is. The
English poet of the nineteenth century told us that there is no
moving of a flower without the stirring of a star, so intimately
connected by the laws of gravitation is the universe. In the microcosm
something of this same thing is true and a titillation of even the
most trivial nerve ending may produce, in Ramon y Cajal's phrase, "an
avalanche" of cell disturbances in the central nervous system which
may seriously disturb the whole system.

What is thus true for the brain is true, also, for the cord, and the
complexity of spinal cells needs to be seen to be properly realized.


  [Illustration: Fig. 4.--SERIES OF SECTIONS SHOWING THE FINE NERVE
  ENDINGS AND BRANCHINGS OF THE FIRST AND SECOND LAYER OF THE VISUAL
  CORTEX OF A CHILD FIFTEEN DAYS OLD. A and B, very thick nerve plexus
  of the layer in which the little pyramids are contained; C, a plexus
  containing a series of branches that is less thick and intricate; D,
  small cells whose ascending axis-cylinders have resolved themselves
  into a set of similar branches; E, arachnoid star cells whose axis
  cylinders produce a thick plexus in the first layer; F and G, small
  cells with short axis cylinders that have very few branches. (Ramon
  y Cajal.)]



Psychic States.--There are a number of human states representing
extremes of sensory and intellectual conditions in man, that have
always attracted attention, and in recent years have been special
objects of investigation by physiologists. Natural sleep is one of
these; the unconsciousness of narcotism or anesthesia is another.
Hypnotism is allied to both of these, and would seem to lie on a plane
between them. Then there are various states of exaltation in which
sensations fail to produce their usual effect. Those {112} escaping
from a fire, or passing through a severe panic of any kind may sustain
all manner of injuries without being aware of them. Martyrs, for all
manner of causes, are able to withstand suffering with such
equanimity, and sometimes even joy, that it is evident that they
cannot feel, as would people under ordinary conditions, the pain that
is being inflicted on them.


  [Illustration: Fig. 5.--FIRST, SECOND AND THIRD LAYER OF THE
  ANTERIOR CENTRAL CONVOLUTION (THAT IS, OF THE ASCENDING FRONTAL
  CONVOLUTION) OF THE BRAIN OF A CHILD ONE MONTH OLD. A, B, and C,
  little pyramids; D and E, medium-sized pyramids; F, cells with two
  sets of tufts; their axis cylinders resolved into end tufts; G,
  protoplasmic layer that comes from one of the large pyramids of the
  fourth layer; H and I, fine dentrites of the cells of the sixth and
  seventh layer; J, small cells with two end tufts; K, spindle cells
  with long axis cylinder. (Raymon y Cajal.)]


  [Illustration: FIG. 6.--LAYERS OF THE POSTERIOR CENTRAL OR ASCENDING
  PARIETAL CONVOLUTION OF A NEWBORN CHILD. 1. plexiform layer; 2.
  small pyramids; 3. medium-sized pyramids; 4. external large
  pyramids; 5. small pyramids and star shaped cells; 6, deep layer of
  large pyramids; 7, spindle and triangular shaped cells. (Raymon y
  Cajal.)]


In the midst of intense mental preoccupation one may hold so cramped a
position as would be quite impossible for the same length of time with
the faculties normally engaged. There are pathological conditions,
like hysteria, in which the pain and fatigue sense may, for a time at
least, be quite in abeyance.

{113}

  [Illustration: FIG. 7.--DIAGRAM OF CELLS OF CEREBRAL CORTEX (after
  Starr, Strong and Leaming). I, superficial layer; a, fusiform; b,
  triangular; c, polygonal cells of Ramon y Cajal; II, layer of small
  pyramids; d, smallest; e, small; f, medium-sized pyramidal cells
  with axones descending to the white matter and giving off
  collaterals in their course; III, layer of large pyramidal cells; g,
  largest (giant) pyramidal cells; k, large pyramidal cells with very
  numerous dendrites; all pyramidal cells are seen to send long apical
  dendrites up to I; m, Martinotti cell with descending dendrites and
  ascending axone; n, polygonal cells; IV, deep layer; p, fusiform
  cell; q, polygonal cell; V, the white matter containing the axones
  from the pyramidal cells, d, e, f, g, and from a cell of the deep
  layer q; r, neuroglia fibers. (Barker.)]

{114}


  [Illustration: Fig. 8.--SCHEME OF LOWER MOTOR NEURON. The motor-cell
  body, with protoplasmic processes, axis cylinder, side fibrils or
  collaterals, and end ramifications, represents parts of a neuron. a.
  h., axon hillock devoid of Nissl bodies, showing fibrillation; ax.,
  axon. This process near the cell body becomes surrounded by myelin,
  m., and a cellular sheath, the neurilemma (not an integral part of
  the neuron); c, cytoplasm showing Nissl bodies and lighter ground
  substance; d, protoplasmic processes (dendrites) containing Nissl
  bodies; n., nucleus; n., nucleolus: n. r., node of Ranvier; s. f.,
  side fibril; n. of n., nucleus of neurilemma; tel., motor end plate
  or telodendrion; m., striped muscle fiber; s. l., segmentation of
  Lautermann. (Barker.)]


Neurons.--With the advance in our knowledge of brain anatomy, various
explanations for these curious conditions have been suggested. The
discovery that the central nervous system is composed of a large
number of separate units, and not of a feltwork of continuous fibers
with cells here and there, revolutionized all previous attempts at
explanation of these conditions. We know now that it is not fibers but
cells that are the most important components of the brain and
spinal-cord substance, and that, indeed, the fibers are only
prolongations of cells. The central nervous system is made up of nerve
cells with various appendages, and each one of these cells and its
appendages is called a neuron. These appendages are of two kinds, one
the axon, the long conducting fiber which transmits the nerve force of
the cell, the other the dendrons or connecting elements by which the
cell is linked with the axon of another cell. The contact of the axon
of one neuron with the dendrons of another is called a synapse. Each
neuron does not extend to and from the brain and the periphery, but
series of neurons connect the surface of the body with the brain.
There is usually a group of neurons in the path from the surface to
the brain cortex. The peripheral neuron for sensation runs from the
surface of the body to the spinal cord, while for motion it runs in
the opposite direction. There is a secondary neuron in each chain that
runs up or down the spinal cord to and from the base of the brain. A
third--sometimes, perhaps, a fourth--neuron connects in the two
directions, afferent and efferent, the cortex and the base of the
brain.


_Neuronic Movement_.--Duval, the French anatomist and histologist,
suggested the possibility of voluntary and involuntary movement in the
neurons or nerve cells themselves, thus making and breaking
connections.


{115}

  [Illustration: FIG. 9.--SCHEME OF THE VISUAL CONDUCTION PATHS (after
  C. von Monakow). a, rods and cones; b, rods; c, nuclei of rods; d,
  bipolar cells for the cones; e, bipolar cells for the rods; f, large
  multipolar ganglion cells giving rise to the axons of the N.
  opticus; g, centrifugal axon of a neuron, the cell body of which is
  situated in the collieulus superior, its telodendron being situated
  in the retina; h, Golgi cell of Type II, or dendraxon in the corpus
  geniculatum laterale; i, neuron connecting the corpus geniculatum
  laterale with the lobus occipitalis, its axon running in the radiato
  occipito-thalamica (Gratioleti). The visual impulses are indicated
  by the arrow. (Barker)]


{116}


  [Illustration: FIG. 10.--SCHEMATIC FRONTAL SECTION THROUGH THE
  OCCIPITAL LOBE ILLUSTRATING MANIFOLD CONNECTIONS IN A SINGLE LOBE
  (after H. Sachs), v, cornu posterius ventriculi lateralis; f. c,
  fissura calcarina; b, upper division: i, lower division; coll,
  sulcus collateralis; s. o. I, sulcus occipitalis superior (fissura
  interparietalis); s. o. II, sulcus occipitalis medius; s. o. III,
  sulcus occipitalis inferior; c. a., calcar avis; g. l., gyrus
  lingualis; g. f., gyrus fusiformis; g. o. s., gyrus occipitalis
  superior; g. o. m., gyrus occipitalis medius; g. o. i.. gyrus
  occipitalis inferior; c, cuneus; 1-10, forceps; 11-14, stratum
  sagittale internum: 15, stratum sagittale externum; 16, stratum
  calcarinum; 17, stratum cunei transversum; 18, stratum proprium
  cunei; 19, stratum proprium s. o. I; 20, stratum proprium s. o. II;
  21, stratum proprium. s. o. III; 22, stratum proprium, s. coll.; 23,
  stratum profundum convexitatis. (Barker.)]


According to his suggestion, sleep would be due to a separation of the
neurons that run from the surface of the body to the brain cortex,
because the various neurons had become too tired for further function.
As a consequence of fatigue, their terminal filaments would fall away
from one another, external sensations would no longer be communicated
to the brain, because the peripheral neuron was not connected with the
next in the chain. As a further result, the brain, undisturbed by
sensations, would be left at rest so far as the body was concerned.
Within the brain certain connections through which flow thoughts that
would keep us awake, are also supposed on this theory to be broken,
and consequently all the nerve cells have a chance to rest, except, of
course, those concerned with such very vital functions as heart
movement, respiration and peristalsis.

{117}


  [Illustration: FIG. 11.--ISOLATED CELL FROM HUMAN SPINAL CORD
  (Obersteiner).]


Somehow, these vital neurons obtain their rest in the intervals
between the impulses which they send down, just as cardiac cells do
between heart beats.


_Neurons in Psychic States_.--This same explanation would serve for
narcosis, that is, for anesthesia, due to chloroform or ether, or any
other drug. As a consequence of the effect of the narcotic upon the
central neuron, they are brought into a condition resembling fatigue,
at least to the extent of breaking their connections with other
neurons so long as they are under the influence of the drug. While
sensory nerves at the periphery, then, are being stimulated by the
cutting of tissues to which they are attached, the message from them
does not reach the brain because of a disturbance of the connections
in the chain of neurons. Drunkenness illustrates the same phenomenon
in a less degree. The effect of the intoxicant upon the central
neurons disturbs sensation because it makes the connection much less
complete than before, and so it is easy to understand the familiar
occurrence of even severe injuries to drunken men without their being
aware of them, or at least without their suffering nearly so much as
would be the case if they were not intoxicated.


_Hypnotism_.--The same theory would also hold for the phenomena
observed in hypnotism. After all, the best explanation of hypnotism
that we have is that there is a turning inward of the patient's
attention, so that only those sensations are allowed to reach the
brain to which mental attention has already been called by suggestion.
Hypnotism usually begins with a certain fatigue of peripheral neurons
until these do not act normally, and then the cerebral neurons become,
as it were, short-circuited on themselves with a consequent internal
concentration of attention. The anesthesia so often noted in hypnotic
or hysterical states is explained by the same theory. For the time
being, at least, the connection between the peripheral neurons and the
central neurons is broken or but imperfectly made, and conduction does
not take place, or is hampered. There may be loss of motion as well as
of sensation, or of motion without sensation. In all these cases, the
discontinuity of the nervous system enables us to understand more
readily the mechanism by which these curious phenomena occur.
Exaltation or intense interest or profound preoccupation may so
concentrate nervous energy within the nerve centers themselves as to
inhibit the flow of sensory impulses from without and thus enable
{118} people to stand pain and fatigue that would otherwise seem quite
unbearable.


_Unconsciousness_.--The unconsciousness due to apoplexy, or to a blow
on the head, would be comparatively easy of explanation on the same
theory. The hemorrhage would actually push certain neurons apart
within the skull, or the intracranial pressure produced by it would
keep them from making proper connections. A blow on the head may
readily be supposed to jar neuronic terminal filaments so severely
that it would be some time before connections could be made, and the
injury might be serious enough to prevent certain cells from ever
again coming in contact in such a way as to allow the passage of nerve
impulses from one to the other. Concussion of the brain would, on this
theory, mean that neurons were so shaken apart as to produce some
confusion in their terminal filaments and consequent serious
disturbances of consciousness, if not its complete loss, and
corresponding disturbance of the power to move. In a word, this theory
would seem to afford a reasonably satisfactory explanation for most of
the extraordinary phenomena of mental life and, therefore, might also
be expected to be applicable to the ordinary phenomena, though these
are so elusive that it is difficult to satisfactorily apply theories
to them.

  [Illustration: FIG. 12.--NEURON FROM THE OPTIC LOBE OF THE EMBRYO
  CHICK (after Kölliker). The axon n runs toward the center, giving
  off in its course several collaterals. One of these, c, is much
  branched. (Barker.) ]

_Tired States_.--When fatigued, it becomes extremely difficult for us
to follow a train of thought, especially if it is somewhat intricate.
It becomes easy to forget things, even such as under ordinary
circumstances would be readily remembered. Names are much more likely
to be forgotten. Facts and, above all, dates, refuse to come as they
do under normal conditions. Efforts in the direction of recalling
details are eminently unsatisfactory. The command goes forth, but
there is {119} evidently hesitation about obedience. Other thoughts
intrude themselves. Ideas come unbidden. The connection of thought is
readily broken, and is hard to get at again. There may have been very
little mental work, but somehow the fatigue of the general physical
system is reflected through our central nervous system on the mind as
well as the body. The early morning hours are the best for mental
work, not, it seems, because the mind is fresher after its rest, but
rather because the physical factors that are important for mental
action are in good condition. Later they become disturbed by the
fatigues of the day. The delicate cells of the brain become fatigued
by sympathy with the somatic cells and it is harder to secure those
nervous connections necessary for thought.


  [Illustration: FIG. 13.--DEEP LAYER OF GIANT PYRAMIDAL CELLS OF THE
  POSTERIOR CENTRAL OR ASCENDING PARIETAL, CONVOLUTION OF A CHILD
  THIRTY DAYS OLD. a, axis-cylinder; c, collateral branch; d, long
  basilar dendrites; e, end tuft. (Ramon y Cajal.)]


 [Illustration: FIG. 14--PYRAMIDAL CELL OF CEREBRAL
 CORTEX OF MOUSE (after Ramon y Cajal).]


_Voluntary Neuron Motion_.--This theory of Duval's supposes that to
some extent the neurons or nerve cells are possessed of voluntary
movement. At least during certain states of the mind, they are moved
and seem to have an inherent, if not quite voluntary, power {120} of
motion. There are many objections urged against the theory because of
this neuronic motion. It has been said that the movement of neurons
has been observed in certain of the _Medusae_. The observation has
been doubted and it lacks confirmation. In higher animals, of course,
the observation is impossible because an investigation of the nervous
system for this purpose would necessarily bring about the death of the
animal and the cessation of spontaneous mobility. Whether it occurs or
not, therefore, is a theoretic problem. So many objections tell
against Duval's theory that it is now only discussed because of its
subjective value.


Neuroglia Theory.--Ramon y Cajal elaborated a second theory of
explanation for the mechanism of the nervous system that has seemed to
many authorities in brain physiology much more satisfactory than
Duval's theory of the actual motion of the neurons themselves. The
Spanish nervous histologist had made a special study of the neuroglia
or connective tissue cells in the central nervous system. These are
very small in size but very numerous. Ramon y Cajal suggested that it
was because the terminal filaments of these neuroglia cells inserted
themselves between the neuronic filaments, thus insulating one from
another, somewhat as if an insulating plug were inserted between two
portions of an electric circuit, that the interruption of nervous
currents took place. This explanation is free from many of the
objections urged against Duval's theory.

The small size of the neuroglia cells makes it easy to understand how
movement may take place in them sufficient to bring about separation
of neurons. It would not be surprising if they should be more or less
actively contractile. Whenever they contract, neuronic filaments which
they have been holding apart, come together so as to permit the
passage of nervous impulses, if any are flowing at the time. When the
neuroglia cells become fatigued or seriously disturbed, they refuse
any longer to obey the will in any way, or at least gradually get
beyond control, and in their relaxation becoming prolonged, push
neurons apart. When a man is very tired it gradually becomes
impossible for him to keep awake. This is partly because poisons,
produced in the course of fatigue, exhaust the vitality of the
neuroglia cells and also of the neurons, so that less energy is
required to push these latter apart.

It is easy to understand that the neuroglia cells might well become
affected by the various narcotics and intoxicants in such a way as to
produce the phenomena of anesthesia and drunkenness. The rapid
recovery from anesthetics seems to indicate that it is not neurons, or
essential nerve cells, that are so deeply affected, but some
extraneous, and less important, mechanism within the brain. The
neuroglia theory explains this very well and does away with the
difficulty. Certain curious phenomena of hysteria are easily explained
on this theory. When there is anesthesia in a member because of
hysteria, this anesthesia does not follow the distribution of certain
nerves, but is limited by a line in the shape of a cuff drawn round
the limb. This indicates that the trouble is not peripheral but
central, and that owing to psychic disturbance, all the neurons that
receive sensory impulses from a particular portion of the body are so
affected by a psychic condition that they are no longer capable of
receiving impulses from the periphery. The neuroglia cells in a
particular area have passed from the control of the will and, relaxing
themselves, have {121} inserted their processes between the terminal
filaments of neurons, thus preventing conduction.


  [Illustration: FIG. 15.--NEUROGLIA CELLS OR THE FASCIA DENTATA; IN
  THE NEW-BORN RABBIT (method of Golgi). A, molecular layer; B,
  granular layer; C, layer of polymorphis cells; D. horn of ammon; a.
  neuroglia cell furnished with a descending appendage; b, another
  neuroglia cell; piroform; c. a cell more deeply situated; d, spider
  cell; e, fusiform neuroglia cell. (Ramon y Cajal.)]


_Varieties of Neuroglia_.--The connective tissue cells are of many
kinds, each probably exercising a special function. Ramon y Cajal has
described and pictured a special kind of neuroglia cells for the gray
and another for the white matter. In his description of these cells he
has pointed out many interesting diversities of form, and probably
also of function. He has also described particularly a special form of
neuroglia cells which lie close to the blood vessels. These he calls
perivascular cells, and they seem to have an important function in
regulating the amount of blood that goes to a particular part of the
brain. He has written so clearly and yet so concisely with regard to
these that it seems better to cite his own words:   [Footnote 15]

    [Footnote 15: This article is a translation made by the author shortly
    after a visit to Ramon y Cajal in Madrid, in 1900. See _International
    Clinics_, Phila., Vol. II Series Eleventh.]

  Under the term neuroglia are included at least three kinds of
  cells,--those of the white brain substance, those of the gray
  substance, and the perivascular cells, which have been described by
  Golgi. The neuroglia cells of the white brain material are easily
  recognizable, being large and with rather prominent, smooth, and
  sharply outlined processes. As my brother seems to have shown, their
  object appears to be to furnish an insulating, or, at least, a badly
  conducting, substance to serve as an interrupter of nerve-currents.
  They certainly do not represent interstices of true nerve substance
  through which lymphatic fluid can conveniently find its way.

  The neuroglia cells of the gray matter present a very special and
  highly characteristic appearance. They are of manifold form,--at
  times star-shaped, at times {122} like a comet drawn out in length.
  These are the tall cells of von Retzius. They have very numerous
  prolongations, with a large number of short branched collaterals
  which give the whole cell the appearance of having feathers
  projecting from its periphery. These cells have been observed in two
  different conditions. One is that of relaxation, and the picture is
  that given above. The other is that of contraction, during which the
  cell body has more protoplasm in it, and the processes become
  shorter and thicker, and some of the secondary branches disappear
  entirely. These cells resemble, in certain ways at least, the
  pigment cells which occur in the skin of some animals. By means of
  their contractility, these pigment cells can stretch out their
  processes while in a state of contraction. It must be remembered
  that this form of neuroglia cells is most abundantly present in
  those parts of the brain in which it might be expected that a number
  of nerve currents would frequently come together. They occur, for
  example, with special frequency in the molecular layer of the
  cerebral cortex, where the bundle of pyramidal fibers, with their
  immense number of terminal nerve-endings, come in contact with one
  another.


    [Illustration: FIG. 16.--NEUROGLIA CELL FROM THE SUBCORTICAL LAYER
    OF THE CEREBRUM FROM WHICH TWO PROCESSES GO TO A BLOOD VESSEL
    (Obersteiner).]



    [Illustration: FIG. 17.--NEUROGLIA CELLS FROM THE SPINAL CORD.
    Longitudinal section (Obersteiner). ]


  The third form of neuroglia cells consists of those known as the
  perivascular cells. They are found only in the neighborhood of the
  capillaries of the gray matter and they send one or more firm
  prolongations to the outer surface of the endothelium of the blood
  vessels.

  These processes are inserted in the walls of the blood vessels.
  Every capillary has thousands of these little pseudopod
  prolongations, and from the vessel the cell reaches out in a number
  of directions. The object of these cells undoubtedly is by
  contraction of the prolongations to bring about local dilatation of
  the blood vessels. This dilatation of the blood vessels causes
  greater or less intensity of the psychical processes in certain
  parts of the brain, because of the greater or less congestion of the
  circulation in a part which it produces.

  With the exception of these last cells the object of the neuroglia
  cells is to insulate nerve fibrils and cells from one another. When
  the cells are relaxed, the passage of a nerve current is either
  entirely prevented or rendered much less easy than before. It is in
  this way that the true nature of intellectual rest is explained.
  Sleep--not only natural sleep, but also artificial narcosis, such as
  is produced by narcotics, hypnotics or hypnotization--is evidently
  the result of the same conditions.

  During the state of contraction the pseudopod of the neuroglia cells
  are drawn in; that is to say, the protoplasm of the cells absorbs
  the processes, and so the true nerve cells and nerve fibrils which
  were separated from each other by the interposition of neuroglia
  come into contact. By this mechanism the brain passes from the
  condition of rest into one of activity. These neuroglia contractions
  may, particularly in certain parts of the brain, occur
  automatically. Often, however, they are produced by the action of
  the will, which, in this manner is able to influence {123} the
  definite groups of neuroglia cells. As the result of this influence
  of the will the association of intellectual operations can be guided
  in various directions. The unusual course that the association of
  ideas sometimes takes, the flow of words and of thoughts at certain
  moments, the passing difficulty of speech, the recurrence of
  tormenting thoughts, the disappearance of expressions or ideas from
  the memory, even the increase of mental activity and of every kind
  of motor reaction as well as many other phenomena of intellection,
  can be satisfactorily explained on this hypothesis. It is only
  necessary to suppose that in certain parts of the brain the
  neuroglia cells are at rest, while at other parts they are in a
  condition of active contraction.

  To put it all in a few words, the neuroglia cells of the gray
  substance of the brain represent an insulating and switching
  apparatus for nerve currents. They are an insulation apparatus when
  in a state of contraction, a switching and insulating apparatus when
  in a state of rest. It is to be remarked, then, that according to
  this theory the contraction of brain cells does not take place, as
  in Duval's theory, during intellectual rest, but, on the contrary,
  during the state of activity of the cerebral cortex. It is much more
  probable that the action of cells coincides with the active stage of
  intellection than that brain cellular activity--that is,
  contraction--should correspond with psychic rest.

The application of some of these theories enables us to understand
just how short-circuiting may come about, how many of the curious
phenomena of memory happen, and what are the effects, as well as the
causes, of attention and distraction of attention and of diversion of
mind. It is particularly the latter portion of Ramon y Cajal's theory,
with regard to attention and the more or less voluntary though
unconscious and usually indeliberate control of blood supply to
various portions of the brain, that is of special interest. If the
neuroglia cells, whose end plates are attached to blood-vessel walls,
become over-contracted or lose their power of relaxation or of
contraction, many of the curious phenomena of over-tiredness in
neurotic conditions, and the lack of the power of concentration, and
sufficient attention to things, can be readily understood. In a word,
the theory enables us to translate many expressions that are vague and
indefinite, from terms of mind into terms of the physical basis of
mind--the anatomy and physiology of the brain.

While I have dwelt on Ramon y Cajal's theory, because for years it has
been familiar, of course I must reëcho his own warning that it is,
after all, only a theory. It presupposes an active interposition of
the glia cells between the axon of one neuron and the dendrons of
another. This cannot be demonstrated. A third theory of mental
operations, then, has been suggested, and the English school, so ably
led by Sherrington ("Integrative Action of the Nervous System,"
London, 1903) and McDougal ("Synapse Theory of Fatigue," _Brain_,
1910) has deservedly attracted wide attention. They contend that all
the phenomena can be more simply explained without postulating the
movement required for the Duval Theory or the glial activity of Ramon
y Cajal's hypothesis. They consider that each nerve cell has, as it
were, a certain potential energy which it sends forth in nerve
impulses. These are transferred from neuron to neuron through the
synapse. If what we might call, to borrow a figure from electricity,
the voltage of the cell impulse be sufficient to overcome the
resistance at the synapse, the impulse passes from neuron to neuron.
In fatigue the potential energy of the cell is gradually dissipated.
The impulses become feebler till they cease to pass. This occurs in
the state we usually experience as tiredness and in analogous states
such as sleep, unconsciousness, narcosis and the like. Obviously this
{124} theory can be elaborated and applied parallel with the neuroglia
theory except that here we are substituting synapse resistance for the
hypothetical, undemonstrated action of the glial cells. But, as the
latter seems a simpler process upon which to explain the various
phenomena, especially to those not familiar with very recent
developments in nervous histology and studies in nervous mechanism,
and as it merely involves a question of the nature of the resistance
and not of its site, I have used it for explanatory purposes without
advocating either theory in the present state of our knowledge.



CHAPTER V

BRAIN CELLS AND MENTAL OPERATIONS


While the theories of neuronic action we have discussed do not
represent absolute knowledge, they are at least suggestive and helpful
in psychotherapy. Whenever there are disturbances of mental
operations, patients are likely to become very solicitous, lest these
represent organic and incurable changes. The application of Ramon y
Cajal's neuroglia theory serves to bring out the fact that most of
them can be very well explained as merely functional, due to passing
disturbances of activity, and not necessarily to tissue changes. When
patients become possessed of the fear that certain nervous symptoms
portend definite injuries to the nervous system, this unfavorable
suggestion keeps them from using, to its proper and full extent for
repair and convalescence, the nervous energy which they possess. This
disturbing influence can be counteracted by a straightforward
exposition of Ramon y Cajal's or the newer English theory of brain
mechanism.

Patients become very much disturbed if they observe a failure of
certain faculties in themselves, and are prone to think that such a
failure means serious exhaustion or enduring change. The power of
attention is one of the faculties often disturbed in neurotic cases
and causes patients needless solicitude. Disturbances of memory are
the next most alarming elements in these cases. There are then many
forms of mental distraction, absorption and preoccupation that
sometimes frighten neurotic individuals who have become solicitous
about themselves. Though only passing incidents, due to overattention
to themselves and their ills, real or fancied, and the consequent lack
of concentration of mind on a particular subject, the patients fear
serious deterioration of their mental condition, or at least of mental
control. The neuroglia theory of mental action throws a light on all
these phases of mentality that serves to lessen the solicitude of
patients and enable them to understand that, in spite of their fears,
there is nothing but functional disturbance. The condition can be
readily explained and it admits of complete restoration to health.


ATTENTION

Even more important, perhaps, than any other of the functions
attributed to the neuroglia cells, is the rôle they may play in
enabling the individual to concentrate attention on a particular
subject, or at least to use a particular {125} portion of his brain,
by bringing about a more active circulation in that portion than in
any other, Ramon y Cajal attributes this power to the perivascular
neuroglia cells. Every capillary in the brain has thousands of these
little pseudopod prolongations. When the cells in a particular region
contract, the blood vessels of the part are pulled wide open and a
larger supply of blood flows more freely, stimulating the nerve cells
by which it passes and supplying them with nutrition for the
expenditure of energy that they may have to make. This is the physical
process that underlies attention. When too much, that is, too
long-continued attention is paid to any subject, without diversion of
mind, the capillaries may easily acquire the habit of being open, and
cells the custom of contraction, so that relaxation does not readily
take place. Something of this kind is the most important element in
the etiology of many functional nervous disorders.


  [Illustration: FIG. 18.--AN ARTERY FROM THE CEREBRAL CORTEX.--One
  can see numerous fine fibers passing over to the brain substance
  (Obersteiner).]


Ease and Pleasure in Mental Operations.--On the other hand this same
set of ideas explains many things otherwise difficult of
understanding. For instance, we all know that habit enables us to
apply ourselves to a particular subject with ever growing ease. What
was extremely difficult for us at the beginning, may after a time
become comparatively easy, and later even positively pleasant. Study,
that is application of mind, is, at the beginning, for most people,
not agreeable. If persisted in, it almost inevitably becomes a
pleasure. Hard exercise of any kind is, at the beginning, sure to
require great energy of purpose, and requires some subsidiary motive
of approbation or reward to make us persist in it. But what was a
distinct labor at the beginning becomes pleasant after a while. This
may be applied to the neuroglia cells apparently as well as to the
muscle fibers. On this theory, the reason for the gradual acquirement
of an intense pleasure in the intellectual life becomes easy to
understand.


Dangers of Over-attention.--The danger of concentration of mind on
one's self, quite as much as on any other subject, becomes clearer
when this theory is accepted as explaining the physical basis of the
mental operations involved in attention. If people allow thoughts of
themselves and of their physical processes constantly to occupy their
minds, gradually that portion of the brain ruling over these becomes
over-fatigued and fails to respond to the calls for relaxation.
Insomnia may develop readily as a consequence of continued solicitude
and prove to be, as the worst forms of insomnia so often are, quite
unamenable to direct drug treatment, because, even during the enforced
sleep that comes from drugs, dreams with regard to self and the
supposed ills may still occupy the overworked portion of the brain.
Nervous people are, most occupied with those parts of the brain which
have something to do with the omission and transmission of trophic
influence to particular parts of the body. As a consequence of the
persistent hyperemia, too many trophic impulses are sent down. These
cause an exaggeration of physiological function, in the stomach, the
heart, or some other important organ. Hence these organs may become
oversensitive.

For all these reasons, this theory of attention, of the great Spanish
{126} investigator, deserves to be well known by those who hope to
treat neurotic affections, especially functional diseases of the
brain, and therefore I prefer once more to give it in his own words.
[Footnote 16]

    [Footnote 16: _International Clinics_, Vol II, Series 11.]

  Ramon y Cajal's Theory of Attention.--Under usual conditions, the
  motor apparatus of the gray matter suffices for the explanation or
  the varied course of association of ideas and of the reaction
  produced by voluntary motion. But as soon as attention is
  concentrated upon an idea, or a small number of associated ideas,
  there enters into the problem, besides the active retraction of the
  neuroglia of the corresponding part of the brain, a new factor--the
  active congestion of the capillaries of the over-excited region. As
  a consequence of this, the energy of emotion reaches a maximum. The
  heat and metabolism of the hyperemic parts is increased, which, of
  course, makes these parts capable of more work.

  [Illustration: FIG. 19.--NEUROGLIA CELLS OF THE SUPERFICIAL LAYERS
  OF THE BRAIN FROM AN INFANT AGED TWO MONTHS (method of Golgi). A, B,
  C, D, neuroglia cells of the plexiform layer; E, F, G, H, K, R,
  neuroglia cells of the second and third layers; I, J, neuroglia
  cells with vascular pedicles; V, blood-vessel. (Ramon j Cajal.)]


This congestion of various parts of the brain has been experimentally
observed {127} by a number of physiologists. It can be best explained
by considering that the will has an influence upon the nerves which
produce a dilatation of the blood-vessels in different parts of the
cerebral cortex. The process of attention, however, by which
intellectual activity is concentrated upon a limited number of ideas,
seems to be but very little under the control of the sympathetic nerve
endings.

As a matter of fact, the capillaries of the brain are wanting in
nerves and smooth muscle fibers. Hence they are not under the control
of the sympathetic system. Only the relatively large arteries of the
pia mater, which possesses a tunica muscularis are under a certain
limited control of the sympathetic, which is able to produce in them
an incomplete and not very well limited congestion. One of the
difficulties of the problem of the activity of the sympathetic is best
realized when we recall that vasomotor activity is usually
involuntary. The process of attention, however, is entirely conscious
and voluntary.

In the hypothesis that we have given, most of the difficulties
disappear. Under the influence of the will, the pseudopod branches of
the neuroglia cells, which end in the walls of the capillaries,
contract. As the result of this, the bloodvessels, all of which are
surrounded by lymph spaces, dilate, and this dilatation may proceed to
such an extent that the vessels occupy the whole of the lymph spaces.
Thus we can easily understand how the very limited congestions which
are necessary for the concentration of thought upon a single idea may
be brought about.

The perivascular lymph spaces which exist in the brain seem to be for
the purpose of making these limited hyperemias easier. At the same
time they serve a very useful purpose in preventing pressure or
concussion, such as might be caused upon the neighboring nerve cells
by too great dilatation of the blood vessels of a part.

It is needless to add that we do not consider the hypothesis that we
have advanced to be absolutely without objection. On the contrary we
believe that, owing to the difficulty of the problem and our, as yet,
extremely slight knowledge of the anatomy and physiology of the nerve
protoplasm, any theory as to the special mechanism of psychic
processes is sure to be faulty. Rational hypotheses, however, which
are supported by well-known facts, are not only justified, but are
often fruitful of suggestive ideas. A scientific hypothesis often
gives a new direction, suggests an untried method of observation, or
hints at new ways of experiment, and, though it may not lead directly
to truth, always brings us closer to methods of investigation and of
criticism that are invaluable. Even though our further investigations
should not confirm our hypothesis, the result will not be less
positive. Negative conclusions lessen the number of possible
hypotheses and therefore diminish the possibility of error in future
investigations.


MEMORY

It is evident that some of the physical mechanisms that are employed
for the lower grade mental processes at least can be explained on the
neuroglia theory. Memory we share to a great extent with the animals,
and for this the physical processes can be rather interestingly
studied. We have all had the experience of being unable to recall a
word when we wanted it. Commonly the word is a proper name with which
there are not many direct connecting ideas, so that, somehow, we seem
unable to trace the word to its depository in the brain. Occasionally
we are sure that we know the first letter of the word. Sometimes we
are able to name this letter, and, if we do so, the rest of the word
will usually turn up a moment later. At times, however, the word fails
to come and we grope for it. Then if we stop deliberately seeking it,
the word will often after a longer or shorter time, come up
spontaneously.

This experience is familiar to everyone. It is especially frequent
with public speakers. Certain words have a habit of slipping away just
when we {128} want them. At times by beginning a sentence confidently,
even though there is a feeling that there is a missing word ahead, the
word will turn up in time. Often it will not, and then a weak
circumlocution must be indulged in. If it is a proper name, a
description may have to be substituted, sometimes a confession may
have to be made that the name will not come and the audience, unless
it is very young, will sympathize with the speaker.

If we accept the idea that the memory has a definite location in the
brain, the process is easily understood. Just how we cannot say, but
somehow brain cells serve as the media by which our memory processes
revert to knowledge that has been previously stored up. If now we
assume that the repetition of things known is accomplished by bringing
brain cells into connection with one another, and with the organs of
speech, it is easy to understand that somehow the connection with a
particular cell or set of cells cannot be secured at a given moment.
This delay prevents us from being able to repeat things that we know,
and know that we know, though we cannot somehow get at them. The will
fails to reach the proper insulating plug of a neuroglia cell, which,
if acted upon, would put a cell or group of cells in communication
with others. As a result the message from it cannot flow down. We feel
that we have it on the tip of our tongue, as we say, that a little
effort may bring it to us and sometimes that effort succeeds. If there
is any disturbance of consciousness by secondary motives, however, as
by the excitement of public speaking or the flustering that comes to
some people when they try to introduce even old-time friends and
forget their names, then we cannot control the brain processes and
memory fails. We do not for a moment think of attributing this failure
of memory to the faculty of memory itself. We have the feeling that
there is some mechanical obstacle. Ramon y Cajal's theory enables us
to understand this obstacle better, perhaps, than any other.

An interesting phase of this lapse in memory helping us to a
revelation of something of the physical process which underlies the
faculty, is the fact that it implies a very intricate machine.
Recalling has become such an obvious incident that we do not think of
the complexity of action involved. Many things are brought together,
and relations of all kinds serve to recall various facts and names and
dates. Some of these relations are most bizarre. Particular names
recall a definite series of facts. A color will bring up a scene or
the memory of an individual. An odor will recall scenes long since
apparently forgotten and will set trains of thought at work that are
quite unexpected. Sometimes we wake in the morning with a name or a
fact on our lips that we have been looking for for several days.



UNCONSCIOUS CEREBRATION

Some people actually learn to depend on unconscious cerebration. A
man, for instance, who has to make an address on a particular subject
or to write an article, will record that fact on a tablet and after
gathering a few basic thoughts in connection with the subject
proposed, will put it aside for the time being. He is confident that
various illustrations and thoughts in connection with the subject will
occur to him at intervals during the next few days, and that he will
thus without direct labor accumulate an amount of {129} material for
use. In the early morning hours he may find that thoughts on it come
to him unbidden. Sometimes he will find these thoughts precious germs,
that will develop during the course of the following days, and will be
of great help to him. If he is worried and preoccupied with other
things very much, this may not happen, but under ordinary
circumstances he can continue routine occupations which demand
practically all of his time, yet continue to develop the subject
selected for his paper or address. The more he has occupied his mind
with the subject at the beginning, the more will this unconscious
cerebration continue.


ABSTRACTION OF MIND

Features of the mechanism of mental operations are brought out in
certain phenomena of abstraction of mind, which show how the attention
can be so short-circuited that sensations from the periphery utterly
fail to penetrate to the consciousness. Most men have had the
experience of taking out their watches, looking at them, and then
putting them back. Presently somebody asks what time it is. Unable to
recollect what it was that they saw, they have to look again. There is
no doubt that they meant to observe the time.

The same thing is true for practically all the senses. A pickpocket
takes advantage of our being occupied with many other feelings in the
midst of the jostling in a crowd on a car, or before a show window, or
he has a confederate add to the sensations already streaming up to us,
calling attention particularly to the other side of the body, and then
inserts his hand into our pocket and extracts what he finds. Sometimes
we have a faint memory of something having happened to that pocket,
but our attention was occupied elsewhere.

In hearing we have the same experience. When thoroughly occupied with
a book, a person may talk to us or ask us a question and we have no
idea of what was said, sometimes utterly failing to hear the voice;
sometimes we hear the sound of the voice, but do not comprehend the
meaning of the words.

When we are unprepared for a question we nearly always have to have it
repeated to us. Sitting in a railroad train, if the person behind us,
whom we did not expect to talk to us, asks a question, it is very
probable that on the first asking we shall not notice it at all,
considering that it is addressed to someone else. On its repetition,
it may appeal to us as addressed to ourselves, but even then we
readily lose its significance because our attention has not been
called to the wording of it soon enough to enable us to comprehend it
thoroughly. These experiences, so familiar that we have probably all
had them at some time or other, indicate how universal is the power of
the mind to concentrate itself upon itself to the extent of neglecting
sensations from the outer world, even though they may pass the
periphery of the organism and manifestly affect the first neuron of
the chain that leads up to our brain and consequently to
consciousness. They do not reach the center with sufficient intensity
to be understood, and a conscious act of attention must be made before
we comprehend their meaning.

{130}


PREOCCUPATION OF MIND

This is true, not only for ordinary sensations, but even for such as
would ordinarily be presumed to be so insistent in their call that
they could not be neglected. The concentration of mind necessary for
this is not common to all mankind; it is possessed only by a few
individuals whose intellect represents the larger portion of their
personality. Certain of the great investigating scientific geniuses
have had the faculty of so concentrating their attention upon the
questions with which their intellects were engaged, that even the call
of appetite did not make itself felt. Newton was one of these. Over
and over again, he was known to neglect to take his meals, even though
they were brought to him, and, occasionally, he would entirely forget
whether he had taken a meal or not. But Newton is not an extreme
exception. Most of the great mathematicians have had experiences of
this kind and, indeed, mathematics seems to be that special branch of
intellectual work which most readily brings about a preoccupation of
mind sufficient to completely shut out the outer world for the time
being. Archimedes, the great ancient mathematician, lost his life
because of preoccupation with mathematical problems that kept him from
telling the Roman soldiers, who had strict orders to spare him, who he
was.

Complete absorption of mind to the exclusion of all external
sensations is not, however, confined to the mathematicians. Mommsen,
the historian, was famous for his fits of mental abstraction. Once he
patted a school-boy on the head and asked whose boy he was, to be told
rather startlingly, "Yours." Lombroso, the criminal psychologist, was
subject to abstraction in almost as great a degree. Men have become so
preoccupied in study as not to appreciate the significance of
warnings, indicating that a serious accident was about to happen, such
as a fire or the fall of some object that they should have avoided, or
some other danger to themselves. The tendency to such abstraction is
responsible for many accidents on busy city streets. When so
preoccupied, painters walk off scaffolds, and such preoccupation of
mind is extremely dangerous, not only for the man himself, but for
those who are working with him.

Everyone knows that a slight headache frequently disappears in
pleasant company. There is sometimes the suspicion, though it is quite
unjustified, that because a person has a headache which can be cured
by engaging in a favorite occupation, the headache is more imaginary
than real. The common experience with toothache shows the falsity of
this opinion. There is no imagination in regard to toothache, yet it,
too, except in very severe cases, will be so modified as to be quite
negligible if the victim has some mental occupation that is very
absorbing. Pains of other kinds that are just as real, may be modified
in the same way. I have known a boy to suffer enough from the presence
of an unsuspected kidney stone to give up play and come into the
house, yet he could be made entirely to forget his discomfort by a
game of checkers. On account of the ease with which the pain was thus
dispelled, the suspicion was harbored that his ache was more imaginary
than real. The ache continued and at the end of about a year there was
an acute exacerbation which justified an operation, and the stone was
removed.

In all these instances there is evidently a question of the unmaking,
or at {131} least imperfect making, of connections between the
peripheral and central neurons, because of the existence of
connections between different portions of the brain itself which take
up the attention. This attention to mental things may become
exaggerated, and must be guarded against, but it represents a valuable
psychotherapeutic remedy. Whenever the peripheral connections are
unmade, external sensation is unfelt. Even though the peripheral
neuron may be suffering to some extent, this is true. It is this law
of attention that must be taken advantage of for psychotherapeutics.
People who are liable to be too much concerned with their sensations,
must be taught to occupy themselves with interests that will absorb
the attention. Central neurons can, except under very serious
circumstances, be made to connect with one another so intimately as to
bring about the neglect of many bothersome external sensations.


  [Illustration: FIG. 20.--COMPLEXITY OF CELL OF THE CENTRAL NERVOUS
  SYSTEM. A Golgi cell after Andriezen. (Barker.)]


On the other hand, when the connections with the periphery are well
made, external sensations flow in on us to the exclusion of thought
and then even simple sensations may be exaggerated so as to become
painful. Anything that attracts our attention so much that we cannot
think quietly about it, is likely to be a disturbance rather than a
pleasure. Music is distinctly pleasant, yet very loud music becomes
painful. The reason is that the peripheral neuron is so much disturbed
that these excessive vibrations are communicated to other neurons
connected with it and they are unable to occupy themselves with
anything except this over-strenuous sensation. A very bright light has
something of the same effect, and the same thing is true for all the
other senses. A pleasant odor, if over strong, becomes disgusting. A
very sweet taste is cloying. This over excitation of neurons may come
from without, or may come from within. If the central neuron is so
much occupied with itself, and the sensation that is flowing into it,
that it is prevented from making such connections as would communicate
and distribute the sensations properly, then the sensory phenomenon
becomes painful, though it may not be exaggerated in the peripheral
neuron.


VITAL ENERGY BEHIND BRAIN CELLS

In all of these phenomena there is something more than brain cells at
work. Brain cells are guided, co-ordinated, controlled, and even
overseen, in their labors. The same conclusion becomes inevitable with
regard to the action of the cells of the body generally. A generation
or two ago it was the custom to attempt to explain all the processes
in the body by chemical and physical principles. Respiration, for
instance, and absorption of gases into the blood in the lungs and the
expiration of gases that have been generated within the body during
vital processes, were supposed to be entirely explicable on the
principle of the diffusion of gases. The absorption of various
substances into the body proper from the intestinal tract, and the
excretion {132} of various substances from within the body into the
excretory organs, as well as the process of secretion, were supposed
to be nothing more than varying phenomena of osmosis and exosmosis.
There has since been a general recognition of the fact that these
principles do not explain many of the incidents within the body in its
relations to its surroundings, and that vital processes are something
much more than merely manifestations of physics and chemistry.

The lungs are not mere laboratories in which refinements
of the laws of the diffusion of gases may be studied, for under
varying pressures from without that would vitiate the ordinary
laws of diffusion, inspiration and expiration continues. Fishes
live at depths where the pressure is so great that expiration
would seem to be impossible, yet they succeed in eliminating
harmful gaseous material. Prof. Haldane of Cambridge has
called attention to many of these processes. Animal stomachs
are not test-tubes. Animal excretion, and above all, secretion,
is carried on sometimes in accordance with but, almost more
often, in defiance of chemical and physical principles. The
individual, even in the lower animals, counts for much more
than the chemical constituents of the tissues and the physical
principles involved.

Besides, all the parts of the organism are co-ordinated, and
there are wonderful checks and counterchecks which show that
animals are much more than colonies of cells fortuitously
growing together and habituated to such common life by many
generations of heredity and environment and training. In a
word, the old vitalistic principle has become popular once
more and even great physiologists have insisted that there is a
principle of life which guides and controls and co-ordinates the
different portions of the body. Especially does this seem to be
true of the brain. We have here an intensely complex machine,
composed literally of billions of parts which work together, and
in doing so accomplish wonderful results. Of the existence of
this machine, much more of the great intricacy of its parts
and mechanism, we are quite unconscious. We learn to use it
in very early years with an assurance and a perfection that is
amazing, considering how complex it is. The less we think
about it and its workings, the better does it work and the less
disturbance of function is there in its accomplishment.


  [Illustration: Fig. 21.--SECTION THROUGH THE CORTEX OF THE
  GYRUS OCCIPITALIS SUPERIOR. (Hammarberg. Barker.)]


If a vitalistic principle were needed to enable us to understand the
workings of the ordinary body cells, how much more is it required for
the workings of brain cells. There is something behind that guides and
rules the brain, and through which it accomplishes its work. It is
this that brings about an unconscious cerebration accomplishing
intellectual results for us even when the brain machine itself is at
rest as when asleep, or fails, for some reason, to be in readiness to
take up the work that we demand of it. It is this vital principle that
coordinates the movements of brain cells which represent {133} the
physical processes underlying memory and the nervous elements of the
sensitive and motor phenomena of the organism. Reflection on the
physical mechanism underlying mental operations of various kinds,
demands the vitalistic explanation much more than the physiological
phenomena which have converted physiologists to the old way of
thinking in our time. Our individuality is probably largely due to the
physical basis of our mentality, but there is something more than that
required for any theory of mental operations that would satisfy all
the questions that come to us. There is, then, actual proof of the
existence of a force that is part of us, that constitutes a bit of the
essence of our personalities, yet is capable of accomplishing results
that we cannot understand, and of managing a machine that transcends
any physical powers that we can think of.


  [Illustration: FIG. 22--MOTOR CELL OF VENTRAL HORN OF SPINAL CORD
  FROM THE HUMAN FETUS, THIRTY CENTIMETERS LONG (method of Golgi;
  after von Lenhossek. Barker.)]


This vital force behind the nervous system contains stores of energy
that can be called on for therapeutic purposes. It is the directing,
co-ordinating and energizing force which controls the central nervous
system, and enables it to accomplish its purposes. It is the
disappearance of this force at death which leaves the body without
vital activity, though no physical difference between the dead and the
living body can be demonstrated. Changes in the body _follow_ death;
they are not simultaneous. This vital force supplies the energy that
we call the will, and underlies the process called "living on the
will" which so often serves to maintain existence when there is every
reason to think that a fatal termination is due. The amount of energy
thus available is limited, {134} but is much more powerful than has
been thought. It is of the greatest possible service in preserving
health and eliminating disease. Its existence, demonstrated by the
complex nervous system which we employ with such confidence, though we
know nothing of it, furnishes the best possible basis for confident
attempts at rousing the patient to use the vital energy he possesses
for the strengthening of weakness, the correction of deficiency and
the control of evil tendencies.



CHAPTER VI

UNCONSCIOUS CEREBRATION

Many of the exhausting neurotic and psycho-neurotic affections so
common in recent years are largely due to the failure of patients to
secure such mental relaxation as will permit complete repair of
nervous waste. We are proud of being a generation of specialists. Some
men never get completely away from the set of thoughts with which they
are occupied in their particular specialty. Waking or sleeping these
thoughts are with them. It is almost impossible, then, for cells of
the central nervous system to secure such rest as they need. Cells
must be put at absolute rest so that nutritional processes may go on
entirely undisturbed, and every portion of the cell be renewed in
vigor. Re-creation, in its original meaning, is exactly what must be
provided for nerve cells.

The trouble is not alone that men occupy a very narrow set of brain
cells with their special interest, and make all their energy pass
through that set, but among men who are lacking in a certain
insulation in the nervous system, this particular set of cells
continues to be active, even at times when they think they are resting
or diverting themselves. Unconscious cerebration (the occupation of
the mind with subjects when we are not deliberately giving our
attention to them) is a common phenomenon in human psychology. With
the rise of extreme specialization, it has become even more dangerous
than before. In the past unconscious cerebration might mean any
occupation, with any one of a number of interests. At the present it
is likely to mean concentration of thought on a particular subject
with which the brain is prone to be occupied more than is good for it,
even during the hours of ordinary labor. It seems worth while to
discuss at some length, then, the subject of unconscious cerebration,
because it constitutes the pathological physiology of many nervous
states that we see in modern life.


Frequency of Unconscious Cerebration.--The mind, having been set to
work over a given thought, continues at it sub-consciously, even while
apparently completely occupied with something else. Most people who
devote themselves to the intellectual life have experienced phenomena
more striking and going much farther in unconscious cerebration than
this. Most writers have a common experience: if they arrange their
thoughts on a given subject and then turn aside to something else,
they find, when they go over the same subject next day, much more
material than came the day before. The thoughts for an article will
often gradually accumulate by unconscious cerebration after the
process has been consciously started.

{135}

At intervals during the next few days succeeding the determination to
write a certain article (at moments when no conscious thought is being
given to it), ideas crop up that help to fill out the original scheme
of thought, and if these are jotted down, a good deal of intellectual
work is accomplished without the necessity for that labor over a desk
that most of us scheme to avoid. The more familiar literary work
becomes, the more frequent are these experiences, and one occasionally
wakes up with a thought that opens up a new vista and adds valuable
material to what has already been accumulated. If the subject is a
large one, as for a book, then most writers will probably confess that
some of their best thoughts have come in this "hit and miss" fashion
rather than at the times when they were seriously applying themselves
to elaborating their theme.


Inspiration.--Some of the great literary writers have felt that their
brain work was so independent of themselves that the word inspiration
properly suited what they were accomplishing. Thackeray destroyed
sheet after sheet of manuscript, utterly dissatisfied with it until,
as the result of keeping at it, inspiration would come. Then he would
be able to fill up rapidly many pages with work so finished that it
needed little correction or polish. George Eliot, at times, became so
absorbed in her writing that it almost appeared to her that some other
personality than her own was wielding the pen. Her imaginary
characters became real to her, and it was while under the stimulus of
this impression of living in an imaginative world with them that she
succeeded in accomplishing her best work. Many other authors were, of
course, very different. Some of them ridiculed the idea of waiting for
inspiration. Most of them, however, found it difficult to begin their
task at certain times, yet if they forced themselves to it, and once
got their minds going, the line of thought ran on easily and, at the
close of the task, they looked back with pleasure and wonder that they
were able to accomplish so much.


_Illustrations_.--This is true not only of literary work, whose main
purpose is the arrangement of details of information of various kinds
with personal opinions concerning it, but also of original thought of
any kind. Many stories of poets are told illustrating this. They
wander round with pencils and jot down thoughts that come here and
there at what are called moments of inspiration. The poets dream over
their subjects, catch fleeting thoughts that, vague at first, sing
themselves into musical expression. Music seems to be on the same
plane with poetry, for there is the well-known story of the
distinguished German musician who, walking with his wife in the park,
found himself without paper at the moment when he had an inspiration.
He used his own cuffs to write upon, and then finally impressed those
of his wife into the service of carrying home the precious musical
motifs that he was afraid might not come again if he allowed the
favorable moment to pass without recording them.

There are stories of Tennyson finding some of his most perfect lines
in the fields, after hours of seclusion and effort in his study had
failed to round them out to his satisfaction, or dreaming them into
shape, or waking to find one ready made to be written down. The
letters of Wordsworth tell how often such incidents happened in his
life.

{136}


SLEEP COMMUNICATIONS

Any one who has been thinking much for several days about a problem is
likely to wake up with the thought that he has dreamed a solution of
it, though unfortunately the solution has not remained in his memory.
It seems as if a communication has been made to him during sleep. I
have discussed dream life with many men engaged in serious work, and
practically all of them confess to such experiences. Preoccupation of
mind with a subject during the waking hours leads to at least some
occupation of mind with the same subject during sleep. This
unconscious occupation must often require rather strenuous attention,
exhausting nutrition, using up nerve force and hampering the rest that
is so important for tired human nature. [Footnote 17]

  [Footnote 17: A number of poetic products of dreams are in our
  literature, some of them interesting for more than their curious
  origin. Dr. S. Weir Mitchell, in his latest volume of poems, "The
  Comfort of the Hills," made an interesting contribution to the
  psychology of dreams by publishing two poems which were composed by
  him while asleep. The little poem, "Which?" has all the curious
  alliterativeness and frequent rhyme that is so likely to be noted in
  expressions that come during sleep, or just as we awake. The other
  is more like a somnambulistic effort. What we might suggest here is
  that the habit of poetizing during sleep would surely be dangerous
  to any one less eminently sane than their author. We give them as
  curious examples that will interest patients who complain that their
  dreams are too vivid.

      APRIL FIRST

    Come, let us be the willing fools
      Of April's earliest day.
    And dream we own all pleasant things
      The years have reft away.

    'Tis but to take the poet's wand,
      A touch or here or there,
    And I have lost that ancient stoop,
      And you are young and fair.

    Ah, no! The years that gave and took
      Have left with you and me
    The wisdom of the widening stream;
      Trust we the larger sea.

    WHICH?

    Birth-day or Earth-day,
    Which the true mirth-day?
    Earth-day or birth-day,
    Which the well-worth day?

  For further details on this subject, see the chapter on Dreams.]


Art in Dreams.--Many a painter testifies that as he slept interesting
details have been added to his scheme for a picture. Mr. Huntington,
who was for so long president of the National Academy, once told me
that some of the arrangements of his famous picture, "Mercy's Dream"
in the Corcoran Art Gallery at Washington, had come to him during
sleep. Giovanni Dupré, the French sculptor, confessed that the ideas
for his beautiful _pieta_ had practically all come to him in a dream.
He had been thinking for a long time how he should arrange it, without
allowing any of the ideas of sculptors whose treatment of the subject
was well known to influence him too much, and had almost felt that it
would be impossible to make anything individual. While deeply occupied
with it one day he fell asleep, and when he awoke the whole scheme was
clear.


Mathematical Dreams.--Such phenomena of unconscious cerebration are
not uncommon in the exact sciences. Some of the best examples of these
{137} curious phenomena that we have are to be found in the history of
them. We all know the stories of mathematicians who, occupied deeply
with a problem which they have been unable to solve, have gone to bed
still thinking about it, have slept deeply and, as they thought,
dreamlessly, and yet they have waked in the morning to find by the
bedside the problem all worked out in their own penciling--all
accomplished during a somnambulistic state. Missing factors have been
found in dreams; mistakes in the working out of problems have been
clearly pointed out in dreams, so that, on awaking, the calculator
could at once correct his calculations, and even serious errors have
been thus corrected.


Agassiz's Experience.--Some examples of these experiences in other
sciences are striking. One that is likely to be impressive because it
occurred in the experience of Professor Louis Agassiz, seems worth
reporting.   [Footnote 18]

  [Footnote 18: "Louis Agassiz, His Life and Correspondence,"
  edited by Elizabeth Cary Agassiz, Houghton, Mifflin and Co., 1885.]

  It is interesting both as psychological fact and as showing how,
  sleeping and waking, his work was ever present with him. He had been
  for two weeks striving to decipher the somewhat obscure impression
  of a fossil fish on the stone slab in which it was preserved. Weary
  and perplexed he put his work aside at last, and tried to dismiss it
  from his mind. Shortly after, he waked one night persuaded that
  while asleep he had seen his fish with all the missing features
  perfectly restored. But when he tried to hold and make fast the
  image it escaped him. Nevertheless he went early to the Jardin des
  Plantes, thinking that on looking anew at the impression he should
  see something that would put him on the track of his vision. In
  vain--the blurred record was as blank as ever. The next night he saw
  the fish again, but with no more satisfactory result. When he woke
  it disappeared from his memory as before. Hoping that the same
  experience might be repeated, on the third night he placed a pencil
  and paper beside his bed before going to sleep. Accordingly toward
  morning the fish reappeared in his dream, confusedly at first, but
  at last with such distinctness that he had no longer any doubt as to
  its zoological characters. Still half dreaming, in perfect darkness,
  he traced these characters on the sheet of paper at the bedside. In
  the morning he was surprised to see in his nocturnal sketch features
  which he thought it impossible the fossil itself should reveal. He
  hastened to the Jardin des Plantes, and, with his drawing as a
  guide, succeeded in chiseling away the surface of the stone under
  which the portions of the fish proved to be hidden. When wholly
  exposed, it corresponded with his drawing, and his dream, and he
  succeeded in classifying it with ease. He often spoke of this as a
  good illustration of the well-known fact that when the body is at
  rest the tired brain will do the work it refused before.


Hilprecht's Sleep Vision.--Quite as surprising a dream was that of
Prof. Hilprecht, of the University of Pennsylvania. He had been trying
for some time to decipher certain characters on ancient cylinders from
the Orient. In spite of much hard mental labor he had been utterly
unable to reach definite conclusions. In the midst of work on the
subject he dreamt one night that a priest of the olden time appeared
to him and read off the inscription that he had in vain been trying to
decipher. Immediately after waking he told his wife of his dream and
wrote down the interpretation that had thus been given. It was quite
different from anything that he himself had obtained any hint of in
his previous studies. When he got back to the inscription he found
that this interpretation would satisfy the conditions better than any
other, and there seemed no doubt that it represented the missing
solution.

{138}

Somnambulism.--These curiously vivid dreams are occasionally
associated with somnambulistic phenomena. Sometimes very definite
purposes, requiring careful adaptation of means to ends, are
accomplished in the somnambulistic state, and yet the actions are
completely forgotten. I have recently been consulted about a case in
which a young woman, on a visit to a family, had been shown some
pretty though not expensive jewels. Evidently the guest envied their
possession, for she got up during sleep and took the jewels and hid
them. There seems no reason to doubt her statement that she remembered
nothing at all about the incident. The taking was not attributed to
her. There had been previous experiences of the same kind with things
belonging to this young woman's sister. Somnambulism represents a
degree of unconscious cerebration that may have serious results.
Combinations of intellectual work with somnambulism are not
infrequent, though many of the stories that are told are exaggerated.
Some of them are authenticated. Ribot has a typical example of
intellectual accomplishment, in a somnambulistic condition, that shows
how far this may go:

  A clear case of somnambulism was that of a clergyman, whom his wife
  saw rise from bed in his sleep, go to a writing table, and write
  rapidly for some minutes. This done he returned to bed, and slept on
  until morning. On awaking, he told her that in a dream he had worked
  out an argument for a sermon, of which he now retained no
  recollection whatever. She led him to the writing table, and showed
  him the written sheet upon which he found his argument worked out in
  the most satisfactory manner.


PATHOLOGICAL SIGNIFICANCE

Unconscious cerebration is not, then, a trivial matter, and not an
unusual experience. It probably occurs in every individual to a much
greater extent than he thinks, unless he is engaged in analyzing his
mental processes and their ways rather carefully. This constitutes one
of the dangers of the intellectual life, which must also be guarded
against in business life or in any absorbing occupation. When the mind
has become intensely occupied with a subject, it is not easy to
relinquish it. Even when we turn to something else, mental activity in
the old groove continues to some extent, and so will prevent the rest
that is necessary for the repair of tissue. Under these conditions the
_re-creation_ that is so important does not take place quite as well
as it should, and even sleep does not relieve us from the burden of
mental work. Mental exhaustion will result as a consequence of
constant occupation, and so mental relaxation must be secured.
Deliberate means and methods must be employed in order that we may not
deceive ourselves into thinking we are securing mental recreation,
though all the time certain exhausting mental processes continue to be
active.


Dual Mental Occupation.--Many are inclined to think that reading,
especially the reading of newspapers and magazines, which has become
so popular in our time, furnishes an occupation of mind that enables
one, for a time at least, to get away from cares and worries. This is
probably true when the news is of special interest, or there is some
form of excitement, or at the beginning of such reading before one
grows accustomed to the usual {139} formula of the magazine stories;
but as years go on and cares increase, such reading does not afford an
occupation of mind that enables one to throw them off. It helps to
pass the time, but the cares and worries keep insistently presenting
themselves, and the effort to inhibit them, and at the same time pay
some attention to what we are reading, makes a double task. Such
reading, then, far from being restful, rather adds to the burden of
care and to the labor of the mind, for besides the conscious
cerebration, there is the undercurrent of subconscious cerebration
disturbing the rest of cells that should be free from labor. The
constant renewal of effort to keep one train of thought from
interfering with another is itself a waste of nervous energy. This
whole matter of reading is coming to occupy a new place in the minds
of educators, especially of those who are trying to realize the
scientific significance of various phases of education. In his address
as the President of the British Association for the Advancement of
Science, at the Winnipeg meeting in 1909, Prof. J. J. Thompson, the
British physicist, sums up the value of reading as an intellectual
exercise in a way that would not be gratifying to those who, in recent
years, have apparently accepted the doctrine that in much reading
there is much information and, therefore, much education. He says:

  It is possible to read books to pass examinations without the higher
  qualities of the mind being called into play. Indeed, I doubt if
  there is any process in which the mind is more quiescent than in
  reading without interest. I might appeal to the widespread habit of
  reading in bed as a prevention of insomnia as a proof of this.


Social Duties.--So-called social duties are, in this respect, very
like reading. When we meet new people who are interesting, we get
diversion of mind in their company. When the people with whom we are,
however, already familiar, and perhaps most of them a little tiresome,
then what is presumed to be a social diversion becomes merely a bore,
all the problems of the day obtrude themselves, of real rest there is
none, and re-creation can scarcely be possible. Nearly the same thing
is true of the present-day theater, after we have become used to its
offerings. A serious play, well constructed and with life's problems
touched deeply, may grip us and take us out of ourselves, constituting
a complete and magnificent diversion. For a limited number of people
music accomplishes this purpose. Unfortunately, the number is very
limited, and for those for whom music is the greatest diversion, it
sometimes constitutes in itself a poignant source of mental
exhaustion. Music may be a very trying thing, especially for women,
and for those who have souls extremely sensitive to its manifold
effects.

Upon these considerations, the importance of unconscious cerebration
is brought home to the physician. It is impossible for a great many
people to keep their minds inactive, and this is particularly true of
two classes of people: those who have superabundant mental energy and
those who lack self-control. To both of these classes of men and
women, the physician must point out the dangers of unconscious
cerebration--the occupation of mind with some subject, even at times
while they imagine they are occupied with something else, or even
during sleep. Such continuous occupation with a single subject is
dangerous. Physicians must emphasize that many supposed {140} mental
occupations are really so superficial that they allow other more
exhausting processes to continue below them in the sphere of
consciousness. As a consequence, the mind, instead of being relaxed,
is really more tense than before, because occupied with two sets of
thoughts. Very often it would be better for such people to continue
with the more serious problem until its solution came, or until they
realized that they must divert themselves.


MENTAL RELAXATION

What is important for mental relaxation, apparently, is not that a man
shall try to set his mind at absolute rest, for that seems to be
impossible, if a man really has a mind; nor that he shall occupy it
with trivial things (because his interest will not be caught by them
and will revert to the last serious thing that he was doing), but that
he shall have an outlet for mental activity in entirely another
direction from that to which he usually devotes himself. In other
words, it is important that a man shall have a hobby, and that he
shall ride that hobby whenever his ordinary business, whatever that
may be, will permit him, and the more interesting the hobby, the
better.


REMEDIAL MEASURES

The most important general remedy for over-prolonged mental occupation
with a single subject, is some outdoor sport or form of exercise that
requires all the attention. Horseback exercise is particularly
valuable; boating, especially where the man has charge of the boat
himself and where he has to have his wits about him, and the various
sports. It is particularly important that men should not be alone
during the taking of their exercise and diversion of mind. Above all,
human interests take a man outside of himself and keep him from
disturbing his mental equipoise by too much devotion to a single
subject.



CHAPTER VII

DISTANT MENTAL INFLUENCE

There is a very general impression that it is possible, at least under
certain circumstances, for one human mind to influence another at a
distance without any of the ordinary known means of communication.
Many people have had the experience of thinking about a friend whom
they have not seen for a long while, and shortly after meeting him.
Sometimes it is found that the friend was making up his mind to bring
about the meeting just about the time that the thought of him came.
Many have had the experience of writing a letter and having it cross
in the mails with another from their correspondent, evidently written
within a few hours, though there had perhaps been no communication for
weeks or months before. There are people who insist that they can, by
concentrating the mind and fixing their eyes on the head of a {141}
person some distance in front of them in a theater, or a railway car,
cause the person to turn around. There are others who say that by
thinking strongly of some person in a distant part of a large room,
that person can be made to think of them. In general, there are many
persons who are quite sure that there is evidence enough to indicate
the possibility of distant mental influence, or, as it has come to be
called learnedly, telepathy.

Telepathy, from the two Greek words, _tele_, at a distance, and
_pathos_, feeling, has been much discussed in recent years. Many
people who use the word glibly are inclined to think they know much
about it. A long word, however, is not an explanation, and, just here,
George Eliot's expression "we map out our ignorance in long Greek
names" is worth recalling. There are a number of phenomena that seem
to require some such theory as that of telepathy, but the phenomena
are still under discussion and their significance is by no means
clear. As we understand it, telepathy may mean either thought
transference or mind reading, that is, either the active process by
which we communicate our thought to someone at a distance, or the
passive process by which we receive communications from others. These
thoughts include the idea of mental influence at a distance; that is,
we can by willing influence the wills, or at least the motives to
action, of people at a distance and they may, in turn, influence ours.
The further thought has come, that since the mind largely influences
the body in matters of health, so mental influence from a distance by
affecting mind, may either improve or injure health.

Some sensitive people are disturbed by the thought that they may be
influenced from a distance by others, or at least that suggestions
that come to them, may be due to telepathic influence. Investigation
would probably show that there are at least as many persons disturbed
by real or supposed telepathic influences as there are of those who
have hallucinations. Sometimes it is said that such persons are not
quite sane, but the more experience a physician has with them, the
more he dismisses the thought of insanity and proceeds to use contrary
suggestion and frank discussion, in order to counteract the mental
influences. Insane persons think they are being influenced from a
distance just as they hear voices and see visions, but such
hallucinations may occur to the sane, as apparent telepathic
experiences may also.


Witchcraft.--It used to be a common belief that people could be
influenced, even at a distance, by the mere evil wishes or intentions
of others. After all, the old beliefs in witchcraft that were so
common in Europe and in America until well into the eighteenth century
represent the conviction of mankind that at least certain people
might, from a distance, seriously influence them for evil. Always the
fear of malign influence was uppermost in people's minds and literally
hundreds of thousands of witches were prosecuted, and many thousands
of them put to death, because of this belief in the possibility of
their working evil to others at a distance, merely by willing it.
Occasionally some such material auxiliary to malign purpose as an
image in wax of the one to whom the evil was to be done was used. Into
this the ill wisher stuck pins according to the part that he or she
would want to be affected in the enemy, but as a rule the will, and
nothing more, was used.


Absent Treatment.--In our own time a system of healing, that has
attracted many followers, has taken up the idea of beneficent mental
influence at a distance. "Absent treatment" has now become a familiar
expression. {142} That those who believe in such favorable influence
at a distance should also believe in unfavorable influence seems
inevitable. As a matter of fact, we know that the founder of this
special sect always insisted on the power for evil over herself and
her followers of those who want to exert the injurious influence of
animal magnetism--malicious animal magnetism as it is called. A very
definite attempt was made to bring a case of this kind before the
courts, the subject matter of which exactly resembled some of the old
witchcraft trials in New England! And in spite of the insistence and
emphatic assertion that no such thing is intended, from the principles
that are accepted the necessary logical conclusion is a return to the
belief in witchcraft.


Malignant Magnetism.--As a number of persons are likely to fear such
evil influence of others upon them, the question of the possibility of
it must come up for discussion in order that its status may be clear
in the physician's mind, for by just as much as he can make certain to
the patient that modern psychology refuses to accept distant
influence, will he be able to reassure his patient. Of course, the
patients who come with such complaints have usually some element of
mental trouble. The alienist sees any number of people who are sure
that enemies at a distance are working spells upon them, some by
electrical, some by magnetic means, and some by telepathic absent
treatment, or absent ill-wishing. Such notions are the delusions of
the disequilibrated and these persons often cannot be reasoned with.
Yet very often a distinct delusion may be reasoned out of even a
subrational person, if it is taken seriously, and some striking
expression of its irrationality and of its total disagreement with
scientific views can be shown to the patient.


Action Without a Medium.--The medieval scholastic philosophers quoted
as an absolutely accepted principle the Latin axiom, _"actio in
distans repugnat."_ Literally translated this means action at a
distance is repugnant to reason. Expressed less technically, the
principle declares that any action of one body on another, where there
is no medium connecting them, no link that in some way places them in
contact with one another, is absurd. The expression _in distans_ means
that the two bodies are separated from one another and stand in two
places having no connection of any kind. This principle would
ordinarily seem to preclude the possibility of one person acting on
another, unless there is some mode of communication.


Crookes' Theory.--Sir William Crookes, at a meeting of the British
Association for the Advancement of Science about ten years ago, in
discussing telepathy, directed attention to the fact that there exists
by scientific hypothesis, generally accepted, a definite medium of
communication by which minds at a distance might influence one
another. The medium is the ether which, according to physical
theories, besides carrying light, also carries heat and electrical
waves, and in recent years is recognized as transmitting the impulses
of wireless telegraphy. It is possible that when the cells of certain
human minds are stimulated to a particular phase of vibration, they
may, even at long distances, affect the cells of other individuals
that resemble them, or are attuned to them, that is, have the same
moment of vibration. This is the principle which underlies wireless
telegraphy. Whether the vibrations of living nerve cells can be made
thus to radiate out over the ether and arouse in any way other cells,
especially to the extent of communicating ideas, is a matter still
open for investigation. The possibility of this occurring {143} cannot
be denied. We are, however, still in the presence of a condition and
not a theory. The question is whether minds are thus influenced at a
distance--whether we have data enough to establish the occurrence of
telepathy or mental communications of any kind at a distance.


No Practical Thought Transfer.--At the beginning, it is of the
greatest importance to recall that, while many people think there must
be something in telepathy and presume that the investigations of
recent years have shown not only the possibility of the communication
of ideas from mind to mind and of the mental influence of one person
over another, even at long distances, but also its actual occurrence,
yet all our ordinary life is founded on the absolute negation of any
such phenomenon. For instance, our courts of law are conducted in
direct contradiction of the possibility of anything like telepathy.
Juries are summoned of twelve good men and true who, as far as
possible, know nothing about the prisoner and as little as may be
about the case. They are supposed to get all their information in the
court room. We do not believe that any of them by any wonderful
process might be able to know what was going on in the prisoner's mind
in spite of his plea. Nor do we think for a moment that they can know
what is going on, apart from what he communicates in evidence, in the
mind of any witness. Neither is there the slightest presumption that
the judge or any of our lawyers can know anything about what is in the
minds of any of the persons present, except as they reveal it by
outward signs.

A lawyer who could employ telepathy with success would be simply
invaluable. Before a month had passed, he would have all the business
of the criminal courts in his hands.


Mental Retention.--In answer to this it may be said that these
represent conditions in which determined effort is made to keep all
possible information that may be in the minds of all concerned from
passing to others. Everyone concedes the power of such absolute self
retention of our thoughts, when we deliberately wish to keep them from
being known to others. When people wish to communicate their thoughts
to others, then it may be different. In that case the sending and
receiving minds are both active and the conditions for interaction, if
it were at all possible, would be favorable. Just this condition
obtains in the court room every day. An innocent prisoner wants with
all his heart and soul to communicate the idea of his innocence to the
judge and jury. Of course, he does not succeed by telepathic means in
transferring to them any inkling of the truth. On the contrary, his
very nervousness and anxiety to set himself right before them will
sometimes actually cause prejudice.

The rule that has thus been exemplified in our courts of law holds for
all business transactions. The ordinary customs of business presume
that the buyer does not know what the seller paid for the particular
article that is being exchanged, and it is on the strength of this
that profit becomes possible. A few telepathic merchants or customers
would work serious havoc in business life.

What thus holds for important affairs in life is just as strikingly
exemplified in the trivial round of social existence and in our
intercourse with friends. Suppose one woman knew what another woman
thought of her!

That charming, old-fashioned institution "courting" would go entirely
by {144} the board, if there were any such thing as real telepathy. In
general, social life in all its features would become very, very
different to what it is.


How Much Slight External Expression Conveys.--Mrs. Coventry Patmore,
the English poet's wife, once told a little story of some people who
lived in a distant island where the inhabitants possessed tails. These
tails were, as they are on the animals, organs of expression, but of
involuntary and quite unconscious expression. It was utterly
impossible for the people there to say nice things to one another when
they had quite other things in mind, because if they did not like the
person their tails hung down behind; if they did like them they wagged
rather vigorously, no matter what their owner might be saying. This
simple revelation of feelings, so much less than even the slightest
degree of telepathy would occasion, was quite enough to work a
revolution in the social affairs of this romantic island. It made the
people truthful and candid in their relations with one another.


Negation of Telepathy.--There is, perhaps, some evidence of the
occurring of telepathy in special cases, but all of our present-day
life is organized on a firm basis of complete negation of the
existence or occurrence of telepathy to even the slightest degree.
Every-day experiences teach us that husbands and wives, even those who
have the greatest love and confidence toward each other, do not really
know their life partners, for it frequently happens that something
turns up which reveals an unsuspected side of character even after
many years of intimate union.

We human beings are "infinitely repellent particles," to use the
phrase, of Matthew Arnold. We never get close enough to one another to
have a real glimpse into the depths of other minds. The information
that is supposed to pass by telepathy from one person to another is so
often just the kind that we would most sedulously conceal. There is
extreme unlikelihood then that any such passage of information takes
place. The cases cited, as proof of this transference of thought, are
much more likely to be coincidences than any evidence of true
telepathy.


Supposed Examples of Telepathy.--In the first place, though there are
opportunities for the exhibition of the phenomena of telepathy every
day and every hour of existence, the cases in which it is supposed to
occur are extremely rare and are distant from one another, both in
time and place. Even the people who claim to have had the phenomena of
telepathy happen to them once or twice, do not pretend that it is at
all a common occurrence with them, and as for the supposed exhibitions
of telepathy upon the stage, these have been exposed over and over
again as the simplest fakes.

As to the cases of telepathy that have been reported, with careful
collection of evidence, to the psychic research societies, and which
are few in number, though some of them are very difficult to explain,
there is no reason why they should not be striking coincidences rather
than startling examples of telepathy. An example will illustrate what
I mean:

A few years ago what seemed to be a complete case of telepathy was
reported in connection with a railroad accident. A Western man about
to take an express train for the East was the object of a good deal of
solicitude. There had previously been a series of accidents to this
very fast train which he was to take. This fact had been discussed in
the family, and did not tend to allay the fears of those who remained
at home. During the night the {145} train actually left the track, and
the car in which the subject of the story was asleep rolled down the
bank.

At the moment his train went down the bank the thought of his wife and
daughter came very vividly to his mind. For a moment the awful
position in which they would be placed if anything serious happened to
him occupied his mind to the exclusion of all other thoughts. As soon
as he could, he telegraphed home that he was unhurt, with the
understanding that the telegram should not be delivered before the
following morning.

During the night mother and daughter sleeping in adjoining rooms were
wakened at the same moment, and very seriously disturbed, by
something, they knew not quite what. They rose at once to go to each
other and met at the door. They felt vaguely that father was in some
way connected with their awakening and disturbance of mind. After they
received his telegram they were sure that what disturbed them during
the night was the telepathic communication of father's danger. Each
had, however, deliberately kept from speaking of her impression. When
they found that he had passed through the danger unhurt, they were
sure that it was a call from him that each had heard.

This bears most of the ear-marks of a genuine case of telepathy. Here
are minds whose cells by custom and inheritance are finely attuned to
those of a distant mind that is suddenly very much disturbed. If the
perturbations of that first mind were carried through the ether by a
sort of wireless telegraphy, it would apparently not be very
surprising. So carried, they woke the receptive cells of similar minds
at a long distance, and mother and daughter felt the thrill at the
same instant. Vague though it was, there was a telepathic message.

But there were other passengers in this train who had near and dear
relatives, yet none of them received communications. There have been
literally hundreds of thousands of other accidents in the past fifty
years of railroading in which passengers who have been put in very
serious danger, have thought intensely of their loved ones, and yet,
there has been at most only a dozen or so examples of vague telepathy
of this class. Similar cases to this are extremely rare, though
accidents in America are very frequent. At most, then, we are in the
presence of a very exceptional case. Such cases would mean nothing as
evidence for a scientific law, since they occur so rarely as to aptly
exemplify the old adage that the exception proves the rule. The rule
evidently is that there is no communication at a distance, hence the
surprise when there seems to be some reason for thinking that a
communication has actually taken place. Instead of proving that
telepathy occurs, such cases make it clear, to the limit of
demonstration, that telepathy does not occur unless some extremely
special conditions intervene to make it possible.

How much more easy it is to explain such a case on the score of
coincidence! Of course, mother and daughter, with father absent, and
absent in the midst of what they thought was danger, would go to bed
anxiously thinking of him. They would sleep lightly because of the
worry. Any slight unusual noise would wake them, and at once the
thought of father and his danger would occur to them. If the noise was
sudden, and not repeated, and therefore inexplicable to one awakened
out of sleep, they would probably be so disturbed that it is easy to
understand that they would arise at once and seek each other's
company. Their meeting, therefore, in the doorway between their rooms
would be readily explicable. Neither would say much {146} about the
subject uppermost in her thoughts in order to shield the other. The
telegram in the morning would throw a glow of retrospective light on
the events and seem to give an entirely new significance to their
thoughts. The whole affair, though only a coincidence, would seem to
be a demonstration of telepathy.

Even more marvelous instances of coincidence, in which there was no
question of anything more than coincidence, have been related. The
English Psychical Research Society reported the case of a young man
sent to find some trace of his brother who had disappeared
mysteriously from a steamer sailing from Plymouth to Lisbon. On board
the steamer late at night he stood by the rail thinking of his lost
brother and wondering what could possibly have become of him. Suddenly
as he looked down into the ocean a body came bobbing up out of the
waves almost directly under his gaze. He reported it to the officers
of the vessel and it was grappled for and lifted aboard. It proved to
be the body of his brother. Is this an example of telepathy, that is,
of the mental influence of the perturbed spirit of the live brother
upon the dead brother's body floating below the surface? No one would
stretch supposed telepathy to that extent. The steamer disturbed the
body which had been floating below the surface, as bodies do,
gradually developing within themselves the gases of decomposition.
After a time any slight disturbance, as, for instance, the booming of
a cannon or the passage of even a small boat, will bring a body up. It
so happened that the brother was on the spot, and actually thinking of
the body, but that was the merest coincidence. There was no connection
of cause and effect.

Most of the cases of so-called telepathy can be explained in this way.
As we have said, no source of error is so copious as that of
concluding that because one thing happens after another therefore the
second is caused by the first. People who are so inclined will still
continue to accept such a notion of connection of cause and effect,
however, and we shall have many cases of supposed telepathy exploited
for us on no better grounds than this.


Twins and Telepathy.--There is a definite popular impression that
twins are gifted with the power of telepathic communication much more
than others. Accepting Sir Wm. Crookes' theory, the possibility of
mental reciprocal influence, even at a distance, is greater for them,
since their brain cells must be considered as having corresponding
moments of vibration. Twins of the same sex, especially those who
resemble one another closely, are usually born from a single ovum. The
intimate relations of two such beings to each other can be readily
understood, so that we have many stories of mental communication at
long distances and curious warnings, forebodings and communications of
danger, and especially of sickness and death.

Especially does one find stories of wraith-like appearances of one to
the other of such persons at the moment of death. A series of these
stories, apparently well authenticated, is published by the Psychic
Research Society. There are also a number of tales, seemingly well
attested, of cloud-like shapes of other persons at the moment of
death. As a consequence, there has been developed an idea that there
is some evidence of the distinct possibility of such appearances when
the soul leaves the body. It, however, seems very doubtful whether
these are anything more than a very striking coincidence. Twins are
likely to be almost constantly in one another's minds, so there is
abundant {147} room for coincidences. But any number of twins have
died at a distance from each other without there being any such
warning. Occasionally such startling appearances occur in connection
with people who are so slightly related, or whose existence bears such
slight importance to each other, that it is hard to understand why the
appearance may have come. Whether they are anything more than the
figment of an excited imagination remains to be seen, for, while we
have a little positive evidence, this only emphasizes the possibility
of coincidental day-dreaming in nervous persons.


Negative Tests.--We hear much of the possibility of reading minds at a
distance, or of getting definite information from sealed documents and
the like, but it must not be forgotten that whenever definite
conditions have been set down, so that all the actions of the supposed
clairvoyant could be controlled, then telepathy has always failed to
be manifested. Sir James Simpson, for instance, publicly offered to
give a five-hundred-pound note, which he had placed in a safe deposit
vault, to anyone who could read its number which he had carefully
impressed on his own mind. Needless to say, no one got it. In the days
when Bishop, the exhibiting mind reader, was creating such a furore in
New York and London by supposedly reading people's minds, Labouchère,
the editor of London _Truth_, offered a similar opportunity to Bishop,
but advantage of it was not taken. Bishop's power was entirely due to
muscle reading. People make involuntary movements of muscles that are
very slight, but sufficient for a trained observer to notice,
especially if his hand is on the individual experiencing the emotions,
and the consequent muscle reflexes. [Footnote 19] About the middle of
the last century, the French Academy made a labored investigation of
telepathy and found that whatever there seemed to be in it, when
control was not properly kept, it at once was demonstrated to be
impossible when conditions were planned so as to prevent deception.

  [Footnote 19: The story of Hans, the calculating horse, shows that
  even animals usually thought rather dull-witted may catch muscle
  movements so slight as to be scarcely visible to any but one looking
  particularly for them.]

If patients are worried over disturbing influences from others or the
reading of their thoughts or telepathic suggestions, a calm review
with them of the practical side of this subject, as we have come to
know it in the modern time from actual investigation, will do more
than anything else to relieve their apprehensions. Most of these
patients are unfortunately insane, but the reasoning will help even
some of these. There are some quite rational believers in such
manifestations who will be greatly benefitted.



CHAPTER VIII

SECONDARY PERSONALITY

So much attention has recently been directed to the subject of
secondary personality by the startling phenomena described in numerous
books and articles on the subject, that a certain class of "nervous"
patients have permitted themselves to be influenced by the
auto-suggestion, flattering the vanity, that they, too, have a
secondary personality. They even do not hesitate to hint that this
condition is responsible for many of the failures on {148} their part
to do what they ought to do, or at least what they think they would
like to do; but self-control and self-discipline require such constant
attention and effort that they fail. Even when these patients have not
quite reached the persuasion of a complete secondary personality, they
at least think that the subconscious (or their subliminal self) plays
a large role in their conduct. As a consequence, they assert, it is
more or less beyond their power to control themselves, and their
responsibility for certain acts is surely somewhat impaired. This is a
rather satisfying doctrine for those who do not feel quite equal to
the effort of conquering vicious or unfortunate tendencies. Those who
like to have some excuse for self-indulgence take refuge in this
supposedly scientific explanation to absolve them from blame, and from
the necessity of self-control. The drug habitué, the inebriate, the
victim of other habits, sometimes hug this flattering invention to
their souls, especially when they are of the class who delight in the
study of the abnormal. Reform becomes well-nigh impossible as long as
such an auto-suggestion of inherent weakness and lack of will-power is
at work.


The Other Self.--From the beginning of written history, man has always
been inclined to find some scapegoat for his failings. The story of
Adam blaming the first fault on the woman and the woman blaming it on
the serpent, is a lively symbol of what their descendants have been
doing ever since. The less personal the blame is, the better, and the
more it can be foisted over on some inevitable condition of human
nature, the more generally satisfying it is. A secondary personality
can scarcely resent being blamed for its acts by the primary
personality to which it is attached, and so the field of
auto-suggestion as to the blameless inevitability of certain acts is
likely to widen if it is given a quasi-scientific basis. Long ago St.
Paul spoke of the law in his members opposed to the higher authority,
and declared that the things he would do he did not, while what he
would not do he sometimes did. There is no doubt that there are two
natures in the curious personality of man. Everyone at times has the
uncanny feeling that there is something within almost apart from
himself, leading him in ways that he does not quite understand.
Usually the leading is away from what is considered best in us. But
those who have dwelt much on the better side of man and have tried to
climb above mere selfish aims, have realized that there is also a
power within them leading to higher paths. Indeed, some of the
greatest thoughts that men think, and the resolves that lift them up
to heroic heights, are apparently so far beyond ordinary human powers,
that the hero and the poet and even the more ordinary literary man, is
quite ready to proclaim inspiration as the source of his best
ideas--as if they were breathed into him from without and above.


Personal Responsibility.--For ordinary normal individuals, this
question of secondary personality has scant interest. Normal persons
go about their work realizing that what they want to do, they may do,
and what they do not want to do they can keep from doing, unless some
contrary _physical_ force intervenes. There are many metaphysical
arguments for free will, but none of them is so convincing as the
observation that every sane man, with regard to his own actions, has
the power to choose between two things that attract him. He may be
much drawn to one thing, yet choose another. He may allow himself to
be ruled by baser motives; he may sternly follow the {149} dictates of
reason, or he may do neither and hold himself inactive. In any case,
he realizes his power to choose. While this power may be impaired by
many external conditions, his consciousness of its actuality makes him
appreciate his responsibility. He realizes that punishment for wrong
done is not only a part of the law, but it is also a proper
vindication of that consciousness of free will which all men have, and
which does not deceive them. The question has been obscured by much
talk, but the reality is there, and the common-sense of mankind has
proclaimed its truth. All our laws are founded on it. Without it
punishment as meted out is an awful injustice and crime is a misnomer.


Hysterical Phenomena.--Most of the cases of secondary personality that
have been discussed at greatest length have been in persons who were
as desirous of attracting attention, and as pleased over being the
subject of special study as were the hysterical patients who used to
delight in investigation two generations ago. That most of the
phenomena of so-called dual personalities are mainly hysterical seems
now to be clear. In a few cases, where the patient has found that the
existence of a double personality was of special interest, a definite
tendency to the formation of further personalities has been noted.
Some triple personalities have been discussed and, in a few cases, a
group of personalities, even up to five or more, began to assert
themselves. This _reductio ad absurdum_, of the hypothesis of
supernumerary personality has revealed the real hysteric character of
the phenomena.

The whole story of secondary personality in recent years vividly
recalls commonplaces in the older medical literature that gathered
around the study of hysteria, and that afford a striking confirmation
of the conclusion as to the relation of the conditions ascribed to
hysteria. Physicians of a generation or two ago who found their
hysterical patients interesting, because of certain marvelous symptoms
which they presented, were usually astonished to learn that their
patients could, under suggestion, develop still further and more
surprising symptoms. Each new visit, especially when other physicians
were brought to see the patient, showed the existence of still further
symptoms and revealed new depths of interesting disease. Indeed, the
soil was found to be inexhaustible in its power to produce ever new
and interesting crops of symptoms.

When the real significance of hysteria as a mental condition in which
patients devoted themselves to the task of furnishing new symptoms for
the physician began to be realized, one of the most potent objections
against this explanation was that it would have been impossible for
the patients to have studied out their symptoms enough to furnish the
new material for study which physicians found so interesting. The
patients were supposed to be mentally incapable of fooling the
physicians. When, however, a person devotes entire attention to the
one subject of making phenomena in themselves appear interesting to
others, some very startling results are usually produced.

After having attracted the sensational attention so common with any
novel observation and having been exaggerated out of all proportion to
its due significance, the phenomenon is now settling down to its
proper place--a rather obscure neurotic phenomenon of memory in
hysteric individuals.


_Other Neurotic Symptoms_.--Janet's studies at the Salpetriêre seem to
show that the alterations of memory which bring about what we call
{150} secondary personality (the forgetting of certain phases of
existence and the maintenance for a time of a small portion of
consciousness and memory quite apart from the rest) correspond with
alterations in the physical basis of memory, that is, in the
circulation to certain portions of the brain, and probably also in the
modes of association of brain cells. They occur, particularly, in
connection with certain phenomena of hystero-epilepsy so-called, or
with the deeper forms of epilepsy in which there are various
paresthesias, hyperesthesias and anesthesias as a consequence of a
disturbance of the circulation in the central nervous system; and
probably also of the connections made by neurons and the movements of
neuroglia cells in making and breaking these connections. These
alterations of memory are represented physically by such cases as
those in which patients so lose their consciousness of sensation that
they are unable to tell even where their feet are. As they themselves
say, "they have lost their legs." In these cases, patients are often
very deaf or have a limited auditory power, and their fields of vision
are extremely narrowed. In most of these cases, recovery of the
original personality takes place after hypnosis. This probably
represents a relaxation of that short-circuiting, within the nervous
system, which brought about the curious phenomenon studied as
secondary personality.


Dual Dispositions.--The studies of secondary personality that we have
had seem to show us persons under the influence of some strong
suggestion, in what is practically a hypnotic condition. There are
many similarities between the actions and the mentality of hypnotics
and of those in secondary-personality conditions. The individuals are,
for the moment, unable to recall what happened in other states. They
may be very different in disposition, gentle and tractable in one
state, but morose and difficult to get along with in another. Such
differences are, however, only exaggerations of the variations of
normal personality. There are times when, under the stress of
circumstances, even the mildest of men and women become querulous and
difficult. It is often noted that people are much more gentle and
careful in their relations with some people than with others. Men who
are known in their business relations to be quiet, easy to get along
with, are at times bears in their homes. This is a matter of the
exercise of inhibition for certain mental qualities, and this
inhibition is neglected for some places and persons. An American
humorist said not long since that a young girl passing a weekend at
the house of a friend, should remember that she is expected to be
unselfish, thoughtful for others, and ready to help her hostess to
make it pleasant for others, so that the party may be successful. He
adds that, of course, as soon as she returns home she should be
perfectly natural again.

At least in a limited sense, all of us have buried in us secondary
personalities that are due to a lack of control of ourselves, or
occasionally to a lack of such initiative as makes possible the best
that is in us. The secondary personality of some people, that side of
their characters that their friends see only rarely, is the best side
of them. Many people, under the demand of some great purpose, rise up
to be really heroic in quality, yet in the commonplace relations of
life they are quite ordinary. The secondary personality in either of
these cases is not something abnormal. It is due to a tapping of
deeper levels in personality than most people realize that they
possess. When taken in connection with hypnotism and the power of
suggestion over {151} susceptible individuals, these adumbrations of
the deeper problem of secondary personality as the psychologists have
discussed it, furnish the best data for its fuller explanation.
Excuses for actions founded on secondary personality must either rest
ultimately on insanity, or else on that lack of inhibition which
constitutes the source of so many of our actions that we regret.

People who are susceptible to hypnotism may remember absolutely
nothing of what occurs to them in the hypnotic condition, though they
will recall it without any difficulty if during hypnosis it is
suggested to them that they should remember it. This represents the
most prominent feature of secondary personality; the individuals who
are affected by it do not recall in one state of personality what
happens to them in the other. In the two states they are very
different in character. These differences have been much emphasized
with regard to a few cases that are especially abnormal and have not
attracted much attention in cases where the differences are slight.
Indeed, in a number of the cases where secondary personality asserted
itself, the differences in the character of the individual in the two
states were practically nil. The only difference was a lapse of memory
for certain important events. Considerations such as these help in the
understanding and psychotherapy of what are sometimes puzzling cases
of apparent dualism of disposition.

What we have to do with here are the suggestions of secondary
personality which neurotic patients have been inclined to make to
themselves as a consequence of the interest in the subject in recent
years. The investigations of Head and of Gordon Holmes have
undoubtedly shown, however, that there are true pathological
conditions associated with certain definite and very marked
manifestations of dualism of disposition consequent upon lesions in
the optic thalamus. These cases so far as can be judged at the present
time, at least, are quite rare and at most would account for duality
and not for the plurality of personality that has come to be discussed
by certain enthusiastic neurologists in recent years. The magnificent
work done on this shows how much may yet be accomplished in the
elucidation of nervous diseases by faithful study and investigation of
selected cases.



CHAPTER IX

HYPNOTISM

Hypnotism is popularly supposed to be a mysterious psychological
process by which susceptible subjects are brought under the influence
of a person possessing some marvelous power over others' minds and
wills. According to this supposition, during the periods in which the
subjects are under this influence, they either have some new source of
energy transferred to them from the operator's strong personality, or
else they share to some extent in the will power possessed by him. In
the midst of the sub-consciousness which characterizes the hypnotic
condition, then, they are in some way endowed with new strength, which
enables them to overcome obstacles to physical or mental health, some
of which seemed at least quite insurmountable under their normal
condition.

{152}

As a matter of fact, hypnotism is much simpler than this, consisting
merely of a state of mental absorption in which all distracting
thoughts are for the moment warded off, and only such thoughts as are
suggested by the hypnotist reach the consciousness of the patient. The
essence of hypnotism is the concentration of mind on one idea or only
a few ideas dictated by the hypnotist. This mental concentration
produces the effect of greater strength, whether apparent or real, to
carry out the purposes connected with those thoughts. It is usually
considered that hypnotism involves sleep, and in some cases it does.
This is often undesirable. True, therapeutic hypnosis leaves at least
certain senses of the subject open to perceive such things as are
presented by the hypnotist's suggestion though these senses may be,
and usually are, quite closed to all other perceptions. In a great
many cases, though there is a real hypnotic condition, a state
resembling true sleep does not occur. There is only a more or less
complete concentration of attention on the suggestions of the
operator, and a complete cessation of all spontaneous thought, or of
all suggestions that might come in ordinary ways from the subject's
own senses.


Effects of Hypnotism.--Most people have a very erroneous notion with
regard to the effects of hypnotism. Some expect that the hypnotic
sleep will work miracles. Nothing is more common in the experience of
one who is known to employ hypnotism, even occasionally, than to have
a patient who is addicted to some habit, alcoholic, drug, or sexual,
ask, "Do you hypnotize?" If an affirmative answer is given, the
patient proceeds to say that he has heard that one can be hypnotized,
and then all the tendency to fall back into the old habit is
immediately lost, and he has no further bother from it. This supposed
miraculous effect of hypnotism in supplanting the necessity for using
the human will has been cultivated very sedulously in the public mind
by quacks and charlatans of various kinds and even exploiters of
hypnotism who belong to the medical profession. But there is nothing
in it. Hypnotism will not change character unless it be for the worse,
since the habit of it sometimes leads to dependence on suggestion
rather than spontaneous motives. Hypnotism cannot be substituted for
weakness of will. The suggestions given in the hypnotic state are
practically no stronger than those given in the waking state, if the
patient would only equally concentrate his mind to receive them, and
would be as ready in response. It is the readiness of response which
comes in cumulative fashion, in the midst of the utter abstraction
from other thoughts, that characterizes the hypnotic condition.

This is, of course, quite a different valuation of hypnotism from the
very strong expressions, with regard to the power of hypnotists to
influence the human will, which have at various times been made. These
exaggerated claims have been no stronger than those often made for
remedies of various kinds that have been long since discredited. I
have heard a serious though young professor of psychology declare that
he was not sure whether he was justified in using all the power that
he possessed by hypnotism to influence men's wills to keep them from
indulging in liquor to excess, because after all men had a right to
their free will, even in a matter of this kind, and it would be wrong
to take it away from them. He added very philosophically that no human
being had the right to play the role of Providence in directing
others' actions even for good, unless they themselves were perfectly
satisfied. {153} If there was any such force in hypnotism as is thus
suggested, the reformation of the world, or still more its
deformation, at the hands of some of the strong-minded practicers of
hypnotism, would be a comparatively easy process. As a matter of fact,
however, the hypnotizer has, except as regards abnormally suggestible
people, only as much influence over the person hypnotized as the
subject permits, and the subject retains all his personality as an
individual with all his weaknesses. After he has been helped away from
his weaknesses by hypnotism, he is just as likely as ever to yield to
them again, unless, during the interval of conquest, he has succeeded
in bracing up his will to resist them.


FORMER METHODS OF HYPNOTIZATION

All the methods of hypnotizing, then, are directed to securing this
state of concentration of the patient's mind. The hypnotic state is
brought about in different ways by different operators, and even the
same operator must employ quite different methods to secure hypnotic
influence over different subjects. In the old times, mysterious passes
and strokings and rubbings of various kinds, and instruments that
flashed light, or that made special sounds, were employed. Among the
pioneers, each worker invented methods of his own. A review of these
will bring out the fact that none of them represents essentials, and
that they are only auxiliaries to secure concentration of the
patient's mind.

The methods of hypnotism practiced by those most noted in the history
of the art were very different from one another, but not more
different than are the methods in vogue to-day among individual
hypnotizers. Indeed, the practices of the past have come down as a
heritage to our own time. Stroking and touching, of which we have
hints in the oldest times in Egypt and Babylonia and Greece, have
always been prominent features. Valentine Greatrakes dreamt that he
heard a voice in his dream telling him that his right hand should be
dead and that stroking it with his left should cause it to recover its
power once more. After this had happened three times in succession he
began to apply this method to the ills of others. Greatrakes seems
really to have come in to replace the touching by the king for the
King's Evil at a time when there was no king in England, Pastor
Gassner, the next worker who attracted attention by hypnotic
procedures, used words of command after attracting the profound
attention of his patients. Father Hell employed the touch of magnets.
Mesmer used music to predispose the mind, but had many of the methods
of modern hypnotists.


Mesmer.--While Mesmer undoubtedly attracted attention to certain
phases of hypnotism that were to prove valuable, he was by no means
the first to do so, and what he did had such a tincture of
charlatanism it is no wonder that he was discredited. There was a
little truth, but there was a deal of mere pretense in his work. While
he undoubtedly obtained results, he did so mainly because of certain
mentally impressive methods that he employed in connection with
whatever of hypnotism he used. Binet and Feré, who have given us some
details of his work, describe his methods in such a way as to make it
clear that they smacked largely of quackery:

{154}

  Mesmer, wearing a coat of lilac silk, walked up and down amid his
  agitated throng, accompanied by Dezlon and his associates, whom he
  chose for their youth and comeliness. Mesmer carried a long iron
  wand with which he touched the bodies of the patients and especially
  the diseased parts. Often laying aside the wand, he magnetized the
  patients with his eyes, fixing his gaze on theirs, or applying his
  hand to the hypochondriac region and to the abdomen. This
  application was often applied for hours, and at other times the
  master made use of passes. He began by placing himself "en rapport"
  with his subject. Seated opposite to him, foot against foot, knee
  against knee, Mesmer laid his fingers upon the hypochondriac region
  and moved them to and fro, lightly touching the ribs. Magnetism,
  with strong electric currents, was substituted for these
  manipulations when more energetic results were to be produced. The
  master, raising his fingers in a pyramidal form, passed his hands
  all over the patient's body, beginning with the head, and going
  downward over the shoulders to the feet. He then returned to the
  head, both back and front, then the belly and the back, and renewed
  the process again and again until the magnetized person was
  saturated with the healing fluid and transported with pain or
  pleasure, both sensations being equally salutary. Young women were
  so much gratified by the crisis that they wished to be thrown into
  it anew. They followed Mesmer through the halls and confessed that
  it was impossible not to be warmly attached to the person of the
  magnetizer.


De Puysegur and His Successors.--De Puysegur has some definite
instructions for hypnotizers, whom he called magnetizers. It is
instructive even now to read these, for they emphasize the most
important element in all hypnotism, the confidence of the operator in
his own power, for this, communicated to the subject, produces the
beneficial results:

  You are to consider yourself as a magnet; your arms, and
  particularly your hands, being its poles; and when you touch a
  patient by laying one of your hands on his back, and the other in
  direct opposition upon his stomach, you are to imagine that the
  magnetic fluid has a tendency to circulate from one hand to the
  other through the body of the patient. You may vary this position by
  placing one hand on the head and the other on the stomach, still
  with the same intention, the same desire of doing good. The
  circulation from one hand to the other will continue, the head and
  stomach being the parts of the body where the greatest number of
  nerves converge; these are, therefore, the two centres to which your
  action ought to be mostly directed. Friction is quite unnecessary;
  it is sufficient to touch with great attention.

Some of these methods continued to be employed by the successors of
Mesmer and De Puysegur, the sense of touch being the principal
adjuvant, though Mesmer employed also the sense of hearing. Braid
seems to have been the first to realize that the sense of sight could
be used effectively, or perhaps that the tiring of the muscle sense
might well serve as a point for the concentration of attention. He
used the flash of a light from some bright object or tired the eye
muscles by having the patient look upward at some object brought near
so as to require convergence of vision. His methods were imitated by
most of the hypnotizers of the nineteenth century. Liebault and
Bernheim, at Nancy, employed them regularly, and they were used in the
investigations at the Salpêtrière. It was found, however, that after a
patient had been once hypnotized, all that was needed was a word of
command or a definite suggestion, and the hypnotic state recurred.
Further experience showed also that the original hypnotic phenomena
might, in most cases, be secured very simply by word-suggestion to the
patient, though some individuals required persistent efforts in the
application of several methods {155} to secure the concentration of
mind on a single idea or set of ideas that is the essence of
hypnotism.

By most serious hypnotists, especially those who use hypnotism for
therapeutic purposes, all the rubbings and manipulations are now
either completely eliminated, or are used only under special
circumstances. The important element of the operator's influence
consists in obtaining the complete confidence of the subject in the
operator's power to control his intelligence for the time being;
getting the subject to resign himself completely, with absolute
assurance that his trust will be for his good, and can by no means
result in harm. Without this attitude of mind on the part of the
subject, anything like real hypnotism is impossible. Even with this,
only a slight degree of the hypnotic condition may be secured in
certain people, but the majority have a distinct susceptibility to it.


PRESENT DAY METHODS OF HYPNOTIZATION

Though various methods of producing the hypnotic sleep are in use, the
rule is now that, in the course of a hypnotizer's experience, less and
less external auxiliaries of any kind are needed, and more and more
dependence is placed on the bringing about of mental _rapport_ between
the active and passive agencies in hypnotism by persuasion and
command. If the hypnotic sleep has once been obtained, usually all
that is necessary is a few gentle words, and then the command to
sleep. It is at the initial attempts to hypnotize a particular person
somewhat refractory to the condition that auxiliaries are needed. In
these cases it is often well to tire the eyes of the patient. This is
done by directing them to the fingers of the operator held well above
the patient's head. After a minute or two of effort the distinct
fatigue which occurs may induce forgetfulness of everything else and
cause absorption in the single idea of attending only to the
hypnotizer's suggestions. This constitutes the beginning of hypnotism.
Occasionally the flash of a bright object, or a revolving mirror, may
be used, but these are only adjuncts and may be dispensed with
entirely if the operator has the patience and the time to give to the
subject.


Accessories.--Some operators use a mirror on which a ray of light is
cast for the purpose of concentrating the attention and bringing about
tiredness of the eye muscles. In so far as it has a more universal
application, sight is certainly the best sense to act upon. Other
senses may be appealed to, as I suggest later. Instead of a mirror, a
polished match-box or pencil-case may be used, but as a rule the less
artificiality enters into it and the simpler the procedure, the
better. One of the inconveniences of using the flash of a bright
object is that occasionally patients who are very susceptible may,
after they have had a number of hypnotic experiences, be thrown into a
hypnotic condition by the flash of a light in the street, or by the
reflection of light from a mirror in their own homes. These conditions
of facile auto-hypnotism constitute one of the serious dangers of the
practice on susceptible subjects. Whatever good may be accomplished by
hypnotism will probably be reached during the first half dozen
seances. To proceed with the treatment beyond this, if it is employed
at regular and short intervals, is almost sure to result in harm
rather than good.

{156}

Sensations.--Besides sight, sounds have sometimes been used for the
purpose of inducing hypnotism. The ticks of a watch, for instance,
placed at a little distance and listened to very intently, have been
known to assist in securing the hypnotic state. Sometimes the sound of
a gong, or an imitation of a cathedral chime, have been used in the
same way. Soft music has also been used by operators with decided
advantage. It is necessary that the sounds should be of a kind that do
not disturb, but only attract attention to one sensation, and then, as
concentration on this is secured, the hypnotic condition results.
Practically any other sensation may be used in the same way. Touch is
often employed. Mesmer stroked his patients gently, and others have
used the same process with advantage. Some of the French workers in
hypnotism have claimed that there were special portions of the body
the stroking of which was likely to produce this favorable effect.
They have called these regions zones hypnogenes--areas that give rise
to hypnotic conditions. Strokings of the forehead, of the cheeks, of
the hands, are favorite locations for these auxiliary touches. In
this, as with regard to sound, the main thing is to concentrate
attention on some one sensation without producing disturbing thoughts.


Stroking.--Stroking seems to affect many people and to easily induce a
sort of hypnoidal condition. It is done very naturally to a child when
one wants to console or encourage or admonish slightly but kindly. In
older people it is a familiar gesture among those who think much of
one another, and represents a very natural tendency. Even in the midst
of physical discomfort its effect is quite soothing, and it is evident
that something resembling hypnotism is at work. Evidently, what really
happens is a concentration of attention on the sensation thus
produced, which concentration prevents distracting thoughts from
making themselves felt and permits the words of the one who does the
stroking to produce a deeper effect on the mind than would ordinarily
be possible. This seems to be nature's method of making suggestion
more effective. It has been adopted, quite spontaneously, by many of
the pioneers in hypnotism as the result of their observations upon its
efficacy. Lloyd Tuckey calls attention to an illustration of this
practice, which makes clear its effectiveness and at the same time
shows how naturally it suggests itself as a mode of using mental
influence. He says:

  Among the medical men who have come to watch some of my cases was a
  gentleman who seemed much struck at seeing the method I adopted with
  a rather refractory subject. I held his hand and stroked his
  forehead while at the same time suggesting the symptoms of sleep.
  The gentleman told me afterward the reason why he was so interested.
  It appears that he had a few months previously been in attendance on
  a very severe and protracted case of delirium tremens. The patient
  could get no sleep, and the doctor was afraid of death from
  exhaustion. On the third evening he resolved to make a strong effort
  to produce sleep, and, if necessary, to sit up all night with the
  patient. He told the man that he would not leave him until he slept,
  and sitting down by the bedside, he took his hand in one of his own,
  and with the other gently stroked the forehead. At the same time he
  talked quietly and reassuringly to him. In less than half an hour he
  was rewarded by seeing the restlessness entirely cease and the man
  drop off into a quiet sleep. That sleep, the doctor told me, lasted
  fourteen hours, and the patient awoke out of it weak, but cured.
  Manipulation about the head has in many persons a most soporific
  effect, and several persons have told me that they always become
  drowsy under their barber's hands.

{157}

Drugs.--A number of drugs and related substances have been used as
aids to hypnosis, but in nearly all of these cases it is doubtful
whether it is true hypnotism that results and whether the suggestions
in these states have much therapeutic value. One of the drugs most
frequently administered by hypnotists is _cannabis indica_, which has
long been used in the East for a similar purpose. After this,
chloroform is most popular. Schrenck-Notzing even ventured to employ
alcohol as an aid in hypnosis, and claims that he has succeeded at
times in making intoxication pass into the true hypnotic condition.
Bernheim and many others of the French school have used chloral and
morphine. These substances are, however, liable to great abuse.
Whenever they have to be employed it means that the patient is but
little susceptible to hypnotic influence. These aids are employed only
because hypnotists do not want to confess that a very considerable
portion of humanity is not directly susceptible to the hypnotic
influence.

Serious harm may be done by the employment of these drugs. A
physician, who hoped that he would be able to overcome a drug
addiction that had been the bane of his existence for a long while,
went to a well-known hypnotist physician with the idea that perhaps
the miracle of hypnotism would be worked in his case. He was one of
these flighty mortals whom it is extremely difficult to have fix their
minds upon any one idea for a definite time. As it was impossible to
bring him into anything like a hypnotic condition by ordinary means, a
large dose of chloral was administered. He already had an idea that
his heart had been affected by his previous drug-taking habit, but the
chloral was administered to him before he realized what it was. When
he came out of the sleep it induced, he was in an agony of solicitude
and anxiety lest his heart should have been further hurt by the
chloral. He went back for no more doses of that kind of hypnotism.

The use of drugs seems to be a confession of failure to secure true
hypnotism, so that it is doubtful whether their employment is
justified. Suggestions received while in the more or less comatose
state induced by drugs, instead of having a strengthening effect on
the patient's will, rather tend to produce the idea of the
impossibility of effectively using his own will, or even exercising
his will when helped, as he supposes, by the will of the operator. The
real value of hypnotism consists in the concentration of mind upon a
particular idea without any distractions, which enables the subject to
make firm resolutions and then to have his mind help his body as much
as possible by directing his energy to the accomplishment of one end.
When drugs are employed, they have a diffusive rather than a
concentrating influence, so that the real purpose of hypnotism is
entirely missed.



PRACTICE OF HYPNOTISM

In the ordinary practice of hypnotism now, the patient is placed
sitting on a comfortable chair and the operator on one side facing
prepares the mind of the subject by proper assurances. The patient
must be brought into a thoroughly assured and comfortable state of
mind and must be quite ready to submit to hypnotism. Then in most
people, if the finger is held rather close to the patient and well
above the line of sight, requiring special effort {158} on the part of
the superior recti muscles as well as of the power of convergence, a
tired feeling will come over the subject with a tendency of the lids
to droop. When this happens the subject is asked to allow the lids to
drop and to quietly concentrate the attention on the idea of sleep so
as to permit the drowsy feeling gradually to increase. On a first
seance this may take ten minutes, subsequently much less time will be
needed, and, as a rule, in five minutes the subject is quite
predisposed to sleep. In more difficult cases a much longer time may
be needed, and repeated efforts may have to be made. Great patience is
required. The operator soon learns to adjust himself to certain
peculiarities of individuals in predisposing them to the hypnotic
condition.


Hypnotism Simple, Natural, Not Mysterious.--The most important thing
to know about hypnotism is the fact that any one who wishes can
hypnotize. There may be need for favoring circumstances, but there is
no need for any special faculty in the operator. If he has confidence
in himself so as to take up the question of hypnotizing seriously, if
the subjects are reasonably susceptible and if they are persuaded that
they may be hypnotized, or even if they are not, so long as they take
the operator seriously a hypnotic state will result. Nothing is more
surprising to the operator himself, the first time he succeeds, than
his success. This at once gives him renewed confidence, and future
hypnosis becomes a comparatively simple matter. To have this idea
widely diffused would do much good, since it would at once strip the
charlatans, who abuse hypnotism, of most of the mystery that surrounds
them. The general diffusion of such knowledge would also do good in
another way. It would expose the supposed wonderful power that some
people are presumed to possess. Hypnotism works no wonders; it is a
mere natural manifestation not unlike sleep, and probably not a whit
more mysterious.


Stages.--A number of divisions of the hypnotic state have been
suggested, but probably the simple division into three stages is the
best for ordinary teaching purposes, and helps to the understanding
both of the conditions themselves and of many things that are written
about hypnotism.

The first stage consists of a subdued, dreamy condition, in which the
patient is not asleep and yet not thoroughly awake to all that is
going on around him. He has his mind so concentrated on certain
thoughts that he is preoccupied, and suggestions are much more
efficient than under ordinary circumstances. This is really only a
state of intense attention to the suggestions that are being made,
with the banishment of all distracting thoughts. It is rather
difficult for any one to keep from being distracted, and whenever this
is accomplished, the ideas that then enter the mind penetrate more
deeply and, above all, seem to affect the will more forcibly than when
they are merely superficially considered. This first stage of
hypnotism would not be considered hypnotic by most people who
associate the idea of sleep with hypnotism.

In recent years it has been found that most of the good that is
accomplished, especially for nervous people, by hypnotic suggestion,
can be attained almost, if not quite as well, in this first stage, and
without the hypnotic trance. The first stage is much less liable to
the dangers of hypnotism in many ways, and it represents one of the
most interesting phases of psychotherapy.

{159}

The second stage of hypnotism is the hypnotic sleep. The patient loses
consciousness of his surroundings, though his senses are still open to
suggestion from the operator. Practically all that happens in the room
apart from what is brought to the subject through the operator's
direction remains unnoticed. If the sleep is very deep, even the
suggestions of the operator do not penetrate after a time, so it may
be quite difficult to awaken the subject. It may be even some hours
before the person hypnotized will come out of the lethargy which has
been induced in these cases. Under these circumstances, this second
stage partakes somewhat of the nature of the deeper trance condition
that characterizes the third stage.

The third stage of hypnotism consists of a profound trance-like
condition in which there is catalepsy--that is, firm contracture of
muscles all over the body--and as the extensors are stronger than the
flexors, this contracture takes place in the extended position. The
cataleptic condition is really a nervous spasmodic seizure rather than
a true stage of hypnotism. It is probably always harmful for the
patient to have it induced. Its occurrence as one manifestation of
hysteria, apart from hypnotism, shows its real character. It is with
this stage of hypnotism that professional hypnotists, who give
exhibitions, make their demonstrations--that is, of course, when their
demonstrations are really hypnotic and are not merely, as is often the
case, performances by actors trained for the purpose. Catalepsy is
entirely pathological; experiment with it then is eminently
undesirable, and certainly should not be undertaken except under the
most careful precautions and by a physician. One of its dangers was
very clearly pointed out by the death of a young man, who in a
cataleptic condition was subjected to certain strains upon his thorax
which brought about the rupture of an aortic aneurism. Catalepsy never
permits of suggestion in such a way as to be helpful to the patient.
It always leads to further functional deterioration of the nervous
system, and yet it has unfortunately come to mean for many people the
most essential characteristic of hypnotism. Its production is supposed
to represent the acme of skill in the hypnotist. Nothing could
possibly be less true nor be more likely to do harm.


Susceptibility.--As to the number of people who are susceptible to
hypnotism, there are great differences of opinion. Liebault declared
that practically every one is susceptible in the hands of a patient
operator. In a carefully made series of cases his failures were less
than three per cent. Van Rentergehem and Van Eeden, in a series of
over 1,000 persons, failed only with fifty-eight, or little more than
five per cent. Schrenk-Notzing's statistics, collected from many
countries, seem to show that only about six per cent. were
uninfluenced. Bernheim, at Nancy, was not nearly so successful as
Liebault, his master, and his failures amounted to twenty-five per
cent. at the beginning and at least twenty per cent. later. I remember
that when I was at the Saltpêtrière fifteen years ago, they were
inclined to discount the enthusiasm of the Nancy school with regard to
the value and significance of hypnotism. They insisted that probably
not more than one out of two of the persons presenting themselves at a
nervous clinic could be hypnotized to the extent that is ordinarily
associated with the word--could be brought beyond the drowsy stage.
There are other workers in the subject who have insisted that not more
than one out of three ordinary individuals can be so {160} deeply
hypnotized as to exhibit the ordinary symptoms. These symptoms consist
of complete neglect of surroundings and absolute absorption in the
suggestions of the operator.

Some people can be hypnotized to the extent of being thrown into sleep
and yet walk and talk under the absolute control of the operator.
These are so-called somnambules, the class of persons who are
exhibited by professional hypnotizers who want to attract popular
attention, and, indeed, the class usually exhibited by physicians
before medical societies, and even by professors before their classes.
This extreme susceptibility is, however, quite rare. Even the most
ardent advocates of hypnotism and of the susceptibility of humanity to
it do not claim that more than one in ten of average individuals can
be influenced to this degree. There are milder degrees of hypnotism
than this, until we reach a state in which all the patients feel is a
certain dreamy sense of well-being and a heaviness of the eyes, with a
readiness to respond to suggestions. Most people who think of the
somnambulistic stage as representing hypnotism would not consider
these latter to have been at all subjected to the hypnotic state.


_Repeated Efforts_.--As to this question of susceptibility, much
depends on how often the operator has tried to hypnotize the
particular subject, for susceptibility develops with repeated trials,
not only where there is a manifest impression at first, but also where
there is not. It is not uncommon to find that a patient who cannot be
brought at all under the influence of hypnotism in the first or second
or third trial, will, at the fifth or sixth trial, yield to the
suggestion to go into a hypnotic sleep. A dozen unsuccessful efforts
may be followed by the development of a very satisfactory hypnosis.
Those who have practiced hypnotism much tell of having tried a score
or even two score of times before finally bringing on a hypnotic
condition. Dr. J. Milne Bramwell, one of the English authorities on
hypnotism, tells the story [Footnote 20] of having tried sixty or more
times to hypnotize patients before finally succeeding. It is this
persistence that enables successful hypnotic operators to accomplish
results where less confident physicians fail. It is also the frequency
of trial that makes all the difference in the statistics as to the
susceptibility of patients to hypnotism in the hands of different
individuals. There must be the confidence of the patient in the
physician's power to hypnotize, but, above all, there must be the
physician's own confidence in his power to bring on the hypnotic sleep
so that he tries and tries again, even to seventy times.

  [Footnote 20: "Hypnotism. Its History, Practice and Theory," by J. M.
  Bramwell, 2nd edn. London, The De la More Press, 1906.]


ANIMAL HYPNOTISM

The hypnotization of animals shows that only a very low grade
intelligence is needed for the production of this state. The famous
experiment of Father Kircher with the hen, which any one may repeat at
any time, is a good illustration. The fascination exerted upon birds
by snakes is another familiar example. The bird is paralyzed with
terror at the sight of the snake, and so cannot escape from its enemy,
fairly glueing its eyes on the terrifying object, and thus loses power
to control its wings. Stories of snake {161} fascination are usually
told as if the eye of the snake attracted the bird, who thereupon
proceeded to approach the snake. These are, however, doubtful stories.
The paralysis of motion seems to be the main effect. The rabbit is
affected in nearly the same way. There is a tremor of horror in
anticipation, and then the animal stands perfectly quiet, though
ordinarily he would be quite able to escape, while its enemy
approaches. The underlying mechanism is evidently a concentration of
attention, which completely precludes the possibility of the exertion
of any spontaneous energy except that involved in the one act of
watching the awful object.


DANGERS OF HYPNOTISM

There are many and various opinions of the dangers of hypnotism. Some
of those who have given it a fair trial have insisted on its dangers.
Some of those who have had very large experience have declared
emphatically that there is no danger at all. Occasionally it has
seemed that such a declaration must be considered as having been
dictated by such intensity of interest as sometimes leads men to
overlook the darker side of things with which they are much occupied.
Certain moral aspects of hypnotism are at least dubious, and, it must
be admitted, present opportunities for abuse. There are certain
dangers connected with its effect upon nervous patients, and
especially with its influence upon character, that have become more
and more clear in recent years. Dr. John K. Mitchell, in his "Self
Help for Nervous Women," a series of familiar talks on economy in
nervous expenditure, [Footnote 21] has dwelt on certain of these
dangers of hypnotism for nervous patients in a passage that deserves
to be recalled. As a representative of a school of thought that is
worthy of special regard from American physicians his expressions must
carry weight:

  [Footnote 21: Philadelphia, Lippincott, 1909.]

  The greatest danger of all is the use of hypnotism in any form or
  degree, a two-edged sword, capable indeed of usefulness, but more
  capable of harm. After years of study, beginning with too easy an
  approval of it, hypnotism, whether called by that name or by the
  unsuitable one of suggestion, has been laid aside by the medical
  profession as a means too dangerous for ordinary use, involving
  great risk of deterioration of character in the subject if often
  repeated, and putting a terribly tempting tool in the hands of the
  user, fascinating in the ease with which it can produce superficial
  and temporary good results and equally capable of being used for
  harmful ones.

  A susceptible person, once hypnotized, is more and more easily
  thrown into the hypnotic state until even the slightest hint
  suffices to bring about the condition. It is not necessary for the
  hypnotization to go so far as deep sleep; this more advanced stage
  is indeed seldom required, and to say that persons are not
  hypnotized because they are not put into a sleep or a trance shows
  ignorance of the subject.

  I am not asserting that very slight degrees of the hypnotic
  condition are as dangerous as the deeper, but I do say that all
  degrees of it are dangerous to the integrity and healthy action of
  the subject's nervous system. The danger of harm increases with
  every repetition of the hypnotization.

  In suggestible, that is, over-susceptible, individuals, who are
  almost universally neurotic persons, to fix the eyes on a small
  point, especially a bright one, sometimes even to fix the mind on
  the one idea of going into the hypnotic state (mild or deep), is
  enough without further intervention from any one to put them into
  that state.


{162}

In an article on the "Danger and Uses of Hypnotism" Prof. Forel, of
Zurich, twenty years ago, while frankly admitting that hypnotism is by
no means a panacea for all nervous affections and unfortunate habits,
found it to be an extremely valuable help in the treatment of many
forms of functional nervous disease. He suggests that some of its many
dangers are due to the fact that hypnotism is practiced by men who are
too distrustful of it, and this distrust, unconsciously communicated
to the patients, produces an unfortunate effect. On the other hand,
fear and distrust on the part of the subjects seriously disturbs the
process of hypnotization, interferes with its effect and sometimes
leads to unfortunate results.

In some cases it seems that the state of dependence on some one else,
at least by suggestion, that had been created during the hypnotic
experience, resulted in a diminution of will power and caused a less
hopeful state on the patient's part than before. I found personally
that suggestion in the waking state might in most cases be used quite
as efficiently as hypnosis itself, and that when improvement came
under these circumstances, the patient always felt more confidence in
himself and less in the operator. Anything that restores
self-confidence and gives patients the feeling that they can conquer
inclinations, tendencies, even habits, if they only will, merely by
firmly resolving to do so, is the best possible mental influence for
them. The hypnotic relief is always easier, but nothing that is easy
is likely to be of lasting value. The enduring effect of gradual cure
by suggestion means much more than the hypnotic miracle that these
patients are so prone to crave.

At present there is a very general feeling among those who have had
considerable experience with hypnotism, that in spite of the claims of
certain votaries for it, there is no justification for its frequent or
habitual use. It has a definite place in diagnosis, in certain
difficult cases, and at the beginning of the treatment of certain
forms of the psycho-neuroses. When repeated frequently it is not
therapeutic, but is likely to produce serious results in a certain
lack of self-control and tendencies to auto-hypnotization with
deterioration of character. There is very seldom need of a repetition
of deep hypnosis, and, as a rule, all the diagnostic benefit can be
secured in one or two seances. Its continued use only illustrates the
tendency noted at all times, in the history of medicine, for the
unthinking or unprofessional to persist in the application of supposed
remedial measures after they have been shown to be useless or even
harmful. The subject well deserves further study, but investigations
should be carefully made by men who realize the dangers, and who are
not likely to be tempted to exploit patients and curious psychological
phenomena for the sake of sensational reputation. The use of hypnotism
for exhibition purposes, by men who are not physicians, is an unmixed
evil, producing entirely wrong impressions on the public, and doing
untold evil to the subjects employed.


{163}

SECTION III

_THE INDIVIDUAL PATIENT_


CHAPTER I

PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT


The most important element in Psychotherapy is the individual patient.
Old Dr. Parry of Bath said a century ago, "It is much more important
to know what sort of a patient has a disease, than what sort of a
disease a patient has." Mental influence is not of the slightest avail
against pneumonia or typhoid fever, nor constipation nor rheumatism as
such; mental influence may be, and often is, of the greatest possible
help to the patient suffering from any of these diseases.

We recognize frankly now that for most diseases we can do nothing to
counteract the disease directly or to cure it specifically. The idea
of specifics in medicine has to a large extent disappeared. Two or
three of them possibly we have, but even with regard to these, there
are certain doubts as to the essential modes of their activity. We
have learned, however, to help the patient to overcome disease. We
know how to conserve his forces, to increase his vital reaction, to
maintain his nutrition without disturbing his general condition, and
to secure elimination in such a way as to prevent nature from being
interfered with in her curative purposes. To this, psychotherapy would
enable us to add such encouragement of the patient as would tap new
sources of energy in him according to the law of reserve energy, and
would prevent discouragement and the inhibition of favorable nerve
impulses that so often follow. The outcome of any disease depends on
two factors. One is the condition of the patient at the time the
infection was acquired, the other is the virulence of the infection.
We can do nothing to modify this latter element, once the disease
manifests itself. We can, however, do much to enable the patient to
throw off the disease and, above all, by securing a favorable attitude
of mind, we can enable him to use his forces to the best advantage.

Anyone who has noted the difference between the patient's state just
before and just after his physician has called, though absolutely no
physical remedy has been employed, is able to realize very well how
much psychotherapy is able to accomplish. One who did not know, would
be sure to assume that some potent remedy had been administered--and
there has been. This potent remedy is psychotherapy. Whether the
personal magnetism necessary to produce therapeutic effects of this
kind can be learned or not depends on the individuality of the
physician. Undoubtedly, however, everyone can add to whatever of
personal influence he has by definitely recognizing its place, by
{164} making every effort to employ it, and then by regular systematic
effort in securing as much personal information as possible with
regard to the patient. This personal relationship of physician and
patient makes instruction easier and suggestion more effective.

The securing of personal information is of the utmost importance in
determining the affections that psychotherapy will relieve, because
very often details of life and habits are discovered that can be so
modified by instruction as to bring about a disappearance of
unfavorable physical influences. It is indeed surprising to find how
many unreasonable things people do from habit, from unfortunate
persuasion, or from lack of knowledge. In many of the minor chronic
ailments that are the source of so much mental discomfort to patients,
the physician finds that a change in the patients' habits, not
necessarily of marked degree, may make all the difference between
cheerful health and rather despondent low-spirited feeling. Now that
epidemic disease has become rarer, a physician's practice, especially
among the better classes, is much more taken up with these minor
ailments than with the typical classical diseases.

The ordinary history of their ailments, as patients commonly present
them, especially when there are neurotic elements, is likely to be
meager in what is objective, but consists mostly of the subjective.
Such patients have much to say of their sensations, their feelings,
their dreads, their surmises, their conclusions as to their particular
condition, and especially the hereditary elements in it, but
comparatively little of the objective realities of their ills and of
their environment. What the physician needs to know about them is
their habits of life, their daily routine of existence, just as
minutely as it is possible to obtain the information. There is just
one way to get the latter details, and that is to inquire particularly
with regard to actual happenings. In chronic conditions of many kinds,
it is so helpful that it will always be worth the physician's while to
get at these details, especially in supposedly puzzling cases for
which various forms of treatment have been already tried.

In spite of every precaution in this matter, the physician sometimes
finds, after a series of consultations, that some point which when
brought to light he considers to be of great importance, has been
thought so trivial by the patient that it was never mentioned, in
spite of the most careful questioning. In all medical practice the
rule is that mistakes of diagnosis are much more due to neglect in
eliciting necessary information than either to lack of expertness in
diagnosis, or lack of knowledge of the significance of symptoms.

In the affections that can be relieved by psychotherapeutics, the most
important element for diagnosis, besides a minute knowledge of the
patient's habits, is just as detailed information as possible with
regard to his ways and modes of thought as to his ills. Practically
every motive, as well as every action of the day, must be scrutinized,
and often it will be found that little things mean much for the
individual. "Trifles make perfection, but perfection is no trifle," as
said by Michelangelo, might well be changed for the physician to,
"Trifles make all the difference between health and discomfort, though
health is no trifle."


{165}

CHAPTER II

THE MORNING HOURS


In getting the history of patients for diagnostic purposes the safest
way is to begin with the getting up in the morning and then to follow
out the various actions of the day. The hour and mode of rising should
be inquired into. Practically all nervous people, and nearly all those
beyond middle life, feel less fit in the morning hours than at any
other time in the day. Apparently as a consequence of their will
having been allowed to lose its hold during sleep, it does not secure
thorough command over the organism for some time. Nervous people, as a
rule, wake up with a tired feeling, a dread of the day, wondering
whether life is worth living. They dread--for it is a real dread--to
get up and tackle the daily round of life once more.

If they have nothing very definite to do, then slight tired feelings
or discomfort, even of very minor degree, may lead them to think that
they cannot get up. Any yielding in this matter is almost sure to do
harm. When there are no objective signs, that is, when there is no
fever recognizable by the thermometer and there has been no diarrhea
or any physical weakness, nervous patients should get up promptly at a
particular hour every morning, because, as a rule, within a half hour
after getting up they feel better, and by the time they are washed and
have had their breakfast, life has grown not only quite possible but
even plausible, and the day's work does not seem such a nightmare as
it was at first. It is not advisable to tell people all this as soon
as they confess their habit of dawdling in the morning, for they must
be gradually brought to discipline themselves. The detail emphasizes
the necessity of knowing how they get up as well as when.


Mode of Awaking.--It is often valuable to know how patients awake.
Sometimes it will be found that they are anxious and solicitous to be
at work at a particular hour, or to catch a train at a particular
time, and that as a consequence their sleep is disturbed in the early
morning hours. At best it may be fitful and when they awake they fear
to go to sleep again lest they oversleep. An alarm clock will
sometimes remedy this state of affairs. Better still is an arrangement
by which someone, who can be depended on, will wake them at a
particular time. Occasionally patients cannot content themselves in
spite of the assurance that they will be waked. They dread that the
alarm clock may not go off, or that the awakener may make a mistake,
and so they go to bed with a dominant idea, which is more or less
constantly present in their mind during all their sleeping hours,
disturbing sleep and preventing complete rest. It may be necessary to
insist on a change of occupation for such persons, or a change of
residence that will do away with the necessity for early rising. When
this is done, many a neurotic condition that has before proved
intractable will disappear.


Amount of Sleep.--It is of cardinal importance to know how long
patients sleep. In our large cities most people have too little sleep.
A comparison of the hours when they get to bed with those when they
get up will often show that at least three or four nights in the week
some patients who are complaining of nervous symptoms, especially
nervous indigestion, are {166} sleeping less than seven hours. There
are but few men, and still fewer women, who will retain their health
under such conditions. Some men have been able to do it, but they are
comparatively rare. King Alfred's rule of dividing the day into three
eight-hour periods--one for sleep, one for work, and the third for
bodily necessities and recreation, still remains the best for human
nature. Whenever people try to live the strenuous life and get along
on less than eight hours of sleep, they are almost sure, sooner or
later, to render themselves uncomfortable, to make themselves liable
to all sorts of neurotic symptoms and, above all, to detract from
their efficiency for whatever work they are engaged in. Whether they
sleep or not, they should be in bed for nearly eight hours.


Bathing.--_Morning Bath_.--In our larger cities at least, many of the
inhabitants begin the day with a bath. In this matter one finds all
sorts of harmful fads that need to be corrected. Many men take a cold
bath, and unless they are particularly strong and vigorous, this is
rather an exhausting experience for the beginning of the day, when the
last nutrition the body absorbed is twelve hours before. On the other
hand, large, athletic men who manufacture a great deal of heat, their
muscles--the heat-making organs--being well developed, will be
benefited by having a cold bath because of the abstraction of heat
that it involves. It is not, however, infrequent to find that the man
for whom it will be good is not taking it, while the thin, neurotic
individual, already exhausting more of his vitality by worry and
dieting and in various fads with regard to his health than is good for
him, is regularly taking his cold plunge or douche. Unless especially
asked about it, few men give particulars in this matter, yet they are
extremely important.

Women, on the other hand, are likely to take hot baths more frequently
than is good for them. Especially when they have maids to assist in
dressing and undressing, it is not unusual to find that women take
two, and sometimes even three, hot baths in a day. They take them in
the early morning when they first get up, and in the evening before
dressing for dinner. I have known cases where some took a third hot
bath before going to bed and sometimes even put in a fourth before
luncheon in case they had had any exercise in the morning
hours--tennis, or horseback riding, or the like--that made them
perspire. These are details which the physician will learn only if he
asks particularly about them. Until he has actually had the experience
of finding that they play an important role in some ailment he is
almost sure not to think of it. It is probable that even two hot baths
a day are too many. I have known women to begin at once to get better
of neurotic symptoms that before had proved quite intractable, when
their hot baths were limited or when they were changed for a single
warm bath with a cold rub after it in the morning, or sometimes just
before dinner.

Bathing is more liable to abuse than is usually thought to be
possible. While the habits of modern life call for it often, and many
people are quite sure that they would not be healthy without it, the
people who live longest, and who have had the best health far beyond
three score years and ten, have usually not been noted for bathing
proclivities. The human body is composed of nearly seven-eighths
water, and so our cells are constantly bathed in it, but the making of
the whole organism a marine animal once more, as seems to be the
definite tendency of some people, is not nearly so hygienic as {167}
it is often thought to be. Enough bathing for thorough cleanliness,
but not for luxury, must be the rule for people who have active work
and want to retain their health.


_Bathing Fads_.--While such mistakes are usually made only by the
wealthy and leisure classes, the physician will sometimes be surprised
to find that women who have no maids for personal service are
indulging themselves in these over-frequent bathing practices. They
have heard that it softens the skin and renews youth, or they have
heard that the Japanese take hot baths and are revivified when they
are very fatigued, and so they go to great lengths in bathing. Often
this is the main reason for the relaxation of muscle tissue and the
sense of prostration that has come over them. Neurotic people are
constantly going to extremes. Even delicate women will sometimes be
found to take very cold baths which are surely doing them harm. Over
frequent washings of hands and face are sometimes responsible for skin
lesions, especially if the soap used is one of the varieties so
scented that the manufacturer is enabled to conceal the impurities in
its ingredients. Some women easily run into what is really a
misophobia, an exaggerated morbid fear of dirt, and need to be
restrained from washing themselves over frequently. Many a chapped
hand would be saved by avoiding unnecessary washings, and especially
in warm water just before one goes out, for it leaves the skin without
its proper oily protection.


Clothing.--Then comes the question of clothing. It is curious how
irrationally many people clothe themselves. People complain of cold
hands and feet when they are wearing thin cotton undergarments, and
who need only to have these changed for wool for their feelings to be
at once improved. In the meantime they have been persuaded that they
have a defective circulation. The usual excuse for not wearing wool is
that it produces hyperemia of the skin with itchy discomfort, but
this, as a rule, is only passing and is due to unaccustomedness. The
coarser wools should not be worn by the sensitive. A thin cotton
garment may, if absolutely necessary, be worn next the skin. There is
too little variety in the underclothing that people wear. Some change
from light to heavy weight and only that, but there should be a medium
weight worn, and occasionally, when there is a spell of mild weather
in the winter time, even during the season when heavy weight is
usually worn, medium weight should be substituted for comfort's sake.

It is even more common to find that neurotic individuals, who fear to
catch cold, wear too much clothing, especially around the chest. Very
often they alternate from this during the day to next to nothing in
the evening, and by so doing subject themselves to special risks of
internal congestions. When the skin is covered with too much clothing
it loses the habit of reacting, and the warmth and the irritation of
wool keep up an artificial hyperemia which gradually lowers the tone
of the peripheral vessels. Many people wear "chest protectors," as is
evident from the prominent display of these abominations in the
drug-store windows. By leaving certain portions of the chest
unprotected while other parts are kept over-warm, these add greatly to
the risk of such disturbances of circulatory equilibrium as predispose
to the infections grouped under the term "taking cold." It is not
heavy clothing that keeps people warm so much as the layers of
non-conducting air between the skin and the outer air. It is better,
therefore, to wear three thin {168} garments than two heavy ones
because of the additional layers of air that are thus confined. A
paper vest, if one is driving in the wind, will probably protect
better than the heaviest woolen garment worn. The wearing of chamois
garments is not, as a rule, advisable because chamois does not permit
free access of air and it hampers transpiration.


Before Breakfast.--After dressing comes breakfast, with regard to
which it may be advisable to ask many questions. It is well to begin
with a query as to whether liquids are taken before breakfast. Many
people have taken to the fad of drinking a large quantity of warm
water, sometimes as much as a pint, before breakfast. Surely this
never does any good and, in most cases, just as surely does harm.
Plain water will not dissolve mucus that may have collected in the
stomach, and warm water merely dilates that organ, relaxes its fibers,
and renders the whole gastric digestive system atonic. If cold water
can be borne, it will often be found that a glass of cold water the
first thing in the morning stimulates peristalsis, and serves to
lessen the necessity for laxatives. Many people complain that cold
water is too much of a shock. Usually, if they are reminded that when
we want to warm our hands we rub them vigorously with cold water and
that the reaction after this gives a healthy glow, the effect of the
supposed shock, which was merely an unfavorable suggestion, will
disappear. Sometimes delicate people cannot drink cold water. If there
is any reason to suspect an accumulation of mucus in the stomach, a
small bouillon cup of _very hot water_, just as hot as it can be
borne, in which a pinch of salt and a pinch of bi-carbonate of soda
have been dissolved will prove an excellent aperitive for the day.
This is physiological and appropriately chemical, as well as naturally
stimulating. Mucus does not dissolve in ordinary water but dissolves
readily in an alkaline salt solution, and this is just what is thus
recommended. This drink is quite grateful to the palate. Indeed, it
tastes very much like clear soup, and, if the eyes are closed, cannot,
as a rule, be distinguished from some of the bouillon commonly served.
I have known this cup of hot water to stimulate an appetite when drug
tonics had failed.

It is better to take the glass of cold water from fifteen to twenty
minutes before the morning meal--say immediately on rising. If,
instead, the small cup of hot water is chosen, it should come
immediately before eating, and will usually prove an appetizer.


Breakfast.--The exact details of the amount of breakfast taken and how
it is eaten should be known. Nervous people eat little breakfast. When
ordered to eat, they find it difficult at first, but the habit is
easily formed, and then they want their breakfast like anyone else. It
is surprising how often physicians will find that nervous persons, who
are under weight, are not taking enough breakfast. They will
ordinarily say that they are eating breakfast about as other people do
and will, perhaps, mention eggs and rolls, but it will be found that
their ordinary breakfast consists of a roll and piece of toast and
coffee, and only occasionally do they have any of the other things
mentioned.

Breakfast is ordinarily the meal which those who work are likely to
eat too hurriedly. Those who are neurotically inclined are especially
victims of the habit. They lie abed until there is only a few minutes
left to get the train so as to reach their place of occupation in
time, and thus their breakfast is {169} skimped. Their oatmeal or
other soft cereal is fairly shovelled in, coffee is gulped, toast is
unchewed, the coffee softening it; if they have creamed potatoes they
are swallowed in such large pieces that, as every physician knows, if
for some reason they vomit they are surprised, beyond all measure, at
the large portions they have been able to pass down into their
stomachs. A breakfast thus eaten makes a bad beginning for a nervous
man's day, and the more that is so eaten the worse for the victim.
With a habit like this, it will be utterly impossible by means of
drugs or directions as to diet to relieve the discomfort of neurotic
indigestion, or to keep the patient from suffering that stomach
discomfort so often complained of in the morning.


Working Women.--Working women are even more prone than are men to take
a hurried breakfast, and having, as a rule, less appetite than men,
their meal is likely to be deficient. It is not unusual to find that a
young woman who is under weight and who needs three meals a day, is
taking so little for the first meal that even she hesitates to regard
it as a meal. Very often her last previous meal has been taken before
seven o'clock the night before, so that she goes out ill prepared for
her day's work. Much more than men, women are annoyed in the morning
by our transportation systems, and by worry as to whether they will
get to the office on time. Suggestions as to the modification of this
unfortunate routine, the taking of an earlier train, the using of a
quiet local instead of a crowded express, a short walk at least before
taking the train, will often help in producing a marked change in the
general health.


Home Keeping Women.--For those who really have homes, the morning
duties are usually sufficient to rouse their activities and make them
begin the day well. For those who live in apartment-hotels, however,
and for those who have the luxury of many servants, the morning hours
are often a serious problem. Madame does not get up, or if she does,
it is only to lie around in dressing gown for most of the morning.
Breakfast is easily neglected or may be eaten hurriedly because the
head of the house is rushing to business. The lack of an incentive
requiring them to rise, and get outside for a time every morning, is
probably at the root of more feminine symptoms among leisure class
patients than anything else. As we grow older all of us are likely to
note the lowered physiological cycle of the morning hours, so that
unless there is some sharp reason to compel action, we are rather
prone to persuade ourselves that it is better to lie abed, or at least
to loll around. This leads to a concentration of attention on self and
on one's feelings that easily gives rise to neurotic conditions.


Interest in life.--In my special clientéle I have often found that
going to church in the early morning hours was an excellent remedy for
many of these patients. It gives them a definite reason for rising
promptly, the service provides motives to rouse them to activity, they
are likely to think during it of how they shall make their life a
little bit more livable for others as the result of their trying to be
better, and so the apathy that is so fruitful of ill feeling is shaken
off. This can only serve for those who have faith in the service. For
others, the old-fashioned going out to market, or the making of
appointments at morning hours that will tempt them to regular activity
early in the day, is of special significance. It is always ominous for
health when a woman can look forward to a whole long day without any
particular duties {170} in it until the late afternoon or evening
hours. This has become so frequently the case for the women of our
large cities, particularly those who live in apartment hotels, it is
no wonder that neuroses and psychoneuroses of various kinds have grown
in frequency. The best prophylaxis for them is occupation of mind. The
cure for them is the securing of many interests and such diversion of
mind as will prevent concentration of attention on self.


Mail Before Breakfast.--Many people receive their most important mail
in the early morning, and personal mail, in cities especially, is
likely to be placed beside the breakfast plate. Not infrequently,
letters contain serious matters that are likely to disturb people, and
occasionally even important business finds its way to the side of the
plate at breakfast time. Authors often find their rejected manuscripts
sent back in the morning's mail. Occasionally bad news of other kinds
comes in this way, and, as a rule, it is the very worst time for its
reception. The human system--it cannot be too often repeated--is at
its lowest physiological term in the morning, the temperature is lower
than during the rest of the day, all the nervous vitality is below the
normal. Half an hour after breakfast the reception of bad news, or the
coming of important matters requiring decision, would not make so much
difference. Hence, the necessity for knowing whether the mail is
ordinarily read in the early morning, in order to know something about
people, and about the consumption and digestion of their breakfast.


Company at Breakfast.--Pleasant company during meals is an important
factor that makes for good digestion. At the other meals there is much
more likelihood of having such pleasant company, while the morning
meal is often a solitary, and quite as often as not, a rather glum
quarter of an hour, preoccupied with the business cares of the day. As
may be readily understood from our discussion of this problem of
mental preoccupation during digestion, this may seriously hamper
digestive processes. Often men take refuge in their paper. The
thoughts aroused by reading the modern newspaper are not the
pleasantest in the world and consist, very often, of the following out
of details of hideous crimes and scandals. When, as is sometimes the
case, these scandals concern relatives, friends or acquaintances in
whom we are interested, and with regard to whom we feel poignantly
because of the publicity involved, nearly the same effect is produced
as when bad news is received in letters, or when business worries are
thus brought to the breakfast table.

The best conditions for the eating of breakfast are those in which it
becomes like the other meals, a family matter. When father, mother and
children eat their breakfast together, nearly always family interests
and especially the enlivening effect of the joyousness with which
children face a new day is the best possible tonic for a business man
in whom a solitary breakfast starts a day of digestive disturbance.
Sociability and sufficient time must be insisted on, whether at home
or in a boarding house, at breakfast as well as the other meals, and
it will often be surprising to find how much difference this makes
both as regards the quantity eaten and the digestion of the food.


Morbid Habits.--In matters of diet, it is important to ask for
details, for it is surprising what unexpected things may be discovered
after weeks of treatment. That was illustrated for me once by a case
of persistent acne in a young girl, which all the ordinary remedies
failed to cure. I felt sure that {171} I had given her such explicit
directions with regard to diet that I knew exactly what she was taking
and that nothing could be hoped for from any change. As a last resort,
I asked once more with regard to all that she ate and only then
discovered that before breakfast every day she ate a baked banana. It
had been recommended to her by a friend as a sure cure for
constipation, she had formed the habit of taking it as a medicine, and
so had not spoken of it. Baked bananas agree with many people well,
but just as soon as this was eliminated from her diet her acne began
to improve and before long had disappeared almost entirely. The taking
of large amounts of warm water, already spoken of, is another of these
morbid habits. Then many people take a glass of salt water, or
laxative water, and some have curious habits with regard to the eating
to excess of salt on cereal or on fruit, or sometimes they eat too
great a variety of fruit. All this should be known, but often will not
be ascertained unless particularly inquired about.



CHAPTER III

THE DAY'S WORK

Probably even more important than details with regard to the early
hours of the day, is detailed information as to the day's work, the
kind and character of the occupation and the length of time spent at
it, the interruptions that may occur, the habits with regard to
luncheon, and, above all, the state of mind in which the occupation is
pursued. The physician will only learn these details when he sets
before himself a definite schedule of what he wants to know, and then
proceeds to secure information with regard to it. With this sufficient
can be learned in a short time to ascertain the source of the
affection or the symptoms complained of. In some cases it is, however,
only when the whole day's occupation is reviewed that proper
suggestions can be made.


Getting to Work.--Many a man, especially if he has been accustomed to
much exercise in younger years, craves muscular exercise, feels much
better whenever he has the opportunity to take it, yet rides down to
business every morning and back every evening. On his vacation in the
summer time, he gets up early for the sake of a morning walk, but he
scarcely has time to take his breakfast and ride to business at other
times, though the main reason for his better feeling during his
vacation is his exercise. There is usually the story of crowded cars
in the busy hours, often with annoying thoughts pestering him that he
may not be in time and with a constant call on nervous energy while he
stands up in the train, jolted, pushed, crowded, or unable to read his
paper with satisfaction, even if he has a seat. The discomfort
experienced during a ride in crowded cars to business is about as bad
a way to begin a day for a nervous person as could be imagined.

As a rule, it will take more than half an hour to get to business in
this way. If an extra twenty minutes were taken, it would be possible
to walk the distance. On at least two out of every three days in the
year this would give a magnificent opportunity for exercise of the
best kind, for fresh air, {172} for diversion of mind, for the route
could be frequently changed, and, during the spring and fall, if there
are parks on the way, these would provide occasion for pleasant
thoughts to replace the annoyances which too intimate contact with
over-strenuous humanity in overcrowded cars is likely to occasion.

This seems almost too trivial for a doctor to talk about, but it is on
the care of trivialities that good health often depends. It is easy to
assume that this amounts to little for health but tempt a dissatisfied
patient, whose digestion and sleep are disturbed, to do it, especially
in the spring and in the fall, and see what a difference it makes in
all his physical functions. If he is not used to walking, he will have
to begin by walking only a mile or two, but after a time he will do
his four-mile walk in about an hour, with no waste of business time,
and with a renewal of energy that will seem little short of marvelous.


Details of the Day's Work.--If patients are to be benefited through
mental influence it is extremely important that details as to
occupation be completely secured. This must include, especially in
cases where there are objective but obscure symptoms, minute
information that may seem trivial, and yet which often proves to be of
great importance. In recent years there has been profound study of the
dangers of trades and occupations. Anyone who wants to treat nervous
patients, must know much about these occupations, for otherwise
symptoms may be ascribed to old infections, to obscure rheumatic
conditions, to intestinal auto-intoxication, or to nervous weakness or
exhaustion, when they are really the result of occupation-conditions.
The various poisons must be carefully looked for, or affections will
be wrongly treated. I have had a series of cases of lead poisoning
[Footnote 22] under most unexpected conditions which have taught me
much as to the possibilities of obscure plumbism. Lead poisoning from
new lead pipes--with no one else in the household suffering from it,
lead poisoning from frequent drinking of carbonated waters, the
bottles of which had the old-fashioned lead stoppers, lead poisoning
from the painting of a flat by a settlement worker who could not get a
painter to do it, show how carefully such things must be looked for.

  [Footnote 22: "Curiosities of Lead Poisoning,"
  _International Clinics_, Eighth Series, Vol. II.]


_Dust and Respiratory Affections_.--Mechanical conditions connected
with trades are especially important. Workers in dusty trades are
almost sure to suffer severely from bronchitis at times, and to have
the affection oftener than others, to have it "hang on longer," as
they say, and eventually to have tuberculosis develop. There are some
of the polishing trades in the metal industries in which it is
impossible to maintain the ordinary death benefit fund that workmen
have in other trades, because the men die so frequently and at such an
early age from consumption that the drain on the treasury makes it
impossible to maintain the fund. Practically all of the dusty
occupations have this same tendency. This is true often in occupations
where dust is sometimes not supposed to be much of a factor. Railroad
trainmen suffer more frequently from colds than do those in other
trades because of the dust to which they are exposed, and a trainman
with incipient consumption will be greatly benefited by getting out of
the dust during the summer months. Sweepers in large buildings,
janitors and janitresses have colds that are often untractable because
of the dust in their occupations. It is to be hoped that {173} the new
vacuum cleaning system now becoming so popular will obviate these
dangers, though like all improvements, it will probably bring its own
dangers with it.


_Lack of Light_.--People who work at occupations that keep them from
the light are likely to suffer from lung symptoms and to have quite
intractable colds which will not clear up until they get more
sunlight. Workers in theaters and like places who do their sweeping
where sunlight does not penetrate, are in more danger than others from
respiratory disease. Those who work in gloomy lower stories,
especially in narrow but busy and dusty streets, suffer the same way.
Attendants at moving picture shows who work much in the dark where the
frequently changing crowd brings in dust which cannot be well removed,
and in quarters where the sun does not penetrate, are almost sure to
have persistent repeated respiratory troubles.


_Habitual Movements_.--After the question of dust comes the mode of
the occupation. Many occupations demand certain habitual and repeated
movements. When people come complaining of pains in muscles in and
around joints, or of achy conditions in the limbs, it is important to
know every detail of their occupation movements, if the physician is
to appreciate just what pathological causes are at work. It is not
enough, for instance, to know that a man is a clerk, or a bookkeeper,
but it should be asked whether he stands much at his occupation, or
walks considerably, or whether he sits practically all the day. If he
stands much, we can expect that he will have various painful
conditions in his feet and legs, unless he takes care to change his
position frequently, to wear the most comfortable shoes obtainable
and, above all, to provide against any yielding of the arch of the
foot. Often it will be found that people who complain of discomfort in
the feet stand much on a cold, and sometimes damp and draughty floor,
and this needs to be corrected or their symptoms, often carelessly
called rheumatic, will not disappear. If he sits down always during
his occupation, he will need exercise and air or he will suffer from
many vague discomforts, over sensitiveness and irritability of nerves,
as well as from physical conditions.

Most patients prefer to think that they are suffering from some
constitutional condition, rather than from a merely local
manifestation due to their occupations. Those who have to stand much
can often make such arrangements as will permit their sitting down
from time to time. They may, if they are standing at a desk, have a
high stool; they may during their hour of lunch sit down restfully, or
even to recline for a time, so as to restore the circulation in the
legs. For many people who suffer from the achy discomfort connected
with varicose veins in the leg, a rest of half an hour in the middle
of the day with the feet a little higher than the head, will do more
than anything else to make them comfortable. This same thing is true
for people with flat-foot, and there are many occupations with regard
to which advice of this kind will be appreciated. The well known
tendency of many men to sit with their feet higher than their head is
not a mere caprice, but is due to the fact that this is an extremely
restful posture and thoroughly hygienic for those who have been
standing much.

Unfortunately, it is not so easy to secure such relief for working
women, but occasionally the advice to lie down during the middle of
the day on the couches of the retiring rooms may be the best medical
prescription that can {174} be given. This will carry young women over
trying periods of the month when everything seems to be going wrong.
In women particularly, if there are complaints of the pains in the
lower limbs, footwear must be investigated. When the heels are too
high those who have to stand much are thrown forward and there is a
strain of the muscles of the thighs and on the muscles of the back.
Many young women suffer from backache supposed to be due to internal
conditions usually of gynecological character, when it is only due to
high heels or a combination of high heels and constipation. On the
other hand, heels that are too low are not comfortable and women's
shoes, in spite of the outcry against them, have been better adapted
than men's to prevent them from developing flat foot. Fewer women than
men suffer from this affection. Shoes that are too loose are almost as
bad, sometimes it would seem worse, than those that are too tight.


_Habitual Motions and So-Called Rheumatism_.--The habitual movements
of various trades are extremely important for the diagnosis of
conditions that develop in the muscular system. Much of the so-called
rheumatism of the working people is really due to the muscular
over-activity demanded by their trades. This affects all kinds of
working people. Men who have to work foot-lathes, or women who have to
work sewing machines, or men or women who have to use their arms much
in repeated vigorous movements, are likely to suffer from achy
discomfort. The strong and healthy ones do not suffer, but the
delicate do. The suffering is much more prevalent in rainy, damp
weather; it is worse during the spring and fall than at other times.
It is particularly noticeable whenever the patient is run down
physically, is worrying about many things, or, above all, is getting
insufficient nutrition. The discomfort is particularly likely to recur
in those who do not know how to use their muscles properly, who are
naturally awkward, and who perhaps have from nature an insufficient
control over opposing and coödinating muscles, so that they do not
accomplish movements quite as readily as would be the case if they
were normal. The personal element enters largely into these
affections. Many patients, however, can be trained to do their
habitual movements under the best possible mechanical conditions,
whereas very often they are found accomplishing them under the worst
possible mechanical conditions.

Men who have to do much writing may have to be taught the application
of Gowers' rule, that the forearm should so move as a whole during
writing that if a pen were fastened to the elbow it would execute
exactly all the movements of a pen held in the hand. The writing must
all be done from the shoulder. People who do typewriting may have to
be instructed not to allow the machine to be too much above them, nor
on the other hand, too much below them when they sit down. Young
people particularly who, from long hours of practice on the piano,
suffer from neurotic conditions, may have to be instructed to do this
under good mechanical conditions.

Men who do much filing of metal will often suffer from painful
conditions in the arms. These will be much worse in case the filing is
done at a table or workbench so high that pressure has to be brought
to bear upon the file by the arms instead of through the weight of the
body. This same thing is true for women who iron much. If the ironing
board is so high that the additional pressure applied is made by the
arms, then painful conditions will {175} almost inevitably develop if
the work is long continued. These details are discussed in the
chapters on joint and muscular affections.


Night Work.--In a large city there are many workmen who are on night
duty. They will be disturbed in many ways in health, unless they make
special arrangements to live under conditions that enable them to have
full eight hours of sleep every day and, above all, to have their
meals regularly. When they come home in the morning they usually have
a rather hearty meal. Most of them can sleep very well with this, but
very few of them sleep the full eight hours, and all need this amount.
Usually they have another full meal about five in the evening. Very
often it will be found that the third meal of the day consists of a
sandwich, with a glass of milk or a glass of beer, and some cake or
some crackers and cheese, or the inevitable pie. Every workman should
have three full meals, and a man who is suffering from almost any
symptoms will be improved at once if the third good meal is insisted
upon. At one time I had occasion to see a number of men whose work
began not later than seven in the evening and did not finish until six
or seven in the morning. They were sufferers from all sorts of
complaints. Most of them were under weight. Not a few were
constipated. Some were suffering from severe headaches that came
rather frequently, and a few from a headache that was severe but came
only every two or four weeks. These patients alternated night and day
work, and it was the week after they had been on day work, and first
went on to night work, that they suffered from headache.

In every one of these cases instructions with regard to eating and
sleeping proved to be the best remedy. Nearly all of them were not
eating enough, and were skimping the third meal. Three of them were
taking only between four and five hours of sleep. They stayed up after
breakfast to read the paper, went to bed about nine and got up about
two o'clock. Just as soon as two or three hours was added to their
sleep, they began to feel better, and various symptoms, digestive,
rheumatic and nervous, of which they complained, began to disappear.

Nearly always night workers are more prone than the ordinary run of
workmen to some indulgence in spirituous liquors. Cold and shivery on
the way home from work in the early morning, they take a nip of
whiskey to brace them up. Alcoholic cirrhosis of the liver is a little
more common among sea captains, policemen, printers and night workmen
on the railroads than among the average of the population. The reason
for it seems to be that undilute whiskey is thrown into the
circulation by being taken into the stomach at a time when that viscus
is empty and all the cells are craving food and drink. It is carried
directly to the liver, and there either produces or predisposes to the
bad effects upon liver cells which we know as cirrhosis.

It is usually useless to treat such men for the indigestion and other
symptoms that are likely to develop as a consequence of their habits,
without getting at their story completely. It is easy, as a rule, to
relieve them of certain of their symptoms by ordinary drug
therapeutics. Unless their habits are changed, this relief, however,
is only temporary. It must not be forgotten that in recent years women
have come to do a good deal of work at night that was not usual to
them before. In the telephone service of certain cities, as cashiers
in restaurants, as ticket sellers in various places of entertainment,
{176} as office help at busy seasons of the year, women may be kept
occupied either all night or at least until quite late. Not
infrequently during times when rehearsals are on, chorus girls are
kept until the wee small hours. They are particularly likely to suffer
from such variations in normal habits, and no treatment is so
effective with them as pointing out how they must live, if they want
to preserve their appearance and continue in such exacting
occupations. A healthy young woman can burn the candle of life at both
ends with less protest from nature at the beginning than man, but she
suffers more for it and the suffering begins sooner.


Positions During Occupations.--The question of position during
occupation, especially as regards its influence upon digestive
processes, has always seemed to me much more important than most
people think. Our idea of digestion has been so largely one of
digestive secretions, to the neglect of the motor side of the gastric
and intestinal functions, that we have missed some important points.
If a person leans over a desk shortly after a meal, there is no doubt
that the crowding of the abdominal viscera hinders peristalsis, at
least to some degree, not of course in the robust and healthy, but in
those who already have some irregularity or sluggishness in this
region. The old high desks at which many clerks used to stand, at
which even proprietors did not hesitate to take their position, had a
reason in common sense that has been forgotten in the modern times,
and the variation of position thus permitted seems to have been good
for the workers.

A good deal of comfort may be obtained by having a suitable desk and
chair for business hours. Not infrequently it happens that a desk is
too high for comfortable writing. Any discomfort that is continuous
and makes itself felt intrusively during occupation with other things,
will have an unfortunate effect. Such things seem trivial by contrast
with serious disease and may seem safely negligible. Trivial they are,
but little things count both in themselves and as to the attitude of
mind which they occasion. It is the attitude of mind that we try to
modify by psychotherapy, and even the removal of little sources of
annoyance help a patient materially to get through life more happily
and through work more efficiently and without any more discomfort than
is absolutely unavoidable.


_Positions After Meals_.--While we have talked thus of business
people, what is said refers, also, to the positions assumed out of
business hours, as, for instance, at home after dinner. A Morris chair
that permits of a somewhat reclining position, or a rocking chair that
temps one to sit back, pretty well distending the abdomen and giving
all due play to the internal viscera, will be found not only much more
comfortable than a straight-back chair which tempts a man to lean
forward, but also there will be less interference with gastric
motility, the most important digestive function of the stomach.
Arm-chairs which really support the arms, and therefore tend to keep
the shoulders up, have something of the same effect. We naturally
assume these positions, though occasionally social usage forbids them.
The tendency, for instance, for elbows to be put on the table,
especially toward the end of a meal, represents a natural instinct to
lift up the shoulders and keep the weight of the upper part of the
trunk off the abdominal organs. Children's instincts often curiously
guide their postures--as is illustrated by the story of the little boy
who, when asked by his grandmother if he could manage {177} another
tart, said that he thought he could if he stood up. (See chapter on
Position.)


Mental Conditions of Occupations.--While the details of manual
occupations have to be learned with great care if we are to modify the
conditions so as to prevent certain unfortunate effects, just as much
care has to be exercised, with those not employed manually, in finding
out details as to mental worries, and the various disturbances
consequent upon business conditions. Many a man has not brain enough
to run his business and his liver. This is the old English expression,
and the liver, as the largest of the abdominal organs, is taken for
the physical life generally. Many people have not vital energy enough
to waste any of it on worries and then be able to complete their
digestion and other physiological functions with success. The
preceding mental condition is a predisposing cause of many a purely
physical ailment. It used to be said that during a cabinet crisis in
England, or rather just after it was over, attacks of gout were most
frequent among prominent politicians. Mental influence usually kept
the attacks off until the very end of the crisis. Merchants come down
with pneumonia or digestive disturbances more frequently during
periods of acute business depression. Physicians are attacked by
pneumonia, or influenza in bad form, after they have been wearing
themselves out in an epidemic and worrying about patients. Just after
a mother has nursed a child through a severe ailment she herself is
prone to suffer from some acute infection. Such common-place
infections as boils, styes, abscesses and even the more serious
osteomyelitis are likely to come at these times.

It is important, then, to know as much as possible about a business
man's affairs. Any one who has had a series of tuberculous patients
(who were getting along quite well in spite of latent or even active
lesions) disturbed by anxieties of one kind or another, knows how much
worries may mean. Men will lose weight and appetite and weaken in
their general condition as a consequence of some serious business
incident, while all the time physical conditions are the same as they
were when they were improving. And it must not be forgotten that even
in those who do no physical labor, there may be physical conditions of
their occupation that are important. Many a business man does his work
cooped up in a small office, with insufficient ventilation, and
sometimes, especially where his business is on the ground floor of a
large building, with so little sunlight that his environment is quite
unhygienic. The great air purifier is sunlight. Unless sunlight is
admitted for hours every day to the rooms in which people live, the
dust that is inevitably breathed will contain living germs, active and
noxious, though had they been exposed to sunlight these germs would be
harmless.

Especially then for people with respiratory defects of any kind,
whether these be tuberculous or of chronic bronchitic character, the
conditions surrounding the occupation should be carefully inquired
into. Once the family physician knew such things as a matter of
course. Now he is likely to know very little. The lack of such
information may not be important for the more serious conditions that
he has to treat at patients' homes, but they usually mean much for the
submorbid conditions, so to say, the discomforts and chronic
conditions, which come for office treatment. They mean much for
comfort in life, and for the conservation of health and strength. They
{178} represent that newer medicine which people are asking of us now
so much more than before, which shall keep them in good health and
prevent them, as much as possible, from suffering even from minor
ills.


Business Habits.--The modern idea of having a flat-top business desk,
instead of a roll-top desk, and having it thoroughly cleared off every
evening, so that each day's work does not accumulate, is an important
psychic factor in the strenuous life, which in recent years many
corporations have been taking advantage of. It is well for those who
are their own masters to realize the value of this principle. Nothing
so disturbs the efficiency of work, nor adds so much to the incubus
that work may become, as having a number of unfinished things which
keep intruding themselves. It is not always possible to dispose of
problems, but discipline is necessary to keep us from pushing business
matters aside. Then they have to be done in a rush, very often at a
moment when other things are also pressing. The result is poor work,
but, above all, a waste of nerve force and energy that leads up to
nervous symptoms and eventually nervous exhaustion. The orderly man,
who has learned to settle things as they come up, or at definite
times, can accomplish an immense amount of work. Some men are born
orderly, but any one who wants to do much work must have order grafted
on his makeup--a habit which can be made a second nature. It may seem
that a physician is unwarranted in intruding on a man's business
affairs thus to inquire about the ways he does things, but this is the
difference between psychotherapy and the regulation of life as
compared with cures by more material but less effective means.


Personal Hygiene.--Expert Advice.--For many men who are much occupied
with business, the best possible safeguard for health, as well as the
best guarantee against nervous or physical breakdown, would be a
detailed consultation once a year with a physician regarding their
habits of life and their business in relation to their health, present
and future. In recent years many a business firm has found it not only
expedient but profitable to turn to an expert accountant or auditing
company and ask advice with regard to the management of its business.
It is often found that certain business customs are causing serious
drains, and that there are newer ways of doing things that save time
and money. Sometimes a reorganization of the accounting system, or of
the method of dealing with credits and debits, or the receiving or
shipping department, proves advantageous to the business. Sometimes it
is found that the capital invested will not justify the extension of
business that is proposed, and not infrequently it is shown that a
proposed extension adds to business movement but does not add to
profits. Sometimes there are departments that can be dropped to
advantage, though they seem to be adding to both business and profit.

All of this may well be transferred to the question of health in its
relation to business. Not infrequently it is found that the capital of
strength of the business man is not sufficient to justify the
extension that he is planning or has already attempted. Sometimes
suggestions can be made with regard to the mode of doing business, the
hours employed and the hours of relaxation, that will make business
less of a drain on the system. Occasionally arrangements for sleep and
exercise, as well as for afternoons or special times of diversion, may
save a man from that concentration of attention on one thing {179}
which frequently leads to nervous breakdown. Not infrequently business
men who are of neurotic habit have customs of doing business which add
to their nervous irritability, and these might be modified so as to
lessen the call on nervous energy. There is need that the physician be
looked to as an expert in personal health and its relation to
business, just as the expert accountant or auditing firm is looked to
for advice with regard to business methods.



CHAPTER IV

THE MIDDLE OP THE DAY

Information regarding the mid-day meal will be of value to the
physician in many cases. In cities, luncheon, likely to be rather an
apology for a meal, is taken rapidly, and immediately there is a
return to work. As a medical student in Vienna, I was much interested
in the mid-day meal of the bankers and merchants of the old Austrian
capital. At that time--I hope they have not changed the good custom
since--the banks closed at 12 o'clock and did not open again until 3
o'clock. This gave time for taking the mid-day meal in comfort, and
for a proper interval for digestion. In all the southern countries of
Europe, for seven or eight months in the year at least, little is done
during the two or three hours in the middle of the day. The people get
up earlier and rest at mid-day as a break between the afternoon and
morning. It is quite beyond expectation that anything like this will
ever again be possible in the great commercial cities. The fact that
this was the custom of our European forefathers, however, shows how
business has obtruded itself on the habits that man would naturally
form for himself. Business men hurry to luncheon, or if they take any
time over it, it is because they have invited some one to lunch with
them with whom they wish to talk over important matters. This means of
saving time recalls the well-known expression of James Jeffrey Roche:
"Time is money. Every second saved from your dinner now is a sequin in
your doctor's pocket later on in life!"


Hurried Lunch.--The seeds of our frequent American dyspepsia are sown
partly at the hurried breakfast and then at the hurried mid-day lunch.
When a physician finds this to be the case, then the patient's habits
must be reformed. Otherwise there is little prospect of relief from
neurotic digestive symptoms, or from those uncomfortable feelings so
often supposed to refer to the heart, or other important organ, when
digestion is interfered with. There should be pleasant company at
luncheon if possible; it should be preceded by fifteen or twenty
minutes in the open air, with, as far as possible, complete seclusion
from business thoughts so as to allow the stomach to secure its share
of blood, and it should be followed by at least half an hour of
pleasant occupation that does not call for serious mental work. This
may not be possible for every one, and many will complain that this is
asking too much in our busy time. We physicians are not here to make
the nice customs of medicine courtesy to great kings of finance or to
the busy tyrants of the professions, but to tell them what we think
should be {180} done in order that nature may not be abused. Men
should be advised to take their luncheon in some building different
from that in which their offices are located, or, if they eat in the
same building, to go out on the street for a while before the meal. In
the old days men used to call on one another in order to transact
business, and these little trips were often made just before or after
luncheons.

Now the telephone and the messenger boy have done away with this, with
a great saving of time, but with an increase of intensity of labor
that makes for nervous exhaustion. Luncheon clubs are excellent things
when men do not talk shop, but they have one fatal defect. Almost
invariably they lack simplicity of menu, and, because of the variety
supplied and the example of others, there is a tendency to eat to
excess. A game of billiards after eating is often excellent, because,
when standing, digestion is accomplished with more comfort than when
seated. A walk after the lighter midday meal is a good thing, though
the old saw said "after dinner sit a while," but that was in reference
to the largest meal of the day, and may still hold good for the
evening meal, which is likely to be the heaviest one.


Women's Lunch.--Women are very likely to take their mid-day meal, when
it is their luncheon, very irregularly. If they have to get it for
themselves they are likely to be satisfied with almost anything. If
they get it outside the house they are likely to take it rather late,
so that if they have breakfast before eight o'clock, this putting off
of the next meal causes some disturbance of the economy. When the
stomach gets to be empty, either there is a tendency to swallow air,
or there is a rumbling sense of fullness that disturbs the appetite,
or the appetite itself is capricious, and a headache develops. How
many headaches are due to missed meals it would be hard to say, but
this is one of the most fruitful causes of the ordinary passing
headache. Delicate women, and especially those who work, are likely
not to eat enough luncheon. All the details with regard to this meal
must be known or the physician will find it hard to get rid of many
neurotic symptoms, particularly in working women. The same thing is
true for the so-called society woman, since she is likely to have a
late breakfast and then skip her mid-day meal. This is permissible if
she is so stout as to be able to spare it, but it is all wrong if she
is thin and needs every ounce of weight.


Nature of the Noon Meal.--During the last two generations fashion,
custom and the increasing demands of business have pushed the hour of
taking the principal meal farther and farther away from mid-day. There
are, however, cases in which it seems better that the principal meal
should be taken in accordance with the old custom, about noon time.
For tuberculous patients this is especially important. They often have
fever in the afternoon that seriously disturbs appetite. They may eat
with comfort and relish a couple of hours before the fever is due. For
delicate persons, especially those who have not much appetite for
breakfast and who can not be persuaded to eat a sufficient amount
early in the morning, a hearty meal at noon is almost a necessity.
They should be shown how low their nutrition is during working hours.
Their principal meal of the day before was taken between six and seven
o'clock. They have had a light breakfast, a meager lunch, and
naturally have little reserve force during the afternoon hours. As a
consequence they become overtired, this lessens the appetite, they do
not eat properly, and, {181} above all, they do not digest as well as
they would if their last good meal were not so far away. They are
suffering from inanition, and, as is well known, starving people
cannot be allowed to eat heartily, because their stomachs have not
enough vitality to digest well.

It is often difficult to change the hour of taking the principal meal,
but in special cases this can be done with decided advantage. I have
seen such a change make all the difference between slow recuperation
from bad colds, and have seen it of the greatest possible importance
in tuberculosis. The very changing of the hour will sometimes
suggestively react to make the patient eat more heartily than usual,
the day is broken up better, the reaction against the morning
discouragement comes earlier, and the patient's general condition
improves. Many people rest better at night if their principal meal is
taken at the middle of the day.



CHAPTER V

THE LEISURE HOURS.

Then comes the return from business. Here once more the ordinary
method of getting on a crowded train, standing up to be pushed and
jammed, to have all sorts of unpleasant things happen, to have the
pessimism of one's nature stirred to its depths by the utter disregard
for women, the heedless rush of men, the roughness of railroad
employees, and the general lack of humanity that characterizes the
evening rush from business in a large city, is eminently unsuitable as
a preparation for dinner; while a calm walk of three to five miles is
ideal. To walk home will probably take twenty minutes or half an hour
longer, but not more than this--and it avoids the undesirable features
of the usual method.


Gymnastics.--Occasionally one finds that men rush through the last
hour of business in order to spend an hour in a gymnasium. Often this
is quite undesirable. Exercise within doors, taken in a routine manner
and merely for the sake of exercise, with no diversion of mind, is
eminently unsuitable for the busy man. What he needs is air much more
than exercise. Walking out of doors is the very best thing for him. If
he walks at a rapid pace, swinging his arms a little freely and
carrying a cane in one hand and perhaps a book in the other, because
this exercises his fingers and keeps him from having any unpleasant
congestion of the hands when they hang down, then the exercise is
almost ideal. Owing to the novelty of it, and the interest that a new
occupation arouses, great benefit will at first be derived from the
gymnasium. Very often, too, the cold plunge after the exercise does
more good than the exercise itself. The plunge is real fun, especially
when taken with many others, but the exercise itself is likely to
degenerate into the sorriest kind of a task. If the man who walks home
will take a bath before dinner, the temperature of the water being
made suitable to him and the reaction that comes to his particular
nature, there is no need of anything else, and there is nothing better
that he could do. The walk must be varied. The course must not always
be through the same streets. Occasionally it {182} should even lead
one to see some monument or new building, or to go out of the way with
a friend, so that variety is introduced.


Work at Home.--There are men who in busy times take some of their work
home with them. This is a mistake. And though it is the custom to tell
the doctor that they cannot do otherwise, it is practically always a
bit of self-deception. When the case is properly put before them, they
realize, if they already have any neurotic symptoms, that to continue
home work will be a serious risk. Most men who carry business home
with them, easily get into the habit of pushing certain details away
from them during the day with the idea that they will have more time
for that in the evening. They do a certain amount of dawdling over
their work. If they really resolved to finish work during business
hours they could do it, and do it better than during the evening at
home. Six hours of work is about all that a man ought to do with his
intellect at high pressure. This should be pretty well divided into
two periods of three hours each, with an interval of an hour to an
hour and a half between. The nearer a man can come to this arrangement
the better for him, and the better, also, for his affairs. If he has
assumed obligations that require more of his time and attention than
this, he is trying to do too much.


After-Dinner Hours.--The evening hours and their proper occupation are
important for the business man, or for anyone who is much occupied
during the day. The temptation to let the work of the day run over
into the evening must be overcome at all costs, or it will prove
serious for the health of most men. It is important as far as possible
to get something completely different for men to do at night. Many men
settle down to the reading of a newspaper or of a magazine or novel.
While this does very well under some circumstances, reading does not
provide diversion whenever there is serious worry or solicitude over
business matters. A man may think that he is occupying himself with
the newspaper, but we all know very well that business cares intrude,
that business troubles are often doubled by reading about others. The
reading of novels does well for a while, but the serious-minded man
tires of them and then, while they may occupy a couple of hours, they
have exactly the same objection as the newspaper. A genuine diversion
should give the physical basis of mind an opportunity literally to
remake itself by storing up new energies.


_Amusements_.--The fact of the matter is that a man must have, if
possible, some other serious interest in life besides his business. He
must have a hobby. We have discussed this in the chapter on Diversion
of Mind and refer to it here only to indicate the importance of
knowing something about a man's recreation as well as his work. It is
not a casual occupation but a real interest that he should have. This
need not necessarily be a useful employment and, indeed, it may be
absolutely useless provided it is absorbing. Card playing is an
excellent diversion for many people. When joined with gambling, new
worries and feverish excitement usually make it harmful for neurotic
persons. Chess is hard work, but of a different kind from that of the
day and, therefore, often makes an excellent recreation. Any games are
good. Bowling, for instance, is excellent, and billiards, if a man has
an interest in it, is a fine sport for evening hours. It has the added
advantage of physical exercise. A man does not sit down during
billiards, crowding his {183} already well-distended abdominal
viscera, but walks around and gives his viscera a better chance for
their work and aids rather than retards peristalsis.


_Encroachment on Sleep_.--There is just one defect about some of the
more absorbing recreations--they keep a man up too late. Whenever a
so-called recreation takes up such time that a man has less than eight
full hours in bed, then a mistake, almost sure to be serious sooner or
later, is being made. When the physician tries to limit a man's
recreation by suggesting an earlier hour for retirement, he may be
told that his patient must have some time for diversion and
recreation. But the physician must insist that no form of recreation
is as good as sleep, and any other form must be limited in order that
sleep may be obtained. A man may easily regulate his affairs so that
he shall have eight hours of sleep, and it is only negligence of such
regulation that gives him the idea that recreation cannot be obtained
except after eleven o'clock at night. Little suppers after the theater
are often fine diversions, but whenever they interfere with sleep they
must not be allowed except at long intervals. Other diversions that
keep a man out of bed after midnight are sure not to do good in the
long run, though an occasional lapse in this matter may prove a
stimulant rather than a depressant. It is custom that must be
regulated; an occasional variant from it is rather good than
otherwise.


Leisure of the Working Woman.--A woman's occupation, unlike a man's,
holds out little future for her. Her occupation does not arouse her
ambition. Daily work is a monotonous grind that must be endured for
the sake of the wages that it brings. For a time this serves to occupy
attention. After some years, when the prospects of matrimony grow
less, and further advance is out of the question, women often need to
have some special interest that will grip them. The working woman may
then need to be tempted to some occupation of mind, especially with
the companionship of others, that will give her renewed interests in
life. Clubs, charities in which they are active, friends, serious
intellectual interests, must all be appealed to, in different cases,
in order to secure diversion. Women must have something to look
forward to each week. They must know on Monday that before the
following Sunday there is going to be a theater party, a lecture, a
visit to friends, something to break the deadliness of weekly routine,
which is anticipated with pleasure and then pleasantly remembered.
This may seem to be only a slight matter, but it is of importance in
many cases.


Feminine Occupations.--The occupations of women who stay at home are
even more important than those of women who go out to work. In our
time the root of much nervousness, as it is called, neurotic symptoms
of various kinds and of many symptoms apparently quite distant from
real nervousness, is really a lack of occupation. Many women who live
in apartment hotels have almost nothing with which to occupy their
minds. They are not obliged to get up in the morning if they do not
want to, or, at least, any excuse, however slight, serves to keep them
in bed. Very often there are either no children or the mother has
nothing to do with her children early in the morning. After the age of
three, they go off to kindergarten; later on they go to school.
Breakfast is sent up, there may be a nap of an hour or two after the
meal, and often a magazine is glanced over lying in bed, and perhaps
it will be twelve o'clock before madame gets up. Anyone in a position
to do this, and who allows the habit to grow, is sure to be profoundly
{184} miserable. Without any real occupation of mind, the mind
occupies itself with the body and emphasizes every sensation, evokes
new pains and aches, and the consequence is likely to be a highly
neurotic state.

Such women have nothing serious to think about in the afternoon. At
best it is a luncheon engagement with a friend, or attendance at the
matinee, or a lecture, or a meeting of a club. For a while, and for a
certain few, these things are satisfying, but after they have been
indulged in for a time, they pall so completely on most people as to
leave them almost helplessly at the mercy of their feelings. These
persons may have some favorite charities that occupy part of their
time. They may have other interests, but most of these interests are
quite amateurish. They create no obligations; they arouse no sense of
duty; they are abandoned at a moment for anything else that turns up,
and consequently they lack that absorbing power that a real interest
gives. It is quite impossible that these people should be either happy
or healthy. These ladies of leisure sometimes have fads for physical
exercise that keep them from becoming absolutely sluggish, but except
in a few cases, these fads pall after a time, and in a few years women
of the leisure classes are generally without any interest that will
save them from themselves. The root of many a case of nervousness that
wanders from physician to physician and then from quack to quack, and
from charlatan of one kind to charlatan of another kind, that takes up
now this remedy and now that, and advertises each new method of
healing--mental, hypnotic, mechanical--is due to nothing more serious
than lack of proper occupation of mind.


The Ambition to Have Nothing to Do.--It seems to be the ambition of
everyone to reach a place in life so that he can give up work and do
nothing. Men and women often envy those whose material situation is
such that they are not compelled to work. It is from the leisure
classes, however, that our neurotic invalids are mainly recruited. The
symptoms these people give will sometimes make one wonder whether they
may not be suffering from some serious ailment, but just as soon as
the details of their daily occupation are gone into, the real cause
for their complaints can be readily seen. Nothing will do them any
lasting good until they get interested enough in life to be distracted
from themselves. Such men and women are invalids by profession. They
are profoundly to be pitied, for they are much more the victims of
present-day social conditions than of any special fault of their own.
They go from one health resort to another seeking relief and now and
again finding it, not because of any special effect of the remedies
that they take, but just in proportion to the amount of diversion and
occupation of mind they are able to secure in their wanderings. After
a time they relapse, then, the old cures having lost novelty, the
physician who succeeds in occupying their minds does them good; his
brother physician, who does not, fails; but anyone else, however
absurd his quackery, who can in any way catch their attention, will
benefit them at least for the time being.


Business Anxieties.--The physician should know all that concerns such
sources of excitement, worry and anxiety, as are suggested by the
words speculation, investment, going on bonds and securities,
especially when the person bonded gets into trouble. Fortunately most
of these latter sources of worry have been eliminated by the bonding
companies of recent years. Details {185} of this kind were given to
the old family physician as a matter of course. With the going out of
the family physician there has often been no one to replace him in
hearing such stories, and it has been harder for some to bear the
consequences in solitude. The very telling of many cares lessens the
burden of them. The warnings of a medical friend may be more effective
in keeping a man from serious loss than those of financial friends.
Everyone realizes that the physician's advice is quite unselfish and
that what he objects to, even more than the danger and loss of money,
is worry and anxiety which may lead to loss of health.

For ordinary therapeutic purposes, the physician may be content to
know only the physical signs and symptoms of his patient's affection.
For psychotherapeutics, he must, if he would be successful, know every
possible source of worry and annoyance and, as nearly as may be
ascertained, every slight phase of physical fatigue that may be a
disturbing factor in his patient's life. It is surprising how many
things the physician will find to correct when he carefully goes over
all the actions of the day and ascertains all the possible sources of
worry and anxiety his patient may have. It may happen that in many
cases he will be unable immediately to remove these sources of worry.
But there is relief in telling them, and then, even when they cannot
be completely eradicated, they can often be modified. Every
improvement of this kind, however slight, is a fountain of favorable
suggestion which makes the patient look on the brighter side of life.
From every amelioration, however trivial, there is a reaction on the
feelings that gives more and more confidence.


{186}

SECTION IV

_GENERAL PSYCHOTHERAPEUTICS_


CHAPTER I

GENERAL PRINCIPLES OF PSYCHOTHERAPY


In formal, deliberate psychotherapeutics the first and most important
principle is the treatment of the individual patient, and not of his
disease. It is much more important to know the kind of an individual
who has pneumonia, as a rule, than to be able to tell the amount of
pulmonary involvement. If heart, kidneys or lungs are affected when
the disease declares itself, the outlook is extremely unfavorable.
Similar conditions are true of the patient's mind. If he is of the
worrying kind, the outlook is serious. If, on the contrary, he faces
it bravely, and without after-thought except that of responding to
medical treatment, he will probably get well.

Pneumonia is only one example of the part the individual plays in
therapeutics. In the popular mind it is supposed that for each disease
there is a definite remedy, and that when the physician gives that
remedy the patient gets well. This idea of specific remedies has come
to the people from the physician, but only the quack now pretends to
cure disease, the physician helps the patient to overcome the
affection from which he is suffering.


No Incurable Patients.--There are many incurable diseases, but there
are no patients to whom a doctor should say with truth, "I can do
nothing for you." We may be unable to do anything for the underlying
disease. That may be absolutely incurable. In spite of this, there are
practically always symptoms for which the patient can be afforded so
much relief that he feels better than before. This is the most
important attitude of mind for the physician who would use
psychotherapy. He can always do something. Prof. Richet said not long
since, "Physicians can seldom cure, but they can nearly always relieve
and they can always console," and it is the physician's duty to lift
up and console the mind as well as to heal the body.


Unfavorable Suggestions.--Patients often have many opinions and
conclusions with regard to their ailments which are not confided to
their medical attendants, and which constitute the basis of many
annoying symptoms. They have mental convictions with regard to the
incurableness of their ailments, the supposed progressive character of
the disease, and the development of symptoms which will still further
annoy them, that are often more serious and harder to bear than the
symptoms from which they are actually suffering. Unless the physician
has their complete confidence, these patients may suffer much in
silence, though the revelation of their state of mind would {187}
often be sufficient to afford a good measure of relief, and the
correction of false notions would do nearly all the rest.
Psychotherapy confers its benefits mainly by securing the most
complete _rapport_ between the mind of patient and physician. Good
advice is often more important than any medicine. The correction of
wrong notions will do more to relieve the patient, and make whatever
symptoms he has bearable, than most of the anodyne drugs. The
stimulation of hope means more than almost anything else in arousing
the latent forces of nature and predisposing to recovery. The removal
of unfavorable suggestions is but little less efficient.


_Study of the Individual_.--The great differences in the relations
between physicians and their patients is well recognized. To some
physicians a patient will present only conventional symptoms, while a
follow practitioner will discover the elements of an interesting case.
Above all, the painstaking physician, interested in psychology, will
find mental and other personal manifestations in his patient that
distinctly modify the course of the disease. We must know all that is
possible about the patient's attitude of mind toward his malady, and
all the ideas that he has acquired with regard to it, either from
previous relations with physicians or from what he may have read or
heard from others. The removal of many false notions that are thus
working harm will reward the medical practitioner who gets at his
patient's ideas. The old rule in therapeutics is _non nocere_--to be
sure to do no harm. The special rule in psychotherapy is to be sure to
remove all the ideas that are doing harm to the patient and making his
symptoms mean more to him than they really signify.


_Neutralizing Contrary Suggestion_.--In the application of
psychotherapy, then, the first principle is the neutralization of
unfavorable mental influence. In our day men have such a smattering of
knowledge about disease, especially about the worst forms of it, that
they are likely to be in a frame of mind with regard to many
affections that is quite unfavorable. Many patients think disease and
not health. Disease means discomfort, and consequent loss of vital
energy and disturbance of the resistive vitality that would enable the
patient to throw off the affection. Sometimes the physician does not
realize what a large part unfavorable suggestions are playing in the
affection. Sometimes patients conceal their state of mind lest the
doctor should confirm their worst fears. The preliminary to all
successful treatment is to remove unfavorable suggestion.


Favorable Suggestion.--The next thing is to set certain favorable
suggestions at work. It is possible always to do this. Even in certain
of the acute diseases favorable suggestion has its place, and for all
chronic cases this form of therapeutics is extremely important. The
very presence of the physician, especially if he is thoroughly in
control of himself, placid, imperturbed, evidently ready to use all
his powers without any excitement, is of itself the strongest kind of
favorable suggestion. From the very beginning of medical history the
presence of the physician has in most cases meant even more than his
medicines.

Münsterberg, in his recent book on Psychotherapy, has emphasized this
in a way that deserves to be recalled:

  There is one more feature of general treatment which seems almost a
  matter of course, and yet which is perhaps the most difficult to
  apply because it cannot {188} simply be prescribed: the sympathy of
  the psychotherapist. The feelings with which an operation is
  performed or drugs given do not determine success, but when we build
  up a mental life, the feelings are a decisive factor. To be sure, we
  must not forget that we have to deal here with a causal and not with
  a purposive point of view. Our sympathy is therefore not in question
  in its moral value, but only as a cause of a desired effect. It is
  therefore not really our sympathy which counts but the appearance of
  sympathy, the impression which secures the belief of the patient
  that sympathy for him exists. The physician who, although full of
  real sympathy, does not understand how to express it and make it
  felt will thus be less successful than his colleague who may at
  heart remain entirely indifferent but has a skillful routine of
  going through the symptoms of sympathy. The sympathetic vibration of
  the voice and skillful words and suggestive movements may be all
  that is needed, but without some power of awakening this feeling of
  personal relation, almost of intimacy, the wisest psychotherapeutic
  treatment may remain ineffective. That reaches its extreme in those
  frequent cases in which social conditions have brought about an
  emotional isolation of the patient and have filled him with an
  instinctive longing to break his mental loneliness, or in the still
  more frequent cases where the patient's psychical sufferings are
  misunderstood or ridiculed as mere fancies, or misjudged as merely
  imaginary evils. Again everything depends upon the experience and
  tact of the physician. His sympathy may easily overdo the intention
  and further reinforce the patient's feeling of misery, or make him
  an hypochondriac. It ought to be sympathy with authority and
  sympathy which always at the same time shows the way to discipline.
  Under special conditions, it is even advisable to group patients
  with similar diseases together, and to give them strength through
  the natural mutual sympathy; yet this too can be in question only
  where this community becomes a starting point for common action and
  common effort, not for mere common depression. In this way a certain
  psychical value may be acknowledged for the social classes of
  tuberculosis as they have recently been instituted.


Favorable Environment--After the removal of unfavorable suggestion and
the implanting of favorable suggestion, the next point must be the
persistent occupation of the patient's mind with thoughts favorable to
his condition. A nurse who is inclined to be pessimistic must be taken
out of the sick room, and there must be only cheerful faces and cheery
people around him. Hence the modern trained nurse, and especially the
picked nurse, who does not allow herself to be disturbed, who is not
fussy, who is not forcibly cheerful but quietly placid and confident
and cheery, means much for the patient's recovery. Relatives are
almost sure to exert strong unfavorable suggestions, though time was
when the devoted wife or mother might be depended upon to cover up all
her personal feelings and give the best possible service for the
mental uplift of the patient. When she can thus conceal her own
solicitude, a near relative may be the best possible auxiliary in
psychotherapeutics.


Natural Relief.--The fourth step in the application of
psychotherapeutics is that all the natural modes for the relief of
symptoms, the making of patients comfortable in body as well as in
mind, must be employed. In acute rheumatism, for instance, a number of
small pillows must be at the disposition of the patient so that his
limbs can be fixed in those positions in which there is the least
discomfort. Every physician should frequently read Hilton's classical
volume on "Rest and Pain" because of its unpretentious significance
for psychotherapy, as well as its enduring value in the treatment of
painful conditions. Just as soon as a patient finds that simple
procedures relieve his pain and add to his comfort, his fear of the
seriousness of his ailment is lessened, {189} and he begins to get
bettor. Cold water in fevers, cold fresh air in pneumonia, all the
natural modes of treating disease, thus become active factors in the
application of psychotherapy. When fevers were treated by the
administration of hot drinks the effect upon the patient's mind must
have been quite serious. Freedom to use cold water, just as one wants
it and whenever it is craved for, is of itself an excellent
suggestion.


Neuroses in Organic Disease.--Fifth, psychotherapy, by suggestion, may
alleviate or even completely eradicate neurotic symptoms that develop
in connection with organic diseases. Such neurotic symptoms may prove
even more bothersome to the patient than the symptoms due to his
underlying affection, and may, by interfering with nutrition, hamper
recovery. The appetite of a patient who is worrying about a chronic
disease will be disturbed, and, as a consequence of insufficient food,
constipation and a whole train of attendant evils may ensue. Headache,
sleeplessness, worry at slight irritation and exaggerated complaints
from slight pain may all be due to this worry and not to the
underlying disease. All these, the result of over-solicitude, are
attributed by the patient to his chronic ailment. They can be relieved
by simple measures after he is saved from his own worry. Until the
patient is made to rouse himself and look hopefully at the situation,
eating more, getting out more, and relaxing his mind from its constant
attention to himself, he cannot get better.


Application of Principles.--It should be pointed out to the patient
that there is a constant tendency to exaggerate the significance of
disease. This is true in acute as well as in chronic disease, but in
acute diseases the necessity for removing unfavorable influences
directly is not so urgent, since usually the presence of the
physician, with his simple declaration of the meaning of symptoms, is
sufficient to neutralize the effect of previous exaggerations.

Secondly, the action of unfavorable suggestions due to imperfect
knowledge (everything unknown is magnified, as Cicero said), or to
previous medical opinions which the case does not justify, must be
stopped. The natural dread which comes to all men in the presence of
symptoms of disease must be as far as possible removed.

Thirdly, the favorable elements in the case should be emphasized. This
needs to be thoroughly done in order to secure the patient's
co-operation, even though the serious possibilities of his ailment may
be pointed out to his friends. These friends, however, must be persons
who can be absolutely depended on not to reveal by word, or, what is
much more important, by their looks or actions, the possible worse
prognosis of the case.

Unfortunately, people expect a doctor to tell them the worst, rather
than the best. Many physicians seem to have formed the habit of
representing the condition of patients as grave as possible, in order,
apparently, that they may have more credit when the patient recovers.
Not a little of the tendency of ills to hang on in neurotic persons is
due to this habit. Over-cautiousness leads some physicians to reveal a
case in its worst aspect, lest, by any chance, something unexpected
should happen, and the friends of the patient might think that the
physician was incompetent because he had not anticipated it. Some of
the serious accidents of disease are quite beyond anticipation; but
they occur only rarely. For the sake of safeguarding the possible
reflection on the physician because of them, it is quite unjustifiable
to make bad {190} prognosis habitually, for this acts deterrently on
the vital resistance and delays recovery.


_Symptoms of Organic Disease_.--It is usually considered that
psychotherapy is beneficial only in nervous cases; yet we know that
all sorts of affections with tissue changes in the skin, in the
circulation, and very probably also in the internal organs, may be
produced in hysterical affections--ailments dependent on loss of
control over the vaso-motor nervous system. Just as ills can be
produced, so they may also be cured. As a matter of fact, analysis of
the statistics of disease cured by mental influence, shows that it has
been more strikingly manifest in organic than in so-called nervous or
functional diseases. Neurotic patients often make extremely unsuitable
subjects for the exercise of mental influence, because their very
nervousness is a manifestation of lack of power properly to control
the mind. Cures by mental influence have oftenest been reported in
non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence
of the Mind on the Body" as long ago as 1884, it is in such cases as
rheumatism, gout and dropsy that benefit was most frequently reported
by mental means.

Tuberculosis, certain digestive and intestinal ailments that evidently
are associated with tissue changes, have in recent years come
particularly into this category of ailments affected by psychotherapy.
Dr. Hack Tuke's declaration, made nearly thirty years ago, seems
conservative even at the present day: "The only inference which we are
justified in drawing from the statistics of the affections cured by
mental means is that the beneficial influence of psychotherapeutics is
by no means confined to nervous disorders." Many physicians are likely
to hold that when cures take place the so-called organic diseases were
not actual, but were only _supposed_ to exist because of certain
obscure symptoms that apparently could not otherwise be explained. But
many of the cases have had external symptoms, striking and
unmistakable. To assume that physicians of experience and authority
were in error in diagnosing them is simply to beg the question. It is
more probable that mental influence acted curatively even over tissue
changes as it so often does, directly under our observation, in the
production of such changes in the skin.


_Tissue Changes From Nerves_.--Until one recalls how many physical
changes may be brought about by mental influences or emotional
disturbances, it is not always clear just how mental influence can
affect disease favorably or unfavorably. Prof. Forel, of Zurich, in
his "Hygiene der Nerven und des Geistes im Gesunden und Kranken
Zusande," Zurich, 1905, English translation 1907, brings together into
a single paragraph most of these physical and physiological influences
of the mind upon the central nervous system:

  Through the brain and spinal cord, thoughts can lead to a paralysing
  or stimulation of the sympathetic ganglion nodes, and consequently
  to blushing or blanching of certain peripheral parts. Through
  disturbance of this mechanism, many nervous disorders arise, such as
  chilblains, sweats, bleeding of the nose, chills and congestions,
  various disturbances of the reproductive organs, and, if it lasts
  long enough, nutritional disturbances in the part of the body
  supplied by the blood vessels affected. In the same way there are
  peripheral ganglionic mechanisms which superintend glandular
  secretion, the action of the intestinal muscles, etc. These likewise
  can be influenced through the brain by ideas and emotions. Thus we
  can explain how constipation and a vast number of other disturbances
  of digestion and of menstruation can be produced through the brain,
  without having their cause in {191} the place in which they appear.
  It is for the same reason that such disturbances can be cured by
  hypnotic suggestion.

_Health and the Central Nervous System_.--Nature has so constituted
and ordered the human economy that its health depends to a great
extent on conditions in the central nervous system. We discuss
elsewhere the return of vitalism in physiology--that is, the
reassertion of a principle of life behind the chemical and physical
forces of the human organism regulating it, supplying energy,
occasionally enabling it to transcend the ordinary laws of osmosis, or
the diffusion of gases. The main seat of this principle of life is in
the central nervous system and especially in the cerebral cortex. The
importance of this portion of the human anatomy can scarcely be
exaggerated. In his inaugural address to the Royal Medical Society,
[Footnote 23] delivered at Edinburgh in 1896, Prof. T. S. Clouston,
the distinguished English psychiatrist, has a passage on this subject
that deserves to be recalled:

    [Footnote 23: _British Medical Journal_, January 18, 1896.]

  I would desire this evening to lay down and to enforce a principle
  that is, I think, not sufficiently, and often not at all, considered
  in practical medicine and surgery. It is founded on a physiological
  basis, and it is of the highest practical importance. The principle
  is that the brain cortex, and especially the mental cortex, has such
  a position in the economy that it has to be reckoned with more or
  less as a factor for good or evil in all diseases of every organ, in
  all operations and in all injuries. Physiologically, the cortex is
  the great regulator of all functions, the ever active controller of
  every organ and the ultimate court of appeal in every organic
  disturbance.


_Psychotherapy in Its Relation to Patient and Physician_.--In spite of
the present-day fad for psychotherapy, I have no illusions with regard
to its popularity among patients, unless practiced with due regard to
individuals and with proper tact. Psychotherapy has been most
effective in the past when it was cloaked beneath the personality of
the physician; when it was felt that there was in him a power to do
good that must help the patient. This personal influence has to be
maintained if the patient's mind is to be influenced favorably. Very
few people are willing to think, and still less to welcome the
thought, that they themselves are either bringing about a continuance
of their symptoms or are hindering their own recovery. They are quick
to conclude that this would be a confession that their ills are
imaginary. "Imaginary" has no place in medicine. There are physical
ills and mental ills. Mental ills are just as real as physical ills.
There are no fancied ills. A person may be ailing because he persuades
himself that he is ailing, but in that case his mind is so affecting
his body that he is actually ailing physically, though the etiology of
the trouble is mental.

It is the duty of the physician to get at these mental causes of
physical ills and remove them by persuasion, by reassurance, by
changing the mental attitude, by making people understand just how
mind influences body, but this must be done tactfully. From the
beginning of time we have written our prescriptions in such a way that
ninety-nine out of one hundred patients have not been able to
understand them. It has often been said that we should change this
method of prescription writing, and write directions for the
compounding of our medicines in plain vernacular. Besides the many
{192} scientific reasons against this, it is better for patients not
to know exactly the details of their treatment. Physicians, because of
their real or supposed knowledge, are usually the worst patients. If,
when a physician is ill, a drug is administered in which he has lost
confidence, he will really oppose its action by contrary suggestion,
and perhaps neutralize it. Confidence added to the action of the drug
itself, makes it much more potent and much more direct. Hence the
suggestive value of a prescription the ingredients of which are
unknown. Every physician knows of patients who have declared that a
drug has been tried on them without avail, when it has only been used
in such small quantities as to be quite nugatory in its effect. Such
use was enough to prejudice them against it so that when given in
physiological doses it failed to work properly.

Opium given to a trusting patient, in gradually reduced doses until
practically there is nothing but the flavor of the drug in the
compound that he takes, will continue to have its effect. But to a
patient prejudiced against the drug, even large doses of opium will
prove unavailing, because the lack of confidence disturbs the mind,
directs attention to whatever discomfort may be present, emphasizes
the ill and prevents sleep by preoccupying the mind with the thought
that neither the drug nor the dose can accomplish its purpose. In a
word, medicine plus mental influence is extremely valuable. Medicine
minus mental influence is valuable but sometimes ineffective.
Medicine, with mental influence opposed to it, is often without effect
because of the strong power the mind has over bodily functions.

Most people would rather be cured by some supposedly wonderful
discovery, which presumedly made it clear that they had been suffering
from a severe and quite unusual ailment, than by ordinary simple
methods. The recent growth of interest in psychotherapy and psychology
has, however, somewhat prepared people to accept mental influence as
an important factor in therapeutics. The direct and frank use of
psychotherapy will be of benefit to these people. But in most cases
mental influence will have to be exerted in such a way as to conceal
from patients that it is their own energy we want to tap to help them
cure themselves. This would be for them quite an unsatisfactory method
of being cured. In practically all cases such a combination of methods
is needed that the place of mental influence is not over-emphasized.
As a rule, mental influence must not be used alone. Its place is that
of an adjunct, a precious auxiliary, to other methods of treatment.

Psychotherapy represents one of the important elements in
therapeutics, and we must learn to use it in a way suitable to our
patients. We have to learn to use our drugs in accordance with the
nature and physical make-up of the patient. We have to find out by
experience just how to use hydrotherapy for each individual. Varying
currents of electricity and varying forms of electrical action are
needed for different individuals. Just in the same way, our
psychotherapy must be dosed out according to the special need of each
individual, the form of the affection and the particular kind of mind
that is to be dealt with. To learn the place of mental influence in
healing, so that we shall not be attributing to other therapeutic
factors what is really due to the mind, will be a great advance in
therapeutics. This is the mistake that we have been making in the
past.

In brief, the applications of the general principles of psychotherapy
{193} include all means, apart from the physical, of influencing
patients. Drugs will always have a large place in rational therapy.
Many physical remedial measures, hydrotherapy, electrotherapy,
climatotherapy and others, must be important adjuncts. To these is now
added psychotherapy. It has been used before, as have most of the
other forms of therapy, but in our day we are trying to systematize
therapeutic modes so as to secure the greatest possible information
with regard to their exact application. This is what must be done with
regard to psychotherapy also. Just now its importance is being
exaggerated by ardent advocates. In every department of therapy this
has always been done by enthusiasts. The business of the practicing
physician must be to select what is best, and above all what is sure
and harmless, from the many suggestions offered, so as to build up a
practical body of applied truth.


{194}

SECTION V

_ADJUVANTS AND DISTURBING FACTORS_


CHAPTER I

SUGGESTION

Under the head of Adjuvants and Disturbing Factors in the psychic
treatment of patients come the various phases of life which make for
and against such a favorable state of mind as predisposes to the
continuance of good health, minimizes inhibition, and adds to
favorable suggestion. By modifying the modes of life, an ever renewed
set of suggestions is initiated. By definite instruction and advice
with regard to exercise, position, training, habit, pain, occupation
of mind and diversion of mind, patients may be profoundly influenced,
and gradually made to take on an entirely new attitude of mind towards
themselves. These chapters, then, while apparently much more concerned
with physiotherapy than psychotherapy, are really directions for the
use of such physical methods as by frequent repetition make the most
valuable suggestions. There is probably nothing more valuable in the
ordinary application of psychotherapy than these various auxiliaries,
with their power to remove disturbing factors, while, on the other
hand, nothing aids more in bringing relief for many conditions than
the removal of certain disturbing factors.

There is now a general recognition of the fact that suggestion in the
waking state can in most cases be as therapeutically efficient as
hypnotism, and is probably even more enduring in its effects when
successful, without the dangers and sequelae connected with hypnosis.
_Every idea tends to act itself out_. When we crave something, when
there are active ideas of desire, there usually are movements of our
flexor muscles. These affect the hands especially. At moments of
hatred, detestation or abhorrence our extensor muscles are affected,
as if we would wave these things away from us. There may even be an
involuntary turning of the trunk muscles, as if we would no longer
face what is abhorrent, though the repulsive thing may be present only
to the mind. It is not far-fetched to argue that, since the voluntary
function of muscles is thus influenced, other functions are also
touched by emotions, ideas, trains of thought, especially when the
mind is much concentrated on them.

Bishop, the so-called mind-reader, whose exhibitions attracted much
attention in London and New York some years ago, confessed that his
feats were accomplished mainly through muscle reading. He would permit
a committee to select a book in a library in a certain house, and even
a particular page of {195} that book, and then, blindfolded, sitting
with the committee in a carriage with his hand on the forehead and the
arm of one of the committee, he would direct just where the carriage
should be driven and would, while always continuing his contact with
the member of the committee, go to the particular house and room,
select the special book, and eventually find the page. There was no
opportunity for collusion in some of these feats. The most startling
things were often accomplished by the system of forcing a choice which
prestidigitateurs use in order to compel the taking of the particular
card by suggestion (though all the time they seemed to be leaving
absolute liberty of selection to the person), but there was much,
besides this, required to accomplish what he did. He said that there
were always involuntary muscle movements, little starts and tremors
that guided him in his work. Other exhibitors have been able to use
this to a considerable extent, though not with Bishop's success. That
our thoughts can be read in our muscle system is interesting and
valuable confirmation of the unconscious tendency of ideas to affect
the body.

When a single idea occupies the consciousness it will, some
psychologists insist, necessarily act itself out unless some
distracting thought prevents it. We know how difficult it is to stand
at the edge of a height, say at the brink of a waterfall or on the
cornice of a high building, or to look down a mine or elevator shaft,
because the thought comes to us, how dreadful it would be to plunge
over. As a consequence of this insistent idea taking possession of our
consciousness, we have the sense of falling, we become tremulous and
have to withdraw, or we would actually fall, or find in ourselves a
tendency to throw ourselves over. There are persons who cannot even
sit in the front row of a balcony because of the constant effort
required to neutralize the suggestion that they may fall or throw
themselves over its railing. Curious sensations become associated with
this idea--a feeling of numbness and tingling in the back, sometimes a
girdle feeling, sometimes a sense of suffocation. All of these are due
to the concentration of attention on a single idea and its
suggestions.

Very few men, shaving themselves with an old-fashioned razor, have
not, at moments of worry and nervousness, sometimes had the thought of
how easy it would be to end existence by drawing the edge of the razor
through the important structures in the neck. Some are so affected by
this thought that they have to give up shaving themselves. It is a
surprise usually to find how otherwise sensible, according to all our
ordinary standards, are the individuals who confess to having had
annoyance from such thoughts. This illustrates how strongly suggestive
the concentration of attention may make an idea, and how much a single
idea, when it alone occupies the center of consciousness, tends to
work itself out in act, though there is no reason at all for willing
in that direction. It is not improbable that in some inexplicable
cases of suicide the tendency has actually worked itself out.

The expression, "he is a man of one idea," enshrines in popular
language the conclusion of psychologists that if a single idea is
present in the mind it will surely work itself out. We all know how
much men of one idea accomplish. All their powers, physical and
mental, are brought to bear on its development. Obstacles that deter
other men, conditions that prevent others from daring even to think of
doing the thing, seem as nothing to the man {196} of one idea, and in
spite of discouragement, and even apparent failure, he often succeeds,
notwithstanding obstacles that seemed insurmountable. What is thus
true in the practical world is paralleled, for both good and ill, in
the microcosm of the human body. A man who has one idea to urge him on
is capable of accomplishing things in spite of pains and aches and all
sorts of disturbances of function. On the other hand, if the one idea
is unfavorable, then, in spite of a heritage of good physical and
mental powers, his efficiency is inhibited. If a man gets an idea that
there is something the matter with any organ, and concentrates
attention on it, he will surely disturb the function of that organ.
Just the opposite, however, will happen in case, even with physical
defect, he believes that there is nothing the matter, or only
something that can be overcome. This is the power of faith as
illustrated in the various forms of faith healing, from mental science
to Eddyism and the rest.

This is the power that the physician must learn to use. In _The
Lancet_ for November, 1905, Dr. J. W. Springthorpe, writing on the
"Position, Use and Abuse of Mental Therapeutics," said:

  Few indeed are the medical practitioners who daily prescribe
  suggestion as well as diet, hygiene and drugs. Yet the physician who
  makes even a minimum effort in this direction often does more for
  his patient than his more highly qualified confrère, who makes none.
  To some, and they naturally the most successful, this endeavor comes
  without conscious search, and improves with experience, but in some
  measure it may be acquired by all and no one who has become familiar
  with its powers will henceforward be content to remain without its
  constant aid.

This power is thoroughly exploited by the irregular practitioner, and
the regular practitioner is bound in duty to learn to use it just as
thoroughly.

What is true for the lesser faculties is eminently true for our most
important faculty, the intellect. We all know how intellectual
training enables us to accomplish without difficulty what at first
seemed almost impossible. Not only that, but we acquire the power to
devote ourselves to a subject that was at first irksome, if not
actually forbidding. There are educators who insist that this
discipline of mind, by which the power to devote ourselves to what we
do not care for is gained, is the principal fruit of genuine
education. It has been lost, or at least impaired to a great degree,
by educational experiments, especially those related to the elective
system which pushed interest, instead of discipline, into the
foreground of education. In the same way the power of self-control,
and the faculty of self-denial, so precious to the human race, have
been lessened by the methods of training which omitted the
consideration of these and emphasized the idea of personal comfort.
Much can be done to make the unpleasant things that are inevitable in
life not only tolerable, but actually to give a satisfaction
surpassing selfish pleasure. It is this discipline that is needed in
psychotherapy at the present time and the physician must endeavor to
encourage it by every means in his power.

The one purpose of the use of suggestion in therapeutics, then, is to
secure as far as possible concentration of mind on a single idea. This
is what is done in hypnosis, but frequently in such a way as to leave
the idea {197} to work out unfavorably associated suggestions. If
there could, in the conscious state, be the same absolute
concentration of mind on an idea, a great force for good, without
accompaniment of ill, would be secured. Experience has shown that with
patient effort and definite methods such concentration of attention on
a single idea can be secured, at least to such an extent as to make it
efficiently therapeutic.

Ordinarily, suggestion accompanies the material remedies that the
doctor prescribes. He must emphasize just when and how the medicine is
to be taken, and it is well to emphasize the effects that are expected
and just about how they will come. If he is prescribing a tonic, he
does not merely say before meals. He specifies from ten to twenty
minutes before meals, according as he wishes it taken, with a definite
amount of water, stating that the taste of it will excite appetite and
that only food in reasonably liberal quantities will satisfy the
craving produced by it. If he is prescribing a laxative, he states
just when it should be taken and when its effects may be expected. The
arousing of expectancy does much to relax inhibition and to permit the
flow of nervous impulses that may be helpful. If a sleeping potion is
given, the patient is directed to compose himself for sleep
immediately after it is taken, or to take it just a definite time
before he gets into bed, and then to expect its action in the course
of twenty minutes or a half hour, designating rather definitely just
when it shall have its climax of effect. Two or three things done
together, as, for instance, a gentle rubbing with cool water over the
body to produce a glow, a warm foot-bath, and then a sleeping potion,
will combine to produce a climax of physical and psychical effect.

In many conditions that come for treatment to the modern physician,
the physical remedies are much less important than the psychical. This
is particularly true for the affections known as psychoneuroses, in
which some slight nervous disturbance is exaggerated into an extremely
painful condition or a disturbing paralytic state; in the so-called
hysteria of the older times; in the drug habits; in the sex habits; in
the over-eating and under-eating habits, and then with regard to
dreads and other psychic disturbances connected with dreams,
premonitions and the like. In all these cases it is important to
secure concentration of the patient's mind on a neutralizing
suggestion. This must be done deliberately and in such a way as to
secure thorough concentration of attention. It is often a time-taking
process, but nearly everything worth while requires time, and the
results justify the expenditure. Methods mean much in the attainment
of this. They must be impressive, the patient must be convinced of the
power of the physician to help him, and he must have trust in the
efficacy of the mode of treatment.

The patient should be put into a comfortable position, preferably in a
large, easy arm-chair, should be asked to compose himself in such a
way as to bring about thorough relaxation of muscles, and then to give
his whole attention to the subjects in hand. Occasionally the arms
should be lifted and allowed to fall, to see whether relaxation is
complete, and the knee jerks may be tested, to show the patient that
he is not yet allowing himself fully to relax. There should be no
lines in the face: the muscles around the mouth, and especially those
in the forehead, should relax. It is surprising how {198} much can be
done, sometimes by slight touches on the forehead, to secure this. The
patient should then be made to feel that the tension in which he has
been holding himself, and which makes it so difficult for him to
relax, has really been consuming energy that he can use to overcome
the tendencies to sensory or motor disturbance, or to supply the lack
of will which makes him a victim of a drug or other habit, or takes
away from him that mental control that would enable him to at once
throw off dreads and doubts and questionings and bothersome
premonitions which now, because of the short circuiting on himself
through worry and nervousness, he cannot do.

Two or three séances usually show a patient how much better control
over himself even a short period of relaxation will give. He comes out
of a ten-minute session of relaxation, during which he has been talked
to quietly, soothingly, encouragingly, with a new sense of power.
Often he feels that there will be no difficulty in overcoming his
habit. This may pass, of course, but he has received a new idea of his
own resources of energy and self-control.

In most cases it is well, after securing relaxation, to ask the
patient to close his eyes gently and to keep them closed till all his
muscles are relaxed. Then suggestions may be made to him with regard
to his power to control cravings, and to put away doubts and
questionings, because, after all, as he sees them himself, they are
quite irrational and entirely due to habitual tendencies that he has
allowed to grow on him. A concentration of attention on the idea, not
only of conquering but of being able to conquer, will be secured.
Unless this complete attention can be had, suggestion in the waking
state may not prove efficient. There are nervous, excitable people for
whom, at the beginning, it will be quite impossible to secure such
relaxation and peaceful quiet as will be helpful to them. For these a
number of séances may be necessary, but on each occasion a little more
of quieting influence is secured.

In recent years, this quiet, peaceful condition, with eyes closed,
thorough relaxation and absolute attention, has sometimes been spoken
of as the hypnoidal state. If it be recalled that hypnos in Greek
means sleep, and that this is a state resembling sleep with the
restfulness that sleep gives, the term is valuable in its suggestions.
If, however, the word is connected with hypnotism, then there may be
an unfortunate connotation. This state is entirely free from the
dangers of hypnotism, and instead of making a patient dependent on his
physician, teaches him to depend on his own will. It is not a new
invention as this term hypnoidal might seem to indicate, but is as old
as our history at least.



CHAPTER II

EXERCISE

In recent years a great change has come over the popular mind
regarding exercise, especially in the open air. It is well to
emphasize at the very beginning the subject of too much exercise,
because there is no doubt in the minds of many who study the question,
that many Americans, and indeed people of the northern nations
generally, take a certain amount of voluntary {199} exercise that is
not good for them, though they take it at the cost of considerable
effort and sacrifice of time and are firmly persuaded that it is of
great benefit.


Sufficient Exercise.--There is a much larger number of persons who do
not take sufficient exercise. The amount to be taken is eminently an
individual matter. Neurotic patients exaggerate everything in either
direction, so that perhaps the state of affairs that exists is not so
surprising as it might otherwise seem. Instead of the uncertainty that
prompts now to too much exercise, and again to too little, for
health's sake there must, as far as possible, be a definite settlement
of the needs.


National Customs.--There is a curious difference in the attitude of
mind of the various nations towards exercise. Most of the southern
nations of Europe do not as a rule take any violent exercise. As is
well known, however, they are not for this reason any less healthy
than their northern contemporaries, though perhaps they are less
strong and muscular. But muscularity and health are not convertible
terms, though many people seem to think they are. An excess of any
tissue is not good. Our economy should be taxed to maintain only what
is useful to it. Nature evidently intended, in cold climates at least,
that men should maintain a certain blanket of fat to help them retain
their natural heat, but any excess of fat lessens their resistive
vitality by lowering oxidation processes. Fat in cold climates can be
used to advantage as a retainer of heat. In the warmer climate it
would be a decided disadvantage. Muscular tissue is a manufacturer of
heat and this is a decided advantage in the colder climates, but in
the temperate zone, where the summers are very warm, muscle in
over-abundance, unless its energy is consumed by actual physical
exercise, may be quite as much of a burden as fat. Muscular people do
not stand heat well. They demand exercise to keep muscle energy from
being converted into heat, and they require frequent cold baths, and
other forms of heat dissipation, in order to be reasonably
comfortable.


Exercise in Early Years.--The question of the amount of exercise that
is to be taken must be decided at an early age for individuals. Most
of the young people of the Celtic and Anglo-Saxon races are tempted by
traditions and by social usage to develop considerable muscle during
their growing years. In this respect, the difference between the
German and the English schoolboy is very striking. The English
schoolboy is likely to be as "hard as nails," as the expression is, as
a consequence of violent exercise in his various sports, taken often
to the uttermost limit of fatigue. The German schoolboy has his walk
to and from school, and some other simple methodical exercises, with
some mild amusements that make little demand on muscle, but of games
in the open he has very few, and of the violent sports he has none at
all. A comparison of the health of the two nations will not show that
the English boy, who receives a public school and a university
education, with all their temptations to exercise, enjoys any better
health, and, above all, reaches an average longer life than the German
youth, who has gone through a similar educational career in his own
country, but without the athletic training that the English schoolboy
has had.

As a consequence of the absence of athletics and its diverting
interest, the German is apt to have learned more than his English
colleague, but a {200} comparison of mortality and morbidity tables
would show that his resistive vitality, his power to overcome disease
and recover from accident is not lower than that of his colleague from
across the North Sea. The German is less strong muscularly, and in a
contest of physical effort would as a rule come out second best, but
then we have gotten beyond the period when it is important for a man
to be able to defend himself by physical force, except in emergencies
that may never come. Surely the English time and effort devoted to
athletics is not justified by this.


_Preparation for a Sedentary Life_.--Certainly if a young man is going
to live a sedentary life in his after years, it does not seem
advisable for him deliberately to devote much time to muscular
exercise during his growing years. This only provides him with a set
of muscles for which he has no use. Ordinarily it is assumed that
muscles are organs for the single purpose of evolving energy. This is
not true, since they are important organs for the disposition of
certain food materials and for the manufacture of heat for the body.
Nature in her economy probably never makes an organ for one function
alone, but usually arranges so that each set of organs accomplishes
two or three functions, thus saving space and utilizing nutrition to
the full. The man with a well-developed muscular system, which he is
not using, will have to feed it, and besides will have constantly to
exert a controlling power over the heat that it manufactures whenever
it is not dissipated by actual exercise. For these reasons he will be
constantly nagged by it into taking more exercise than his occupation
in life demands, and if he does not do this, his developed musculature
is likely to deteriorate so as to be a serious impediment, or to
degenerate by fatty metamorphosis into a lower order of tissue that is
a clog and not a help to life.

The Germans are more sensible. As students, they live quite sedentary
lives, develop their muscles just enough to keep them in reasonably
good health, and then, when it comes to living an indoor life, as will
be almost inevitable in their chosen professions or occupations, they
do not meet with the difficulties that confront the Anglo-Saxon with
his burdensome, over-developed muscular system. German professors, as
a class, do not find themselves under the necessity of taking
systematic daily exercise. They are quite content and quite healthy
with an hour or two of sitting in the open air, and a quiet walk from
the home to the university or the school. With the ideas that some
people have with regard to the value of exercise for health, it might
be expected that the German professors would be less healthy than
their Anglo-Saxon colleagues. This is notoriously untrue, for the
Germans live longer lives on the average, and most of them accomplish
much more, and above all are much more content in the accomplishment,
than their physically strenuous Anglo-Saxon colleagues. They are not
oppressed by the demands of a muscular system that insists on having
its functions exercised, since it has been called into being in the
formative period. These German professors live to a magnificent old
age, requiring very little sleep and often doing a really enormous
amount of work. The man with a developed muscular system generally
requires prolonged sleep, particularly after exercise, but even
without it very seldom is it possible for him to do with less than
seven hours, while the Germans often are content and healthy with five
hours, or less.

{201}

Our muscular system is our principal heat-making apparatus. It is easy
to understand. If we have larger heat-making organs than are necessary
for the maintenance of the temperature of the body, and if we have no
mode of dissipating our heat by muscular energy, as through exercise,
then there will be a constant tendency for our temperature to rise,
which must be overcome, at considerable expense of energy, by the
heat-regulating mechanism of the body. This heat-regulating mechanism
is extremely delicate, yet does not seem to be easily disturbed. With
the external temperature at 120° F. or--10°, human temperature is
constant. With a heating apparatus entirely too large for its purpose,
it is no wonder that irritability of the nervous system ensues because
of the constant over-exercise of a function called for from it. It is
this state of affairs which seems to me to account for the marked
tendency to nervous unrest, and to the presence of many heart and
digestive symptoms that often characterize athletes who develop a
magnificent muscular system when they are young, and later have no use
for it. They must learn the lesson and keep up the practice of using
their muscles sufficiently to dissipate surplus heat, so as to prevent
this energy from being used up in various ways within the body, with a
resulting disturbance of many delicate nervous mechanisms.


Useless Muscles.--Whatever a human being has to carry round as useless
can only be expressed by the telling Roman word for the baggage of an
army, _impedimenta_. Prof. James, in his "Principles of Psychology,"
sums up the law very well:

  The great thing in all education is to make our nervous system our
  ally instead of our enemy. It is to fund and capitalize our
  acquisitions and live at ease upon the interest of the fund. For
  this we must make automatic and habitual as early as possible as
  many useful actions as can be and guard against the growing into
  ways that may be disadvantageous to us as we should guard against
  the plague.

An over-developed muscular system, with its tendency to manufacture
heat and its craving to be used, and the consciousness it is so apt to
produce of ability to stand various dangerous efforts, is a
disadvantage rather than an advantage.


Useless Fat.--This reminds us very much of the attitude with regard to
children in the acquisition of fat. Chubby babies with rolls of fat
all over them and deep creases near their joints are considered to be
"perfectly lovely." Mothers are proud to exhibit them. They are
supposed to be typical examples of abounding good health. Neighborly
mothers come in to coo over them and, in general, the main aim of
existence for children in their early years would seem to be to make
them as fat as possible. Such children, as is brought out in the
discussion of the subject in the chapter on obesity, are not healthy
in the true sense of the word, are well known to be of lower resistive
vitality than thinner infants, and easily succumb to diseases.



Resistive Vitality.--One reason for the early deaths of many athletes
is the fact that, confident of their strength, they allow themselves
to become so overwhelmed by an infection, before they confess that
they are sick and take to bed, that often the cure of their affection
is hopeless. Ordinarily neither pneumonia nor typhoid are likely to be
fatal diseases for men between twenty and fifty. If a man's heart and
kidneys are in good condition during this {202} period, an attack of
either of these diseases, while a serious incident, is likely to be
only a passing loss of time. Rather frequently, however, strong and
healthy men without any organic defect that may be considered
responsible for the fatal termination, succumb to these diseases. The
reason for the fatality is that they are not willing to admit that
they are ill enough to be in bed, they have a large reserve force of
strength on which they call and which enables them, for a good while,
to resist the weakening influence of disease. Doctors know and dread
these cases. A young man in the flower of youth, with magnificent
muscular development, comes into the office breathing very rapidly and
with a laboring pulse. Almost exhausted, he sinks into a chair,
confesses that he is nearly "all in," and wonders what is the matter.
At times the physician will find practically a whole lung solidified
by pneumonia, and at times both lungs are seriously affected. The
wonder is how the young man succeeded in holding out so long.
Sometimes the doctor is summoned to see him because he has fainted in
his home, or in his office, and his friends are alarmed. These cases
are almost invariably fatal. Any one who continues to be up and around
until the third or fourth day of pneumonia will have so exhausted his
vitality, no matter how great that may be, that he will have no
reserve force for the life-struggle that must come before the crisis
is reached.

Nearly the same thing is true for typhoid fever in the same class of
persons. A young athlete, who considers it babyish to confess to
illness, complains of feeling out of sorts but nothing more, until
some morning he is literally unable to leave his bed, or has a
fainting fit after going up-stairs. He is found by the physician with
a temperature of 104°, or near it, and with evident signs of being in
the middle of the second week of typhoid fever. The termination of
such a case is generally fatal.

The ordinary man knows his limitations better; he recognizes the fact
that he may be ill, and gives in quietly and rests, so that nature may
employ all her energies in conquering the infection. Most of the
long-lived people of history have been rather delicate and have
learned young the precious lesson of caring for themselves. This care
has not been exaggerated, but it has consisted in avoiding danger, in
resting when tired, in not overdoing things, and above all in yielding
to the symptoms of disease before these become serious.


Regulation of Exercise.--Each man must be a law unto himself as to the
amount of exercise that is necessary for him. He must take enough to
use up the energy supplied by the food he eats, just as, on the other
hand, he must eat enough food to make up for whatever waste there is
in his body. There are many men who eat over-heartily and then have to
take exercise to use up this material or else suffer for it. This is
one of the compensations that the hearty eater must pay: he overfeeds
and becomes obese, or, if he succeeds in keeping down his weight to
the normal, it is only by the expenditure of time in securing such
muscular action as will use up surplus energy. Many men find it
difficult to control their appetites, and prefer to take exercise
rather than to deny the appetite which they created during their days
of indulgence in athletics. It is for such men to decide just what
seems preferable. If the fuel is supplied to the heat engine, which
all human beings are, it must be used for the production of energy or
else it will exert {203} itself in accumulating certain waste in the
tissues, just as over-abundant fuel serves merely to clog up the
fire-box of an engine without doing any work.


Air and Exercise.--It is easy to deceive one's self in the matter of
exercise. With regard to air such a mistake is almost impossible. As a
rule, it is air rather than exercise that people need when they have
the restlessness and nervousness which comes from over-abundant
nutrition. Fresh, pure air enables the individual to burn up nutritive
material to the best advantage by the encouragement of oxidation. It
is a surprise to those who are not accustomed to it, to see how
tuberculosis patients who come to sanatoria with very little appetite,
soon acquire an appetite and are able to consume large quantities of
food, to sleep well and become restful--all as the result of living
constantly in the open air during the day, and also having an
abundance of fresh air at night. This is particularly true if the air
in which they live is rather cold, and, above all, if it has a large
difference of temperature every day, so that there is an upward and
downward swing of the thermometer of from thirty to forty degrees.
This varying temperature seems to use up nutritive material, and keeps
all the natural processes going.


Gymnastics.--The very opposite to this plan of open air life is that
followed by those who take gymnastic exercises for health's sake, with
the idea that the use of certain muscles is necessary to keep the
bodily economy in equilibrium. Such gymnastics are usually undertaken
indoors, sometimes in stuffy quarters, and the movements are commonly
repeated with such continued routine that absolutely all interest is
lost. That there are many who advocate this form of exercise, it has
nearly always seemed to commonsense physicians an entirely wrong
solution of the important question of the encouragement of oxidation.
It is like running an engine, not for the purpose of having it do
something, but simply in order to have it oil itself, and consume the
fuel that has been put into its boiler and that must be used up
because more will be put in to-morrow. It would be much better, either
to limit the amount of fuel or to give the muscular exercise some
useful purpose, above all connect it with some interest that furnishes
diversion of mind at the same time that the muscles are used. This
last is the most important consideration, for, after a time,
gymnastics pall in spite of artificial incentive.

Dr. Saleeby, in "Health, Strength and Happiness," has expressed very
forcibly what has come to be the feeling of many physicians with
regard to gymnastics, especially indoor gymnastics:

  The natural spontaneous exercise having been forbidden, and the bad
  consequences of no exercise having become conspicuous, there has
  been adopted a system of factitious exercise--gymnastics. That this
  is better than nothing, we admit; but that it is an adequate
  substitute for play we deny. . . . The common assumption that, so
  long as the amount of bodily action is the same, it matters not
  whether it be pleasurable or otherwise, is a grave mistake. . . .
  The truth is that happiness is the most powerful of tonics. . .
  Hence the intrinsic superiority of play to gymnastics. The extreme
  interest felt by children in their games and the riotous glee with
  which they carry on their rougher frolics, are of as much importance
  as the accompanying exertion. And as not supplying these mental
  stimuli, gymnastics must be radically defective.

  Granting, then, as we do, that formal exercises of the limbs are
  better than nothing--granting further that they may be used with
  advantage as supplementary aids, we yet contend that they can never
  serve in place of the exercises prompted by nature. For girls, as
  well as boys, the sportive activities to which the instincts {204}
  impel, are essential to bodily welfare. Whoever forbids them,
  forbids the divinely appointed means to physical development.


Play and Exercise.--There has been a distinct tendency in modern times
to think that gymnastic exercise can be a substitute for play for
growing young folks. When certain of the instruments and methods of
the modern systems of gymnastics which have been introduced into
schools, and are supposed to be so wonderfully beneficial, are put to
the test of the psychology of exercise, the conclusions are likely to
be very different from the theories under which they were introduced.
Dr. Saleeby has expressed these differences rather strikingly:

  Anyone who will consider for a moment the natural constitution of
  man and the principles of natural education, must agree that the
  deplorable thing called a dumb-bell offers an exquisite parody of
  what exercise should really be. The cat, as she exercises her
  kittens along the lines of their natural proclivities and needs,
  never telling them that this is exercise for the sake of exercise,
  and certainly prepared, if she could, to turn up her nose at any
  artificial implement we might offer her--should be our model in this
  respect. It may be imagined that some unfortunate girl, brought up
  on early Victorian lines, having never been permitted to wear
  comfortable garments, or to stretch her arms, would welcome and
  enjoy the dumb-bells when first introduced to them. But any one who
  has had a natural childhood and who has been taught to play, and who
  has taken his or her exercise naturally, or incidentally in the
  course of pursuing some mental interest--any such person may be
  excused for saying that a pair of dumb-bells should be deposited in
  our museums as indications of what was understood by exercise even
  as late as the earlier years of the twentieth century. All exercise
  for the sake of exercise is a mistake--or, at any rate, a second
  best. You may do your mind--and body, too--more harm by sheer
  boredom than you may gain good from the exercise you go through. The
  dumb-bell symbolizes the fact that the most elementary and obvious
  truths of psychology are still unrecognized, though the play and
  games of every natural child--if you object to be instructed by
  kittens--should be perfectly sufficient to teach us what indeed
  nature taught us ages ago, if only we would listen to her.


Indoor Sport.--Indoor sport is another thing. In wintry weather it is
impossible to play outside conveniently, and indoor games have their
place. Unfortunately they are usually associated with dust, and when
played before crowds of spectators, the participants suffer also from
the disadvantage of rebreathed air containing, too, the emanations of
those who are looking on. It must not be forgotten that these two
factors are the most prominent predisposing causes of tuberculosis.
Those who have any tendency to tuberculosis, by which is meant
specifically all those who are associating with tuberculosis patients,
whether those patients are related to them or not, or who are more
than 20 per cent. under the weight that they should have for their
height, should not be allowed to take part in indoor sports where
these drawbacks are sure to be encountered.

Sport, because of the diversion of mind involved, is an ideal form of
exercise. An exercise that becomes a mere routine and that can be
eventually gone through with so mechanically as to leave abundant room
for thoughts of business or study or worries of other kinds, loses
sight of one of the principal purposes of exercise as nature demands
it.


Horseback Biding.--It is because of the complete diversion of mind
that is necessarily involved in it, that horseback riding makes such a
magnificent exercise for the busy man. The old expression "the outside
of a horse is the {205} best thing for the inside of a man" is founded
even more on the mental influence of horseback riding than its
physical quality. The same amount of exercise in the open air, taken
otherwise, often does not accomplish so much good, because a man's
thoughts may continue to run on his business or be occupied with his
worries, or he may not be able to divert his thoughts from himself and
his digestion or his ills. A horseback rider must pay attention to the
other animal, rather than himself, and that represents the complete
diversion of mind so necessary for the health of most people. Just as
soon as man rides an old favorite animal on whose back he can throw
down the reins, allowing it to saunter on as it will, while he
occupies himself with other things, then horseback riding loses its
efficacy and falls back into the class of bicycle riding or carriage
riding or walking in the open air unless there is diversion of mind in
the scenes, or the necessity for care at street crossings, to banish
preoccupation of mind. Unless business troubles and worries are
necessarily excluded by its conditions, or are deliberately eliminated
from the mind during the course of any exercise, it may even become a
renewed source of worrisome thoughts, rather than a renewal of energy,
mental and physical.

It is doubtful whether horseback riding should ever be recommended for
those who have not been accustomed to it from their youth. To ask a
man past forty to learn to ride horseback for the sake of exercise is
nearly always a mistake. It becomes a trial rather than a recreation,
and may thus do harm rather than good. On the other hand, horseback
riding is one of the things that may be, and indeed often is, much
abused. The old English fox-hunting squire would never have lived out
his life even as long as he did, consuming the amount of proteid
material that was his custom, and drinking his three or more quarts of
port at dinner every day, but that the excessive drain upon his system
by long days of hard riding in the hunting field made calls upon his
nutrition which kept even this amount of food and stimulant from doing
immediate harm. Just as soon, however, as long spells of severe
exercise become excuses for the consumption of big dinners, and
exercise is used as a factor to enable one to overeat with more
comfort than would otherwise be the case, a vicious circle is formed,
and one serious abuse is counterbalanced by another. What many
well-to-do people of leisure need is not so much more exercise as less
eating.


Walking.--Perhaps the best and most readily available form of exercise
for most people is walking. It has one disadvantage. As soon as the
walk becomes too much of a routine, and the ground gone over has lost
its interest, or is even of such a nature as to permit or, indeed,
tempt introspection and occupation with other things, rather than with
the surroundings, then walking loses most of its efficacy as a form of
exercise. Walking in the country, for instance, becomes monotonous,
though at first it is a great source of pleasure. Walking in a large
city, however, has little of this objection and as large city life has
grown more and more strenuous in recent years, the good effect of
walking to and from the office or walking in the busy parts of the
city has been increased. Between the trolley and the automobile, and
the hustling commercial traffic of the streets, it is impossible for a
man to walk through the busier portions of any large American city
without keeping his wits thoroughly intent on what he is doing, nor
without requiring all of his {206} attention for his transportation.
An abstracted man will in the course of a half hour have so many
narrow escapes from being run down in a busy quarter that he will
either eschew walking in that particular neighborhood, or give up his
habits of mental abstraction, or else he will come to himself some day
in a hospital.

Besides, the passing show in city life is itself of surpassing
interest. It is not things but men that interest us most. There are so
many phases of human life to be seen on busy city streets, so many
things happen in the course of even a short walk to bring out
prominently traits of human nature that, if a man is at all
sympathetic, he finds much to occupy his attention, to distract him
from his own worries and take him away from his business cares. The
long walk to and from the office may thus become an efficacious source
of thoughts that are different and of profound pleasure. All depends
on the man and his mood. Men who try it whole-heartedly soon find a
renewed interest in life. An hour of daily walking in the open air
with the distractions of city life all around, provided the walking is
done briskly and faithfully, is of infinitely more hygienic value than
an hour of gymnasium work. There is only one thing that hampers this
form of exercise--there are so many excuses to tempt one not to keep
it up. If one gets to a gymnasium there is an instructor or director
who keeps tabs on one's hours and so helps a weak human will, and
excuses are easier made to one's self than to others.


Massage as Exercise.--This curious tendency of men to take their
exercise far more regularly, provided some other is concerned in their
taking it so that it cannot be neglected without explanation, is
illustrated in many of the experiences of the doctor in modern life. A
number of forms of massage have come into vogue as wonderful
cure-alls. It is comparatively easy for some men, and above all for
many women, to take their exercise by means of massage rather than in
some more vigorous way that requires their own initiative. A man who
is working hard, and who feels the need of exercise, will not take the
easy natural way of getting up half an hour earlier, having his
breakfast half an hour sooner and then walking down to his office four
or five miles, but he hears of someone who gives vigorous massage and
he engages him to come every morning and exercise him for half an hour
or an hour. In order to do so, he has to get up an hour earlier, but
the fact that he has the engagement with someone else, rather than
with himself, makes it more difficult for him to make excuses, and so
morning after morning, in spite of the fact that he may have been up
late the night before, perhaps to a big dinner, he gets up to be given
his exercise. If he is a heavy eater he will, of course, at the end of
a week or ten days feel ever so much better for he has been using up
material that was clogging his circulation and irritating his nervous
system.

At the end of a month he will probably feel so much better that he
will conclude that he has found the root of all evil in life, or of
all disease, in a failure of circulation that can be removed by means
of massage, manipulation and passive movements. When he gets well
enough to give it up, he drops straight back into his old troubles,
because what he needs is a radical change of life that will adapt his
eating to the amount of exercise that he takes, and his exercise to
the amount that he eats. If this fails to come, he has had only a
temporary benefit that has probably tempted him rather to increase
{207} the amount that he eats normally than otherwise and will
probably do him harm in the end. This massage brings about a distinct
reduction in the weight of women, and as most of them are very
desirous of this, the remedy becomes even more precious to them than
to men. Here, too, however, it is only a temporary expedient. They are
tempted to eat more than before, or at least not to reduce their diet,
and the good that is accomplished is only for the moment, while no
habits, either of restraint of eating, or of more exercise in the open
air which so many of them need, have been formed.


Passive Movements.--The success of osteopathy has been largely founded
on this curious peculiarity of human nature. People are not satisfied
to regulate their eating and exercise in a sensible way. They prefer
to submit to various methods of exercise, manipulations and passive
movements which make up for the muscular exertion that should help the
circulation within the body, but do not accomplish the purpose nearly
so well as the voluntary exercise of muscles. It requires little
exercise of will to submit to this treatment, while for many people it
requires considerable exertion of will power to exercise their muscles
for themselves. The old particularly, who are likely to suffer from
achy conditions around joints, always worse on rainy days, which would
be expelled by enough exercise to stimulate the circulation in these
structures, find the new remedial measures of vicarious exercise of
great service to them and consequently osteopathy has gained many
votaries. Old members of many a state legislature who have been
accustomed to ride for so long that exercise is almost an unknown
quantity in their lives, are treated by the osteopath and lose so many
vague pains and aches and discomforts of various kinds that it has not
been difficult to persuade them that it is a great new discovery in
medicine, and so in many of the states the osteopaths have secured
legal recognition.


Summary.--Exercise, as exercise, often does harm rather than good.
Thin people seldom need exercise, stout people seldom take enough of
it. No one should be encouraged to exercise merely that he may be able
to use up material that he has eaten, when it is evident that he is
eating more than is required for his ordinary occupation. The question
can never be settled without taking into consideration all these
individual peculiarities of each case. Properly used, exercise is one
of the most important therapeutic aids. But it is liable to as many
abuses as are drugs, and the patient's attitude of mind toward any
particular exercise is always an extremely important factor. If the
exercise produces fatigue and disgust, then it will do no good, in
spite of all that is hoped from it. If it creates true diversion of
mind, it will surely be precious, even though it may, for other
reasons, seem unsuitable.



CHAPTER III

POSITION

There are many changes of position that relieve pain, lessen
discomfort, aid in excretion, and in the evacuation of material from
the body, yet it is often found that very little advantage is taken of
this natural method of therapeutic aid. Traditions and habit often
rule to such an extent that {208} certain quite unfavorable positions
are assumed, modifications of which frequently bring about distinct
amelioration of symptoms. Very often patients learn this alone. There
are many mechanical principles that can be applied in the treatment of
pathological conditions which patients will not use unless definite
suggestions are made. Often the physician has to suggest that they
should try first one position and then another, in order to determine
whether a certain amount of relief may not be afforded by position
alterations, and perhaps function encouraged, or at least certain
inhibiting factors modified for the better.


Favoring Return Circulation.--For people who have to stand much during
the day, position in their resting hours is often extremely important.
The caricature of the old-time American exhibited him with his feet on
the mantlepiece, or somewhere as high as his head. For thin
individuals there is no doubt that the placing the feet about as high
as the head often makes a very comfortable position for a time. To
those who have been standing much it is particularly restful. This may
be easily accomplished lying down, though it must not be forgotten
that the tendency to place the feet on a neighboring chair, or over
the arm of the chair, so often seen in young folks, is in response to
a physiological stimulus that brings relief to the heart by
encouraging by means of gravity the return circulation in the veins
from dependent portions of the body distant from the heart. For people
who have not much exercise, and who have to stand all day, a brisk
walk or leg exercises that thoroughly empty their muscles of blood by
bringing about active contraction of them is important as a factor in
their hours of rest. It makes all the difference in the world between
the feeling of intense tiredness due to the sluggish circulation, and
a return of vigor in the muscles.


Varicose Veins.--For patients suffering from varicose veins, position
is particularly important. When they have to stand much, their limbs
get painfully tired. The ache in the sense of fatigue is reflected
over the body with the resultant depression. Active exercise, for a
time, is not so good for them, and yet it is helpful. The ideal relief
from their achy condition is afforded by gentle massage upwards of the
limbs. That empties the dilated veins of blood and restores vigor to
the circulation. It must not be forgotten, that when the circulation
in the lower limbs is rendered sluggish by varicosity, the heart is
also affected because it is so much more difficult to secure the
return of blood through the tortuous dilated veins. This accounts for
the intense general sense of fatigue that many of these patients have.
Varicosities have a definite tendency to develop in those who are
occupied in standing occupations, waiters, footmen, clerks, and the
like, and often they have to continue at these occupations in spite of
the varicose condition. It is particularly important for them to have
an hour of lying down during the middle of the day so as to break
their day's work in two. With a little insistence it can be secured in
a great many cases and will afford more relief to the patient than
anything else that can be done, even the wearing of rubber stockings,
bandages and the like. I have known waiters massage each other at the
time they had their period of rest with excellent results.

For the rupture of a varicose vein, position may be one of the most
important auxiliaries to prevent serious hemorrhage. I remember as an
ambulance surgeon once being called to see a case in which a great
deal of blood {209} had been lost because efforts had been used to
stop the bleeding by the application of a tourniquet. This shut off
the superficial arteries, but not the deep ones and effectually
prevented the return of any venous blood into the trunk, while all the
time the ruptured varicose veins continued to bleed profusely. Local
applications of styptics failed, of course, because the varicose vein
itself had nearly the diameter of the little finger. Pressure over the
wound did good for the time, but the bleeding was renewed whenever it
was let up, and the two physicians in charge, alarmed at the loss of
blood, were beginning to lose their heads. The ambulance was summoned
to take the patient to the hospital and when it was suggested that if
the tourniquet were removed and her foot was elevated the bleeding
would probably stop without more ado, the suggestion seemed too simple
to be true, but the event showed that that was all that was necessary.


Relief for Flat Foot.--For the achy discomfort of flat-foot, which is
usually felt much more in the calf and the knee than in the ankle,
some vigorous exercise for the foot, and especially for the calf
muscles, at times during the day is likely to give great relief. Ten
minutes of vigorous movement of the calf muscles followed by half an
hour lying down will save most of them from the intense tiredness that
is very discouraging in the late afternoon in many of the standing
occupations. This relief removes from patients' minds the common idea
that there must be something serious the matter with them. A good many
of those who are cured of rheumatism by osteopathy, and of kidney
trouble by the advertising specialists, and of various nervous
diseases by new thought and irregular mental healing, are only
sufferers from conditions such as can be relieved in this way. When
flat-footed people sit down they should be advised to cross their feet
(not their legs), because this emphasizes the arch of the foot
somewhat and helps to strengthen and preserve it.


Abdominal Relaxation.--Many of the discomforts within the abdomen of
which patients complain, especially whenever their attention is
concentrated on them, can be benefited by suggestions as to position.
Many a man who feels very uncomfortable after a hearty meal when
sitting curled up beneath a lamp to read the evening paper, does not
notice it at all when he stretches out on an easy Morris chair and
with head back talks to friends. Many a man who thinks that his
discomfort after dinner must mean serious dyspepsia, finds that a game
of billiards after dinner will often dissipate almost completely his
ill-feeling, unless, of course, it is due to overeating. After meals
generally, positions that crowd the abdominal organs should be
avoided. It must not be forgotten either that when lying down a full
stomach may very well interfere with the heart action and produce
marked palpitation. There are many men who cannot lie down within two
hours of having eaten a hearty meal without decided heart
irregularity, though while they are sitting up or standing quietly, or
even moving, there will be no sign of this. Many of the vague
discomforts within the abdomen, those due to movable kidney, or even
chronic conditions in the biliary or urinary tracts, are only manifest
when there is crowding of the organs within the abdomen.

How much the mechanical element may mean in kidney and biliary
conditions is well illustrated by the relief often afforded by changes
of position when calculi in these organs are giving trouble. Both
renal and biliary calculi, which perhaps have been lying quite
harmlessly in their positions {210} for years, are especially likely
to become productive of discomfort by a jolting ride, or the jar of a
fall, or by the influence of changes of position produced by gymnastic
efforts of an acrobatic kind, or by a loop-the-loop experience, or
something of the kind. In spite of this, only rarely does the
physician try to use changes of position for their relief. I have seen
a man suffering from excruciating biliary colic get almost immediate
relief when put standing on his head alongside of a lounge. He looked
upon it as magic. It was only that the stone, in the midst of the
relaxation of all abdominal muscles produced by the unusual position,
was able to drop back into the gall bladder, where it had been for
months perhaps years before without giving any trouble. Similar relief
is often afforded from the pain of kidney stones before they become
definitely engaged in the ureter.


Raising the Head.--Patients suffering from respiratory difficulties
usually learn to accommodate themselves to such changes of position as
will afford them the greatest relief. The difficulty of breathing
leads to such tossing about that the position easiest for the patient
is almost inevitably found. When respiratory difficulties first
declare themselves patients may not realize how much relief will be
afforded by raising the head, or by the assumption of a sitting
position. Often such patients prefer to sit in a chair. It should be
borne in mind that, wherever this is compulsory, dispositions can be
made so that the chair shall be as comfortable as possible, that its
seat edge shall not press upon the underportion of the legs so as to
impede blood circulation, nor press upon nerves, and that comfortable
arrangements shall be made for the arms. When the patient's head has
to be raised in the bed, it is much better to raise the mattress by
placing some large properly-shaped object underneath it, so as to
secure a gradual slant rather than have the patient's head and upper
portion of the thorax bent by pillows. In default of something better,
a chair placed so that the mattress lies along its back will be a
handy aid. This is a matter of nursing rather than strictly of medical
attendance, but unless the physician pays attention to it, it will be
neglected, or at least in many cases not used to the best advantage.

Whenever there is difficulty of expectoration, especially when
expectoration is abundant as in certain of the chronic bronchitises,
and above all in dilatation of the bronchi, the advantage of position
should be taken to aid in the expectoration. Patients who have to
cough up large amounts in dilatation of the bronchi and who have long
severe fits of coughing in the early morning, will often obtain a
great measure of relief by leaning out of bed with one hand on the
floor, doing their coughing in that position. Gravity helps in the
emptying of the pockets of the bronchi and in five minutes they
succeed in getting up satisfactorily as much material as would come
up, only after severe convulsive efforts for an hour, when gravity was
in opposition to their efforts. Children in whooping cough naturally
bend over in order to cough. They will cough easiest if placed on a
bed with a pillow beneath their chest so as to lift the face from the
mattress, or in the case of older children, with the head projecting
beyond the edge of the bed. This is only a trifle, but it will often
save children severe convulsive efforts. Tuberculous patients who have
to cough much, should be encouraged to find for themselves by trial
whether certain positions, leaning out of bed, may not be of great
service to them. There is often in advanced cases an accumulation of
material during {211} the night that must be expectorated, and the
patients are severely shaken up by their efforts to bring it up. I
have known cases where a considerable measure of relief was afforded
by leaning out of bed with the elbow on a pillow, a chair or
foot-stool somewhat lower than the level of the bed. The mechanical
help of gravity is particularly important where cavities exist and a
considerable amount of material has to be emptied out of them.

In modern surgical times one does not often see the emptying of a
purulent pleurisy through the bronchi, but I once had an opportunity
to see the termination of one of these cases in a very favorable way.
When I saw her the patient had already coughed up a cup full of
purulent fluid and, altogether, about a quart of pus was thus
evacuated. The patient had been so ill that the effort was
considerable, but the evacuation was greatly helped by having her lean
out of bed whenever material was to be expectorated. The patient is
still alive and in good health--fifteen years after the event.


Heart Cases.--Position is also often of very great importance for the
relief of the symptoms of patients suffering from heart affections.
For organic heart affections, rest in bed is often advised. It must
not be forgotten that this does not necessarily mean in a recumbent
position. Whenever there is difficulty of breathing in connection with
an affection of the heart, the recumbent position is extremely
uncomfortable. This is nature's safeguard against the accumulation of
fluid in the dependent parts of the lungs at the terminal capillaries
of the pulmonary circulation. Most of the natural demands have a
definite reason and are prophylactic rather than merely a symptom of
aimless discomfort. Patients with heart disease often want to sit up
in a chair. Their wish should, as a rule, be yielded to. There is no
need of their sitting in a narrow uncomfortable armchair, nor of being
incommoded by the position they have to assume. The end of a large
lounge, especially one that curves over towards the floor on which
pillows can be piled so as to make the patient comfortable, and yet
afford many changes of position, is the best.

In general, the arrangements should be such that changes of position
can be secured without much difficulty. These prevent hypostatic
pneumonia and guard the patient against serious accumulations in the
lung tissue because of sluggish circulation. Changes of position can
be used as valuable suggestions. Often the main portion of the
patient's symptoms consists of the intense fatigue due to one
position. This can be relieved and the patient made to feel that,
after all, the ailment to which he is suffering must not be so serious
since relief can be afforded so simply. Besides, when patients
complain, something must be done for them. Medicine cannot be given
for every symptom and yet some remedial measure there must be to
satisfy them. This satisfaction will often be secured by changes of
position, by slight local treatment, by the adjustment of pillows so
as to relieve fatigue of particular muscles and parts of the body, and
by the movements of the limbs and the head into other positions than
those in which they have become fatigued. The experienced nurse is of
the greatest possible value in these cases.


Restlessness.--Usually restlessness is considered to be an unfavorable
symptom of disease, just as are pain and tenderness. Like these,
however, it is really conservative rather than in any sense
destructive. Pain prevents serious changes from taking place without
our attention being effectively {212} called to them. Restlessness
induces the patient to change position frequently and often leads to
the discovery of some position in which there is much more comfort
than the one that had been assumed. Restlessness, in the recumbent
position, is usually nature's protest against the maintenance of a
posture in which, owing to failure of circulation, there may be
leakage of serum into the lung tissues with dangerous results.
Restlessness, in abdominal pain, often leads to such a change of
position as affords the best condition for the relief of the
discomfort as far as that may be brought about by position of muscles.
The man with colic very soon discovers that lying on his stomach may
relieve his pain. The drawing up of the knees in peritoneal conditions
is the result of a similar reaction. The physician must learn to
imitate nature, and recognize what mechanical conditions are likely to
be of help. As soon as these afford relief, they act as a strong
favorable suggestion, on the patient, and relieve dreads with regard
to his affection.


Joint Affections.--In painful joint conditions, position may help much
to bring relief or at least considerable mitigation of symptoms. In
rheumatism, for instance, of the acute articular type, a number of
small pillows can be disposed in various ways, underneath the
patient's limbs, between them and in other positions, so as to give as
much comfort as possible and will often be of great value. There
should be at least half a dozen pillows at the disposal of the
patient, besides three or four for the head. In certain relaxed
positions of the joints, there is more room within the capsule than
others and, almost unconsciously, the patients assume such positions
when there is pain from effusion. Occasionally, however, in the midst
of fever, or because of apathy, patients may not do this, and then
care should be taken to bring them some measure of relief. Generally
patients suffering from fever, with delirium of typhoid condition,
that is, when there is considerable apathy, should have their
positions changed gently from time to time to prevent discomfort
developing, and as a prophylactic against skin disturbances from
pressure. In children, this is particularly important.


Bladder Evacuation.--In emptying the bladder position may mean much.
After childbirth, especially the first, many women are quite unable to
empty their bladders while lying down, though if they are allowed to
assume the usual position there is little or no difficulty. In certain
sensitive men whose power over their bladder is disturbed by
self-consciousness, the presence of anyone in the room or near them,
makes it impossible for them to urinate, and this is particularly true
if they are lying down. In the milder forms of prostatism position
occasionally seems to have some influence in helping to empty the
bladder. When there is a prostatic bladder pouch behind the prostate,
it is quite impossible to empty this in the standing position. It may
be emptied in the prone position, that is, lying face downwards,
particularly if the pelvis is elevated above the rest of the trunk.
Undoubtedly some of the cures reported after operation, when the
operation itself effected no reduction in the size of the prostate (as
the removal of the testicles or vasectomy), the improvement was
brought about partly by the more favorable position in which, for
weeks after the operation, the patient emptied his bladder, and also
by the greater control gained over it, by the persuasion that the
operation would do him good. The same suggestion can be made in
connection with the new position for urination with just as good
effect.

{213}

Intra-abdominal Conditions.--There are many intra-abdominal conditions
in which position is of great importance for the relief of pain.
Appendicitis cases are found with the right knee drawn up because this
relieves the tension of the abdominal muscles, and probably also of
the large muscles that go to the thigh and lie behind the peritoneal
cavity. In most cases of intra-abdominal pain flexing of the knees on
the abdomen means much in affording relief, and patients usually
discover this for themselves. There are certain apathetic patients,
however, who need to be helped by suggestions. In certain of the
painful conditions, due to intra-pelvic conditions, relaxation of
muscles by flexion lessens the pain. Pressure upon the abdomen, as by
lying on a pillow, often does this also. Apparently one reason why
children with flatulent colic stop crying almost at once, when laid on
their stomachs, is because the pressure thus produced tends to bring
about a movement of the gas that, collected at one or two places, was
causing painful distention.


Importance to the Physician.--There are many other suggestions with
regard to position that will occur to thoughtful physicians in
particular cases. The one idea is to secure such an alteration of the
posture as is likely to bring about mechanically relief of pain. If
relief is afforded in this way, as has already been emphasized, a very
favorable influence is produced on the patient's mind. Above all, he
realizes that his physician not only understands his general
condition, but his experience with many patients suffering from the
same ailment has given him the power to direct even such slight
changes of position as will give comfort. Nothing that I know adds
more to the confidence that a patient has in his physician than the
realization of this sort of knowledge. Therefore, the necessity for
such consideration of each individual case as will enable the
physician to recommend such modifications of position to patients. At
the same time the patient's mind can be influenced very favorably by
attaching definite significance to these alterations, and having them,
as it were, repeat their favorable suggestions every time that he
thinks about them, and be pleased as to the relief they have afforded.
This is the sort of psychotherapy that is particularly likely to be
successful, and it needs careful cultivation and development.



CHAPTER IV

TRAINING

One of the most important factors for therapeusis in the sense of the
amelioration of defective motor conditions, the relief of disturbing
sensory affections and the restoration of or compensation for
defective functions of various kinds is training. By this is meant the
training of the power of attention and its concentration in such a way
that defects are overcome. There are many examples of almost marvelous
improvement of function brought about in this way that are familiar,
but it is well to recall some of them here in order to illustrate the
uses to which this therapeutic mode may be applied. A blind man is
able to read by means of his finger tips, and to recognize raised
letters that seem quite beyond the possibility of tactile recognition
by {214} ordinary individuals gifted with all their senses. The
peculiar skill is simply due to the individual being able by
concentration of attention upon slight variations in touch sensation
to recognize even minute differences readily and so read raised
letters with comparative ease and rapidity.

Over and over again it has been shown that neither the congenitally
blind nor those whose vision has become defective have any better
sense of touch than the average person. With an esthesiometer, their
power to recognize the distance between the points of a calipers is
shown to be no better than that of an ordinarily sensitive individual.
This is illustrated in other ways. Certain blind persons, even those
born blind, are known to be able to distinguish colors more or less
accurately, that is, at least the three primary colors. Their power to
do this is consequent upon a faculty of recognizing differences in
heat absorption. The ordinary seeing person going into a room in the
dark recognizes at once the difference between a pencil and a piece of
metal of the same shape and size by its weight and the greater
tendency of the metal to feel colder. When we are not sure whether a
pillar in a structure is of stone or an imitation, we determine this
by touch, and the fact that stone absorbs heat rapidly while wood and
other imitations of stone do not. It is the same faculty for
distinguishing specific heat that enables certain blind people to
recognize colors. If pieces of cloth of different colors are put over
snow when the sun is shining on them, it will be found that black
absorbs much more heat than the colored cloths, or white, and
consequently that the snow melts faster beneath the black. After black
comes red, then green, then blue. It is this difference in the power
to absorb heat that the blind recognize and thus distinguish colors
after long patient training of themselves.


Obstacle Sense.--An example of the value of training is the so-called
obstacle sense which has been rather carefully studied in recent
years. By means of it blind people are able to avoid larger obstacles
and to know when they are passing an open door or window on a corridor
or a building alongside a street. Blind children have been known to
play in a garden where there were trees and other obstacles and
carefully avoid them even while moving rather rapidly. This sense is
disturbed whenever there is loud noise in the vicinity. It is not very
active and yet it is of considerable value to the blind. Its
disturbance by noise would seem to indicate that it is due to some
sense faculty in the tympanum, or ear drum. It exists in everybody,
but remains quite undeveloped except in those who need it and
therefore learn to make use of it.


Touch and Sight.--The triumph of training is to be seen in the cases
of those who are born blind and deaf and who yet are taught to
understand through lip and throat reading by the tips of the fingers
and taught to talk by being shown patiently the method by which others
accomplish it, though the only avenue to their brain is the dull sense
of touch which means so little for the ordinary individual. The cases
of Laura Bridgeman and of Helen Keller illustrate how a sense that is
usually quite neglected can be made to supply the place of both the
eyes and the ears by patient, persistent training. Lip reading by
sight is, of course, a very interesting example of the same principle
that can be learned by anyone who has good sight in a comparatively
short time. There are compensations of this kind and powers of
development latent in every sense and function of the body that can be
{215} employed to make life interesting and to restore usefulness
after nearly every form of lesion or defect. Practically all of this
compensatory power is mental, hence its place in psychotherapy. We do
not increase the power of the sense but by concentration of attention
the mind is rendered capable of obtaining definite information from
sensory stimuli that are present in every person but that are
ordinarily neglected.


Hearing.--One of the most surprising instances of the value of
training for cases in which favorable results seemed quite out of the
question, is Urbantschitsch's method of training the deaf to hear.
After investigating it personally I reported it in the _International
Clinics_.   [Footnote 24] Patients who could hear but very little,
indeed, only the loudest noises, were trained by means of loud
shouting and the hearing of loud notes gradually to catch sounds more
and more easily until not infrequently they could hear rather well.
Sometimes even those who were thought to be absolutely deaf to sound
were found to be able to hear very loud sounds and then it was
invariably discovered that by practice they could be made to hear much
more. The secret of the success consisted not in any increase in the
power to hear, but entirely in training the attention to recognize and
differentiate sounds so that what seemed at first a confused murmur
gradually became intelligible. It is exactly the same process as that
by which a man learns to read with his fingers. He is not able to
differentiate the letters but after a time it is possible to do so
without difficulty.

  [Footnote 24: Lippincott & Co., Phila., Vol. IV, 8th series, 1899.]


Equilibrium.--There are typical examples of almost as striking
increase of muscle sensation, or rather of ability to distinguish
minute differences in muscular sensation, noted in those who train
this faculty carefully. Acrobats succeed in developing wonderful
control over muscles and marvelous response to slight disturbance of
equilibrium. The ordinary individual has comparatively small balancing
powers, but the slack-rope performer seems almost to defy the laws of
gravity, because he has learned so to coordinate all muscular action
as to enable him to maintain his balance. He has trained himself to
distinguish every variety of message from his semicircular canals. Of
itself neither of these senses gives us very much information, indeed,
only as much as we ask for from it, but when we pay careful attention
to the minute details of the information that it imparts, we are able
to use it to great advantage.


Muscle Training.--It is this power of training to enable us to
appreciate minute sensations that forms the basis of the Frenkel
treatment of tabes. For the proper guidance of the muscles the
muscular sense is all-important, though ordinarily we are quite
unconscious of the information it conveys. This is seriously disturbed
by the degeneration in tabes. The patient can, however, be taught to
use even the slight amount of it that remains to great advantage or
else to avail himself of some other compensatory sensations which will
enable him to guide his muscles in various motions much better than
before.

This same faculty can probably be employed in many other conditions.
Frenkel has shown that it is applicable in paralysis agitans and
markedly relieves the rigidity that is so annoying a symptom. It gives
these patients something to occupy their minds, too, which means a
great deal for their {216} general condition, for occupation of
attention saves them from neurotic disturbance of themselves.

Sufferers from infantile paralysis can be taught to do many things
with their weakened muscles that seem to be quite impossible to them.
It requires patience to get results, but they mean so much that the
efforts are well worth while. After cerebral incidents, sometimes
actual apoplexies, sometimes injuries, occasionally serious effusions
due to kidney diseases, there may be disturbance of motor functions.
It is surprising how often training will enable the sufferer to use
his muscles much better in these cases than at first seemed possible.
I have seen a man who had lost most of his power for writing after a
cerebral incident regain it as a consequence of being taught to write
from his shoulder, instead of from the forearm as had been his custom.


Heart Training.--In recent years we have learned that training is not
only good for the external muscles and enables them to do more work
without discomfort, but that it is particularly beneficial to the
heart muscle whenever that organ can respond to it favorably. At all
of the heart cures in recent years, exercise of some kind or another
is one of the important features and the failure of physicians
generally to secure as good results while pursuing all the other
methods followed at these cures, seems to show that exercise was
probably the most important factor. Nauheim is the typical heart cure
and there, besides the resisted movements in the bath, there is the
graduated exercise of the walks around the town, all of which, owing
to the situation, lead up hill. Walking up hill, even though it be a
gradual ascent, might seem to be the worst possible exercise for heart
patients, yet it proves eminently beneficial.


Respiratory Training.--Shortness of breath is often a bothersome
symptom, especially for stout people, and prevents them from taking
necessary exercise. When it cannot be traced directly to some
affection of the heart or of the circulatory apparatus, it is usually
due to lack of exercise. Much can be done for it by deliberate
training. In the modern time, with elevators so common, people seldom
have to walk up-stairs, and consequently one of the modes of exercise
that was particularly likely to furnish some training in deep
breathing is absent. Any one who has seen the shallow breathing of
many of the patients who come to Nauheim and how much it has improved
by the gradually increased walks up the hills around the valley, will
appreciate how much training in deep breathing means. This exercise of
the diaphragm will often give benefit besides in making the bowels
more regular, and in getting rid of the accumulation of fat in the
abdomen, which is one of the mechanical causes of the interference
with the diaphragm and consequent shortness of breath.


Training the Appetite.--Just as training may be used for the sensory
and motor systems that are external, so it may also be used for many
internal functions analogous to these. There are a great many people
who eat too little. They are the nervous, irritable persons with no
fund of reserve energy to draw on when anything happens, and who are
in their years before middle life likely to be the victims of
infectious disease. They suffer much from lack of proper covering in
the winter time and from a certain protection that is afforded to the
nervous system generally by being up to weight. Often their
under-weight is a life-story, and occasionally it is a family matter.
When {217} they suffer from neurotic symptoms a gain in weight nearly
always does them good. They complain that when they increase their
diet they have uncomfortable feelings. This is only what is to be
expected, since the muscularis of their stomach--much more important
than its secretory function--has not been accustomed to as much
exercise as is now being demanded of it.

On the other hand, for those who are over-weight, training in eating
less is the one important therapeutic factor. If their diet is cut
down suddenly, they soon become discouraged. If there is a gradual
reduction of food quantities, variety being allowed, so that they may
eat practically everything they have been eating before, the system
gradually accommodates itself to less and less food. This is the only
sensible way of bringing about reduction in weight. It requires
constant attention over a long period, but it can be done with
excellent success.

In the same way the bowels may be trained to perform their work
regularly. Habit means probably more with them than any other factor.
Our digestive tract, however, is largely dependent on habit. We get
hungry three times a day or twice a day, according to the custom that
we have established. Countries differ radically in the matter, and
nearly always, when a man goes from one country to another in early
years, he changes to the habits of the new country, though if he comes
after middle age he usually clings to those that he is used to.


Training to Stand Pain.--There are many painful conditions, especially
involving the muscles in the neighborhood of joints, that are worse on
rainy days and are spoken of as rheumatism, that can be very much
improved by training in the use of muscles. As men grow older and gain
in weight, the lack of exercise in their sedentary lives incapacitates
their muscles for activities of many kinds. The consequence is that
where most strain is put upon them, in the neighborhood of joints,
they readily become tender and painful. It is this class of cases
particularly that is benefited by irregular practitioners of all
kinds. Mental healing, osteopathy, Eddyism, the many liniments,
rubbings and manipulations prove beneficial. What is needed is
training in the use of muscles so as to enable them to do the work
that is required of them without discomforting reaction. This is
particularly true for the leg and foot muscles. Exercises that
strengthen the muscles of the calf and of the thigh, and particularly
such as require free movement of the foot, are almost sure to relieve
these patients of many annoying symptoms. Pains around the ankles and
in the knee and hip, worse in rainy weather, disappear as a
consequence of such gradually increased use of these muscles as gives
them increased nutrition and power. This subject is discussed more
fully under Foot Troubles and Painful Conditions of the Knee.

There may be a training in bearing discomfort which is of great value
to over-sensitive patients. Some nervous patients seem to suffer
merely from their ordinary physiological functions. These are the
patients who abuse the drugs that are supposed to bring relief. There
is just one mode of treatment that is successful with them: they must
be told to bear their discomfort for a while without seeking drug
relief, but always securing freedom from discomfort by means of
attention to other things, until gradually they have succeeded in
diverting their minds from the concentration of attention on their
functions which is causing their disturbance. The whole programme
{218} need not be outlined to them or they will perhaps have a
revulsion of feeling against it that will make its accomplishment
impossible. They can, however, be made to stand their discomforts for
a time with the promise that it is for the best, since there will be
eventually an improvement.


Intellectual Faculties.--Nearly every one of our faculties can be
trained to do much better work than we have any idea of if we only are
willing to take the trouble and give the attention. I have often shown
people who came complaining of loss of memory that if they wanted to
train themselves to remember they could do so. The memory probably
cannot be bettered any more than can the sense of touch in the blind
man, but by attention to minute details, in the concentration of the
mind on certain subjects, it can accomplish results that seemed quite
impossible before. All systems of improving the memory are founded on
this method of concentrating attention on what one wishes to remember
and connecting it with other things that we know by experience are
readily remembered.



CHAPTER V

OCCUPATION OF MIND


Two classes of patients frequently apply to physicians for relief from
various discomforts. They are, first, people who have no regular
occupation and who often are in what is supposed to be the happy
position of being able to do just what they please. The second class
consists of those who take their occupations too seriously, so that
they never get away from them and, as a consequence, disturb their
physical functions. The feelings that these two classes complain
of--for, when analyzed, their symptoms prove really to be
uncomfortable feelings--can usually be "bothered" away and, if not
entirely forgotten, made to disappear when the patients become deeply
interested in something other than their usual occupation. The first
class of patients needs occupation of mind; the second needs diversion
of mind, and that subject will be taken up in another chapter.


Uncomfortable Sensations, Their Location and Causes.--These pains and
aches, as patients call them, though it is well to remember that they
are only discomforts, senses of unequal pressure, of constriction, or
perhaps only unusual feelings, or consciousness of sensation, may
occur in every part of the body. Perhaps they are most commonly
complained of in the head. Many of the so-called headaches that are
more or less continuous consist of these senses of pressure or of
constriction over a particular part of the skull. Sometimes there may
be a sense of pressure at the back of the eyes. Very often there is a
feeling of heaviness at the back of the head that makes the patient
feel as if relief would come if the head were allowed to drop forward
and if sleep could be thus obtained. Every other portion of the head,
however, even within the cavities, may have some of these
uncomfortable sensations. In some persons, there is a tightness in the
throat. In others, there is a feeling of fullness of one cheek and the
dread that they may not be able to use it properly in talking.
Sometimes the uncomfortable feeling is within the nose. Not
infrequently the discomfort is in the ear.

{219}

All of these may be due to local conditions which need to be
corrected, but in most cases nothing is found locally, or at most
there is some functional disturbance so slight that, though it is
shared by a great many people in our climate, others do not complain
of it at all. It seems evident, therefore, that the discomfort must
result from the sensitiveness of the individual emphasizing the
significance of some slight disturbance.

Every portion of the body may suffer from these discomforts. The upper
part of the back, especially below the base of the neck, is a favorite
location in men, and particularly in those who bend over a desk. The
lower part of the back is affected in such men as tailors and cutters
who stoop incessantly at their work. In women, the lower part of the
back is likely to suffer, and this is usually attributed to genital
conditions, but constipation may play quite as large a role as the
genital organs. Some of the stooping occupations of women, at the
sewing machine or dressmaking, or even harder occupations, as
sweeping, washing, and the like, may also be responsible. The
commonest source of discomfort is, perhaps, the upper left-hand
quadrant of the abdomen. This seems to be due to the distention of the
stomach, either by gas or by liquid. Vague discomforts may occur
around the umbilicus, often due to the presence of gas, with or
without borborygmi.

Generally the local condition is only an occasion, and the real cause
of the complaint is the lack of occupation of mind and consequent
concentration of attention on any organ whose function happens to be
disturbed sufficiently to make one conscious of its action.


_Lack of Occupation_.--For all of these cases the most important
therapeutic factor is occupation of mind and diversion of attention.
In our time, social conditions allow a large number of people to have
very little occupation. For instance, many women of the well-to-do
classes have absolutely nothing that they must do. Various phases of
this are discussed in previous sections.

As a rule, it is useless to try to relieve these discomforts by
anodynes. Many an opium habit has been formed by a turning to opium in
such cases. The coal tar products are greatly abused here, for they do
not bring relief to queer feelings nor to a sense of pressure or
discomfort; they rather add to depression. What they are efficacious
for is acute pain. The coal tar products relieve even toothache or
neuralgia, as well as a real headache, but I have had patients tell me
over and over again that the continuous headaches from which they
suffered were not relieved in the slightest degree by phenacetin or
acetanilid. Occasionally one hears of hyoscine or hyoscyamus suggested
for these conditions, but they are quite as useless and as much
contraindicated as opium or the coal tar products. As a rule, these
headaches are relieved by lying down; they disappear during sleep. The
real indication for treatment, however, is found in the fact that all
of these vague discomforts are much better or even disappear when the
patient is intensely occupied, or at least pleasurably engaged.

What these people need is occupation that really catches their
interest and takes attention from themselves. One of the most striking
expressions of this truth that we have comes from the poor, sad, mad
poet, Cowper:

  Absence of occupation is not rest;
  A mind quite vacant is a mind distressed.


{220}

And surely poor Cowper, himself the victim of depression, saved from
himself only by the suggestion that he should put into poetic form the
thoughts that came so abundantly to him, could well understand the
depth of wisdom in his couplet. The story of Cowper's life is enough
of itself to encourage physician and patient to persevere in the
effort to lift depression by occupation, since the fruits of that
occupation may prove so valuable.


_Mental Short-Circuit_.--The minds of these people must do something,
and since there is nothing really occupying for them to do, in a very
expressive modern phrase, they are doing their possessors. As we
suggest elsewhere, the nearest simile is that of the short-circuiting
of a dynamo. Mental energy is exerted harmfully within the machine
instead of in doing work.

See what happens in these cases when by some chance the women, or the
men, who complain almost constantly are suddenly deprived of the means
which enabled them to live an aimless life. The physician often has
patients who have been in affluence but after a financial panic are in
straitened circumstances. It is interesting to note what an excellent
tonic effect, in younger people always, in older people very often,
the change of life has on these chronic valetudinarians. Sometimes
this is attributed to the simpler life which they lead when poorer,
occasionally to the lack of responsibility, or other similar reason.
Nearly always it is easy to see that the real cause of the improvement
in health is the occupation of mind with serious interests outside of
self.


Regulation of Life.--In the matter of occupation, and especially
occupation of mind, the formation of habits and the training of the
will are extremely important. In his book on "The Education of the
Will," which was so popular that it went through over thirty editions
in France, M. Jules Payot [Footnote 25] emphasizes the necessity for
deliberately arranging the details of life so that time shall not hang
heavily on the hands, he reverts to certain rules of life of the old
religious orders, and to the habits advised by spiritual directors. He
counsels that every one should make an examination of the day's
happenings at the end of it, in order to see just where the failures
lay and in what accomplishment was made. At the end of this
old-fashioned examination of conscience, he counsels that a set of
resolutions for the next day be made and an arrangement of work for
various times, so that even more may be accomplished.

  [Footnote 25: English translation by Dr. Smith Ely Jelliffe.
  New York, 1909.]

M. Payot further suggests that a certain time be given up to
reflection, or as he calls it, meditation, on the significance of life
and on the consideration whether something valuable is being made of
it. Without this he insists that it is easy to let one's self slip
into habits of life in which absolutely nothing is accomplished for
self or others. If there is no real accomplishment, then pleasure soon
palls, because pleasure has a place only as an interval in the midst
of labor and as a relief from effort. These reversions to the old
modes of life and thought of the monastic communities show how little
of real advance there is in life, and what excellent conclusions
serious men came to even in the distant past. Certainly for many of
the leisure class in modern times only the use of periods of
reflection and the examination of {221} results obtained will serve to
prevent that utter waste of time which leads to the intense
dissatisfaction that is often reflected in the general health.


Thought for Others.--After forgetfulness of self, the most important
factor in psychotherapeutics is thoughtfulness for others. Ordinary
diversions are quite insufficient to occupy most people. One must have
a serious occupation that appeals deeply, and then diversions of mind
will be useful for purposes of recreation. Pleasure, so-called, if
pursued not as an interruption from work but for its own sake and
without serious occupation, palls, and after a time its votaries find
life is scarcely worth living. The pursuit of pleasure as the sole
interest of life is one of the most fruitful resources of depression,
discouragement and neurotic symptoms with which modern physicians are
brought in contact. The only way to be sure of having compelling
interests is to be so much occupied with other people that one forgets
self.

  Yet mere flippant excitement and superficial entertainment is
  nothing but a cheap counterfeit of what is needed. Voluntary effort
  is needed, and this is the field where the psychotherapist must put
  in his most intelligent effort. There is no one for whom there is
  not a chance for work in our social fabric. The prescription of work
  has not only to be adjusted to the abilities, the knowledge, and
  social conditions, but has to be chosen in such a way that it is
  full of associations and ultimately of joyful emotions. Useless work
  can never confer the greatest benefits; mere physical exercises are
  therefore psychophysically not as valuable as real sport, while
  physically, of course, the regulated exercises may be far superior
  to the haphazard work in sport. To solve picture puzzles, even if
  they absorb the attention for a week, can never have the same effect
  as a real interest in a human puzzle. There is a chance for social
  work for every woman and every man, work which can well be chosen in
  full adjustment to the personal preference and likings. Not
  everybody is fit for charity work, and those who are may be entirely
  unfitted for work in the interest of the beautification of the town.
  Only it has to be work; mere automobiling to charity places or
  talking in meetings on problems which have not been studied will, of
  course, be merely another form of the disorganizing superficiality.
  The hysterical lady on Fifth Avenue and the psychasthenic old maid
  in the New England country town both simply have to learn to do
  useful work with a concentrated effort and a high purpose. From a
  long experience I have to confess that I have seen that this
  unsentimental remedy is the safest and most important prescription
  in the prescription book of the psychotherapist.


_Care of Children_.--Probably the most important therapeutic factor in
the cure of the ills which come to unoccupied women is the finding of
some occupation that will absorb their hearts as well as their
intellects, that is, satisfy their feelings as well as appeal to their
intelligence. That very acute observer and kenner of her sex, Mrs. St.
Leger Harrison, who is Charles Kingsley's daughter and writes under
the pseudonym of "Lucas Malet," said in "Sir Richard Calmady": "Feed
their hearts and the rest of the mechanism runs easy. I have known
disease to develop in a perfectly healthy woman simply because the
heart was starved." For most women the only thing that will entirely
satisfy the heart or keep it from hunger is children. Fortunately an
interest in other people's children can, under certain circumstances,
be almost as satisfying as in one's own.


_Interest in Others_.--Probably the best possible occupation that a
childless woman can have is the care of others. Charity in one form or
another satisfies the emotions as well as creates interest and gives
varied occupations. Even the frequent disillusions that are
encountered in charity work only add variety {222} to the experience,
and do not discourage those who have the real charity instinct. For
women particularly, as we have said, some charity that brings them
much in contact with children is the surest preventive of
over-occupation with themselves and over-emphasis on their feelings
and sufferings. Many a woman in our large cities owes her freedom from
the neurotic symptoms to which her sisters are subject, to her
interest in tuberculous children. There is just enough of suffering to
arouse all the pity of the visitor, without so much of anguish as
would deter the more delicate from being interested in the work.


_Touch with Real Suffering_,--For patients who think they have much to
suffer, yet whose complaints are all of subjective feelings of
oppression and depression, there is no better remedy than to come in
touch with real suffering. I have known not a few neurotic young
women, who were preparing for themselves years of suffering by
over-attention to little pains and aches, saved to a life of
usefulness and even happiness by having to nurse near relatives
through the last stages of fatal cancer. When these neurotic persons
are brought intimately in touch with real suffering, have their
sympathies aroused, and see how well human nature can bear pain when
it has to, and yet not be impatient, nor wish to end it all, then a
renewed life comes over them and they cease to be preoccupied with
themselves.


_Sympathy as a Remedy_.--In former days, when hospitals were not so
well provided and trained nurses non-existent, all forms of suffering
had a wider appeal and aroused more active sympathy than at present.
It is true that patients, in both hospitals and homes, suffered from
the lack of trained nursing, and that was an even greater
disadvantage. But it is, nevertheless, too bad that more actual touch
with suffering does not come to people now, for nothing is so sure to
make little ills disappear as the sympathy aroused by the sight of
real suffering. Certainly, our cancer cases might well be a strong
therapeutic factor for many of the neurotic ills of the world. They
are, of course, deterrent to many people. It would seem to add
needlessly to human suffering for some of the delicate to have to be
in contact with what is one of the most awful afflictions that flesh
is heir to. If death and suffering were not inevitable, we might try
to save people from the suffering which sympathy entails. But there is
no avoiding them; soon or late they are sure to come to everyone. The
upbuilding of character, consequent upon intimacy with them, is of
great value, and really brings so much of contentment to people who
are over-worried about little things that it is worth while to recall
how valuable this sympathy for suffering is in psychotherapy.

I have spoken of this phase of occupation as if it referred only to
women. There are many men of whom one may well say that they need more
human sympathy in their lives and that if they had it their supposed
ills would drop from them, or seem so slight as to be quite
negligible. Over and over again, I have seen men who had become too
occupied with themselves lose their pains and aches in an interest in
some real charity. Charity, however, not philanthropy, is the secret.
The sitting on a board of trustees of a charitable institution may
mean little though even this usually has its good effect; but close
contact with the poor, intimate personal relations with other human
beings who are in suffering, are quite as necessary for men
over-occupied with themselves as for women.

{223}

_Care of the Incurable_.--Mother Lathrop (Hawthorne's daughter) in her
cancer work prefers not to take patients suffering from incurable
cancer into the homes that she has for them, if they can in any way be
cared for reasonably at their own home. Of course, the main reason is
because there is so much of cancer in the community (one in thirty of
the population now die of it), that it is impossible to take care of
all the cases that apply for admission. Another excellent reason is
that it would be too bad to take out of a home the opportunity for
self-discipline that is afforded by the care of one of these patients,
when it does not inflict an intolerable burden on someone already
overworked. As a rule, the effect of attendance on such a patient does
so much for character upbuilding, and for a proper realization of
values in life, that trivial things fall into their right places.
Anyone who has seen the development of character, And the growth in
amenity of disposition of those who bear such a burden with patience,
will realize just what is meant by the expressions used.


Finding Mental Occupation.--For many of his patients the physician
simply must find occupation of mind. Not a little racking of brain is
needed for this, until experience helps. One form of occupation of
mind that seemed quite unpromising at first, but that has in a number
of cases proved of value, is the committing to memory of passages in
verse. A generation ago it was quite common for people to have their
memories stored with fine passages from authors which they could
repeat literally. Latin verse particularly was learned by the school
boys of fifty years ago. Frenchmen know their classical poets, and
some of the Italians also know theirs with wonderful fidelity. It is
said that, even in his advanced years, Pope Leo XIII could repeat long
passages of Dante and often found a relief from pressing cares of
state in the ponderings of the great thoughts recalled by the verses.
I have known half a dozen Italian clergymen who could from memory
follow up a line of Dante, taken anywhere in the poet's writings, with
the rest of the passage.

Such well-stored memories furnished much more abundant food for
thought to their possessors than do those of the modern time. Our
modern system of education has done away, to a great extent, with
learning by heart, but as one of those educated under the older system
and who is still able to recall many passages from Pope, or
Goldsmith's "Deserted Village," or "The Traveler," or from Virgil or
Horace, I feel sure that this is a serious mistake. In some cases I
have deliberately tried to make up for it by having people, even well
on in years, settle down to memory lessons again. Under disorders of
memory I suggest the use of this practice as a valuable training which
serves first to dispel the idea that memory is failing when it is only
lack of attention and of concentration of mind that is at fault, and
secondly, because after a time there can be observed an actual
improvement of the memory faculty. Here I would insist on its value as
an occupation of mind for those who lack some serious interests. I
have found it to be ever so much better as a diversion than reading or
the theater. If the interest in it can be awakened, it represents a
valuable adjunct in the treatment of some rather difficult cases of
mental short-circuiting. Lord Chesterfield, in one of his letters,
suggested to his son that even very brief periods during the
day--those that are ordinarily used for the fulfillment of bodily
necessities--might be employed to store the memory with valuable
quotations, great thoughts {224} greatly expressed, and this should be
recalled. After a little practice not near so much time is required
for memory work as might be imagined, and the effects are excellent.

Much of this may seem too trivial for the physician to occupy himself
with and quite apart from his duties as a practitioner of medical
science. But it must not be forgotten that medical science is as yet
quite imperfect and the practice of medicine is an art. What we have
to do, is to treat individual patients rather than cure cases, for
that is why medicine is a profession. Each affected individual who
comes to us is quite different from any other. In spite of our
grouping them under certain heads, the diseases of the race are as
distinct from one another as the features of the individuals affected.



CHAPTER VI

DIVERSION OF MIND--HOBBIES


There are two classes for whom diversion is of the utmost value. The
first are over-occupied with themselves; and the second group are so
occupied with some one interest in life, or with one narrow set of
interests, that it becomes an obsession, never leaving them. Constancy
of mental occupation with one set of thoughts proves seriously
disturbing after a time, especially if the only amusements available
are so superficial that they do not really act as a diversion. Many of
the so-called neurasthenic or psychasthenic states (I would prefer to
call them conditions of nervous weakness and of psychic impotency,
because the simpler names carry with them no suggestion of a definite
ailment) are really the consequence of this lack of any true
diversion. The patients do not get any genuine rest.

The typical example of such lack of diversion is the business man who,
contrary to the wisdom of the ages, takes his business home with him.
If we accept Ramon y Cajal's theory of attention, by which whenever a
particular portion of the brain is occupied with a subject the
capillary blood vessels in that particular part are pulled wide open
by the contraction of the neuroglia cells, certain of the brain
tissues in these cases are constantly in a state of congestion. It is
not surprising that such men suffer from insomnia. It is scarcely less
to be wondered at if their digestion suffers, since that function is
so important that it requires most of the nervous energy that a man
can provide at certain times. Besides his brain cells are never really
resting. If a man goes to sleep with a thought and wakes with it, even
though he may not be quite conscious of the fact, his mind has been
occupied with it. Brain cells need definite periods of rest. These
cells are not getting such rest--hence the development of many
pathological conditions.

I have described the extreme case, but it is not exaggerated. Writers,
editors, scientific investigators and generally those whose work does
not bring them much in contact with others, are likely to thus suffer.
Contact with others, even on business matters, seems to have a
relaxing effect. Social amenities and personal interests prevent
absolute concentration of mind over long periods. In some people even
milder degrees of preoccupation with a {225} single subject may work
harm. Some people are able to stand concentration of mind for many
hours a day for years. Others cannot. We have come to recognize that
more than eight hours a day is a mistake, but there are many people
who cannot work more than a four-hour day. The sooner this is
recognized and diversion of mind provided, the better for them. This
is one of the most important benefits that psychotherapy can confer on
many of the so-called neurasthenics.


Possibility of Diversion of Attention from Ills.--The necessity for
diversion of attention from one's ills is best realized by considering
what happens in the opposite direction. Headache, toothache, and many
other uncomfortable feelings, especially discomfort associated with
abdominal disturbances, can be entirely banished from the mind by
pleasant association with friends, by an interesting play, by a game
of cards, or, indeed, by almost anything that takes up the attention
completely. It is well understood that the severer forms of pains can
not be thus banished, but discomforts that make life miserable for the
patient may be entirely relieved for the time being. If this power of
mind to divert attention from the ills of the body means so much, it
is not hard to understand that if this mental influence be directed in
the other way, that is, to emphasize the ailment by attention to it,
it will not be long before symptoms become quite unbearable.


Hobbies.--A hobby is the physical salvation for a man who wants to
work hard, yet not become so absorbed in his work that it becomes an
obsession. Unfortunately, it is not possible to create a hobby for a
man or a woman in a short time. It must be a growth for many years
until it has become a portion of one's life. It must, as far as
possible, be something to which one turns with as much interest as to
one's regular occupation, so that the time taken from it, even for the
necessary vocation of life, is more or less resented. If a man has two
occupations that are intensely interesting, then he gets the best
possible rest. Otherwise it will be necessary in many cases for the
physician to help him in the choice of another interest in life. It is
not enough that there should be a vacation once a year, or a
conventional day off on Sunday. There must be much more than this,
deliberately planned and faithfully carried out.


_Gladstone_.--Men with hobbies have done some of the best of the
world's work; busy for many hours every day, they have yet lived to be
eighty and even ninety years of age, and have been industrious to the
end. A typical example in our generation was Gladstone, the great
English statesman. Few men had their minds occupied with more serious
problems than he for nearly forty years of a busy existence. In spite
of this, he found time to make a study of Greek literature and of
ecclesiastical writers; He acquired even more authority perhaps in
these subjects than in political science, doing the work of several
men, yet he lived to be an extremely old man. He welcomed the
opportunity to get away from one kind of work in order to devote
himself to another, but this occupation of an entirely different set
of brain cells gave those that had been previously at work opportunity
for complete rest. Very probably, except at times of special crisis or
stress of anxiety, his political problems did not disturb his studies
of Greek literature, not because he insisted on keeping them away, but
because this other interest was so absorbing that it required no
special effort to occupy his mind completely with it.

{226}

_Virchow_.--For more than a year I lived close to the great German
pathologist, Virchow, and found that his varied interests were
probably the secret of his power to devote himself to work for many
hours a day, take only a small amount of sleep and yet live healthily
and happily for over eighty years. Frequently he did not leave the
Prussian legislature until 1 a. m., or even later, and yet he seldom
failed to be at his laboratory before 7:30 o'clock in the morning,
though it was several miles from his home and took over half an hour
to get there. Besides pathology, he was deeply interested in
anthropology and in most of the biological sciences, and his favorite
hobby was the practical care of the health of the city of Berlin. From
the time when Berlin, just after the Franco-Prussian war, began to
grow out of the half-million provincial town that it was, into the
great world capital that it became, a transformation that took less
than twenty years, Virchow had charge of the health of the men engaged
on the sewer farms of the city. Berlin, unlike other great capitals,
is not situated on a large stream that will carry off its excreta, and
consequently a new problem in sewage disposal had to be met. The
sewage was spread over fields outside the city and proved, as might be
expected, a magnificent fertilizer. The whole cost of sewage disposal
was recouped from the sale of the farm products.

Prophecies of dire disaster of many kinds were made when this system
was first proposed. It was said that the men engaged on the farms
would suffer from all sorts of disease, especially respiratory and
intestinal diseases, that the farm products would be insanitary, and
the whole plant would be such a disease producer for the city as to
become a nuisance. Virchow was put in charge of the sanitary side of
the project, and how well he fulfilled his obligations is shown by the
statistics. The people who worked on the farms were healthier than the
average inhabitants of Berlin, and were especially free from
intestinal disease. Every phase of disease that occurred among the
workers on the farms, and there were many thousands of them with their
families, was reported to Virchow. Every night, the last thing before
he went to bed, he looked over this report and if there were any
suspicious cases, made arrangements for the prevention of the spread
of disease.

This of itself might seem work enough for one man, but it was only a
diversion for Virchow, turning his mind away from his other
intellectual work completely during certain hours of the day. His
visits to the farms, his planning for the prevention of the spread of
disease, his deep interest in the reports and the constant improvement
of conditions, instead of hampering his other intellectual activity by
wasting brain force, probably proved restful by diverting the blood
stream away to the cells that occupied themselves with this other and
very different problem, and so proved a benefit, not an evil. Perhaps
other men might not have had the store of nervous energy to enable
them to carry on work in this way, but for those who have, this is the
ideal arrangement. There are many others whose names might be
mentioned here. John Bigelow and Pope Leo XIII are typical recent
examples. Great workers are usually long livers, barring accident, and
all of them have had variety of occupation.


Necessity for Diversity of Occupation.--Even for those of lesser
intellectual capacity, it is advisable to have, in a lower order of
intellectual occupation, two very different things in which there is
intense interest. The blasé {227} attitude in which the individual
finds no interest in anything and nothing worth doing, makes it
impossible to secure such relaxation as will give relief from worry.
So long as nothing happens to call for special resistive vitality,
such people may go on nursing their unhappiness. It is from this
class, however, that the suicides come. The mind becomes occupied with
the worries that it cannot get away from, sleep is interfered with;
the worries become an obsession, and brain exhaustion results. It is
usually said that suicides are insane, and to this extent certainly
the expression is true. Certain brain cells have so long been occupied
with a particular subject, because the mind has no other interest to
divert attention and blood supply to other portions, that these cells
are overborne and become utterly beyond the control of reason and
will.


Intervals in Work.--The old university rule of long ago was that no
one should do more than two hours of intellectual work continuously at
the same subject. Certain of the monastic orders required scholars and
students to take a break from an intellectual occupation for a
measured interval at least every two hours. The modern business man,
and even the literary man or reporter, would think this preposterous.
The rule is, however, founded on good common sense, for it relieves
the tension and keeps conditions of strain from inveterating
themselves in such a way as to do harm.

As a matter of fact, better work is accomplished if it is done in
two-hour intervals, with a break of fifteen minutes to a half-hour
between, than if the attempt is made to work longer. This may not be
true for certain forms of creative literary work, where, when the mood
is on, it is easier to finish things than if a break occurs, but these
are exceptional cases, and even here there may be serious abuse. Many
of the men who work late at night eventually get into habits that
seriously impair their sleep. This system of rest prevents such a
strain from being put upon the physical organs underlying attention as
will prevent them from promptly relaxing when the call upon them has
ceased.

There are, of course, men for whom no such rules as these seem to be
needed, because they apparently thrive on work. These are exceptions,
however, that prove the rule. They will usually be found on
investigation to have been men who lived very simply and permitted
themselves very little excitement. There is great danger in imitating
them because most of them had a superabundant vitality which expressed
itself in longevity as well as in a noteworthy capacity for work. They
had superabundant brain power to run their business (even though it
was deeply intellectual), but then, too, these men were careful not to
throw extra burdens upon their digestive organs, nor to abuse
stimulants, nor to permit a regular routine of work to be disturbed.
When symptoms of nerve weakness begin to show themselves, even the
exceptional men must be warned of the danger. The causes of the
exhaustion of nervous vitality should be pointed out, and an
improvement of habits insisted upon.


Amusement and the Mind.--The theater, as it is at the present time,
affords very little opportunity for mental relaxation. Most of our
theatricals are mere show that occupies the eye but does not seriously
catch the attention, especially after a certain number of types of
these performances have been attended. The humor of the comedians of
our musical comedy may, for {228} a certain number of people, mean
something as a diversion of mind, but it does not last. Unfortunately,
practically all their humor runs along the same line, most of it is
extremely superficial, much of it is borrowed and wears signs of its
origin, not a little of it is mere horse-play, which may divert
children but not grown men, and so the theater as a mental relaxation
has lost nearly all of its effect. Other diversions are sometimes more
hopeful. For baseball enthusiasts, attendance at a game may be such a
complete occupation of mind as to furnish thorough relaxation.

The kind of work that provides mental relaxation for others often
proves exhausting to those who do it. Humorists, especially those who
have to grind out paragraphs or columns of humor every day or every
week, are usually melancholy men. The story of Grimaldi illustrates
how serious may be the effect of work that seems mere play if pursued
too singly. This humorist on one occasion consulted a specialist in
mental diseases, for certain symptoms of nervous breakdown and
depression that were causing him much annoyance and even more
solicitude. The specialist believed in diversion of mind, and, having
been to see Grimaldi the night before and enjoyed him hugely, though
he did not recognize him off the stage, counseled him to go and see
that humorist and have his "blue devils" banished for good. "If
Grimaldi won't cure you of your depression," he added, "I don't know
anything that will." "My God!" the humorist said, "then don't leave
me in despair. Man, I am Grimaldi!"


Sports.--Unfortunately in our modern life we have to a great extent
lost the idea of sport. The conventional make-shifts of life in a camp
that is really a luxurious country house, or on a luxurious yacht, do
not replace the complete diversions that came with real camping,
hunting, fishing, sailing and the like. People now go to the country,
but take the city with them. They live in country hotels and make five
changes of clothing in the day, if not more. If men are interested in
hunting and fishing and can go into the forest (unfortunately even the
Adirondacks can scarcely be so designated now and we have to go into
the Canadian wilderness to get away from the pall of regular life and
civilization), complete recreation is secured. This makes a real
vacation which does not mean absolute freedom of mind, but freedom
from other cares so that one may with complete absorption apply
himself to something different. During the year sports for grown-ups
are difficult to obtain. Some men continue well on in middle life to
play tennis, hand-ball, and certain other games, _O fortunati nimium_,
that make the best kind of diversion. Fortunately, in recent years
golf has become a favorite and for many makes a genuine diversion.


Children's Diversions.--In recent years we have so interfered with the
normal natural development of the child that there is need to
emphasize certain details in this matter. The modern child is apt to
be precociously occupied with books and adult interests, because he is
brought so much into the foreground of family interests. True play for
some city-bred children is almost an anomaly. Exercise and air they
get. They are conducted solemnly to the park by a nursemaid, who is
instructed to see that they do not play with other children unless
quite as well dressed as they are themselves, and their dress is often
so elaborate that it is quite impossible for them to think of any real
play. There is absolutely no recreation for the child in this
procedure: on {229} the contrary, a new effort of will is required to
walk with the stately propriety that is expected of it. Then the child
is preoccupied with the thought of its clothes. Relaxation of mind is
often quite out of the question, and yet we wonder why children are
nervous and do not sleep well, why they have night terrors and do not
digest their food properly, while all the time they are living
unnatural lives that give no proper outlet for their energies and
little diversion for their mind.

Games are important, but their true spirit has gone out in recent
years. There are still a few young people who play for the sake of the
sport, but everything now seems to be a preparation for some sort of
contest. Only those are engaged in these contests and the preparation
for them whose muscular development is such as to suggest that they
will help to win. Winning, and not sport, has become the purpose of
our games. This makes the participants worry about the games and
associate them with dread of errors and ill chances. It is true that
the interest for the contestants during the game is sufficient to make
up for this and make the game valuable as relaxation; but those who
need such relaxation most--the boys and girls who are underdeveloped
muscularly--must sit and watch the contests, and this, after one has
become accustomed to it, like newspaper reading and the theater,
constitutes a poor apology for the complete relaxation of mind and
diversion of brain-cell energy that used to come with sports when they
were freely indulged, for the sake of the sport and not for the sake
of winning.



CHAPTER VII

HABIT


Few people realize how powerful a factor for physical, as well as
moral, good and evil is habit. The old expression that habit is second
nature is amply illustrated in the most familiar experiences. The
child, unable at the beginning to make any but the most ill-directed
movements, learns during its first two years to make the most complex
co-ordinated movements--first with difficulty, then with ease, and
finally with such facility that there is no need for it to pay any but
the most perfunctory attention to their execution. Walking requires
the co-ordination of a large number of muscles so that the absolute
position of every muscle in both the legs and in the trunk, at least
as far as the shoulders, must be definitely known and their activity
properly directed. Perhaps nothing brings out more clearly the
difficulty of walking, though it depends on only one factor, the
co-ordination of the two sides of the body, than the story of the
Italian Tozzi twins. They were born with two heads and shoulders and
with only one pair of legs. It was found that each head ruled the leg
on its own side of the body. It was impossible for the creatures to
walk. They lived to adolescent life, yet never succeeded in walking.
The intimate association of the lower parts of their trunk and the
long years of companionship of their brains, did not enable them to
accomplish what seems to us so commonplace a co-ordination of movement
as walking.


Formation of Habits.--The co-ordination of the two limbs is after all
only a small portion of walking. The body must be held erect, the
curve of {230} the spine must be managed so that the center of gravity
is kept well within the base, and gluteal and femoral and calf muscles
must all be co-ordinated with one another. In a few months a child
learns to do all this, and in a couple of years it executes all the
co-ordinate motions with such certainty that walking becomes not only
an easy matter but an absolutely unconscious accomplishment that can
be carried on while the mind is occupied with something else or while
it becomes so abstracted that surrounding objects are not noticed.

A far more difficult co-ordination is required for talking. It is only
when we analyze how nicely adjusted must be every movement, in order
to pronounce consonants and vowels properly and to combine them in
various ways, that we realize how complex is the mechanism of talking.
A difference of a hundredth of an inch in the movement of the tongue,
or less than that in the movements of various muscles of the larynx,
makes all the differences between clear articulation and a defect of
speech. In the course of the years up to seven, the child learns this
wonderful co-ordination apparently without difficulty, but really at
the cost of constant well-directed effort. There is no time in human
existence when the child really learns so much as during the first
four years of its existence, even if it learns nothing else except to
walk and to talk. The foolishness of obtruding other things,
information and study of various kinds, on the child's attention at
this time should be manifest.


_Unconscious Regulation of Muscles_.--What is thus prefigured in early
life invades every activity in later years. The boy who learns to ride
a bicycle must at first devote all his attention to it, but after a
while rides it quite unconsciously, his muscles having learned by
habit to accommodate themselves automatically to all the varying
positions of his machine. Anything well learned by habit is never
forgotten. How hard it is to learn to swim, yet, after years away from
the practice of it, the art comes back at once. The same is true of
skating, and of the nice adjustments of muscles required in various
games. Such is the influence of habit in forming a second nature. It
is no wonder that Reid, the Scotch philosopher, should have written:

  As without instinct the infant could not live to become a man, so
  without habit man would remain an infant through life, and would be
  as helpless, as unhandy, as speechless, and as much a child in
  understanding at threescore as at three.

Commenting on this Prof. J. P. Gordy, in his
"New Psychology," [Footnote 26] says:

    [Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.]

  Strong as this statement seems, it is probably an understatement of
  the truth. Without habit, we should rather say, a man would be as
  helpless, as speechless, as unhandy at three-score as at birth.
  Habit is the architect that builds the feeble rudimentary powers of
  the child into the strong, developed powers of the full-grown man.
  If a child's vague, purposeless movements give place to definite
  movements performed for definite purposes, if his sensations become
  more definite, if his perceptions become clearer, if his memory
  becomes more accurate, if he reasons more and more correctly and
  logically, it is because of habit.


Law of Habit.--The law of habit is that every time we perform any
action, mental or physical, or allow ourselves to be affected in any
way, we have more proneness to, and greater facility in the
performance of that action or in {231} experiencing that affection
under similar circumstances, than we had before. In the chapter on
Tics, I call attention to the fact that all the curious gestures by
which we are individualized, are due to the law of habit. It is
infinitely amusing to watch a group of people and note the endlessly
different habits of which they have become the victims. There are
tricks of speech and tricks of gesture eminently characteristic and
often quite laughably individualistic. We imitate, especially those of
whom we think much. Sometimes it is only when a father's attention is
called to them in his sons that he realizes the ludicrousness, or at
least laughableness, of some of the things he does, and he proceeds to
correct both generations of their faults.


PHYSICAL HABITS


Habit and Food.--Most of our likes and dislikes for food are neither
physical nor physiological, but simply habitual. We have become
accustomed to certain things, and so we like them. We are unaccustomed
to them, and do not care for them. It is amusing when people put
forward these lacks of habituation as if they were physiological
idiosyncracies. Many thin people do not like butter and milk. The real
reason for this is not any peculiarity of digestion, or any gastric
incompatibility, at least in 99 cases out of every 100, but the mere
fact that they are not habituated to their use. That is one of the
reasons why they are thin. Our tastes for curious foreign foods are
nearly all deliberately acquired. Not one in ten ordinary Americans
likes olives or caviar when first tasted. Nearly every curious article
of food is "caviar to the general" at first trial. Later it becomes
impossible to understand how we could have had any objection to them.
At times, even an actual craving for them asserts itself as a
consequence of the habitual use, and then deprivation means positive
discomfort.


Slow Eating.--One of the most valuable habits that a man can
cultivate, but one of the most difficult to acquire in our time, is
that of eating slowly. Most Americans bolt their food to a degree that
would be quite appalling to them if they realized what they were
doing. Pieces of potatoe as large as the end of the thumb are
swallowed. Bread and milk may be eaten so hurriedly as to be as potent
a source of digestive disturbance as fried onions. There seems no
doubt from what we know of Fletcher's experience and Chittendan and
Follin's studies that a man derives more nutrition from food that is
masticated properly, that he can get along and do his work on less
material and that, above all, there is not the same tendency for him
to put on weight that is so common among people after reaching middle
age.

Sir Andrew Clarke used to have his patients chew a definite number ol
times on each bite--say thirty times. Even so great a man as Gladstone
submitted to this rule and gradually learned to accustom himself to
eating very slowly. Fletcher's system of chewing the food until it
passes down the esophagus of itself without any swallowing effort is a
better rule. It is a surprise to most people how unconsciously
swallowing can be accomplished in this way and how little liquid is
needed in order to prepare food to be swallowed. The formation of the
habit, however, is not an easy one. Persistence and frequent reminders
are needed, or else the beginnings of the habit are soon dissipated
and old bolting habits reassert themselves.

{232}


Water Drinking.--In drinking, habit is as supreme as in eating. The
majority of people who work outside and perform muscular labor crave
and take an abundance of water. Many of those who live indoors,
especially in steam-heated houses, may need it quite as much if not
more, but get out of the habit of drinking water. As we need about
three quarts of water per day for use in our economy, this no water
habit often becomes a serious factor in the production of
physiological disturbances. We have replaced water drinking and the
milk drinking of the olden times by tea and coffee, and as these are
stimulants, habits form very readily with regard to them. I have known
people who were sure they would be miserable without their half-dozen
cups of tea or coffee each day, and who actually would be miserable
for a few days, when deprived of it. They were seriously impairing the
efficiency of their nervous system by so much stimulation.
Unfortunately, it is just those whose nervous systems have least
stability, and are already the subjects of more stimulation by
conscious introspection than is good for them, that are most likely to
form the tea and coffee habits, and who are most harmed by them,
though they find it hard to understand the reason therefor.


Air and Exercise Habits.--Habits with regard to exercise and fresh air
are particularly important. In this matter it is only habit that can
be really helpful. To work at high pressure indoors for several days,
and then, when one is quite on edge, to take a lot of severe physical
exercise is not good. Every human being should go out between meals. I
am not one of those who believe much in exercise for exercise's
sake--what is needed is fresh air. Our sanatorium patients who sit
out-doors all day have fine appetites. The advice to a busy man that
he must form the habit of being out between every two meals for from
half an hour to an hour would usually evoke a strenuous protest, but
all he needs to do is to get up half an hour earlier and walk down to
his office, and if he will walk back in the evening he will have
plenty of air and exercise between his meals.


Change of Habits.--Patients do not want to change their habits. They
come to a doctor to be treated. They want some medicine that will,
without further inconvenience, rid them of certain discomforting
symptoms. At the beginning, at least, patients resent interference
with their habits. They are quite satisfied, and to modify them
requires an effort that must be continued for some time. The changing
of old habits and the formation of new habits are most important for
the ordinary ills to which mankind is prone. Modifications of habit
constitute real hygiene and are not mere corrections of symptoms,
permitting the habits that have led up to them to go on.

Patients may conclude that it is too much trouble to change their
habits. We all know persons who feel that they can not give up their
coffee. As to whether or not the modification of a habit is worth the
trouble it involves, the patient must be the judge after the case is
put properly before him. It is possible that he may learn to endure
the inconvenience given him by his symptoms rather than to stand the
inconvenience of changing a nicely settled habit, and forming a new
one. The reward should be put very plainly before him, however, and
besides, the consequences of his habit in the future should be
suggested so that he may realize just what it will lead to.

{233}


MENTAL HABITS

It is evident from the foregoing that physical habits have much to do
with making life easier and saving expenditure of nervous energy, but
just this same thing holds good for mental states. With care, a proper
habit of mind and of the mental attitude towards difficulties in life,
can be so cultivated as to ward off many of the discouragements, and
most of the causes of depression that weigh heavily on some people.
The natural disposition can not be entirely overcome, but habit, as a
second nature, can modify the personality so as to make conditions
much better than before.

With this wonderful power in habit, it is too bad that its force for
good is not used. It is especially important that its force for evil
shall not allowed to dominate human actions so as to make them harder
of accomplishment. Many people, who are greatly troubled by the
inconveniences and discomforts necessarily associated with human life,
worry over it to such a degree as to make themselves sick. The
expression I have quoted elsewhere of the old man who said, "I have
had many troubles but most of them never happened," is a typical
example of what the habit of looking at things from a wrong standpoint
means to many people. They are confirmed pessimists. Their one
consolation, when a small evil happens to them, is that perhaps this
may be sufficient to ward off the greater evil that fate surely has in
store.


Pessimism.--Pessimism has been defined as sticking one's nose in a
dungheap and then asking, "How is it that it smells bad around here?"
Some people are always nursing a grievance. No matter how many times
they may happen to have been undeceived, still the next time the
opportunity occurs they are sure that fate or friends or someone has
it in for them and that the worst may happen at any time. In the
expressive words of a recent slang phrase, they have a "perennial
grouch." This state of mind toward the environment not only prevents
the physical and mental good that cheerfulness brings with it, but it
unfavorably influences physical conditions within the body. People
suffering from indigestion are usually morbid, petulant, and hard to
get along with. Many a dyspeptic makes this an excuse for his bad
temper. Anyone who has had to study these cases much soon comes to the
conclusion that the beginning of the digestive disturbance was the
gloomy outlook on life, which flowed inward to disturb the digestion
and all the other animal functions.


Depression of Mind and Body.--Patients suffering from melancholia
nearly always lose in weight. As a result of their lowered vitality,
there is a suppression of the nervous impulses which rule over
nutrition, with a consequent loss of weight. In cases where there are
only tendencies to depression and gloom, the effect upon the digestive
system is not so marked but there is no doubt that there is some
effect, and that the indigestion in these cases is more often than not
a result of the depressed state of mind, rather than the depression of
mind the result of the indigestion.


Moodiness.--The habit of looking at the gloomy side of things is
easily formed and, once acquired, it becomes very forceful. Many a man
who was quite cheerful when young, becomes moody as he grows older.
Nearly everyone permits moods more than is good for him. The attitude
of mind that should be cultivated is one in which it is realized that,
though there may be {234} many sources of evil in the world there is a
preponderance of good even in the worst environment, and that
opportunities for making the best of things will be found by any
cheerful disposition. _Mrs. Wiggs of the Cabbage Patch_ is a typical
example in fiction of the optimism that counts. Miss Helen Keller in
real life is a typical example of how the most untoward circumstances
can not crush the spirit of man if he only wishes to be cheerful--if
he only tries to lift himself above his surroundings, no matter how
discouraging they may seem to be. No one is without discouragement and
causes for unhappiness. "Happy he who has least," the Greek dramatist
said.

The difference between the optimistic and the pessimistic point of
view is much more a matter of habit than is usually thought to be the
case. Indeed, there is good reason for assuming that it is so largely
a matter of habit, that other factors count for little. We all know
individuals who, after having, been cheery, bright, hopeful and
helpful, have had some incident sour them and then they have been just
the opposite. This did not come all at once; it was a growth. They
felt hurt and aggrieved, and then began to look at things through dark
glasses, and after a time could see nothing on its brighter side. Not
infrequently, as doctors well know, the growth of such a moody
disposition has been the signal for the development of a series of
complaints, if not of actual symptoms, and men and women who have not
been in the doctor's hands before now become valetudinarians. This new
physical condition is often attributed by their friends, by
themselves, and even by complacent physicians, to the effect upon them
of the trial or disappointment that struck them. Only too often it is
wholly due to the cultivation of a habit of pessimism consequent upon
a shock that for the moment pushed their cheerfulness into the
background. Strong characters will not be thus easily affected, but
weaker characters need not suffer such a change of disposition and
with it a deterioration of health or well-being unless they so will
it.


MANNERS AND DISPOSITION

Habit can modify nature so much as to make what is practically another
man. We all know how the dancing master can transform a country gawk
into a refined, courteous society man (not gentleman, for that is
something else) of graceful carriage and even handsome bearing. He
cannot do this for all the pupils that come to him, for it is
impossible to make a silk purse out of a sow's ear, but for anyone
that comes with good will the revolution in manners is often a
revelation to those who have known the man before. When the exterior
can be changed so much, the interior attitude toward other people
certainly can be greatly modified.

Persons of a melancholic disposition may be surprisingly cheerful, and
even gay, with comparative strangers when they make the effort to be
so. For many people, meeting with strangers is an excellent remedial
measure. It stirs them up to present the best side, and it occupies
attention to the exclusion of themselves in a way that is extremely
beneficial. If people would only form the habit of being as courteous
to their own folks as they are to others, the disposition involved in
this would often save them from certain symptoms, and save their
physicians from many complaints.

{235}

Happiness is the basis of good health. The phrase is often put the
other way: Good health is the basis of happiness. Without health there
is no happiness. But every physician knows that many a patient
suffering from real organic ills, and having much physical pain to
bear, still has many hours of happiness in working for others. This
happiness reflected back upon his physical life is not able to cure
his ailments, but does so lessen the significance of the symptoms as
to make the ailment more bearable.


THERAPEUTIC IMPORTANCE OF HABIT

The most important therapeutic element in the formation of good
habits, mental and physical, is that habit does away with the
necessity for conscious regulation of many details of life. Without
habits of doing things, we have to make numerous decisions and keep on
making them under conditions that require special effort and waste of
energy. When habit asserts itself, there is little or no difficulty.
Habits of living in airy rooms, of taking exercise, of food regulation
as to quantity and quality, of methods of taking food as regards
mastication, the quantity of fluid ingested, the hours of meals and
the like, can all be formed and then followed without effort. Just
inasmuch as life can be ruled by habit, nerve force is conserved. This
is as true for our attitude towards life, our disposition and
consequently our satisfaction with life, as for anything else that we
do. Habitual cheerfulness, habitual readiness to make allowance for
others and to be helpful to them, habitual self-control--all of these
things can be cultivated. Properly cultivated, they save much of the
wear and tear of life, and make for contentment and happiness much
more than many of the things for which men strive so anxiously because
they seem to promise happiness.



CHAPTER VIII

PAIN

Pain, while always a dreaded symptom of disease, seems, with the
increase of comfort and the gradual abolition that has come in our
time of many of the trials of existence, to have had its terrors
increased. Even a slight pain or ache is dreaded, and if continuous or
frequently repeated, becomes for many people a trial that is almost
impossible to bear. This is all the more to be deplored because
ability to stand a certain amount of pain, with reasonable equanimity,
is almost a necessary condition of rapid recovery from disease or
injury. Placidity of mind favors the flow of nerve impulses for
reconstructive purposes, while over-reaction to pain inhibits the
natural processes of repair. According to Shakespeare's heroine:
"There was never yet philosopher that could endure the toothache
patiently." Pain is usually supposed to be an essentially physical
phenomena for which mental influence can be of little, if any,
benefit. As a matter of fact, however, the mental attitude towards
pain modifies it to a considerable degree. I have quoted Hippocrates'
declaration that a greater pain drives out a lesser pain. Any strong
preoccupation of mind will greatly lessen pain at any time.

{236}

Pain is not, after all, in the nerves, nor in the central nervous
system, but in the consciousness. Just as there is no sound unless the
waves in the air arouse recognition in the consciousness, so there is
no pain unless the disturbance of nerves finds its way above the
threshold of consciousness. Nerves may be racked, yet no sensation may
be felt. There may be pain in the mind apart from the nerves, and
slight nervous affections may produce severe pains. The whole question
of the treatment of pain involves the individual much more than it
does the affliction which causes the pain. What seems unbearable pain
to many may be little more than a passing annoyance to others. What
would be, under ordinary circumstances, intolerable torture,
especially to sensitive people, may, because of intense preoccupation
of mind, remain absolutely unnoticed. Maniacal patients sometimes
inflict what would normally be extremely severe pain on themselves by
burning or mutilation without any manifestation of pain. In the
excitement of a panic men may suffer what would, under other
circumstances, be excruciating agony, and yet not know that they are
hurt.

To a mind that is without serious interest, even slight pain, if
continuous, soon becomes unbearable. The course of pain, where there
is no diversion of mind, is an interesting study. While suffering, we
seem always able to bear the pain of the present moment, and it is
only the cumulative effect of the pain that is past and the
anticipation of the discomfort to come, that make the pain unbearable.
Nearly, always it is much more the dread of what the pain may mean,
and the lack of power to endure which gradually develops as a
consequence of suffering, that constitute the worst features of pain.
At the beginning of a period of pain we stand it well, as a rule, but
its continual nagging debilitates us and heightens our susceptibility
until we cannot nerve ourselves to further endurance. If our power of
endurance were not thus gradually lessened the pain would not seem
severe. There are many neurotic people whose susceptibility to pain
has been so much increased by their lack of self-control and their
tendency to react easily to pain, that even slight pain becomes a
torment. Psychotherapy should gradually train these people to a power
of endurance.


Pain from Over-Attention.--Much of what is called pain is really due
to such concentration of mind on a particular portion of the body that
the ordinary sensations of that part, usually accomplished quite
unconsciously, become first a source of uneasy discomfort and then an
ache or pain. There may be some slight physical disturbance which
calls attention to the part, but there is no really serious
pathological condition. While such pains are spoken of as imaginary it
must be remembered that this does not mean that they are non-existent.
On the contrary they may be much more real to the patient than
physical ailments. A pain in the mind is a much more serious condition
than having it in the body.

While pain may be thus created by concentration of attention, it must
not be forgotten that what the mind can do in increasing pain is even
more important than in originating it. Slight discomforts by
concentration of attention on them may be made insupportable. It is
this element in pain, above all, that the physician requires skill to
alleviate. Habits of introspection and the lack of serious occupation
of mind of many people leave them the victims of over attention to
themselves. In trying to relieve their pain it may be {237}
comparatively easy to alleviate their physical condition, but the
mental condition, once aroused, may remain, and may easily tempt to
the use of habit-forming drugs or others that may do serious harm. The
story of the evil effects of headache powders in recent years, and of
the opium habits formed in olden times, are a significant commentary
on this fact. It is probable that in most of these cases, the
discomfort for which remedies were frequently taken was of a kind that
should have been treated only partly, if at all, by drugs. It is more
important to lessen susceptibility than to try to cure the pain.

The relation of the mind to what is often considered severe physical
pain, has come to be generally recognized in recent years. Neuralgias,
for instance, have often been reported as recurring after fright, or
strong emotion, or worry. It is at moments when patients are much run
down in health that pains are particularly likely to be unrelievable,
and during periods of emotional strain that anodyne drugs are most
called for and are most likely to be abused.


Rest and Pain.--In any study of pain and its relief, one must always
recur to that classical contribution to medicine, now in the fiftieth
year of its publication and still as important as when it was written,
Hilton's "Rest and Pain." He calls attention to the fact that what he
wrote was only a development of what many practical physicians had
thought long before his time. He quotes a prize essay of the French
surgeon, David, written in 1778. Hilton's development of the idea that
pain is usually a signal on the part of nature for rest, and that rest
will usually enable her to overcome the pathological condition and so
relieve the pain without recourse to drugs, is, and ever must be, the
basic element in the therapeutics of pain. How many forms rest may
take can only be judged by a careful reading of Hilton's book. The
oftener one reads it, the better one realizes how much of precious
common sense and acute clinical observation there is in it. It is
essentially a book of psychotherapy. It treats the patient's mind
first and then through that changes his habits, persuades him of the
need of rest, directs how that rest should be taken and so leads up to
his natural cure.

Every treatment of pain must include rest of mind as well as body.
Hilton has particularly dwelt on the rest of body. Rest of mind is
just as important. Many pains could be easily borne were it not for
the worry that accompanies them. A slight pain becomes greatly
annoying because the patient's general condition makes it impossible
to stand discomfort with equanimity, and there has been no training in
self-control. In spite of all our advance in medicine, we are not
likely ever to make life so free from pain that people can go through
it without needing self-control. Training in self-control is an
important psychotherapeutic prophylactic. If, with a certain amount of
capacity to bear discomfort, there goes such rest of mind as does not
exaggerate or emphasize the condition, then many of the pains of life
lose their power to annoy, all of them are distinctly lessened and the
relief of them by accessory physical methods becomes easier.


Pain in Its Relation to Life.--There is an unfortunate tendency to
exaggerate the significance of pain. We have cultivated irritability
in the physical sense, rather than the power of endurance. Patients
should, as far as possible, be lifted out of this condition of
over-delicate sensitiveness and put into a state where the idea of
pain is not so serious. Only in this way can {238} the more or less
inevitable discomforts of life be borne without such reactions as
seriously interfere with health. It may be said to be other than the
physician's business to secure this magnanimity, but as magnanimity is
needed in our patients, and there is no one else to respond,
physicians must start its cultivation. The necessity for learning to
bear minor discomforts, at least without exaggerated reaction, need
not be presented to the patient directly, but can be gradually made a
part of the system of treatment. By absorption in other interests, the
consciousness of these discomforts disappears without the necessity
for recourse to drugs.


Self-Denial.--Many thoughtful people are sure that what is needed to
make a large number of our generation more happy, or at least less
miserable, is training in self-denial and in self-control. The word
self-denial has come to have a very distant sound for most of our
generation. From early childhood anything that is unpleasant is
shunned and anything that is difficult is likely to be shirked. The
head-master of Eton College has recently insisted that too much is
being done to please young folks and too little to stimulate them to
activity. He declares that, as a rule, any undertaking begins to be
useful just where it ceases to be simply pleasant. Unpleasantness is
avoided to such a degree that the habit of thinking that it has no
part in life comes to be a second nature. As a consequence, the
reaction to any continued unpleasantness is likely to be exaggerated
and make the subject very miserable, and sometimes disturbs and
discourages, whereas it should have the effect of stimulating to
reactive efforts, to bring out the best that is in us.

Hinton emphasizes the fact that an ingredient of pain is necessary to
all health or pleasure. The fatigue and the hardship associated with
mountain climbing is a portion of the essence of the pleasure in it.
All healthy, pleasant exercise has an accompaniment of fatigue and
some aches and pains. What is needed, then, in our time is the
training to do things for the sake of doing them. We should be
neglectful of the discomfort that may be associated with them, or we
should even consciously rejoice in the fact that this very discomfort
is of itself a sign that functions are being used to such an extent,
that their limits are being expanded, their limitations overcome.

It may well be said that it is not the physician who, as a rule,
should do this; it should be accomplished in the early years by the
teachers and trainers of the young. True enough. But physicians can at
least help in reforming the tradition in this matter so as to
neutralize the present state of mind which seems to look upon pain as
an evil. Pain is always either a conservative sensation or an actual
stimulus to function. Besides, many of the present generation who come
to us, having had no training in the precious qualities of self-denial
and self-control under difficulties and discomforts, must have this
knowledge supplied for them as far as possible by suggestions of
various kinds. It is more difficult to accomplish much in this matter
for the adult, but even in apparently hopeless cases of over-attention
to self and incapacity to bear discomfort, much can be accomplished by
patience and persistence.

The common dread of suffering is quite unwarranted by what we know
about the effect of pain. There are many motives that may be adduced
to make it seem less terrifying than it now is to many people. The
effect of pain upon character is always excellent. The difference
between two brothers, as we have said, one of whom has had the
discipline of pain or suffering and {239} the development of sympathy
that comes with it, and the other who has not had the advantage of
this great human experience, is likely to be marked. In the one there
is a depth of human nature that enables him to appreciate and even to
express the meaning of life better than his apparently more fortunate
brother. Practically all the men who have ever got close to the heart
of the mystery of life, and expressed it in poetry or other form of
literature or art, have gone through suffering as a portion of their
training. Even the suffering that comes from ill health is never
wasted. Men have gone through it who have thought that the ecstasy of
relief following it made the experience worth while.

Men are not deterred from action by the prospect of even severe pain.
Probably no greater physical suffering can possibly be invited than is
sure to come to those who go on Arctic expeditions, or who undertake
prospecting in Alaska. Of course, many of the prospectors find
themselves in the bitter cold of the North without having realized
what they would have to stand. But Arctic explorers, as a rule, know
exactly what they have to expect. Most of of them have been through it
all before, yet they deliberately choose to go again for rewards that,
to an average man's eyes, seem trivial. The memory of past pain is
rather pleasant. Virgil's "Perhaps it will be pleasant to recall these
trials at some future time" is not poetic exaggeration.


_The Discipline of Pain_.--There is only one way to learn how to bear
pain, and that is by practice in it. There might be no necessity for
this in case life were arranged differently. But all men must die, and
death inevitably involves a painful process. Suffering is practically
unavoidable for the majority of men. Even in the midst of every
possible material comfort, cancer may come with all its hideous
connotations. It is important, then, that everyone should be prepared
to stand some pain. Certain suggestions help in bearing special pains.


Pain Diffusion.--Pain along one nerve may readily become diffused.
This diffusion will sometimes cause discomfort, and even tenderness,
at a distance from the original seat of the pain. Such diffusion tends
to produce in the patient's mind the idea that the underlying
pathological condition is spreading, though it is only a sign that the
nervous system is becoming irritable and easily responding to sensory
disturbance. Dr. Head's investigations ("Brain," 1893), should be
known to physicians, and the conclusions that flow from them should be
presented to patients who are sometimes suffering quite as much from
their apprehension of the spread of pain, and its significance, as
from the discomfort itself. Dr. Head says:

  If I have an aching tooth, the pain is at first localized to the
  tooth affected. The longer the toothache continues the more I become
  worn out, and the pain is rapidly accentuated by a "neuralgia," that
  is, a pain in the face. The neuralgia is soon accompanied by
  distinct cutaneous tenderness over a definite area on the face
  corresponding to the tooth affected. If I am anemic, or if the pain
  remains untreated until my bodily health is affected, I no longer
  have a localized area of tenderness, but the pain, and with it the
  tenderness, spreads until the whole of one-half of the head and even
  the neck may be intensely tender. Thus at last the pain of an aching
  tooth has produced tenderness over areas which bear no relation to
  the affected organ.

As pain can be suppressed by diversion of mind, or concentration of
thought on something that creates great preoccupation, it must not be
{240} forgotten that pain may almost be created by concentration of
attention on certain areas of the body, or certain nerve tracts.
Over-attention will actually make sensations intolerable that are at
first quite indifferent, or at least very easy to bear. Sensitive
people, in the ordinary meaning of that term, are those who are much
given to paying attention to their sensations, and who therefore have
much to complain of them. There is much in modern life that has the
tendency to produce this sybaritic condition in which even slight
discomforts become the sources of almost unbearable annoyance.

Even where there is no good physical reason for the occurrence of
pain, thinking may produce discomfort. The one thing that Freud's work
has made clear is that in neurotic persons the memory of a mental
shock or strain may be transferred to some portion of the body related
in some way to the shock, and then prove to be the source of
hysterical pains and also of hysterical palsy. The case told by him in
which the young woman massaging her father's limbs allows them always
to rest on her own lap during the process, and after his death suffers
from an hysterical, painful condition in this region, is a typical
illustration. Her sympathy for her father, accentuated by his
subsequent death, and her sorrow at a time when her nursing efforts
made her particularly susceptible, led to an explosion of nervous
energy along those nerves which had always felt the impress of his
legs. The hysterical condition resulted. This is an extreme case. In
milder forms it would be possible to explain many otherwise
inexplicable pains and aches in sensitive young people along these
same lines.

More than once I have seen young women, who had been asked to rub
father or mother with liniment, complain of tingling pains in their
fingers which were followed by some redness so that one would be
tempted to think of Weir Mitchell's disease, though evidently the
pathological cause at work was the slight disturbance of the vasomotor
system due to the liniment and the rubbing, emphasized by the
sympathetic feelings, and by the over-attention which this brought
about. Whenever women have, for a prolonged period, to nurse others in
whom they are deeply interested, and have to perform some habitual
action that is somewhat fatiguing for them, after the death of the
patient there will not infrequently be the development of hysterical
or neurotic over-sensitiveness in the parts employed. This may give
rise even to an hysterical joint, or to severe neurotic pains. Once
these cases are recognized, the attention can be diverted from
themselves and they can be made to understand that their grief and
sympathy are being concentrated on the part and by transfer are
producing physical manifestations. The pain is not imaginary, but the
condition will improve as soon as the mind is diverted from it.


Neurotic and Organic Pain.--The distinction between pain due to a
neurosis and to a definite lesion is often difficult to make. If there
is a definite localization of pain, it is almost surely not neurotic,
but organic. If there are certain positions in which pain is felt
while it disappears in others, there is some local inflammatory or
congestive condition and not mere hypersensitiveness of nerves at the
bottom of it. These positions of maximum pain are important. When pain
radiates a great deal, even though there may be complaint of a
particular region, it is usually neurotic. If patients are asked to
tell exactly where their pain is, and they indicate its location by a
wave of the hand, it is probable that the condition is neurotic. When
there is a definite {241} localized point of tenderness with the pain,
even though there may be radiations, usually the condition is based
upon some organic trouble. It must not be forgotten, however, that
slight local troubles may by concentration of mind on them, become
exaggerated and that, in spite of the fact that there is or was at the
beginning a definite localization of pain with some tenderness, the
neurotic elements may, after a time, become manifest and prove to be
much more important than the others.

Pain that is definitely influenced by motion, as by the jarring effect
of walking, or by bending and stooping, is practically always organic.
The best differential diagnosis between neurotic abdominal conditions
and organic trouble can be made by the help of information obtained in
this way. If the appendix is inflamed, or the gall bladder infected,
or contains a calculus, or if the kidney has a calculus, these are all
made worse by movements, by jarring, by stooping as in tying the
shoes, by riding on rough roads, and the like. If patients who suffer
from obscure abdominal conditions associated with pain of which they
complain much, can, at certain times, indulge with impunity in these
exercises and motions, it is probable that their attacks are neurotic
in character. Especially is this true if the indulgence in these rides
and motions is without effect when they are in pleasant, agreeable
company, though there may be some complaints when they have to ride
alone, or under conditions that are less pleasant. If a hint of this
distinction by which the physician differentiates one form of pain
from another is given a neurotic patient, the suggestion will serve
the purpose of producing complaints whenever the opportunity presents
itself. Such patients take such suggestions, as a rule, without
wishing to deceive, but they become persuaded that their sufferings
are of the character asked for.


{242}

SPECIAL PSYCHOTHERAPY

SECTION VI

_THE DIGESTIVE TRACT_


CHAPTER I

INFLUENCE OF MIND ON FOOD DIGESTION


With the progress of biological chemistry, digestion came to be
considered a purely chemical process. Now we realize that even more
important than the chemical factors of digestion is the individual
liking for particular kinds of food, and the mental attitude of the
patient toward digestion.

Not only may mental factors interrupt or hamper digestive processes
generally but, as the investigations of Pawlow at the Imperial
Institute of St. Petersburg show, they may modify very materially the
chemical processes within the stomach. If, for investigation purposes,
a stomach pouch be experimentally segregated in a dog from the rest of
the stomach, and the dog be fed food that he has a particular liking
for, the gastric juice manufactured will be especially strong and
effective. If the food given be less to the dog's liking, the gastric
juice is not nearly so efficient in its activity. Finally, if food be
consumed for which the dog does not care, but which he takes because
hunger compels him, the gastric juice manufactured for its digestion
is quite weak and the process of digestion is slow. If this is true
for an animal like the dog, whose psyche is comparatively of much less
importance than that of human beings, the corresponding influences in
men and women will be even more emphasized. This is only what common
experience has always shown us. The human stomach is not a test-tube
in which mere chemical processes are carried on, but its vital
activity is of great importance. That vital activity depends to a
large extent on the state of mind, on the relish with which food is
eaten, on the individual likes and dislikes, and on the emotional
condition during digestion.


Prejudices and Digestion.--Perfectly good food materials may become
difficult or impossible of digestion as the result of learning
something about their mode of preparation. In the country this is
often noted, with regard to butter, milk, and even eggs. The story of
the farmer's wife who wanted to trade her own butter for an equivalent
amount made by someone else illustrates the influence of mind over
relish for food. She was candid enough to say that the reason she
wanted to exchange the butter was that a mouse had been seen in the
cream, and her children could not, therefore, eat it. She took {243}
back home with her exactly the same butter in another crock, and there
was no further difficulty, though before this the children would have
been actually sick if compelled to eat the butter. I once saw a family
of three women who had vomited because they heard that the dishes had
been washed in a slop pan, though this proved to be a mistake. Such
occurrences emphasize the necessity for properly predisposing the
mind, and for removing unfavorable suggestion, if digestion is to
proceed properly.


Mental States and the Stomach.--The typical example of the influence
of the mind on the digestive tract is to be found in the experiences
of Flaubert, the French novelist, while writing "Madame Bovary." When
he was writing the scene in which he describes the effects of the
arsenic which Madame Bovary takes, he himself suffered from
practically all the symptoms due to the drug. In order to describe it
faithfully he had studied it carefully. He had the pains, the
vomiting, the burning feeling and even the garlicky, metallic taste in
his mouth. Such an incident is extremely exceptional, yet its
possibility is recognized, and it illustrates how sensitive some
people are to the action of mental states upon the body, and how large
a role a strongly excited imagination can play in producing definite
physical symptoms. There are many more such realistic imaginations
than we have, perhaps, been inclined to suspect. It is over these
particularly that the psychotherapeutist can exert his influence by
helping to modify the cause of their symptoms, the mental attitude
which exists, rather than by trying to change the symptoms which are
only effects, for diseases must, as far as possible, be treated in
their causes.


_Disgust and Disturbance of Digestion_.--Max Müller's story, told in
his book on "Language," to show how language might have been a human
invention from imitation of natural sounds, illustrates the influence
of an unfavorable state of mind in disturbing digestion. An
Englishman, traveling in China, fearful lest he should not be able to
obtain food that he cared for, because of his lack of knowledge of the
language of the country, was rather surprised on his first day's
journey into the interior, to be served with a stew made of some kind
of dark meat that tasted very well indeed and with which he was so
much pleased that he asked for a second helping. Just as he was about
to eat the second portion, he thought it well to ask the waiter what
sort of meat it was, as he wished to be able to obtain the same kind
at other places. Calling the waiter to him, he said, pointing to the
dish of meat with a questioning tone, "Quack, quack?" The waiter at
once shook his head and said, "Ugh! bow wow!" The Englishman pushed
the second portion away and got up from the table.

Tinder the same circumstances nearly everybody would feel the same
qualmishness--at least all who had been brought up according to our
Western notions. Reason has little or nothing to do with it. It is a
question of feeling. The dog is much more cleanly in its habits than
the hog, but we in the West are used to the idea of eating hog-meat
just as they in the East are used to eating dog-meat. The objection,
of course, might be urged that the difference between the hog and the
dog is that we do not eat carnivorous but only herbivorous animals.
But the slop-fed hogs from the neighborhood of our large cities,
constituting a goodly portion of those brought to market, eat meat
quite ravenously. They certainly are not exclusively herbivorous.
There is no {244} principle behind our objection to dog meal
then--only the unfamiliarity of the idea of eating it.

The treatment of patients with digestive disturbances requires a
careful analysis of the conditions of mind towards foods. If prejudice
exists with regard to certain foods, there will be no relish for them,
and unless these prejudices can be removed, the foods either will not
be taken, though they represent important nutritional elements, or
else they must be taken in such small quantities and digested with so
much consciousness of their presence and such difficulty as to be a
disturbing factor for health. Persuasion, the custom of the country,
habit, training, mean much for this modification of mental attitude.


_Custom and Food_.--In recent years many parts of animals, not
generally eaten before, have come to be consumed with a relish because
of the removal of prejudices against them. It might be thought that
organs like the kidney, the essential function of which is excretory,
and through which so much of the offensive waste products of the body
pass, could not be a relished article of food. But it has become quite
a dainty. The liver, owing to the peculiar nature of its function, its
very special flavor, and the staining with bile, might be expected to
be objectionable. It is not, but, strange to say, a third organ of the
abdominal cavity, the spleen, which has none of the external
objectionable features of kidney or liver, is not yet eaten, and most
people would probably find it rather difficult to eat it. This
difficulty would result, not because of anything in the organic
substance itself, but because of the lack of accustomedness to it.
There are a number of people who now have trained themselves to eat
it. Such apparently impossible portions of the animal as the
intestines, even those of the hog, are eaten with relish by a great
many people, though there are others who have never been able to get
used to them. The dainties of some peoples are utterly repulsive to
others. The French like brains and other special portions of animals
that are not much eaten by Anglo-Saxons. Fried brains in black butter
sauce are enough to turn the stomach of some people by the very
thought of it, though it is a highly prized dish in the south of
France.

In Italy most visitors eat snail soup with relish before they know
what it is. It seems to be a special kind of gumbo soup. Down at
Marseilles, gourmets occasionally eat angle-worms and find them to be
a very appetizing dish. In all of these things the question of relish
and peaceful, happy digestion depends entirely on the attitude of
mind. The first men who ate eels must have been looked upon with
considerable suspicion by their neighbors as viper eaters, and
probably they themselves were not comfortable over the feat. It has
been said that the first man who ever swallowed an oyster performed as
great a feat as any of our important inventors or discoverers.


_Gastric Antipathies_.--To the great majority of mankind the idea of
eating horseflesh is repulsive. Numbers of people in various parts of
Europe have found, however, that after the initial repugnance is
conquered, it is quite as pleasant to eat as cow's meat. To my taste,
at least, it is much more palatable than venison or bear meat. At the
beginning, its sweetish taste has a curious reflex effect. Taken in
connection with the thought that this is horse meat, the taste is apt
to produce a sensation of nausea. This is readily overcome, though the
first time it is necessary to keep constantly inhibiting {245} the
mind from acting unfavorably upon the stomach during the course of
eating and digestion. Custom, I learned from many, soon made it quite
as savory as beef.


_Food Varieties and the Mind_.--How easy it may be to overcome many
prejudices in the matter of food digestion under the stress of
necessity and the influence of example, was well illustrated during
the siege of Paris. The Parisians, though a most delicate people in
the matter of eating, were able to accommodate themselves to the
conditions, and practically every kind of animal was eaten with a
relish. Before the siege, to most of them it would have seemed quite
impossible, that they should sit down with complacency to the dishes
which afterwards were so appetizing. At the beginning there was a
definite attempt to conceal the eating of rats, mice, cats and dogs
under various names, and by various modes of preparation. But it was
not long before there was an end of this pretense. The animals in the
zoological garden proved a veritable life-saving store of meat. Every
one of them was eaten, people were glad to get them, and paid high
prices for them. Camel steaks, elephant cutlets, lion and tiger stews,
appeared under their own names, even at the banquets of the wealthy.

What is true of the mental attitude for meats influencing not only the
relish for them, but their digestion, is also true for many
vegetables. There are unfavorable suggestions in the minds of many
with regard to the supposed indigestibility of potatoes, turnips,
carrots, beans and occasionally with regard to tomatoes, lettuce, or
the like. A few definite physiological idiosyncrasies against these
vegetables, or certain of them, do actually exist. The attitude of
mind, however, is largely responsible for the discomfort that occurs
after the consumption of most of them. Patients who ought to consume
more starchy substances, or whose bowels need the residual materials
that are contained in these vegetables, for the sake of their effect
upon peristalsis, should be persuaded to take these vegetables, first
in small quantities and then in gradually increasing amounts. Many of
them can thus be brought to a diet at once more nutritious and more
likely to help out intestinal function. Their objection to them is
usually but a fancy.


Genuine Food Idiosyncrasies.--There are certain genuine idiosyncrasies
with a physiological basis which prevent the taking of certain kinds
of food, or cause disturbance if they are taken, but these are rare.
Their presence should never be considered as demonstrated by
subjective signs alone for these are eminently fallacious. In certain
cases, however, so rare as to be almost always curiosities in medical
practice, there are definite objective symptoms of the idiosyncrasy.
These consist of urticarial rashes, tendencies to vomiting, or
diarrhea, or both. Sometimes these result from the most bland and
nutritious of foods. I have notes of the cases of two children--whose
father could not eat eggs without vomiting--and to whom fresh eggs fed
at the age of two and three years, always produced this same effect.
Even small portions of egg would cause it. It mattered not how the egg
was prepared, nor even whether it was carefully concealed in custard
or in cake provided there was a certain amount of it, the food eaten
with it would be vomited. There are many such idiosyncrasies for shell
fish, cheese, and such fruits as strawberries, pineapples,
pomegranates and the like, but they are demonstrated by objective
signs. But by far the greater number of food dislikes are entirely
{246} subjective and the subjective feelings can probably always be
overcome by habit and training.


Food Dislikes.--_Milk_.--Nothing makes more clear the absolute
dominion of the mind over the stomach than the likes and dislikes of
people for various kinds of milk. Most Americans can take cow's milk
with good relish, though there are a few to whom it is distasteful. In
this country we have not had much experience with the milk of other
animals. Even goat's milk is not commonly used. The very thought of
taking it disturbs many people, and to take it with other food would
almost surely produce disturbance of digestion. I have seen people
while traveling quite upset over the discovery that goat's milk had
been put into their tea or coffee. Mare's milk is commonly used in
some parts of Europe and in many parts of Asia, but it would be quite
impossible to most of our people. Sheep's milk is used in some places.
Ass's milk is commonly used in parts of Asia and may be obtained in
Spain and is said to be less likely to disagree with children in
summer than cow's milk. Most American mothers would rather not hear of
it.

The same thing is true of the milk products. Some people find certain
kinds of cheese quite out of the question though other people relish
them. It requires special training, not of stomach but of mind, to
enable one to eat certain cheese, though once the habit has been
acquired such articles are delicious. It is only in recent years that
some forms of cheese with greenish tints have become popular in
America. To serve them at a dinner a generation ago disgusted many
people. Now a dinner does not seem complete without them.

The beverages of various countries illustrate this same principle. The
wines the Spaniards care for are not palatable to the Italians, and
_vice versa_. Beer, as the result of familiarity, is now drunk
everywhere in Europe, but when it was first introduced into Italy from
Germany, it was considered impossible to understand how anybody could
take it and pretend that its taste was pleasant. The question is said
to have been once asked of one of the Congregations at Rome whether it
was permissible to take beer on fast days. The Cardinals who tasted it
declared that not only did it seem to them permissible but that it was
a mortification to drink it and therefore it was proper Lenten
exercise.


_Eggs_.--Many people have a supposed natural repugnance for eggs which
they are sure indicates that these are not good for them. As a result,
the physician gets all sorts of stories with regard to the supposed
effects of eggs. One person tells you that more than two eggs a day
makes him bilious. Another will tell you that they are too heavy for
him. A third will tell you that they are distinctly constipating. A
fourth will tell you that they produce a tendency to diarrhea. Here,
as with regard to milk, the experience of the tuberculosis sanatoria
has shown that there are but few people who cannot, when properly
persuaded and when eggs are given in various forms, take from four to
six eggs in the day without injury, and even without inconvenience. In
these cases, it is largely a matter of mental attitude towards the
food. In many instances, it will be found that the disinclination
began in some experience in childhood when an egg was not very good,
or when it was served insufficiently cooked, or when, perhaps, eggs
always cooked one way were made a staple of the diet for a
considerable period. There are over one hundred {247} ways of cooking
eggs and this variety of preparation will often make them palatable,
and nearly always digestible.

Over and over again I have seen people who had thought that eggs made
them bilious, and who accordingly had for long refused to eat them,
put in circumstances (from tuberculosis, diabetes, or obesity) where
eggs had to form a considerable portion of the diet. Then there was no
difficulty about eating and digesting eggs. In three cases in my
experience patients with an objection they thought constitutional,
developed glycosuria, and then nearly all their desserts were
custards, and eggs became a standing dish in their daily diet. In
every case not only was there no trouble, but they got to like the
eggs and wondered why they should ever have had any prejudice against
them. Two of the patients were women, the third a man who had not
touched eggs for many years. His wife's comment was: "Eggs always made
him bilious when he did not take them, but now that he is taking them
freely they no longer make him bilious."


Mental Changes and Digestion.--The change that has come over the
public mind with regard to sour milk is a typical illustration of how
much a difference in the mental attitude towards a food product may
mean for its satisfactory consumption by many people. Sour milk,
though many farmers and working people thought it a pleasant acid
beverage, was for long looked upon as a product fit at most to be fed
to the pigs, if, indeed, there might not be question even of the
advisability of this. Only the very poor who craved the nutritious
value there was in it, continued to take it to any extent. Even if the
milk still tasted sweet, but broke when it went into the tea, that was
enough to make it quite impossible for many sensitive stomachs.


_Lactic Acid as a Bactericide_.--Then came Metchnikoff's announcement
that his studies showed sour milk to be an extremely valuable food
material, but much more than that, an important auxiliary for the
lessening of microbic life in the intestines. He seemed to be able to
demonstrate that a great many bacteria, whose products, absorbed from
the intestines, hastened that process of deterioration in the tissues
that we call old age, were inhibited when sour milk or lactic acid
bacteria were present. The general health of the person who took sour
milk was, as a consequence, much better. Not only this, but processes
of deterioration being lessened, prolonged life and even old age could
be promised to those who drank sour milk in sufficient quantities.
Metchnikoff had been brought to the study of this question by what he
had seen on the Steppes of Russia. Among the nomad tribes a principal
part of whose diet consists of soured mare's milk, he found a large
proportion of very old people. In looking for the reason for this
disproportionate longevity, he came to the conclusion that the sour
milk had something to do with it. Then laboratory observations and
experiments as to the influence of the bacillus, that causes the
souring of the milk, on the growth of other bacteria, and especially
such bacteria as are usually found in the human digestive tract,
seemed to show that the lactic bacteria had a strong inhibitory effect
on nearly all the pathologic flora of the intestines.

As the result of these studies, all the world is now quite willing to
take its share of sour milk. We no longer hear the complaint that
uncomfortable feelings in the digestive tract are the result of taking
milk that was a little sour.

{248}

Since this doctrine of Metchnikoff's has come to be popularly known,
fewer patients have insisted that they could not take milk in such
quantities as the physician thought desirable for them. Before that, a
persuasion with regard to the ease with which milk becomes
contaminated with microbes, and the dread that it might thus be a
source of disease, or at least of disturbance of digestion, made it
very difficult of digestion for many people. Now that they have a good
authority who insists that, even if it should become somewhat soured
in the ordinary way, this, far from making it a pathological article
of diet, rather adds to its value from a therapeutic standpoint, has
changed the attitude of mind of these people.

We need a similar feeling with regard to eggs in order that they may
be eaten by many people who now refuse them because they fear the
possible evil results of taking even a slightly tainted egg. Our
recent pure food investigations have shown that the bakers in our
large cities have been for many years using canned eggs, and that
these would be quite impossible of consumption except disguised as
they are in the midst of baker's products. Sometimes these eggs have
been kept for several months before being canned. All the cold storage
eggs that cannot be disposed of otherwise are thus treated. In spite
of the common use of these canned eggs by a large proportion of the
city population no serious results have come from them. The change
that comes over eggs in time does not apparently spoil their nutritive
quality, but only disturbs their taste. The main element in the change
is the production of hydrogen sulphide. This gas has a very unpleasing
odor, but its presence is not of pathological significance. This gas
is a common ingredient in those mineral waters that are known as
sulphur waters, and that have a reputation for curing many forms of
digestive disturbance, especially chronic cases of nervous
indigestion. What is true of sour milk, then, would seem to be true of
eggs that have been, to some degree, spoiled, and at least no serious
results may be expected from them. If serious results were to be
expected, we should have had many evil reports of them in recent
years. Whether considerations of this kind will help patients, who
need to get over qualminess with regard to eggs, because they are
always suspicious lest they should not be fresh, will depend a good
deal on the suggestive value of such information as presented by the
physician.


_Another Organic Acid_.--Sauerkraut has shared the fate of sour milk,
and because of its acid bacteria has been accepted by Metchnikoff as
an ally. Yet sauerkraut used to be thought quite out of the question
for invalids, especially those suffering from digestive disturbances.
I recall the case of an old German shoemaker who had lived very much
on sauerkraut when he was a young man and then, having made money in
the manufacture of shoes, had not had much of it for thirty years,
pleading with me, when he was old and it was rather hard to get
anything to stay on his stomach, that he should be allowed to have
sauerkraut. On the principle that what a man craves is usually what
does him good, I allowed it. The physician with whom I was in
consultation was perfectly sure there would be trouble, and the family
were confident that his physicians evidently had given up all hope and
were quite ready to yield to his caprices and let him take anything
that he cared for. He not only took the sauerkraut without any
trouble, though I must confess to some misgivings myself (for I am of
those who unfortunately do not care for it and, therefore, {249} was
prejudiced), but after having eaten a large plateful of sauerkraut
twice a day for several days, he began to crave other things that
would not stay down before, retained them well, digested them without
difficulty, and got over that attack of indigestion and lived for
several years afterwards. His own mental attitude was a better index
than our supposed knowledge, though science has now come to confirm
his state of mind.


_Bacon and a Change in Suggestion_,--Another food material with regard
to which there has been a complete change of view in recent years, is
bacon and hog products generally. Pork in all forms used to be
considered quite indigestible, and was one of the first things that
people suffering from indigestion--or the fear of it--eliminated from
their diet. Now we know how valuable a food product it is, especially
for those inclined to suffer from constipation, or who are under
weight. Many people still look surprised when advised to eat it
regularly. Here we have a typical example of the change in the mental
attitude toward a particular article of food bringing about a
corresponding difference as regards not only the appetite for it, but
also its digestibility. Many persons, who used to have no appetite for
breakfast, now find that after eating a crisp piece or two of bacon,
they develop an appetite for other foods. Bacon has become a fetish
for some people and is considered a help, not a detriment to
digestion.

I recall a case in which I had very nearly the same experience with
bacon as I related with regard to sauerkraut. The patient was an
elderly woman, probably nearly ninety years of age, who, because of a
crippling deformity, had not been able to get outside of the house for
many years. She sat in a wheel chair, transported herself from one end
of an apartment to another, spent most of her time by the window, but
was very helpful in many little things about the house and occupied
her hands with knitting and sewing. In spite of her condition, she was
cheerful, pleasant, happy, and all her life had had a good digestion,
her only trouble being a tendency to asthma as she grew old. I came
back to the city after a summer vacation to find that she was not
expected to live because nothing would stay on her stomach. She was
sinking, and the end seemed not far off. I was asked to see her more
because I had been her regular physician for some years, and it was
thought that it would console her to see me than with any real hope of
betterment. It had been extremely hot weather and this seemed to be an
unfortunate circumstance. At my visit, I asked her if there was
anything that she cared for. She shook her head and yet there seemed a
hesitancy. I urged her to tell me if there was anything that she
wanted, but only after considerable urging did she venture to say that
there was something, only that she knew that she could not have it.
Putting her thumb on the top of her little finger, she said, "Oh, I
would like so much to have just a teenie-weenie bit of bacon." I said
that she should certainly have it. Then taking courage, she asked if
she could not have a little cabbage with it. I said, "Certainly." Her
friends thought that it was just a yielding to one of the last wishes
of an invalid with the idea that nothing could much harm her, since
she was so near the end. She had eaten cabbage and bacon all her life;
she ate it again with a relish, and in spite of the heat kept it down
and digested it well. She had bacon and cabbage next day, and for
several days; she gradually got strong and lived several more years of
her happy contented life.


{250}


CHAPTER II

INDIGESTION AND UNFAVORABLE STATES OF MIND


Indigestion is the characteristic disease of our time. There are few
men or women over thirty who have not suffered from it. The working
classes are spared the most, but with the frequent suggestions in the
newspapers and the introspection which has become so common,
indigestion is often complained of even among them. Sedentary
occupations, involving mental work and little physical effort, seem
especially to predispose to some form of indigestion. Few of those who
live what is called the intellectual life escape suffering from some
of its symptoms. Not infrequently men have been hale and hearty
specimens of muscular manhood when they took up some profession which
compels them to be indoors, yet before long, they begin to complain of
discomfort after eating, of tendencies to constipation, of headaches,
of depression, of incapacity for mental effort after meals, and all
these symptoms are attributed to the almost universal disease,
indigestion.

It is possible for the general attitude of mind to have a great effect
on digestive processes, and the symptom-complex which is called
indigestion, or dyspepsia, is probably much more dependent on the mind
than on any other factor. In many cases it is primarily due to
over-concentration of attention on digestion. In others it is due to
over-occupation with business, worry, or serious thought at times when
the digestive processes need all the energy. In many cases so-called
dyspepsia is due to an unfavorable state of mind toward digestive
processes in general, because of unfavorable auto-suggestion.
Normally, stomachic sensations reach our consciousness only under
special circumstances. When, however, much attention is paid to them,
even the slight sensations that occur with normal digestion may rise
above the threshold of consciousness and become subjects of
solicitude. If they do so, then the increased attention likely to be
paid to them surely interferes with function and changes what may be
merely physiological into pathological processes.


Disease Suggestions.--An unfortunate state of the public mind with
regard to indigestion in general has been cultivated by many
publications on the subject. People dread its occurrence, and fear
that the first sign of discomfort in their gastric region is a signal
of the beginning of a progressive affection. They fear the worst, and
the consequence is a reaction quite out of proportion to the gravity
of the ailment. So much has been said particularly of mistakes in diet
that just as soon as they feel, or often rather think they feel, the
first symptom of beginning dyspepsia they begin to study how to modify
their diet so as to prevent its progress. They begin to eliminate
various supposedly indigestible foods. Usually among the first things
that are greatly reduced in quantity, or are entirely eliminated, are
the fats and certain of the starchy vegetables. Because of expressions
heard and read as to its harmfulness, the fearful ones also are
usually timorous about taking fluid at meal times. As this is about
the only time when they are likely to take fluid, unless it be summer,
they soon suffer for lack of it. Eating only food that {251} leaves
little residue and taking insufficient fluid leads to constipation.
This reacts still further to disturb digestion, and to interfere with
appetite.

This leads to further reduction in the amount and variety of food,
with the consequence that insufficient nutrition to supply energy for
bodily needs is taken. The digestive system gives up to the body as
much as it possibly can, not only of the food materials to be
consumed, but of its own substance. Thus it weakens its own vitality,
with a lessening of appetite and of digestive power. Hence, a vicious
circle of change is instituted, the consequences of which are easy to
see. After a time the patient is taking only the blandest foods,
constipation has become an important element in the case, and the mind
is constantly occupied with solicitude over the digestion and the
choice of materials at meals.


Contrary Suggestion and Digestion.--Hudson, in "The Law of Mental
Medicine," insisted on the necessity for not suggesting to children
the possibility of indigestion of various substances, for that is
almost sure to disturb digestive functions. Children sometimes hear
the remark that father or mother cannot take a certain article of food
because it disagrees with them. The imitative faculty of the child is
sure to be aroused, with the consequence that this particular food is
not eaten with relish nor given a fair show for digestion, and will be
the source of some stomach disturbance. Not infrequently substances
thus spoken of are among those that are especially likely to do
children good, such as milk or eggs, or occasionally butter. The harm
done by the remark may, therefore, even be serious, for these foods
should constitute a large proportion of the child's diet. Indeed, an
excellent prophylactic in the matter of indigestion is to prevent as
far as possible all conversation at table about the indigestibility of
food. Unfortunately, this has, in late years particularly, become a
favorite subject of table conversation.


Transferred Feelings.--Professor Cohnheim called attention to the fact
that many uncomfortable feelings are likely to be mistranslated
because they are referred to organs with which there is nothing wrong.
Whenever this function is hampered in any way, there are many
uncomfortable feelings associated with the digestion of food. The
custom has been to refer the origin of all these to the stomach.
Cohnheim thinks that it is much more likely that they really originate
in the intestines, though the rule has been to take the patient's
feelings as an indication and to treat the stomach. It is not an
unreasonable thing for patients to be deceived as to the exact
location of discomfort. Even in so acute a process as toothache it is
possible to mistake the particular tooth that is giving trouble, and,
as dentists know, a perfectly quiescent tooth is sometimes blamed for
pain that is coming from another. Fillings have been removed, teeth
have been treated, good teeth have been extracted, because patients
insisted on the significance of their feelings in such cases. The
stomach must not always be blamed. Sometimes the only source of
supposed gastric discomfort is the constipation present which is
usually easy to relieve.


_Gastric Reflexes_.--While the mind may serve to disturb digestion and
produce gastric discomfort by over-attention, there are many reflexes
that center in the digestive tract, the origin of which may be in
distant organs. Fright often produces a sensation as of cold at the
pit of the stomach. Looking down from a height has the same effect in
some persons. Discordant noises {252} have the same effect on people
of sensitive hearing and certain reactions to touch may be similarly
reflected. There are a number of affections which produce
uncomfortable reflex sensations in the gastric region. This is the
hypochondrium of the olden time. Whenever feelings were complained of,
for which there was no actual basis in the hypochondriac region, it
came to be spoken of as hypochondriasis, a word that has an innuendo
of imaginativeness about it. Dr. Head's studies with regard to the
transfer of sensations from one portion of the body to the other, show
us that there is a good physical reason in reflexes for many of these
complaints. An explanation of this to patients will often relieve
their minds greatly and make their discomfort seem much less serious.
Dr. Head said:

  With orchitis or prostatitis, we also occasionally find that the
  patient complains of a pain at the epigastrium, representing the
  stomach area. This is put down to hypochondriasis and if it occurs
  in a woman as a consequence of ovaritis, she is said to be
  hysterical. But this phenomena is no more "hysterical," whatever
  that may mean, than is the reference of the pain and the tenderness
  of an aching tooth to the back of the head or the shoulder.
  [Transfers which have been observed actually to take place.]

  This is the phenomenon I have been accustomed to call
  "generalization" of visceral pain and tenderness, and is of such
  common occurrence as to form a very important factor in the clinical
  picture of many diseases.

  The order in which generalization takes place, leads one to speak of
  the relative "specific resistance" of the centers for the sensory
  impulses from various organs. No very definite rule can be laid down
  to govern every case, but each case must be considered on its
  merits. However, the area which appears most easily on a woman, as a
  secondary affection, is the tenth dorsal; then, perhaps the sixth
  dorsal, or inframammary, and then the various gastric areas,
  beginning first with the ensiform or seventh dorsal. In a man the
  tenth dorsal appears rather less readily while the ensiform appears
  with great ease.

Affections of other organs within the abdomen may produce like
reflexes. A chronic appendicitis, for instance, will often be
reflected in the stomach area. So will the presence of gallstones, or
of disturbances of the biliary mucosa. Loose kidney often produces
stomach reflexes. Any disturbance of the intestinal function will
produce gastric irritation and inhibition of digestion. Most of the
other primary conditions are more serious. Often the patient is aware
of their existence, and it is a relief to him to find that the stomach
symptoms are not the index of further pathological development, but
only reflex conditions. This of itself does much to make the condition
more bearable.

Patients who are suffering from symptoms of indigestion often have
areas of their skin surface that are at least very sensitive, if not
actually tender. They feel the pressure of their clothing over a
particular portion of the body, usually on the left side of the
abdomen somewhat above, though at times also below the umbilicus.
Though not painful, as a rule, it is decidedly uncomfortable and
produces a constant desire to loosen the clothing, or lift it from the
part. Mere loosening, it is soon found, does no good, because the
clothing continues to touch the skin and it is not the constriction or
pressure but the contact that produces the discomfort. Sometimes there
is a distinct lesion of the stomach. This cutaneous hyperasthesia may,
indeed, rise to the height of extreme tenderness in cases of gastric
ulcer, or the like. But there is no {253} doubt that a certain amount
of this sensation is present with all functional disturbances of the
stomach and that the reflex sensitiveness of superficial nerves is
only what might be expected from what we now know of this subject.


_Discomfort and Digestion_.--Just as certain food materials disagree
because of the state of mind, so certain feelings in the gastric
region, even in the skin surface, sometimes disturb digestion and lead
to changes of the diet unwarranted by the condition. Patients conclude
that, if the skin is so tender, then the underlying organs, the
disturbance of which causes this tenderness, must be in a serious
condition. For these patients the explanation of the present state of
our knowledge as to reflex disturbance of sensory nerves will be of
therapeutic value. They must be taught that pain is reflected from one
nerve branch to another, and is not communicated by continuity of
tissue, or by sympathetic affection from the stomach mucous membrane
through the stomach wall, and then from the abdominal wall to the skin
surface. This knowledge will prove reassuring.


Division of Energy.--After this mental occupation with digestion
itself, which by consuming nervous energy lessens the amount available
for digestive purposes, probably the most common factor in the
production of indigestion is the concentration of mind on serious
subjects, while digestion is proceeding. An old English maxim is that
some people have not enough brains to run their liver and their
business. The liver in old-time pathology was considered the most
important of the abdominal organs and was taken by metathesis for them
all. Most of us have only a limited amount of vital energy and,
usually, we can accomplish only one thing well at a time. If we try to
do intellectual work while digestion is going on, both the
intellectual work and the digestion suffer. If we persist in
attempting to do both, we will surely disturb the digestive organs and
we may bring about grave neurotic disturbances in the central nervous
system. We may be able for a time to accomplish the two things at the
same time, but it will not be long before evil results will be seen.
Nervous, high-strung people should be reminded of Lincoln's anecdote
of the little steamboat on the Mississippi which had not steam enough
to blow its whistle and run its paddle wheels at the same time, so
that whenever the engineer wanted to blow the whistle he stopped the
boat.

Indeed, much of the indigestion that we see is due to this dissipation
of energy through the attempt to do two things at the same time. Those
who live the intellectual life are the most frequent sufferers.
Worries and anxieties that are allowed to trouble the mind during
digestion time are sure to disturb digestion eventually because they
use up energy that is needed for physical purposes.

A change of environment that takes us away from the ordinary cares of
life, is often sufficient to make all the difference between ease of
digestion and extremely uncomfortable dyspepsia. By worry the mind
apparently becomes short-circuited on itself and uses up a large
amount of the available energy in nervous impulses that do not find
their way outside the central nervous system at all, but are used in
disturbing associated nerve cells. Just as soon as a change of scene
and occupation calls for a different set of thoughts and other
feelings, energy is released for work outside the central nervous
system itself, digestion begins to improve, and in a comparatively
short time what seemed to be a serious gastric disturbance, disappears
almost completely.

{254}

_Lack of Sleep Repair_.--In my own experience one of the most
characteristic stigmata of these cases of indigestion which are due to
exhaustion through other channels of vital energy, is that they feel
much better in the evening than in the morning. They are, therefore,
tempted to stay up late and so do not get the necessary rest. Their
excuse for late hours is that they need recreation. To that excuse I
have no objection. They do need more recreation; they need more hours
during which their minds are absolutely free from business cares; but
these hours must not be taken from their sleep, for they need rest
even more than recreation.


_Worries and Irritations During Meals_.--The presence of worries or
irritation during meals or shortly after, as well as unfavorable
states of mind towards digestion itself, and occupation of mind with
serious affairs during digestion, are likely to be sources of serious
disturbance of digestion. A fright, a fit of anger, nagging,
irritation, or any disturbing emotions, may hamper digestion. An
experiment that is sometimes performed in the physiological laboratory
on the cat nicely illustrates this. If the laboratory cat is fed some
dainty that it likes, mixed with bismuth in order that its stomach and
intestines may be made opaque to the x-rays, and then be examined by
means of the fluoroscope, the peristaltic processes of digestion by
which food is mixed in the stomach, passed out into the intestines,
and by which intestinal digestion is stimulated, may be seen to go on
very interestingly. If, now, the cat is made to arch its back, and
manifest the usual signs of extreme irritation, the process of
digestion is interrupted, and will not be resumed till some time after
the cat quiets down. The lesson is obvious.



CHAPTER III

PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS

If discouragement and solicitude make a healthy stomach digest
imperfectly, the same mental factors will play an even more serious
role with a diseased stomach. Certainly without the mind's aid, there
can be little hope of such a reactive vital resistance as will enable
the organ to recover from the organic ailment.

So many cases of indigestion are due to mental persuasion alone, that
after a time there is danger that the physician may be over-confident
in his diagnosis, and may occasionally overlook serious organic
lesions. Before attempting psychotherapy in these cases, the physician
must assure himself that no organic lesion is present. This is
particularly true for cancer in the middle-aged and ulcer in young
women. At times these lesions are latent except for certain vague
digestive symptoms. After careful consideration it is generally
possible to make a definite decision, and then the indications are
clear. Even when an organic lesion is present, a modification of the
mental attitude will often be of great service to the patient.
Suggestion will even make a cancer patient gain in weight, though one
must be careful of that very fact because the apparent improvement may
occasion delay until the case becomes inoperable.

Once the presence of these serious organic lesions of the stomach can
be {255} excluded, the bringing of influence to bear on the patient's
mind for the improvement of his digestion is indicated. It is true
that there are certain reflex disturbances of the digestive tract
consequent upon affections of other abdominal organs. Chronic lesions
of the appendix may produce stomach symptoms as will also pathological
conditions of the biliary tract. A floating kidney, various affections
of the pelvic organs, especially in women, and of the urinary organs
in men are sometimes said to produce seriously depressing effects upon
the stomach. Where this occurs, the first indications undoubtedly are
to put the patient into as good condition as possible before making
any decision. Where a lesion of the stomach itself exists suggestions
with regard to the increase of diet may do harm. They will not do harm
in the reflex conditions, and so patients can be brought into better
physical condition. As a consequence of this, their symptoms in other
organs will often disappear. In case the symptoms do not disappear the
patients are in better condition to stand and react from operative
intervention.

Before concluding as to the character of the stomach symptoms we must
make sure that other important organs are not affected. Most cases of
tuberculosis begin with stomach symptoms, which often make their
appearance before there is cough or any definite localizing symptom of
the disease. Often there is only a disturbance of pulse, and perhaps a
slightly increased range of temperature. If the patient has been
exposed to tuberculosis, a careful investigation of the lungs should
be made. Any disturbance of the liver or pancreas (especially cancer)
will almost surely give rise to stomach symptoms. Latent cancer in any
part of the body, however, will, by its depressing toxemia, produce
loss of appetite, consequent loss of weight, and a number of symptoms
that are sure to be referred to the stomach. I have seen cancer of the
prostate, without disturbing urination, produce such symptoms for
months before it was recognized. I have seen cancer of the rectum in a
comparatively young woman treated as piles, without an examination,
the development of the piles being attributed to the gastro-intestinal
symptoms which were consequent upon the presence of the cancer.


MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION

It is often said that this teaching as to the effect of the mind on
digestion and its eminent usefulness for the treatment of dyspeptic
conditions, is due to the attention that has been attracted to this
subject as a consequence of the prominence of Eddyism, New Thought,
Mental Healing, and the like. There are absolutely no good grounds for
any such assertion. Here in America, more than twenty-five years ago,
before there was any question of the modern mental healing movements,
our greatest medical clinician, Dr. Austin Flint, expressed himself
very emphatically with regard to mental influence over digestion, and
to solicitude of mind as one of the most frequent etiological factors
in dyspepsia.

Dr. Flint was thoroughly scientific in his medical observations, was
no seeker after notoriety, and he was reading his paper before the
older physicians of the period, and all of those who took part in that
first meeting of the New York Medical Association strove to make their
papers of scientific value. His words, then, must carry great weight:

{256}

  Dyspepsia formerly prevailed chiefly among those who adopted, to a
  greater or less extent, the foregoing maxims [the finicky rules of
  dyspeptics which he deprecates and corrects as quoted later in this
  chapter]. It was comparatively rare among those who did not live in
  accordance with dietetic rules. The affection is much less prevalent
  now than heretofore, because these maxims are much less in vogue.
  The dyspeptics of the present day are chiefly those who undertake to
  exemplify more or less of these maxims. It seems to me, therefore, a
  fair inference, that dyspepsia may result from an attempt to
  regulate diet by rules which have for their object the prevention of
  the affection which they actually produce. It is to be added that an
  important causative element involved in the practical adoption of
  these rules is the attention thereby given to digestion. It is by
  introspection and constant watchfulness of the functions of the
  stomach, that the mind exerts a direct influence in the causation of
  this affection.



Dietetic Rules of a Former Day.--In order to make definite just what
were the views of the olden times which he deprecates, he stated them
briefly and forcibly:

  The views generally entertained, at the time to which I have
  referred, largely by physicians and almost universally by
  non-medical sanitarians, may be summed up in a few maxims as
  follows: Eat only at stated periods, twice or thrice daily, and
  never between meals, no matter how great may be the desire for food.
  Never eat late in the evening or shortly before bedtime. In the
  choice of articles of diet, carefully select those which reason and
  personal experience have shown to be best digested; and never yield
  to the weakness of eating any article of food simply because it is
  acceptable to the palate. In order to avoid the temptation of
  overeating, let the articles of food be coarse rather than
  attractive, and eschew all the devices of the cuisine. Always leave
  the table hungry. Study personal idiosyncrasies, and never indulge
  in kinds of food which, although wholesome for most persons, are
  injurious to a few who are peculiarly organized. With reference to
  this last maxim, bear in mind that "what is one man's meat is
  another man's poison." In order to secure, as effectually as
  possible, a proper restriction in the quantity of food, it was
  recommended by some physicians and to some extent practiced, that
  every article be carefully weighed at meal times, and that a certain
  quantity by weight be never exceeded. Vegetarianism or Grahamism was
  advocated and practiced by many. Total abstinence from drink was
  considered by a few as a good sanitary measure, compelling the body
  to derive the needed fluids exclusively from fruits, vegetables, and
  other solid articles of diet. Restriction in the amount of drink, as
  far as practicable with regard to the power of endurance, was very
  generally deemed important, so as not to dilute the gastric juice.

When to his question, "Do you regulate your diet," the patient
answered promptly and often emphatically in the affirmative, Dr. Flint
insisted always: "This is a good reason for your having dyspepsia; I
never knew a dyspeptic get well who undertook to regulate his diet."
When the patient asks then, "How am I to be guided," the reply is,
"Not by theoretical views of alimentation and indigestion, no matter
how much they appear to be in accord with physiological and
pathological doctrines, but by the appetite, the palate and common
sense." He then goes on to answer certain other objections that
patients are wont to urge, and says:

  But the patient will be likely to say, "Am I not to be guided by my
  own experience and avoid articles of food which I have found to
  disagree with my digestion?" The answer is, that personal experience
  in dietetics is extremely fallacious. An article of diet which may
  cause inconvenience of indigestion to-day may be followed by a sense
  of comfort and will be readily digested to-morrow. A variety of
  circumstances may render the digestion of any article of food taken
  at a {257} particular meal labored or imperfect. As a rule articles
  which agree with most persons do not disagree with any, except from
  casual or accidental circumstances, and from the expectation, in the
  mind of the patient, that they will disagree. Without denying that
  there are dietetic idiosyncrasies, they are vastly fewer than is
  generally supposed; and, in general, it is fair to regard supposed
  idiosyncrasies as purely fanciful. Patients not infrequently cherish
  supposed idiosyncrasies with gratification. The idea is gratifying
  to egotism, as evidence that Providence has distinguished them from
  the common herd by certain peculiarities of constitution.


Dietetic Instructions.--Finally Dr. Flint has a series of instructions
for those suffering from indigestion:

  Do not adopt the rule of eating only at stated periods, twice or
  thrice daily. Be governed in this respect by appetite; and eat
  whenever there is a desire for food. Eat in the evenings or at
  bedtime, if food be desired. _Insomnia is often attributable to
  hunger_ [italics ours]. In the choice of articles of diet, be
  distrustful of past personal experience, and consider it to be a
  trustworthy rule that those articles will be most likely to be
  digested without inconvenience which are most acceptable to the
  palate. As far as practicable, let the articles of diet be made
  acceptable by good cooking. As a rule, the better articles of food
  are cooked, the greater the comfort during digestion. Never leave
  the table with an unsatisfied appetite. Be in no haste to suppose
  that you are separated from the rest of mankind by dietetic
  idiosyncrasies, and be distrustful of the dogma that another man's
  meat is a poison to you. Do not undertake to estimate the amount of
  food which you take. In this respect different persons differ very
  widely, and there is no fixed standard of quantity, which is not to
  be exceeded. Take animal and vegetable articles of diet in relative
  proportions as indicated by instinct. In the quantity of drink,
  follow nature's indication; namely, thirst. Experience shows
  abundantly that, with a view of comfortable digestion, there need be
  no restriction in the ingestion of liquids.


Removal of Solicitude as a Remedial Measure.--Many dyspeptics have no
subject that they occupy themselves with more seriously than their
digestion, and they thus divert blood needed for digestive purposes as
well as nervous energy that would help in it from the stomach to the
brain, in order to exercise surveillance over the process. As has been
well said, "Probably much more than half of the indigestion is really
above the neck." This does not mean that there are not cases that need
definite stomachic treatment, or even that patients who have succeeded
in functionally disturbing their digestion by thinking over much about
it, will not need gastric remedies.

The explanation of the many fads and remedies that _cure_ indigestion,
real or supposed, is exactly this tendency of the suggestive influence
of such remedial measures to lessen the patient's solicitude about
digestion. Any change in diet that carries with it the persuasion that
for any reason digestion ought to be better, will, because of this,
make digestion better. Any habit of taking warm or cold water before
meals, or of chewing in a particular way, or of taking a particular
kind of food different from what is usually taken--exclusively cereal,
uncooked, largely fruit, vegetarian, etc.--will lift the concentration
of attention on the digestive process, and so give the stomach a
chance to do its work without interference from the brain.

Du Bois has quoted some striking testimony in this matter from Baras,
who wrote on the "Gastralgias and Nervous Affections of the Stomach
and the Intestines" as early as 1820. Baras had himself been a
sufferer from {258} gastric discomfort, fullness after eating,
eructations of gas, constipation, and general depression. He consulted
most of the distinguished medical practitioners of his time. With one
exception they were convinced that he was a sufferer from chronic
gastro-enteritis. They added more and more to his concern about his
stomach, and furnished him with numerous sources of autosuggestion. In
spite of all that they did for him, his condition grew worse and
worse, he lost in weight, and was sure that his case was hopeless. He
was cured in a single day. His daughter was attacked with consumption,
and "in the moment my attention," says Baras, "was centered entirely
upon my child, I thought no more of myself, and I was cured."


Brain Workers and Indigestion.--Perhaps the best proof of how
necessary it is that people should not continue to occupy their
intellect seriously during the time when digestion is going on, is to
be found in the frequency with which complaints of indigestion occur
in literary folk. The complaints are heard most from literary folk
because they are more likely to tell their stories. They have their
work, and thoughts of it, always with them. So there is a constant
call for nervous and mental activity and for much blood in the brain
tissues. This subtracts from the nervous energy necessary for
digestion, and makes it impossible to conduct it with that perfection
which comes naturally to people who banish all other thoughts and keep
their minds free for the pleasures of the table and social intercourse
at meal time.

Nervous indigestion is so common among literary folk, teachers and
scientific workers, that various causes have been suggested for it.
Dr. George Gould, in his "Biographic Clinics," calls attention to it
and suggests that the cause is probably the need of properly fitted
spectacles. In our own time, when we are much more careful in the
matter of eyeglasses, and when most writers and professors wear
scientifically adapted glasses, the complaints still continue. The
reason is evidently something associated with the almost continuous
work that they do. Such people, too, are much more self-conscious than
others. They think more about their digestion and what they eat. They
often think that they differ from other people and have special
idiosyncrasies for food. These thoughts are sure to culminate in
nervous indigestion.


Food Faddists.--Literary folk and people who live the intellectual
life are very prone to take up with fads of various kinds and find
surcease from their sorrows in all sorts of out of the way dietaries,
modes of eating, food limitations and specializations. They constitute
a majority of the food faddists. Some of them--sure that they should
not eat meat--are strenuous vegetarians. Others confine themselves
entirely to food the life of which has not been completely destroyed
by cooking. They are fruit faddists, nut faddists, milk-product
faddists, and the like. Some of them try to persuade the world that it
eats too much; others that it eats too frequently. Some of them take
but a single real meal a day and have apologies for the other meals.
All want to lead people to their particular mode of life, as if all
the world had been wrong until they came to set it right. Some want
the rest of the world to chew seventy-times-seven before they swallow
and to adopt other exaggerations of attention to eating that are quite
contrary to instinct, the most precious guide that we have in the
matter of food choice and food consumption.

These intellectuals are always improved by their fads, no matter what
they {259} may be. The reason is apparent. Their original digestive
disturbance was due to over-occupation with intellectual work. Then
they began to worry about their digestion and feared that nearly
everything they ate would disagree with them. This fear and solicitude
still further interfered with digestion. Next they acquired the new
fad. They became persuaded that they could eat certain things in
certain ways. They no longer disturb their digestion by anxiety about
it, but, on the contrary, help it by favorable suggestion. Now under
the new regime everything will surely go on well. Besides, they
usually learn the lesson of not doing intellectual work close to their
meals, and of spacing their work better. They learn to do a daily
stint of work and no more. One of the fads that goes with most food
fashions is abundant outdoor air. This always does good. Between the
favorable mental influence, the lessened work, especially just after
meals, and the increased outdoor air they get better and then they
attribute it all to their special fad about food. The _"cure"_ is due
to psychotherapy and common sense, and not in any way to the special
fad.


Worry.--Worry of any kind will have the same effect as the
over-attention of the literary man or teacher to his work. Anyone who
brings his business home with him is likely to suffer and, unless he
has a superabundant supply of energy, will impair his digestive
function as a consequence of attempting to do business after dinner,
perhaps also stealing some of it in before and during breakfast.


PREVENTION AND CORRECTION

The important rule with regard to the mental attitude of the patient
toward uncomfortable feelings due to digestion must be, first to
correct all other possible sources of the trouble, and only after
these have been proved not to be factors in the case, should there be
any question of modification of diet. This is just the opposite rule
from that which obtains, and by which patients begin to meddle with
their diet at the slightest symptom, or supposed symptom, of
indigestion. My custom is to tell patients at once that there is
probably something else besides their diet at fault. It is not that
they eat too much, nor too great a variety, but that perhaps they eat
too rapidly. Without reducing their diet, and above all without
eliminating supposedly indigestible things from it, there should be
formed a habit of eating more slowly. This will usually result in the
reduction of the quantity eaten, but the variety of food should be the
same, and the patient should not be permitted to limit his diet to a
few supposedly bland, unirritating materials. In that event,
constipation will assert itself, particularly if there is limitation
of the amount of fluid taken.


Longevity of Dyspeptics.--There is one consolation that may be given
to nervous dyspeptics, though in the midst of their worst symptoms
they may not be sure whether it is a genuine consolation or not. It
has been noted that many of those who live to extreme age tell the
story of having suffered from nervous dyspepsia in middle-life. Their
solicitude about themselves makes them safe against over-indulgences
of many kinds in food or drink that might prove hurtful to them. Much
of their discomfort is indeed due to the fact that they do not eat
quite enough. If they succeed in avoiding the {260} pitfalls of the
infectious diseases, and especially tuberculosis during their earlier
years, and most of them are likely to because of the great care they
take of themselves, they often live to old age. Certainly of two men,
one of whom eats very heartily and the other very sparingly, the
latter is much the more likely to attain old age. There are those who
declare that the valetudinarian life, "half dead and alive," which
even Plato satirized nearly 2,500 years ago, ever renews the question
as to whether life is worth living or not. It is particularly
dyspeptics who seriously discuss this question--yet with all their
complaints, they actually do live longer lives.


Pharmaceutic Remedies.--This insistence on the importance of mind in
the treatment of indigestion does not imply that tonic remedies, and
especially such substances as strychnin, which stimulate appetite and
add tone to the muscles of the stomach, should not be used when duly
indicated. They are always helpful. Alone, these remedies give but
temporary relief and after a short time the system becomes accustomed
to them. If prescribed in connection with changes in the patient's
habits, and especially such as divert his attention from his digestive
tract, and from wrong persuasions as to food taking, the good they
accomplish will be lasting. Nervous people usually have an increase of
acidity. They are liable to overdo everything, and even the stomach
overdoes its acid forming function. For this, alkaline remedies such
as rhubarb and soda will do good. But, just as with strychnin, the
benefit is but temporary unless the patient's habits and attitude of
mind are modified so as to eliminate their solicitude as a constantly
disturbing factor.


Circumstantial Suggestions.--There are many changes of habits that are
of great value in the treatment of nervous and allied forms of
indigestion. These changes often make a great difference in the
general health of the patient and thus help to improve digestion.
Besides their influence as alteratives, they are valuable from the
mental influence which they exercise. It requires a definite exertion
of will many times, perhaps, each day to bring about the omission or
performance of certain actions, and this act of the will is
accompanied by the repeated suggestion that this will cause
improvement in the digestion. Many of the cures effected by special
diet. Habits of exercise, health resort regimes and the like, owe
their efficacy to this accompanying repeated suggestion of acts for
the formation of new habits or the breaking of old ones.


Physiological Measures.--There are, of course, certain details with
regard to digestion in which the patient's mental attitude needs to be
changed by instruction rather than persuasion, by knowledge of
physiology rather than by psychology. In the taking of food itself,
chewing is, of course, the most important consideration after its good
preparation by the cook. If patients are told to chew their food
carefully, however, without further directions than this, it will
usually be found that they begin to chew their meat a great deal and
their vegetables scarcely more than before. It is, however, vegetables
that must be chewed particularly. The meat-eating animals bolt their
food. They have only cutting and tearing teeth. Their instinct is
correct, for the saliva has nothing to do with the digestion of meat,
and therefore no chewing is necessary. On the other hand, the
vegetable-eating, and especially the grain-eating animals, chew
carefully. Most of them are ruminants, that is, after a preliminary
thorough chewing of their food, they swallow it, and then {261}
afterwards at their leisure bring it up once more into the mouth and
chew it again.


_Mastication and the Stomach_.--If food is not chewed well, and occurs
in large masses in the stomach, not only is it not dissolved easily,
but the work of passing it out to the intestine is delayed. The reflex
which brings about the opening of the stomach and the ejection of food
into the intestine is best brought about by the liquefaction of the
stomach contents. During the mixing process all the food, as far as
possible, becomes fluid and then is passed on. Large pieces of any
kind are delayed, however, hamper the emptying of the stomach and
interfere with stomach motility. The stomach is only a thin-walled
membranous viscus which finds difficulty in dealing with food in
lumps. It is different from the stomach of the hen, which, having no
teeth, swallows grains of all kinds without chewing, but also by
instinct swallows small stones which, in its thick-walled, muscular
gizzard, are used for grinding up the food.


_Exercise_.--The taking of exercise is an important habit that needs
to be changed in the case of dyspeptics. Many of those who live a
sedentary life, and are much occupied with intellectual or business
matters, are almost sure to take little or no exercise. If earlier in
life they were accustomed to take much, the lack of it leads to
serious disturbances of nutrition. They have formed certain habits as
to the amount of food they eat, and these continue, so that they
consume more heat-making material than they can use. In the process of
dissipating it, there is likely to be much nervous energy wasted,
usually to the discomfort of the patient. This is likely to be
eventually reflected back to the stomach, with disturbance of appetite
and digestion.

We now know that the motor function of the stomach is much more
important than its secretory function. Its main purpose is to mix the
food and pass it on in small quantities, at intervals, to the
intestines. When patients have a sense of uncomfortable fullness in
the gastric region after a hearty meal, or of discomfort after the
taking of food, especially if much liquid is taken with it, they are
prone to attribute these feelings to imperfect secretion not
completing digestion as it should, and permitting fermentation with a
production of gas and consequent stomach distention. The real reason
for their discomfort is not secretory, but motor. It is due to a delay
in passing on the food and to stomach distention because the gastric
muscle is not in good tone.

People who have been used to taking exercises have their muscular
system in good tonic condition. This includes the involuntary muscles,
as well as the voluntary, and if they are neglecting air and exercise,
the whole muscular system becomes flabby. Hence the uncomfortable
sense of distention, because the stomach walls do not contract readily
for the expulsion of food. A second important factor is also
present--the muscles of the abdomen. Ordinarily they support the
abdominal organs without any sense of effort. If by lack of exercise
they have diminished in tone, however, when a hearty meal is eaten,
the abdominal muscles have to support this additional weight since the
stomach itself sags, and the consequence is a feeling of pressure on
the left side of the abdomen about the level of the umbilicus. To
relieve this feeling the tendency of the patient is almost always to
lessen the amount eaten. If he is not distinctly overweight this will
do harm rather than good. Instead he {262} needs to take sufficient
exercise to tone abdominal muscles and reflexly also tone even
involuntary muscles, and with them the gastric muscularis.


_Air_.--Almost more important than exercise is an abundance of fresh
air, and without this muscles soon fail to respond to voluntary or
involuntary impulses. If people do not spend two or three hours in the
air every day, they are likely to develop an over-sensitive condition
in which all nervous sensations are exaggerated. The reason men and
women differ so markedly in their reaction to pains, aches and
discomforts, is mainly that their habits of being out in the air
differ correspondingly. Men are out much and, as a rule, stand
discomfort better. Women are out little and are more sensitive to
pains and aches. The more a man is out, the less is he likely to
notice discomforts and aches that he would otherwise complain about.


_Sleep_.--Another important factor is the amount of sleep. Over and
over again I have found that patients who were beginning to complain
of discomfort, which they associated with the word indigestion, were
taking too little sleep, and as soon as I persuaded them to add an
hour or more to their sleep their gastric symptoms began to improve.
It is easy in our large cities to acquire the habit of shortening the
hours of rest. This is sometimes done so gradually that the individual
scarcely realizes how much he has cut into his sleeping period. Some
people who have to get up at seven or half-past seven in the morning
go to bed about twelve, but really do not get settled for sleep until
nearly one o'clock. Sometimes people read interesting books just
before going to bed, or while in bed, and it is nearly two o'clock
when they get to sleep.

Many people have the habit of reading themselves to sleep. This may be
an excellent way to get rid of bothersome thoughts, provided the
reading selected is not of too absorbing a character, and provided
also as soon as sleepiness comes its call is heeded. Some write
letters late at night. Writing always keeps one awake, though reading
may be helpful for sleep. If this abbreviation of sleep becomes
habitual, the first organs in the body to set up an objection is the
digestive tract. It is one of the hardest worked systems in the body,
having to dispose of its quantum of food three times every day, and if
the organism does not receive due rest, the digestive tract suffers
first. People who get insufficient sleep often have no appetite in the
morning, and suffer from uncomfortable feelings in the gastric region.
What they are too prone to do is to meddle with their diet, and this
practice always does harm.



CHAPTER IV

APPETITE


Two classes of patients come to the physician complaining of lack of
appetite. The first and more important class consists of those who are
eating too little, who are consequently under weight, and who must be
made to eat more. The other class consists of those who eat enough but
complain that they do not relish their food. Careful questioning
usually elicits sufficient information to enable one to decide that
most of these latter are eating too {263} much, or unsuitable food,
and at too frequent intervals. They are usually overweight, and there
is need to reduce the amount they eat. In both of these classes the
physician is tempted to conclude that medicines should form the
principal part of the treatment. We have a number of tonics and
stimulants that undoubtedly initiate a desire for food, or at least so
increase the circulation in the stomach that patients feel much more
inclined to eat than they otherwise would. There are a number of
remedies, also, the so-called anti-fat group, which produce a
disinclination for food.


Power of Mind Over Appetite.--Appetite, whether in deficiency or in
excess, is best regulated through the patient's mind. Patients
frequently state that they cannot eat more than they do, that they
have no inclination for food, and yet, after a little persuasion, they
can be made to increase the amount they have been eating, and then
that can be gradually raised until they are taking what is for them a
normal quantity. There are many things that we swallow without caring
for them. Most medicines we not only do not like, but positively
dislike. We put them down, they accomplish their purpose, and food
will act nearly in the same way. There are few cases where food is
positively rejected. Patients can be persuaded to eat more, and after
a time will be surprised to find that their desire for food increases
with the habit of taking it. On the other hand, patients can be made
to see that they are taking too much food really to enjoy its
consumption. Their appetites are perpetually cloyed, and to them food
has none of the pleasant flavor that exists when it is taken in
moderation.


_The Will to Eat_.--In various parts of this book there is emphasized
the necessity for the exercise of the human will in order to aid in
the accomplishment of even physical functions. The basis of many
nervous symptoms is a lack of sufficient nutrition to steady the
nervous system. Some people not only lack will power, but also
judgment in the matter of eating; they prefer to err on the side of
insufficiency lest they should over-eat. For these people the
important remedial measure is to dictate the amount that they shall
eat, and gradually to increase it until they are eating enough for
their nutritional purposes.

When this advice is given to patients, they are willing to agree that
a gain in weight would be good for them, but they cannot understand
how they can eat more since they are now eating all they can, or
certainly all they care to. Appetite grows by what it feeds on, and
increase in appetite is a function of the habit of eating.

But some patients, after having tried the prescription of eating more,
are still in the same condition, and find that they cannot put on
weight. What is needed in such cases is an inquiry into all the
conditions of the daily life, their habits of eating and the amount of
time that they take for their meals. They are probably eating one good
meal a day, their dinner in the evening--but they confess that the
other meals are not satisfactory. If their habits are rearranged, the
will to eat does the rest. Sometimes they complain of uncomfortable
feelings after eating and this makes them eat less at the next meal.
There are various mental elements that disturb the efficacy of the
will to eat, consequently these patients do not get on. What they need
is emphatic insistence on the necessity for persistent effort in
regular eating day after day, meal after meal, and it is not long
before improvement comes not {264} only in weight, but also in
appetite. I have known patients to gain five or six pounds a week
after having tried weeks in vain to gain a single pound.


_Sitophobia_.--Many people read much of the possibilities of evil in
overeating, and they conclude that a limitation of diet would be
better for them. After a time some of these people of nervous
constitution acquire an actual dread of over-eating and develop what
has been called sitophobia, or dread of food. Before anything can be
done with them, this dread must be removed. The problem is discussed
more fully in the chapter on Weight and Good Feeling, but here it
seems necessary to emphasize that it is often quite impossible by
ordinary medical means to produce an appetite in these patients. Their
mental persuasion with regard to food must first be removed. If it
cannot be removed, improvement is usually out of the question. No
medicines are sufficiently powerful to overcome a fixed unfavorable
idea with regard to food. The same is true as to sleep, or any other
natural function--it comes and must go through the mind.


Disturbance of Mind and Its Influence on Appetite.--The basis of the
psychotherapy of the digestive tract is the fact that appetite is a
function of the state of mind rather than of the state of body. We all
know how easy it is to lose the appetite by emotional disturbance. We
may come into the house after a brisk walk, when we know that dinner
is going to be better than usual, quite ready to anticipate the
pleasure we are to have in eating it and with appetite craving that
dinner shall not be delayed, we find a telegram announcing the death
of a friend or the illness of a relative or some other bad news, and
in an instant our appetite has disappeared. It makes no difference to
us for hours whether we eat or not. What we eat gives us no
satisfaction. It will be taken entirely from a sense of duty and
without pleasure and will digest slowly, even if it does not produce
discomfort.


_Feelings and Appetite_.--There is no need for a serious stomach
condition to develop, to diminish, or eliminate appetite. The sight of
an accident on the street, especially if blood is shed, will entirely
take away the appetite of many persons. Now that suicide beneath the
wheels of subway trains has become a rather frequent way of going out
of life, physicians note that nervous patients who happen to see these
sad affairs have no appetite, not alone for the next meal, but
sometimes for several days. Some people have no appetite at all if
there is a dead body in the house where they live. I have known people
who felt it almost a desecration to eat under such circumstances. Even
much less than this may serve to diminish appetite. An offensive odor
of almost any kind is quite sufficient to take away the appetite of
many people. For some the odor of cooking food, if they have been in
it for some time, is almost sure to cloy any desire for food.

Cooks suffer from loss of appetite for this reason. The sight of a
disagreeable stain on a tablecloth, or of a waiter's thumb in the
soup, or of some unpleasant characteristic of the waiter, may be quite
enough seriously to disturb the appetite of sensitive people.

We know all this very well, and yet we are prone to think of appetite
as something regulated by instinct, and representing the real needs of
the organism in its cravings and the limitations of the necessity of
food by its satisfaction. In our sophisticated modern life instinct
will often fail entirely to fulfill these purposes. Appetite for those
who live much indoors is a question of {265} habit and regulation
rather than of instinct. It has to be voluntary to a large extent, not
only as regards the quality but also the quantity of food. We eat the
things that we care for, but how much of them we shall eat is another
matter. That depends on how we happen to be disposed at the moment,
and whether there is any good reason for eating more or less at the
given time.


Appetizers.--There is a whole group of substances recommended as
appetizers, most of which are effective, but their effect is likely to
be temporary, and to fail particularly in those cases where an
appetite is most needed. Anything that will increase the circulation
in the stomach will usually add to appetite; consequently warm drinks,
alcoholic liquors and spices of various kinds have this effect. In
vigorous people, a dash of cold on any portion of the body, is
followed by a strong reaction of the circulation. Cold drinks,
therefore, will sometimes serve as an appetizer, especially in hot
weather. Almost anything that has a certain peculiarity of taste, and
that is taken with the definite suggestion that it will produce an
appetite, will almost surely have that effect. All sorts of articles
of diet have in various countries acquired a reputation as appetizers.
Fermented mare's milk is effective in central Europe; a glass of
buttermilk in Ireland; some very hot soup with one of the strong
spiced sauces in it in England; and various curious combinations of
fruit and other materials in the shape of what are called cocktails,
in America. Anything that stimulates the stomach a little unusually,
and is accompanied by the idea that it is likely to increase the taste
for food, almost surely adds to appetite.

This question of appetizers is as yet a mystery to us. It is eminently
individual and yet much depends on racial customs, the habits, the
environments and the family training. It is surprising what curious
materials serve to excite the appetite. Caviar, in spite of the
distaste of "the general," is undoubtedly a good appetizer for many
people. Bismarck herring, or kippered herring, acts in the same way.
In the old days men used to take what were called red herrings and
undoubtedly found in the eating of them a renewal of desire for food,
when there had been absence of appetite. There are some people in whom
a little taste of cheese serves the same purpose. Bitter tastes
usually increase appetite. Salt under certain circumstances has a
similar effect. Acid fruits sometimes stimulate a jaded desire for
food. Nearly always the effect of these various appetizers is
increased by the attitude of expectancy. They have the reputation of
being appetizers and so, though often at first somewhat disagreeable,
they eventually prove to be helpful stimulants.


Appetite and Habit.--For those who live an indoor life, and have that
nervous disposition that disturbs instinct, the only safeguard for
nutrition is a definite formula for eating which must be followed
strictly, especially by those who are below the normal in nutrition.
In the chapter on Weight and Good Feeling I discuss the failure of
appetite following a diminution of the amount of food. The stomach may
be described as unselfish, and in times of scarcity it gives up to
other organs more of the nutrition that comes to it than it should. As
a consequence, it is not so well able to fulfill its functions of
digestion and of craving for food, which is part of its function, as
it would otherwise be. It is the people who are eating a proper amount
and have been eating it, whose digestive tracts are in a condition to
crave the proper {266} amount of food. Those whose habits have
unfortunately led them into eating amounts too small, also suffer in
not having the proper desire for food.

Nervous people particularly are likely to lack appetite in the early
morning. Those who are under weight will almost invariably confess
that they take little breakfast. Their reason for so doing is that
they have no appetite. For most of them what is really true is that in
the early hours of the day their will has not yet taken properly hold
of their economies and everything is in a depressed state. These
patients usually confess that they wake feeling not rested but tired,
fearing the day, and wondering now they will be able to get through
it. Only toward the middle of the day do they feel like themselves,
while towards evening they wonder how they could have been so
depressed in the morning. What these people need is the rousing into
activity of their functions. Occasionally, especially in summer, a
cold sponge on rising in a room into which an abundance of air is
admitted will do much for them. Often a walk of even ten minutes
before breakfast will make all the difference between appetite and
lack of it. Above all, however, they should be made to feel that if
they want to eat they can eat--if they want to they can reestablish
the habit of taking breakfast, and then it will be a pleasure instead
of a burden.


_Food and Caprice_.--Those complaining of lack of appetite should
learn not to let caprice rule them in the matter of eating. There are
people who by habit eat too much. What they must do, as pointed out in
the chapter on Obesity, is to unlearn the habit of overeating, and
that is almost as hard to break as the habit of taking stimulants.
Most nervous people undereat, but they must take themselves in hand,
eat three meals a day, and reestablish the habit of taking as much at
these meals as they ought. What each one should consume is eminently
individual, depending altogether on the sort of heat engine that each
one is. Family traits mean much in this. Some must eat much more than
others to keep up their weight and strength, because they are wasteful
heat engines. As a rule, tall, thin people must eat more in proportion
to their weight than shorter individuals of stout build. They expose
more surface for heat dissipation. In this each person must learn for
himself his own necessities. When there is a question of regulating
eating by reason, the rule must be remembered that there is a tendency
in people living indoors to take too little rather than too much.


_Appetite and Food Preparation_.--There are many curious things with
regard to the formation of the habit of eating that show how easily
the appetite or instinct is vitiated. Women, for instance, are nearly
always prone not to eat enough if they have to prepare their own
meals. When a mother and daughter or two sisters live together, they
usually prepare one good meal, but the other two meals are likely to
be picked up any way. The presence of a man in the household makes all
the difference in the world. Meals are prepared regularly for men.
Even for a boy of five to fifteen, meals are regularly prepared, and,
as a rule, the presence of a child makes for regularity in eating.


_Habit of Overeating_.--On the other hand, it is easy to form habits
of eating that go quite beyond appetite and vitiate the desire for
food quite as seriously in the opposite direction. Many stout people
take snacks between meals; women, already too heavy, indulge in the
afternoon tea habit with a surprising amount of substantial food taken
with the tea; many a stout man {267} takes a glass of beer
occasionally and never fails to take something to eat at the same
time, mainly with the idea, as he says to himself, that by taking
something to eat the beer will be less likely to do him harm. Stout
children are likely to form the habit of eating too frequently. When
they come home from school they have a piece of something; before they
go to bed they have a glass of milk, and a piece of cake, and
sometimes are encouraged in these bad habits by their parents. Any
child who is more than ten per cent. above weight, should be kept
strictly to its regular meal times, and should not be allowed to put
on additional weight, for this will be very hard to get off in adult
life. To carry more than ten per cent. of over-weight is a burden, and
not a benefit.


Frequent Eating as an Appetizer.--Thin people should be encouraged to
indulge in some of these between-meal privileges. Very often a thin
person who has been accustomed to take comparatively small amounts at
meal times, will find it easier to gain in weight by indulging in
luncheons between meals than by increasing the amount of each meal.
Large meals on stomachs unaccustomed to them, and somewhat less
vigorous than they ought to be because of lack of nutrition, may be
the cause of considerable discomfort if abundant meals are taken where
small ones have been habitual. In this case, multiple feeding at
shorter intervals will gradually increase tissue strength. After the
patient has come up to normal weight, regular intervals between meals
may be determined and sufficient quantities taken at each meal. Nearly
all thin people sleep better, and are more comfortable if they take
something shortly before going to bed. Most people will eat their
breakfast better after such an indulgence than if fourteen hours
elapse between the evening and the morning meal.


Nervous Loss of Appetite.--Nervous patients often say they have no
appetite, that, even though they eat, their food has no taste. Such
people have often lost their eating instinct to a certain degree. They
eat merely from routine, or because food is placed before them. They
would usually just as soon not eat and they have no instinctive
directions as to quantity. If a number of courses are presented to
them, they eat such as they care for and take a conventional amount of
each kind of food presented, but they have no particular feeling to
guide them in the matter of quantity. There are moods in which these
patients care to eat. There are others in which eating seems a hard
task. If they are in reasonably poor circumstances and have not to
prepare a meal for others they are likely to neglect the preparation
of one for themselves, take almost anything that happens to be at
hand, and then consider that they have eaten.


Instinct and Natural Life.--If one expects the natural guidance of
one's instincts then one must give these instincts a proper
opportunity. Instinct is a part of our animal nature, and unless other
portions of our animal nature are given rather free play, or at least
the opportunities for their natural life, we cannot depend on any
single one of the instincts to be a safe guide. Man was meant to live
much outside. He was meant to take considerable exercise and to have
to get his food by severe exertion. We have changed this. We live
indoors to a great extent in an equable temperature, we very seldom
tire ourselves by exercise, and it is not to be wondered at if we have
not that craving for food that comes to the man who lives a more
animal existence. The {268} Scotch surgeon, Abernethy, once said that
the best possible tonic for the appetite was "to live on a shilling a
day and earn it"--of course, he meant by manual labor. He talked at a
time when the English workmen got but three shillings a day for
fourteen hours of work.


Application of Principles.--What is needed for the mental treatment of
patients with defective appetite, is that they should be made to
realize that appetite is a function of habit, rather than of absolute
natural craving in the conditions in which men and women live at the
present time. The most important physical factor for appetite is not
exercise, as has often been thought, because this, by consuming
material, is naturally supposed to increase the craving for material
to renew the tissue, but air, for it is oxidation processes that
stimulate metabolism and make the call for a fresh supply of
tissue-building material. People without an appetite must be made to
understand that they should spend a considerable portion of the time
between meals in the open air. Sitting in the open air is often even
more effective than exercise under similar conditions, especially in
weak people. The reason is exercise exhausts energy, and sometimes
does not leave enough vitality for digestion, or even for the craving
for food. Exercise is, of course, excellent for those of stronger
constitution, and especially those who have been accustomed to it.

Those who need to eat more, must keep constantly before their minds
the suggestion that if they want to eat they can, and that if they
actually do eat more, satisfaction with eating grows, and appetite is
restored to its normal place of influence. This is as true for those
who are convalescing from some ailment, or who are in the midst of
some progressive disease such as tuberculosis, as it is for the merely
nervous persons whose lack of will and inefficiency of judgment have
disturbed their eating habits. The will to eat is the most important
appetizer that we have. The old Scotch physician's rule that if food
stayed down it would do good, and that if the residue of it passed
through the intestinal tract there was nothing very serious the matter
with the patient, applies to the majority of patients who come to be
treated for obscure ailments, especially of a chronic character,
whenever they are associated with or developed on a basis of lack of
normal weight.



CHAPTER V

CONSTIPATION


To judge by the frequency of advertisements for laxatives of various
kinds, constipation must be an extremely common affection. At least
one out of every three city dwellers suffers, it is said, from
constipation. Proper regard for the taking of food calculated to help
this important function, the formation of appropriate habits, and the
proper disposition of the mind so as to relieve worry and anxiety,
will cure the majority of these patients. There are some who need
additional treatment, pharmacal or mechanical, but these are few.
Undoubtedly the mind plays the most important role in the therapeutics
of the affection. It is influenced partly through instruction, {269}
partly by the modification of unfortunate auto-suggestion, and partly
through auxiliary favorable suggestions of one kind or another.


Prophylaxis.--What is needed in most cases is such instruction as will
lead to a better observance of certain common-sense laws of health,
rather than the addition of remedies which eventually only complicate
conditions.

Many people believe that unless they have an ample movement of the
bowels every day all sorts of serious results are likely to follow. If
they do not have the expected movement before noon, they suffer during
the afternoon from headache that is probably due more to worry than to
any physical cause. Ordinarily it is quite out of the question that
the retention of the contents of the lower bowel for a few hours
should produce any such serious effects as these patients immediately
begin to feel. Especially is this true when on the day previous there
has been, as is often the case, a sufficient movement of the bowels,
due to the use of medicine. Some people have become so anxious in the
matter that they foster the development of feelings of discomfort both
in their abdominal and intracranial regions.

This over-anxiety is all the more important because recent
observations have made it clear that over-occupation of mind actually
hampers peristaltic movements of the intestines, and thus prevents the
muscular action which would gradually pass the excrementitious
material on to the lower bowel, to be evacuated in the normal way. _It
cannot be too often repeated that nature resents too close
surveillance of her functions and operations_. Just as soon as the
over-anxiety is relieved, and patients are made to appreciate that if
they do not have a movement to-day they may wait without serious
solicitude till they have one to-morrow, the amount of medicine
required to bring about movements of the bowels is at once reduced.


The Mind and Peristalsis.--Analogous to Pawlow's ingenious
experiments, with regard to digestive secretion in the stomach, are
Kronecker's experiments at Berne upon the motor function of the
intestinal tract. Pawlow showed that the appetite depended, not on
physical conditions so much as on the mental state of the animal and
its desire for a particular kind of food. Kronecker, by isolating a
loop of intestine in which a metal ball was placed, showed that it was
possible to modify peristalsis very materially by affecting the
psychic condition of the animal. There was a distinct difference in
the movements of the intestine, in the passage of a metal ball, when
the animal was called and expected to go for a walk with its master,
than when it was threatened with punishment or rendered depressed for
some other reason. In animals, the psyche plays a very subordinate
role in inhibition and stimulation compared to that exercised by man's
higher nervous system, since in him this portion of the organism is so
much better developed than in the animal. The condition of the human
mind in its possibilities of unfavorable influence over the intestinal
function, is, therefore, extremely important.

The more one knows about the curious power of the mind even over so
material a function as intestinal peristalsis and movement, the more
is one convinced of the necessity for a properly disposed mind toward
intestinal function, if it is to be accomplished with regularity and
without disturbance. Many persons thoroughly under hypnotic influence,
who are told that they will have a movement of the bowels at a certain
hour the next day will have it. Indeed, this constitutes one way of
treating certain forms of constipation in nervous, {270} preoccupied
people. There are many stories that illustrate the influence of
auto-suggestion upon the bowels. We have already mentioned Flaubert's
suffering as a consequence of realistic absorption in "Madame
Bovary's" poisoning by arsenic when he was writing that scene in the
book. Boris Sidis has told the story of a man who used to have a
disturbance of the bowels at every new moon, as the result of his
memory, acting unconsciously, reminding him of his mother's habit of
giving him a purgative about that time. These may be and doubtless are
exceptional cases, yet they illustrate the influence of mind and show
how much it must be the effort of the physician to use this effective
adjuvant just as much as possible in this very common and often
obstinate affection in which drugs so often fail, or are
unsatisfactory.


So-called Intestinal Auto-intoxication.--Those who are anxiously
interested in the subject are likely to have read so much of
intestinal auto-intoxications, of which a great deal has been written
in recent years, that they will be quite sure the slightest delay in
intestinal evacuation may be serious, or at least may profoundly
disturb their economy. As a consequence, just as soon as the hour at
which they should have a movement passes, they begin to worry about
it. In a couple of hours they feel tingly all over, and they know that
there most be poisonous substances in their circulation. After two or
three more hours, they begin to have a headache. Then they have to
give up work, and still more devote themselves to concentration of
attention on the disturbed condition. Their sleep will be disturbed,
perhaps will be delayed; they wake unrested and fearful of the awful
effects of intestinal auto-intoxication. In most people this state of
feeling is entirely due to suggestion.

So much has been said in recent medical literature of the influence of
absorption of poisonous substances from the intestinal tract--the
so-called intestinal auto-intoxication--that it is a surprise to learn
how little we know, definitely and absolutely, about this subject, and
how many theories have come and gone. Arthur Hertz, in his
"Constipation and Allied Intestinal Disorders" (Oxford Medical
Publications, 1909), reviews the whole subject very interestingly but
shows that we are entirely without any definite conclusive evidence
for what has been talked about so much. The idea had often occurred,
and been expressed vaguely, in medical literature in the old time, but
began to have its great vogue when the high-sounding Greek term
copremia (literally "excrementitious-substances-in-the-blood") was
invented, toward the end of the first quarter of the nineteenth
century. Naturally this had a strong suggestive effect. Bouchard took
it up a generation later, and then intestinal auto-intoxication,
another mouth-filling term, came to occupy much attention as an
explanation for various vague conditions, and especially nervous
discomforts of many kinds. Bouchard's method of proving his theory by
showing how much toxic material was reabsorbed from the intestines,
using the urine for injection into animals, was open to many
objections. Now it has been quite discredited.

Bouchard's disciples exaggerated and theorized even beyond their
master, until intestinal auto-intoxication became the same sort of a
refuge for the puzzled physicians of our time--like rheumatism or the
uric acid diathesis, for those of a score of years ago. Various
methods of demonstrating the toxicity of substances absorbed had a
vogue for a time, but they have now lost their significance. There are
only a limited number of people who seem to suffer {271} from the
symptoms attributed to such reabsorption. Some people who are quite
constipated have none of the symptoms at all, while a delay of an hour
or two in the evacuation seems to affect other people very much. These
latter are especially nervous persons. It now seems very clear that
the liver acts as a safeguard against the absorption of poisonous
materials from the intestinal tract, and that neither degenerate
proteid materials, nor bacterial toxins, are allowed to affect the
system to any serious degree. After all our study, as Dr. Hertz
insists, we have as yet no evidence that poisons are absorbed.


Reassurance as an Element in Treatment.--The most important element in
the rational treatment of constipation is to make patients understand
that under ordinary circumstances the symptoms of auto-intoxication,
of which so much is said, do not develop until there has been
long-continued accumulation of excrementitious material and under
conditions favoring absorption. Even then nature learns to protect
herself against untoward conditions. We have some very striking
examples of good health in spite of even very rare movements of the
bowels.


_Examples of Intestinal Tolerance_.--There is the famous case of the
French army officer who, from his earliest years, did not have regular
movements of the bowels, but secured evacuations of them by artificial
aid once every two months or more. He lived to the age of past fifty,
and then died from an intercurrent disease not connected with his
intestinal condition, having in the meantime enjoyed good health. He
was able to accomplish his duties as an officer without any special
allowances, and he was on the sick list much less than many brother
officers whose intestinal condition left nothing to be desired. This
remarkable man succeeded in doing his life work without his condition
being known by others to any extent, and it was only inconvenience,
and not serious illness, that he suffered from. After his death, it
was found that certain folds of the lower bowel were so large as to
meet across the lumen of the bowel, making shelves and pouches in
which fecal material gathered, preventing the movement of all material
above.

In the Orient, it is said that many people, especially of the better
class, do not expect to have movements of their bowels every day. Some
of them, indeed, do not encourage intestinal evacuations oftener than
once a week, sometimes even more seldom. As their diet is more largely
vegetable than ours, this is all the more surprising. This custom does
not contribute to their good odor, but this they compensate for by
using various Eastern perfumes. The average length of life of such
people is not much below the Occidentals and the difference is
probably accounted for to a great extent by other unhygienic
practices, rather than this failure to have regular movements of their
bowels. In the meantime, they do not suffer any particular
inconvenience, and live life quite as free from the ordinary pains and
aches as do the people of the West. Of course, in such cases the
custom has been established early, and nature has grown accustomed to
it. Nature seems to be able to stand almost anything, if she can only
survive it long enough to neutralize its effects by some of her
marvelous means of compensation.

A case under my observation some years ago deeply impressed upon me
how thoroughly the human system can learn to get along in spite of
extremely unfavorable conditions in the matter of intestinal
evacuation. The case was that of a young woman suffering from some
internal trouble and there was {272} a possibility of the growth of a
tumor. Some charitable people had been interested in her case, and the
question had arisen whether the tumor might not be physiological. Her
story was a very curious one. She and her sister worked in a mill.
They came from a family that had been reduced in circumstances, and
were much more sensitive, as regards the decencies of life, than were
their fellow workers. In order to get to the toilet, the working girls
had to pass a window of an office where a number of men were at work.
The other girls did not seem to mind it, but these two girls were so
sensitive that they preferred not to use the toilet room at the
factory. They had to leave home shortly after six o'clock in the
morning. They did not get home until nearly seven. For a time, they
succeeded in accomplishing their intestinal functions during the hours
of their stay at home. Gradually, however, this habit was broken, and
at first they went two or three days without an evacuation, then four
or five days, and finally a week. It then became their custom to take
a large dose of epsom salts on Saturday night and spend most of the
day on Sunday getting rid of the accumulated excrementitious material
of the whole week.

They taught Sunday School in the afternoons, and as the elimination of
the accumulation of week-long material interfered with this, they
gradually acquired the habit of doing their Sunday School work on
alternate Sundays, each taking the other Sunday for evacuation
purposes. It might be expected that this serious abuse of function
would soon lead delicate girls, compelled to work full eleven hours a
day, into rapid serious breakdown. But it did not. This state of
affairs continued for more than a year. Then finally one Sunday, the
more delicate of the two girls found it impossible to open her bowels
at the end of two weeks, and though she stayed at home the next Sunday
found it likewise impossible. Had not the directress of the Sunday
School, who had become interested in them, succeeded in gaining their
confidence, it is possible that they would not have consulted
physicians even for some time longer, though about three weeks had
passed without an evacuation.

Probably every physician in active practice has women patients who
have been constipated for successive periods of three or four days at
a time, for several months, without much disturbance of the general
condition. While, then, there are many nervous persons who are quite
sure that they begin to notice definite symptoms within a few hours
from the failure to have a motion of the bowels at the time when they
had been expecting it, it seems certain that this is generally rather
the result of anxiety and nervous worry than consequent upon any
actual absorption of toxic materials--intestinal auto-intoxication--as
these patients, with a naïve liking for nice long names, find such
satisfaction in describing their condition. A simple explanation of
the complete lack of inconvenience that is found in so many cases of
constipation, will neutralize the unfavorable auto-suggestion that
exists, and make these people much less likely to suffer.


_Individual Variation_.--Another suggestive item of information that
should be given those who are over-sensitive and anxious in the
matter, is that different individuals vary very much in the need for
intestinal evacuation. Perfectly healthy people have lived long and
happy lives, having an intestinal evacuation only once every two days.
Whether it may not in exceptional cases be rarer than this without
serious injury, immediate or remote, {273} experience has not
definitely settled. Many of these people with infrequent intestinal
movements, have gone on utterly unconscious of the frequency or
infrequency of the calls of nature, paying no attention at all to the
matter until by some chance remark or a newspaper health item, it is
brought forcibly to their notice. They have not had a symptom before
of any kind, but now they begin to note all sorts of symptoms because
they try to order their lives after the supposed rule that they have
heard or read.


_Anatomical Peculiarities_.--On the other hand, some people normally
have two evacuations a day, and seem to require them if they are to
remain in the best physical condition. While daily evacuation is to be
considered normal, individual departures from it in either direction
must be respected as quite within the bounds of good health. Sometimes
there are anatomical reasons, as the capacity of the large intestine.
Sometimes there are physiological factors, as the amount of food
taken, or the fullness or rapidity of function in the digestive tract.


Amount of Food as a Causative Factor.--Frequency, or infrequency, of
bowel movements seems to depend to a great degree on the amount eaten.
It is well known that two men of the same weight and doing the same
work often seem to require quite different amounts of food to enable
them to accomplish their tasks. This is what might be expected, since
it holds true also for the consumption of fuel in heat machines.
Engines built in exactly the same way often require quite different
amounts of fuel in order to release the same amount of energy. Where
men are large eaters, the amount of excrementitious material left will
usually provoke, if not actually demand, more frequent evacuation than
where the amount eaten is small. Variety of food also has an important
bearing. Men who live largely on beef, milk, eggs and food materials
that do not leave much residue, do not require, indeed they cannot
have, frequent evacuations. Those who live almost exclusively on
vegetables, with large amounts of residue, will require more frequent
evacuation of the bowels. Certain other dietetic habits, as the amount
of fluid taken with the meal, or whether food is eaten in the solid
state or cooked into purees, stews and the like, make a decided
difference, the reasons for which are obvious.


Habit in Treatment.--For the regulation of the bowels and the proper
treatment of constipation in nearly all cases, more weight must be
given to the directions laid down for the patient's attitude of mind
and habits of life than to drug treatment. The patient must be made to
realize that the directions given to him are much more important for
the effective relief of his condition, than is the medicine
prescribed. As a rule, medicine is meant only to afford relief from
immediate inconvenience, in the hope that after a short time new
habits will be formed which will remove the habitual constipation by
correcting certain hampering conditions that have unfortunately become
established.


_Habitual Evacuations_.--By far the most important element in the
treatment is to make the patient realize that habit plays the largest
role in the regular evacuation of the bowels. A child, even under two
years, can, by tempting it at certain times to evacuate its bowels, be
gradually brought to establish a habit that will save much
inconvenience for nurses and the family. This has actually been done
for most human beings now alive, and this same thing can be done at
all stages of life. If a particular time be chosen, and the {274}
individual habitually goes to the toilet at that time, results may be
confidently expected. It is rather important that the time chosen be
one when there is not much hurry nor anxiety, and when it is
reasonably certain that the same time can be taken every day. It is
surprising how much so simple a bit of advice as this will do for many
people who have considered that they have been suffering great
discomfort from habitual constipation. Between the persuasion that an
occasional failure to have a movement is not serious and the definite
habit of journeying to the toilet room at a particular time, whether
the desire is felt or not, many cases of habitual constipation will
disappear with, perhaps, only the necessity for the administration of
such drugs as will prove laxative to a slight degree during the first
two or three weeks.


Ingestion of Fluids an Important Influence.--After the suggestion of a
habit and its extremely efficient influence, the most important idea
that a patient suffering from constipation must be made to grasp, is
the necessity for fluids. That there shall be easy movement of
excrementitious material in the digestive tract, there must be fluid
enough ingested to keep the residue, after digestion, thoroughly
moist, so as not to allow it to become dry and compact. To secure
this, a reasonable amount of liquids must be taken. So much has been
said in recent years about the actual and possible harm of taking much
fluid with meals, because of the danger of diluting the gastric juice,
dilating the stomach and the like, that many persons who eat under the
control of their reasons rather than their instincts, have very
materially lessened the amount of liquids taken at meal time. This is
undoubtedly one of the reasons why constipation has become more common
in the last half century. In the olden time considerable quantities of
fluid were taken at meals. With people in our time deliberately
diminishing the quantity, there is often not enough fluid ingested to
keep the human economy in proper working order. Prof. Hawk's work
shows how utterly wrong was this limitation.

The ordinary excretion of water through the kidneys should be at least
three pints, another pint is exhaled from the lungs--the quantity is
even more than this in steam-heated houses where no provision for
moistening inhaled air is made--and probably still another pint is
needed for other purposes, perspiration, nasal and ocular secretion,
and the like. Two quarts and a half to three quarts of liquid must be
daily ingested then, and unless special care is taken to see that this
amount is consumed the system may have to get on with much less, but
as can readily be understood, not without difficulty. The ordinary
glass of water does not contain half a pint; the ordinary tea cup
probably holds not more than from four to six ounces. A glass of water
and a cup of tea or coffee is about the limit of consumption of fluids
at meals for ordinary people, and some take even less. Except in hot
weather, comparatively few regularly take any fluids between meals. At
the most, then, three or four pints of liquid is taken, instead of
five or six, and the consequence is that the intestinal contents are
deprived of their fluids by the call of the system for more liquids.
Peristalsis has, therefore, to overcome the sluggish movement of the
excrementitious material, which usually does not contain as much
liquid as would make its movement easy and normal.


Residual Material.--The next most important consideration after the
amount of fluid in the intestines, is the amount of the residuum which
the lower bowel has to move. Evacuation of the intestines is to a
great degree {275} a mechanical arrangement. When sufficient material
is contained in the lower bowel, it pushes on ahead of it the matter
that has been gathered there during the immediately preceding time,
and so leads to an accumulation in the rectum that brings about reflex
evacuation. It is only indigestible material that is thus excreted. If
sufficient indigestible material is not taken with the food, there
will not be sufficient residue left after digestion to call for the
exercise of the evacuant function of the intestines, and the
consequence will be sluggishness and failure to bring about daily
movements. Originally nature provided food materials so arranged that
the amount of indigestible material was sufficient for the exercise of
peristaltic function; or rather perhaps, the regularity of peristaltic
movement is of itself a development from the habits that were
gradually formed in moving the residue that is normally left from food
materials in the state in which they are produced by nature.

Food materials are no longer taken to any great extent in the form in
which they are provided by nature. We have learned to eliminate the
coarser indigestible portions. Bread used to be made of the whole
wheat, and of rather coarse flour, leaving a large residue for
peristalsis to exercise itself on. Now only fine white flour is used,
leaving a minimum undigested. Vegetables used to be taken with much
more waste material attached to them than is the case now. After being
baked, potatoes were often eaten with the skins on, apples and other
fruits were eaten unpared and many of the coarser vegetables, turnips,
carrots, beets, and greens of various kinds that leave large
proportions of waste were much more commonly used. Movements of the
bowels depend on this residue. If it is not present the bowel
movements will not take place with the regularity observed when food
with more residue is consumed.


Diet--Prof. Otto Cohnheim, in his lecture before The Harvey Society in
New York, December, 1909, emphasized the necessity for a mixed diet.
The less vegetables are taken, the less cellulose remains undigested
to stimulate peristalsis. Liquids find their way through the
intestines by a system of percolation, and do not excite peristaltic
movements. Meat, if well digested, is almost entirely dissolved in the
stomach and becomes a fluid. Vegetables are passed on to the
intestines as a rather thick paste. Occasionally, in the midst of this
paste there are portions of food of good size. Those excite
peristalsis; hence the necessity for vegetables in the diet, if
peristaltic movements and regular evacuations are to take place. This
physiological law is poorly understood. Patients have heard so much
about the indigestibility of starches, that whenever they have any
uncomfortable feelings in their abdominal region, supposed to be due
to indigestion, they commonly eliminate vegetables from their dietary
with the consequence that their disturbed condition is likely to be
emphasized rather than improved.


_Limitation of Diet_.--Just as soon as a patient's attention is
attracted forcibly to any tendency to constipation, he is almost sure
to conclude that this is a symptom of indigestion and he proceeds to
put into practice all the rules which he has heard and read for the
treatment of indigestion. The first of these is elimination from the
diet of all indigestible food products, including most of the
vegetables. The result is a vicious circle of cause and effect by
which constipation is rendered worse than before. This needs {276} to
be explained to intelligent patients in order to make them understand
that some of the new habits which they have been forming and which
they are prone to think highly hygienic, of cutting off all food
containing indigestible material, are really important factors in the
causation of further intestinal disturbance. It will often be found
that the real reason for patients' inability to have daily evacuations
of the bowels, is that they have become persuaded that various forms
of food are either indigestible on general principles, or else are
indigestible for them. For this reason they have eliminated from their
diet most of nature's ordinary and quite natural provocations to
intestinal evacuation, only to have to substitute artificial means to
the same end in the form of the various laxatives.

It is important to talk this matter over with patients; otherwise the
true cause of their constipation may be missed. For instance, from the
very beginning of human life an excess of fat acts as a lubricant of
the intestine, and as a material by means of which other and more
concentrated objectionable matter that needs to be eliminated is
carried out with as little friction as possible. Mother's milk
contains from one-fourth to one-third more fat than the baby can use
in its economy. This is meant to furnish a lubricant for the large
intestine. It is a residue that will aid in securing movements of the
bowels at regular intervals.


_Fats_.--Many people who come to their physicians complaining of
habitual constipation have been told, or have read, that fat is rather
indigestible, and, as a consequence, they have eliminated from their
dietary all fatty materials. Even butter they use but sparingly, and
they exchange the cream in their tea or coffee for plain milk; they
carefully remove as much as possible of the fat of meat and they
abstain from all sauces in which fat is employed. Such practices make
normal, natural, regular evacuations of the bowels extremely
difficult.


_Sugars_.--Another food material that is a valuable aid to nature for
the stimulation of peristalsis is sugar. In its digestion, a certain
amount of fermentation takes place, and the gas from this stimulates
peristalsis. Of course, there may be excessive fermentation, and then
harm rather than good, is done. Ordinarily a certain amount of sugar
is demanded by nature and practically all the food materials, even the
meats, contain it. All the starches from vegetables have, as the end
products of their digestion, various forms of sugary material. These
are just the classes of foods that many nervous persons, suffering
from constipation and anxious about their digestion, eliminate from
their diet under the mistaken notion that they are indigestible, or
are productive of undesirable fermentations. When they do so, it is
not surprising that their constipation should be emphasized and that
they should have to ingest other irritant materials, laxatives, to
replace the sugars. It is probable that where constipation exists in
the bottle-fed infant, the addition of a little brown sugar to the
water with which the milk is diluted, is the safest and most natural
way of correcting the sluggishness of the intestines.


_Supposed Idiosyncrasies_.--The physician will in many cases meet with
the objection that some of these materials that he is recommending
disagree with his patient. Most of the presumed idiosyncrasies in the
matter of food are founded on extremely insufficient evidence.

Not infrequently young persons who are thin and inclined to be {277}
constipated, and who need to take fats plentifully, do not care at all
for butter. Sometimes this is founded on nothing more than the fact
that at some time or other the butter provided for them was rather
poor, and they got out of the habit of eating it. Now they assume that
their disinclination is physiological. In this regard, as with milk, a
little careful persistence will usually convince the person that there
is no natural obstacle and no good reason why they should not partake,
in moderate quantities at least, of this extremely valuable article of
food.

Often the supposed idiosyncrasy against a food is due to no better
reason than that on a single occasion it disagreed, owing to its
preparation, the circumstances under which it was eaten, or the
materials with which it was associated. An aversion, for instance, to
so nutritious and so valuable a food-stuff as hog-meat will be
acquired for no better reason than that fried ham or bacon disagreed
with the patient on one or more occasions. Such people when told that
ham, boiled so thoroughly that it crumbles in the fingers, is a
favorite mode of giving meat to convalescents in European hospitals
and that it agrees very well with them, will often be tempted to try
it. Then they find they have been harboring an illusion as to their
supposed idiosyncrasy for hog-meat. Nearly the same thing is true of
bacon. A trial or two of crisp bacon, with the fat so thoroughly
cooked out of it that it may be eaten out of the fingers without
soiling them, will often convince those who doubt of their ability to
eat it, how tasty a nutriment it is. Bacon is one of the most precious
dietetic adjuvants in the treatment of constipation.


Exercise.--There is always a serious difficulty in the treatment of
constipation in stout people. To counsel fats and starches and liquids
in the quantities necessary to bring about regular natural movements
of the bowels, through the mechanical presence of a sufficient amount
of residue, will often add greatly to their weight. For them,
exercises are needed. Not exercise in general, for many a man who
takes abundant exercise may be constipated. I have patients with this
complaint who are letter carriers, expressmen, even stevedores, and
the like. The mere absence of a sedentary occupation will not
guarantee against constipation. Motormen and conductors not
infrequently suffer from it. What is needed particularly is exercise
directed to the strengthening of the abdominal muscles, and the
increase of peristalsis.

For this certain leg exercises that can be readily and easily done in
less than five minutes each day will be found useful. A patient may be
directed to lie on his back, lift up the leg as high as possible in
the extended position, and do that with each leg an increasing number
of times every day. At the end of a month he is able to lift each leg
up forty or fifty times at each trial. This exercise twice a day,
morning and evening, just before and after sleep, will usually relieve
the constipation. The bringing up of the thigh on the abdomen as far
as possible, not only acts as a sort of massage upon the abdomen
itself, but the bellying of the large muscles within the pelvic and
abdominal regions mechanically helps the movement of the intestinal
contents. If, in addition to this, the patient gradually accustoms
himself to rise to a sitting from a lying position, the constipation
will almost invariably yield. In stout people, the presence of fat in
the abdominal wall seems to weaken the muscles so that the intestines
are not compressed as they should be in ordinary conditions, and
peristalsis seems to be thus interfered with.

{278}

A heavy wooden (bowling) ball rolled on the surface of the abdomen,
beginning low down in the right lower quadrant up towards the liver,
across just above the umbilicus, and then down on the left is often
advised. It is a good remedy but not better than the simple exercises
of the leg and abdominal muscles suggested. The use of the ball has
the advantage of novelty, and of distinctly adding to the suggestive
value of the exercise treatment. It is particularly valuable for
women. All of these exercises have a distinct value from their
suggestive side. If thus twice a day for three minutes people are made
to recall while doing the exercises the necessity for taking an
abundance of fluid, forming a habit with regard to movements of the
bowels and eating so as to encourage peristalsis, a definite good
effect will be produced. In the treatment of stout people
particularly, it is important to remember that the use of sufficient
salt, and then of certain of the natural salts, as Carlsbad or Hunyadi
Janos, may be of distinct advantage for their obesity. If taken
regularly in small amounts, that is, just enough to help to a movement
of the bowels, and if varied from time to time and occasionally
interrupted while some other form of laxative is taken, much good may
be done. It is as well to take simple irritants of this kind as some
of the irritant foods that will have a tendency to add to their
accumulation of fat, though they may increase peristalsis.


Influence of Position.--Little things may mean much in the matter of
the regular movements of the bowels. In my student days in France, our
little hotel in the Quartier had the old-fashioned water-closets
consisting of a hole in the floor in one corner, and a place to put
one's feet properly beside it, thus reverting to the old-fashioned
natural method of bowel evacuation. Some of the American students
found it an uncomfortable proceeding at the beginning, but, on the
other hand, some of them who had suffered from constipation in America
were no longer troubled that way. I have found in quite a few cases of
younger men that the suggestion to revert to this natural mode of
evacuation helped in the formation of the habit of having bowel
movements at a regular time. How much of the effect was physical and
how much was mental seemed hard to decide. The suggestion was
particularly valuable in my experience with patients of the better
educated classes.



CHAPTER VI

NEUROTIC INTESTINAL AFFECTIONS


There is a whole series of intestinal affections dependent on nerve
influence that get worse and better under stress of emotion or relief
from it. Probably the commonest of these is constipation, which is
dealt with in a separate chapter. Often these nervous intestinal
conditions are associated with other neurotic manifestations. On the
other hand, patients are seen who are absolutely without any other
sign of the neurotic habit, and have nothing like hysteria, yet who
suffer severely and rather frequently from intestinal neuroses. Most
of the people who react symptomatically to the eating of strawberries,
or of shellfish, or of pork in any form, or cheese or other milk
products, also have a definite tendency to certain skin neuroses and
to suffer from intestinal troubles as a consequence of emotional
states. It is hard to trace {279} real causation in many of these
cases, because it is so easy to accept the patient's expressions that
they must have taken cold, or they must have eaten something that
disagreed with them.


Neurotic Diarrhea.--But it must not be forgotten that nervousness
alone, without any additional factor, may produce a disturbance of the
functions of the intestines, and may even increase peristalsis and
bring about severe diarrhea. Anyone who has observed students going to
examinations has surely seen many examples of this. There are some
individuals--fortunately they are rather rare--who always suffer from
diarrhea when they have to take a serious examination. Some of these
cases are pitiable because the effects are quite beyond control, and
make it almost impossible for them to do justice to themselves.


_Fright and Loss of Bowel Control_.--Severe disturbance, such as
fright, may bring on this paralysis of proper regulation of
peristalsis, with consequent imperative intestinal evacuation. A
classical case in history is that of James II, for whom the Irish
soldiers invented a special name because of the tradition that he
suffered from an intestinal accident in one of the battles with
William of Orange. The imputation of cowardice on the last of the
unfortunate Stuarts has been completely wiped out by the investigation
of recent historians, and James' character for bravery has been
thoroughly vindicated. The fact that the story should have gained
credence shows that there is a general persuasion and popular
tradition that such intestinal incidents do occur from fright. An
incident told of the Franco-German War illustrates this, though I do
not vouch for the facts. Wishing to test the bravery of some soldiers
whom he was to send on a very dangerous expedition, and above all to
try how they would bear up even before the threat of instant death, an
officer of the French troops is said to have asked that half a dozen
brave men be sent to him. Without a word, he announced that there had
been treason in the ranks, and that the army needed an example. They
were condemned to be shot. A platoon of soldiers was drawn up, the men
were placed with their backs to a wall and they were asked whether
they wished to be blindfolded. They refused though they protested that
they did not know why they were being put to death. Then the word fire
was given. All of the men, excepting one, fell down, though the guns
of the firing party had been loaded with blank cartridges. The one who
remained standing was told that he was the man who would be selected
to go on the expedition, which, though perilous, was also of great
glory for himself and profit for his country. He said that he was
ready to go, but he asked permission to be allowed to change his
clothing, as he had not been able to keep as good control over his
intestinal muscles, as he had over his muscles of station.

Fright often has this effect in children. These stories and traditions
illustrate the influence of the mind and of deep emotions over the
intestines, and while only profound mental disturbance will produce
the most serious effects, there seems no doubt that lesser emotions do
interfere with normal function. This phase of the subject serves to
strengthen the contention that over-attention to the bowels may bring
about constipation by causing increased inhibition of peristalsis,
just as severe emotional disturbance may paralyze inhibition and so
bring about increased peristalsis with consequent diarrheal symptoms.

{280}

Habitual Diarrhea.--There are certain forms of chronic diarrhea,
usually considered most intractable, that owe their origin and
continuance to neurotic conditions of the intestine, rather than to
any gross organic lesion. In these cases the bowels acquire the habit
of emptying themselves two or three or more times a day, and the
stools are seldom formed. All sorts of physical treatment are employed
for these conditions, usually without avail, but whenever the
patient's mind can be set at rest, and his attention distracted from
his bowels by thorough occupation with some interesting work, the
intestinal disturbance gradually becomes less annoying. Ordinarily,
when stools have been frequent for a prolonged period, the case is
considered more or less unamenable to treatment. So far as ordinary
drug remedies go, this is true. What is needed is attention to the
patient's mind, to his habits of life, and to his worries, and the way
that he takes them. The illustrations given of the influence of the
mind over the bowels should make it clear that this therapeutic
principle can be of far-reaching significance and must be applied
deliberately and with confidence in the results.


_Worry as a Factor_.--Very often it will be found that the diarrhea is
particularly bothersome on days when the patient is worried. In a
clergyman friend and patient who was building a church, the approach
of days on which bills and notes became due, was always the signal for
a diminished control over his bowels, and there were frequently three
or four stools in the day. On his vacations, when eating unusual
things, drinking unaccustomed water, exposed to changes of
temperature, all the factors that give many people diarrhea, he was
perfectly regular because the worries had been lifted from his mind.
In another case, where for fifteen or twenty years a writer living
much indoors had had tendencies to diarrhea, always made worse by
worries, self-discipline and the refusal to let troubles occupy him by
always turning to something else, did him so much good that he
considered himself cured. In his case the return of a manuscript from
a magazine would always affect his bowels unfavorably. If, as
sometimes happened, he found that the manuscript had been returned
only for some corrections, there would be an immediate relief of his
condition.


Change of Mode of life and Intestinal Control.--An interesting phase
of the neurotic or mechanical disturbance of peristalsis is found in
the interference with regular movements of the bowels when persons are
aboard trains for long distances, or for more than twenty-four hours.
There are very few people who are not bothered in some way by such a
journey. Those of a nervous temperament are likely to suffer from
diarrhea. This is usually attributed to catching cold because of
drafts, but in recent years, when well guarded Pullmans eliminate
drafts to a great extent, the bowel disturbance continues. For the
majority of people, however, constipation results. The cause of it
seems to be due to a disturbance of peristalsis in the line of
inhibition because of the vibration and jolting of the train. The more
or less conscious assumption of definite positions of the muscles of
the abdominal region in order to save the body from the action of the
unsteady movement of the train, seems to be reflected in the sphere of
peristalsis with consequent constipation. There are other features,
such as a lessened consumption of food and water and absence of
exercise, that seem also to have an influence. If the journey is for
several days patients should be advised to walk out during the longer
stops.

{281}

Mental Influence and Indifferent Remedies.--The best evidence that we
have of the influence of mind upon the intestinal tract, and the
importance of employing that factor for therapeutic purposes, is found
in the number of cases of various intestinal disturbances, often
apparently chronic in character, which have been cured by the
administration of quite indifferent remedies. Dr. Hack Tuke in his
"Influence of the Mind on the Body" reports a number of cases in which
bread pills were used with good effect. _Pillulae micarum panis_ were
not an infrequent prescription in preceding generations. They are
usually supposed to have been effective only against the curious
symptoms that develop in hysterical women, but it must not be
forgotten that neurotic manifestations connected with the abdominal
region may occur very freely in men, and that treatment by suggestion
in connection with some remedy, real or supposed, is the most
efficient cure. The "British and Foreign Medical Review" for January,
1847, has a series of cases among naval officers which were reported
by a surgeon of long standing and wide experience. These cases include
painful intestinal psycho-neuroses, occasionally accompanied by
diarrhea, and sometimes by constipation and sometimes even by
dysenteric movements, all cured by bread pills when these were
administered in certain definite ways, and the patient's attention
concentrated on their expected effects. Bismuth lost its effect in one
case of repeated colic, opium was beginning to lose its effect. The
patient was then told that on the next attack he would be put under a
medicine which was generally believed to be most effective, but which
was rarely used on account of its dangerous qualities, and that would
not be used unless he gave his consent. At the first sign of his next
attack, a powder containing four grains of ground biscuit was
administered every seven minutes while within the hearing of the
patient the greatest anxiety was expressed lest too much should be
given. The fourth dose caused an entire cessation of pain. On four
other occasions, the same remedy was employed with equal success for
the same sort of attack. In a seaman who was suffering from obstinate
constipation which resisted even the strongest purgatives, including
Croton oil, pills consisting of two grains of bread were administered
every seven minutes, and the patient watched with very apparent
anxiety lest an overdose should be given. Within two hours he began to
have nausea at his stomach, which had been foretold as one of the
symptoms to be expected, and his bowels were freely open almost
immediately after. Apparently the administration of the bread pills
eventually cured his constipation.


Skin and Intestinal Sympathy.--Curious intestinal conditions are, as I
have said, often associated with neurotic manifestations of other
kinds. Attacks of hives and other neurotic skin disturbances are
common in association with nervous diarrhea. Sometimes the attack of
hives precedes the intestinal disturbance; sometimes it accompanies
it. Soon after eating the offending material, the skin manifestations
may begin and other symptoms follow. Only a few minutes elapse, even
when the patient does not know that the offending material has been
eaten, because it is concealed in some combination, yet the reaction
takes place evidently not from digestive absorption, but from
intestinal reflex. Very often there is vomiting, as well as diarrhea.
It is not hard to understand that in these cases there is produced an
irritation of the intestinal mucosa, corresponding to that seen in the
skin. Whenever {282} this occurs, it is not surprising that there
should be evacuation of the contents of the digestive tract in every
way that nature has provided for removing irritating material. The
simple nervous diarrhea is often spoken of as an "intestinal blush,"
as the neurotic disturbance of the bladder which causes frequent
urination is spoken of as a "vesical blush." Blushing is certainly the
external manifestation that corresponds most closely to the
disturbance that is probably the basis of these curious
manifestations.


_Urticaria and Diarrhea_.--Patients who suffer from urticaria readily
are almost sure to have other neurotic disturbances, and their
intestines seldom escape. On the other hand, those who have an
idiosyncrasy for certain kinds of food are almost sure to have other
nervous neurotic disturbances, which emphasize the fact that these
curious idiosyncrasies are of reflex nervous origin, rather than due
to any chemical irritation.

Some of these lesions of the intestinal tract related to urticaria may
affect, either primarily or secondarily, the biliary structures. Under
these circumstances there may be symptoms resembling true biliary
colic with some jaundice and pain that radiates toward the right
shoulder. Whether these bile symptoms are due to the occurrence of
actual urticarial lesions in the bile duct, or so close to the papilla
of entrance of the gall passages into the intestine as to occlude it,
is doubtful. Practically all the symptoms of the presence of biliary
calculus may be thus simulated. The differential diagnosis can only be
made by the rapid clearing up of the symptoms, and by the history of
the case. As a rule, where there is the story of repeated attacks of
neurotic intestinal disturbance, the physician and especially the
surgeon, should be slow to conclude as to the presence of a serious
pathological condition anywhere in the intestinal tract, unless the
symptoms are absolute. This is all the more necessary because now, in
patients' minds, the words appendicitis or biliary calculus are
associated with the thought of operation. This thought sometimes gives
rise to so much dread as to seriously disturb the appetite and still
further predispose the patient to the repetition of neurotic
intestinal trouble.

In the chapter on Abdominal Discomfort, the necessity for absolute
assurance of some definite lesion before there is any question of
operation, is insisted on. Here the disturbing mental influence of
suggestion, with regard to certain serious abdominal conditions, may
be emphasized. Many painful conditions in the abdomen are either
primarily or secondarily due to appendicitis. Most of these are quite
acute, and practically all amenable to definite diagnosis. There is,
however, a tendency to exaggerate the place that this organ holds in
the pathology of chronic cases. Many women who suffer from nothing
more than hysterical abdominal conditions are told by someone that
they have recurrent attacks of appendicitis, though there is nothing
except their suggestive complaints of pain on which to found such a
diagnosis, and then it becomes extremely difficult to remove this idea
from their minds, and contrary suggestion applied over a long period
is the only therapeutics that favorably affects them.


Intestinal Idiosyncrasies.--I have had the opportunity to see a series
of cases of intestinal idiosyncrasy in a family that has been an
interesting study for many years. One of the members has the most
exquisite case of susceptibility to various articles of food that I
think I have ever seen or heard of. {283} Even the eating of a little
unrecognized pork in sausage will give rise to a diarrhea so intense
that there is no peace for hours, and slight movements take place
every few minutes. Towards the end of the attack, there is always
considerable blood in the stools. Often the attack is preceded by
vomiting. While in most people the idiosyncrasy is limited to one
article of food, this patient has it for all of the articles that are
usually the subjects of idiosyncrasy. Besides pork, shell-fish will
produce vomiting and diarrhea within a few minutes, strawberries act
detrimentally at once, and cheese produces an almost immediate
reaction.

The most interesting feature of this case is that occasionally an
attack of diarrhea that is extremely severe, will occur merely as a
consequence of a strong emotional stress. Any great anxiety will have
this effect. The knowledge that someone has a telegram for her whose
contents she can not ascertain for a time, will act as a cathartic.
She also has other neurotic manifestations, especially of an
urticarial character, that are equally interesting. On a number of
occasions, when she has particularly prepared for some special event
such as a wedding or reception, for which a new gown has been provided
and preparations made with considerable solicitude to the end that she
shall appear at her best, she has suffered from a severe attack of
angio-neurotic edema affecting either her lips or her eye-lids so that
it was absolutely impossible for her to be present at the social
engagement. This has happened to her over and over again. On the first
two occasions, one eye was closed completely by the edema. In each
case she attributed it to the sting of an insect. There was no sign of
any sting, there was no itching or inflammation, the condition
presented all the signs of angio-neurotic edema, had come without
warning, and disappeared in from 36 to 48 hours without leaving any
mark or trace of its origin.

There is absolutely not a sign of hysteria in this individual, nor is
there any tendency to what would be called an emotional neurotic
condition. On the contrary, she is lively and sensible, the life of
her friends when they are ill, their consolation when they are in
trouble, and she herself has shown the power to bear trials and
difficulties. It is only the peripheral circulation in the intestinal
mucosa, and in the skin, that passes from under her control. She
neither laughs nor cries without reason and she has no other
exaggerated nerve reactions. Even more interesting is the fact that
the angio-neurotic condition can be traced in the preceding
generation, while the tendency to an intestinal neurosis complicated
by diarrhea exists in a sister in this generation. Examinations are
always a source of grave distress to the sister. Although she is a
bright intelligent woman she does not do justice to herself because of
her nervousness. Usually she has a vomiting spell in the morning
before the examination, and rather serious intestinal disturbance
during the day. That this is entirely neurotic is clear from its
constant disappearance immediately afterwards, and its constant
reappearance whenever there is this form of emotional stress.

In certain of these cases of supposed neurotic, intestinal troubles,
one cause of the condition sometimes fails of recognition. Many of
these people are found on inquiry to be taking much more salt than
usual. It is hard to understand how this occurs, but I have seen it in
a number of cases, sometimes in men, but much more frequently in
women. Some sort of a vicious {284} circle has been formed: probably
their original tendency to diarrhea led to a craving for salt, because
of the excessive serous evacuations. Somehow, then, the habit of
taking more salt was formed and its presence reacted to produce
irritative conditions in the patient, which, combined with neurotic
tendencies, produced the intestinal disturbance. I have seen chronic
diarrhea, mucous diarrhea, and even mucous colitis, associated with
the over-free taking of salt. When salt was eliminated from the diet
the cases at once improved. We now realize the value of a salt-free
diet for many conditions disturbing osmosis, and the presence of serum
where it should not be. It is probable that most people take more salt
than is good for them.


Intestinal Troubles Due to Air.--One of the most annoying intestinal
troubles due to a neurosis is the passage of air from the intestines,
or in some people a rumbling through them, which is distinctly of
neurotic origin. It is increased under emotional stress or whenever
there is anxiety with regard to it. This is much more common in the
old than in the young, as if relaxation of tissues had much to do with
it. Old men seldom complain of it to their physicians, but for obvious
conventional reasons, we are rather often asked to control it in older
women, and are occasionally asked to treat poignant cases of it in
young women. The older women are often stout, of flabby constitution,
and one has almost to accept the conclusion that the real trouble is
such a relaxation of the intestinal walls that the empty intestines do
not fall together as they used to, but rather tend to lie apart from
one another with the production of spaces into which gases, perhaps by
diffusion from the blood, find their way and are expelled. Usually
these patients were stouter than they now are.

Often after these patients have walked outside for some time,
especially if they have become quite tired, and then sit down inside
and become warm, the expansion of the air in the intestines leads to
some rumbling and the production of flatus. This experience is so
common with elderly people, when they come in in cold weather, that
they do not feel quite right unless it actually happens. The odor of
the flatus is seldom offensive.


_Air Swallowing_.--There seems to be no doubt that a certain amount of
air is swallowed, that it finds its way along the intestines, and
then, with the change of temperature on coming into the house,
expansion takes place and the air finds its way out. In certain
patients the habit of swallowing air may grow, and the necessity for
its evacuation, either by eructation or flatus, may be a source of
great discomfort. The latter form of relief may be impossible owing to
conditions, though it is quite as natural as other forms of the
evacuation of the bowels, and it must not be considered pathological
unless it becomes too frequent. People of other civilizations than
ours are not so sensitive in this matter. A late distinguished Chinese
Ambassador to this country relieved himself of an accumulation of gas
in his lower bowel quite as indifferently as he would have of gas in
his stomach--but without so much as "by your leave" and evidently
without a thought of anything unseemly in the act--apparently to his
own great satisfaction, though sometimes to the consternation of the
bystanders. Utterly failing to understand why he should not permit
himself this satisfaction, he peremptorily refused to conform to our
Western refinements in this matter.

In many of these cases habit may add to the necessity for relief of
this {285} kind, and habit may require considerable self-discipline
and training of organs to overcome it. To attempt to control this form
of intestinal trouble by ordinary intestinal remedies, and especially
by carminatives, is almost sure to increase it rather than do any
good. It is the patient's mental attitude toward the affection that
must be modified, and the intestinal bad habit must be brought under
control.


_Intestinal Uneasiness_.--In young women the cases are much more
serious, for the presence of gas in the intestines sometimes leads to
such dread of physical events over which they fear they may have no
control, that it makes it impossible for them to carry on their
ordinary occupations, hinders their conformance with social usages, or
even their association with any but very near friends. The cases are
not frequent, but are poignant when they occur. Many young women
suffer from rumblings in the intestines whenever more than four hours
have passed since their last meal. This phenomenon is not likely to
manifest itself unless they are nervous, excited and worried over
something, but is particularly likely to be troublesome when they are
with persons whom they are most solicitous to impress favorably. The
manifestation is undoubtedly associated with emptiness of the
intestines and relief will usually be afforded by taking something to
eat, even something so simple as a glass of milk and some crackers,
shortly before the time when the rumblings are usually heard. Dread of
this annoyance plays a large role in it, and it is due to an
exaggeration of peristalsis with the consequent crowding into larger
masses of small quantities of air that ordinarily would find their way
much more slowly along the intestinal tract. Milk of bismuth will do
more than anything else, though the presence of a certain quantity of
food is probably the best prophylactic and remedy.

Besides these cases, there are some that are even more annoying. These
occur in young women who have all the symptoms of an approaching
intestinal evacuation, and then find when they have excused themselves
that there is nothing but gas to be passed. This gas is nearly always
quite inoffensive, and is evidently air that has been present in the
intestines for some time, and has in the midst of the excitement of
peristalsis been forced on into the rectum and gives the sensation of
an approaching stool. These cases are coming into notice much more
commonly since young women have taken up business occupations. The
symptoms are worse in those who are constipated, though sometimes in
these cases there are recurring attacks of diarrhea showing that the
normal function of the intestine is disturbed. It is more annoying
just before and during menstruation than at any other time.


_Physical Basis_.--Whenever the patients are run down in weight there
is a distinct exaggeration of the condition. Whether the loss of
weight, by removing fat from within the abdomen, does not tend to make
the intestines more ready to take up air and to produce these
manifestations is a question worth considering. The most annoying
cases that I have seen were in people who had lost considerable weight
and though there had been some tendency to the condition before they
lost weight, it was doubtful whether the symptoms were greater than
those often seen and which are not productive of special annoyance
except in very sensitive people. In three of these cases that have
been under my observation in recent years, improvement came promptly
when weight was put on. The presence of an abundance of fat in {286}
the abdominal cavity seemed properly to balance the intestines and to
dampen peristalsis.

Reassurance, absence of worry, occupation of mind with interests that
keep it from putting such surveillance on the intestinal tract as will
surely be resented, must be the chief care of the physician. Without
these any relief afforded will be only temporary. With psychotherapy
relapses will occur, for these individuals are in a state of unstable
intestinal equilibrium, but practically all the successful remedies of
the past have been founded on it and its effect may be renewed over
and over again under various forms.



CHAPTER VII

MUCO-MEMBRANOUS COLITIS

Probably the severest, certainly the most interesting of the neurotic
conditions of the intestines, is muco-membranous colitis. The only
lesions discovered are those which point to a functionally increased
secretion of tenacious mucus from the lower bowel. No definite
pathological changes are known. The colic seems to be due to nothing
more than the effort of the large intestine to push off the thick
mucus which has been secreted, and which in many cases clings to the
bowel walls. This may be of such consistency that it is passed from
the bowel in the shape of tubular casts. These casts have often been
seen in place in the lower bowel. While the word membranous used in
connection with the disease has produced the impression that this
might be a form of diphtheritic affection, it is now known that it is
only due to an abnormally increased function, and not to any
structural pathological condition or infection of the lower bowel. The
membranous material is often gelatinous, and so the casts may hang
together in long pieces.


Neurotic Etiology.--It might be thought that such a cast could not be
formed, remain in situ in the lower bowel for a considerable period,
and then be passed as a whole, or in quite long portions, without
causing serious tissue disturbance in the mucous membrane. As Sir
William Osier says, in spite of the apparent improbability, the
separation may and usually does take place without any lesion even of
the surface of the mucous membrane. The epithelium seems to be left
intact. Owing to the curious nature of the stools, the disease has
been recognized for a long time and the descriptions of this disease
by the older authors are very interesting. Muco-membranous colitis
occurs mainly in nervous individuals, and is much more frequent in
women than in men, but it is not limited to women. Some of the
severest cases have occurred in men, and Woodward, in the second
volume of "The Medical and Surgical Reports of the Civil War," has an
exhaustive description of the disease as it occurred among soldiers.
It is particularly those who are worried and run down from overwork
and excitement who are likely to suffer from it, but it occurs
typically in people who, _faute de mieux_, worry about themselves.
Most of its victims are self-centered, though not hysterical.


Recent Increase in Number of Cases.--According to all the authorities,
there has been a considerable increase in the number of cases in
recent years. {287} At one watering place in France, Plombiêres, which
has acquired the reputation for relieving, or even curing the disease,
about 400 cases had been under treatment during the course of about
two years. This increase was attributed by Boas of Berlin to two
causes. First the struggle for life has become much more intense in
our day, and the nervous conditions which are practically always the
basis of muco-membranous colitis, have as a consequence become more
frequent. Not only this, but mild cases that were not called to the
attention of physicians in the past, have become so emphasized by the
nervous worries of the strenuous life that now they seldom escape the
physician's attention. Besides our generation is getting away from the
old-fashioned idea of patiently standing many pains and aches, and
refusing to call in a physician unless the condition persists or seems
to be producing serious results. There are more cases of the disease,
but physicians also see more of the cases than formerly because
patients come for treatment for slighter causes.

Dr. Boas considered that, besides the strenuous life, there was
another prominent factor in the increase of the disease. This is the
abuse of laxatives and purgatives. Many of these have their principal
effect on the lower bowel. In consequence the nervous mechanism of
this structure has been irritated to a point where occasionally
explosions of nerve force take place. This causes an increase of the
secretion, and a tendency to cramp-like contractions. While there is
undoubtedly much of truth in this, there is no doubt that the most
important factor in the disease is the patient's nervous condition.
Only those who are inclined to be introspective, to worry much about
themselves, and who are constantly examining their stools for the
presence of mucus, suffer severely from the affection.

Very few cases have been seen among the working classes. Most of the
cases have hypochondriacal symptoms that sometimes go to the extent of
real melancholia and the full persuasion that they have an incurable
disease, a visitation on them for some real or fancied lapse from the
laws of health in earlier years. The affection usually lasts a long
time, or has been in existence for some years when the physician is
asked to see it, and patients are made most miserable by it.

Unfavorable Suggestion and Over-attention.--The pathological
physiology of this disease, for, as has been said, it has no pathology
in the proper sense of the word, is in many cases a problem of mental
influence. For some reason, the patient gets his or her lower bowel on
his or her mind. There is so much talk of constipation and its evil
effects in the newspapers, in advertisements and by suggestion from
bill-boards and in the magazines as well as, sad to relate, in
parlors, drawing-rooms and even dining-rooms, that it is easy for
those who are introspective and nervous about themselves, and who have
some little tendency to constipation already, to become much worried
about it. If, then, as was suggested by Boas, they take laxatives in
profusion, the irritation set up further fixes the attention on this
portion of the body. After a while, in these people, a goodly portion
of the waking hours are spent in thoughts with regard to the lower
bowel. The morning thought is the possibility of a stool to-day,
followed by conjecture as to its character. After the stool has taken
place, if there seems anything abnormal about it, comes a morbid dread
of the consequences of having such stools.

{288}

This constant attention sends down a lot of impulses to the lower
bowel. Anyone who has studied the psychology of attention knows how
much influence can be exerted on the skin, or on the mucous surface by
mental influence. Hyperemia is produced, and this leads to over-action
of the glands of the large intestine. These glands secrete a glairy
mucus which is necessary to protect the bowel from the offensive
material that is always present, and from the hardened material that
is so often there when there is a tendency to constipation. This mucus
is secreted in large quantities, while at the same time a hyperemia of
the colon tends to interfere with peristalsis and consequently to
delay the passage of contents and to keep the mucus in place. An
accumulation goes on for some time, until irritation is set up by the
presence of such a large quantity of material in the intestine, and
then colicky efforts for its removal are occasioned. All of this
process is accompanied by suggestive reactions upon the mind that
further complicate the case. This story of the affection points out
the indications for treatment. Unless the patient's mind can be
diverted from its constant attention to the lower bowel, the
possibility of cure is distant, and even after such diversion any
return of attention is likely to bring on a relapse.


Treatment.--The treatment of this affection emphasizes its neurotic
origin. We have had any number of cures for it and each one has
actually relieved many patients. The more trouble the cure involves,
and the greater the impression produced on the patient's mind the more
likely is there to be a relief of symptoms. All sorts of drugs have
been employed. Many of them have for a time been heralded as more or
less specific. The important thing, however, was that the patients
should come predisposed to believe that they were going to be
improved, and then that suggestion should be made at frequent
intervals--a combination of auto-suggestion through the administration
at regular intervals for a long period of simple remedies with the
confident suggestion of the physician that the patient will get
better. Local treatment of various kinds has been reported to bring
about improvement. The more difficult this is, and the longer it
takes, as well as the more bother it involves for the patient and the
attendant, the better the response to it is likely to be. Long rectal
tubes were found beneficial in many cases, though they failed in many
others, and most physicians have seen relapses occur in spite of the
continuance of the treatment that at first did much good. High
injections of water containing various drugs, and of olive oil
sometimes bring improvement though they afford no guarantee against a
relapse. Mineral waters do good only in the suggestive environment of
the spring.


_Surgery and Suggestion_.--The symptoms have sometimes been so severe
and the complaints of the patients have been so great that even
surgery of serious character has been recommended and tried in some of
these cases. The making of an artificial anus in the right inguinal
region, so that for a time the feces are not allowed to pass over the
colon mucous membrane has been tried. This gives decided relief from
the symptoms, but when the artificial anus is allowed to close,
recurrences often take place. It has been suggested, therefore, that
the artificial anus should be allowed to stay open for months, but
even this seems to afford no guarantee against a relapse. In recent
years the appendix has been taken out through the opening in the right
inguinal region, and a portion of it allowed to remain through which,
when {289} fastened to the abdominal wall, injections might be made
into the colon. In these cases ice-water has been found probably of
more effect than any drug solutions. This rather serious surgical
procedure is, however, as yet on trial, and we do not know enough
about the after-course of the cases to be sure that it has any
permanent effect.

A strong suggestion is involved in the removal of the appendix, and
the use of the stump of it as an irrigating tube. When the treatment
consists of something that is so strongly excitant of feeling as
ice-water, applied directly to the colon, it is easy to understand
that suggestion reaches the limit of its possibilities. No wonder
these cases improve, though we are not sure as yet what happens after
the appendix opening is allowed to close, or is deliberately sutured.
I should expect a recurrence of symptoms, if ever a time came when the
patient was run down in weight and worried by external conditions,
introspection, and above all by concentration of attention on the
intestines.


_Direct Suggestion_.--The question is whether suggestion can be used
to advantage in these cases without employing any of the radical
measures that have been suggested. There is no doubt that at certain
watering places where a specialty is made of this disease, and to
which patients go, sure that they are going to be much better than
before, and where they see patients all round them who are improving,
they often get complete relief. This is only what might be expected.
Whether a similar effect can be produced by simple suggestion when the
patient is thoroughly convinced that the physician understands the
case, and that if they will respond he can cure it, remains to be
seen. I know that mild cases improve rapidly under simple hygienic
measures, with a renewal of confidence in the possibility of relief,
and with the diversion of the patient's mind from the intestinal
difficulty. This is the most important factor in the treatment, as it
is the most important factor in pathology. If the patient's nerve
centers can be kept from sending down impulses causing exaggerated
action of the glands, then there is some hope of relief. A habit has
been formed in the matter, and a habit can only be broken by a series
of acts, just as it was formed. It is not effort for a few days nor a
week that counts in these cases, but diversion of mind for long
periods, until normal function is restored. It is usually quite
impossible to keep up this improvement constantly in nervous patients.
There are setbacks, but then this is true in every form of nervous
affection. It is, then, that the renewed suggestion of the physician
is needed.


_Resort Cures and Suggestion_.--Physicians often tell patients that
muco-membranous colitis is incurable, or at least emphasize strongly
that it is very refractory to treatment, and that it is prone to
relapse even after improvement. After a certain number of physicians
have insisted on these points, it is inevitable that patients should
not respond readily to treatment, and that they should be solicitous
about themselves, even when improvement does come.

It is most important then to bring about the neutralization of these
unfavorable suggestions. This is what is particularly accomplished at
the health resorts where muco-membranous colitis is successfully
treated. At these the patients see other sufferers from the disease
who proclaim how much better they are and some at least who are
entirely cured. The waters {290} used at these health resorts are not
nearly so efficient when used at a distance because of this lack of
additional suggestion.

The most efficacious treatment of muco-membranous colitis then is to
bring the patient up to normal weight, for they are often thin people,
quiet their solicitude about themselves, give them a bland and
irritating diet and get them away from worries or anxieties about
themselves or others. I know cases in physicians where the effect of
worry of any kind can be traced very clearly in the increased symptoms
of their colitis and the greater frequency of attacks. It is
particularly important not to give habit-forming drugs in these cases
for they always do harm. Where the pain is much complained of the
coal-tar anodynes are useful, but ice in the rectum or even
suppositories of gluten, or of cocoa butter without any medication
often prove useful. Most of these patients watch prescriptions that
are given them rather carefully and make up their mind beforehand
whether they are likely to do them good or not and the event usually
follows their premonition. They often have habits of self-drugging
which must be stopped and always carefully inquired into for they will
sometimes continue to take things for themselves in spite of being
under the doctor's care. If they have heard of surgical treatment for
their affection they are likely to think that they will have to come
to it eventually and this prevents a favorable attitude of mind
towards their affection. Unless this is secured no treatment will
prove efficient. With it almost anything that keeps up the suggestion
will greatly relieve and often will actually cure the condition.



CHAPTER VIII

OBESITY

Obesity, popularly considered to be an over-accumulation of fat, is
sometimes thought to exist only when there is the large development of
abdomen which is more properly designated corpulency. In its strictly
scientific sense it represents excessive over-weight, that is, above
twenty per cent. more of weight than is normal for the height of the
particular individual. (See table of weight for height in chapter
Weight and Good Feeling.) The Latin derivation of the word gives also
its etiology. Ob-ese means having eaten too much. It is a question of
failure of due proportion between the taking of nutrition and the
oxidation processes within the body. More food being taken than is
needed, there is an accumulation of it in the form of fat, and this is
deposited by natural preference in certain places, such as the
abdomen, the breasts and in the _panniculus adiposus_ beneath the
skin. The fats and starches are most readily converted into this fat,
but under certain circumstances proteid material may be turned into
fat, and then a true pathological condition develops resembling
diabetes in certain ways.

The metabolism of fat is rather simple, but this may be disturbed by
bad habits. When such large quantities of sugar-making materials are
taken that they are beyond the power of the normal metabolism to
dispose of, they are excreted in the urine with the production of what
is known as physiological {291} glycosuria. In the same way, the
eating of a superabundance of fat-forming food leads to the deposition
of fat in the tissues where, when in excess, it is just as much wasted
as if it were excreted. Physiological glycosuria is, however, usually
considered to be dangerous, inasmuch as its frequent occurrence may
disturb the normal metabolism of sugar, and lead to diabetes. In the
same way, the over-consumption of fat-forming materials may disturb
the fatty metabolism, and lead even to the changing of proteid
materials into fat. This represents a real disease requiring careful
management, while ordinary obesity needs only the exercise of the
patient's will to secure such proportion between the amount of food
taken, and the amount of exercise and fresh air, as will not only
prevent accumulation of fat but will lead to the reduction of any
accumulation that may, through neglect of this care, already have
taken place.


Over-eating.--The putting on of weight depends on the individual's
craving for food, and his satisfaction of his appetite. While it is
not ordinarily looked at from this standpoint, this craving for food
and the habit of satisfying it which is developed, is not very
different from the craving for stimulants and the habit that forms
with regard to them. People insist that they can not eat less--that
their appetite simply requires them to eat. We have all heard this
story over and over again from the man who craves alcoholic
stimulation. Usually the obese can be persuaded more easily than the
inebriate to break off their habit, but they relapse into it even more
easily than he does. It is comparatively easy to limit the appetite,
or rather to forego the satisfaction of eating abundantly, for a week
or two weeks or even a month, but the effort finally becomes appalling
and the consequence is a relapse. If the patient really wants to lose
weight, in nine cases out of ten it is a comparatively simple matter.
The trouble is that they want to lose in weight without giving up the
satisfaction of eating.


Under Exercise.--The second factor in obesity--lack of sufficient
exercise, is even more important than the habit of over-eating. This
is illustrated very well by the cases of certain animals who, without
any tendency to fat accumulation by nature, but rather the contrary,
acquire fat to a marked degree, owing to the habits that are forced on
them by their relations to human beings. A typical example is the pet
dog. Dogs living their natural active lives, have little tendency to
put on superfluous flesh. Kept in the house in cities, they
practically always put on weight until, after some years, many of them
are quite incapable of moving except in an awkward waddle, often
comically symbolizing their mistresses in this respect. Besides the
inactivity, the dog is subject to the influence of the other cause of
obesity, the over-eating of fat producing material. Another typical
example, and one that provides evidence of the pathological tendency
to fat accumulation, is found in the Strasburg geese from whom the
fatty goose livers for _pates de foie gras_ are obtained. Geese are
placed in a warm underground room, in a mass of cement that gradually
hardens round their feet keeping them almost completely inactive, and
then they are fed abundantly with fat-forming materials. The absence
of light and air, and the immobility, leads to the production of the
fatty changes, eventually producing the enlarged fatty livers, which
delight the gourmet's palate.

What is true of the dog and the goose is exemplified in the lives of
all other {292} animals. The fattening process is well understood by
butchers--keep the animal inactive and supply an abundance of
fattening food. The inactivity is even more important than the food.


Prophylaxsis.--Of course, if obesity is to be successfully treated,
cases must be seen early and before there has been a large
accumulation of fat. When people are more than 10 per cent. over
weight they are in the danger zone, and with 20 per cent. above the
normal, decrease must come or the condition becomes inveterate. It is
between these two points and not when they are forty or fifty pounds
over weight that they need the advice of a physician and the careful
institution of regular life to prevent further fat accumulation. After
the body has carried thirty or forty pounds over weight for some time,
it has acquired the habit of accumulating fat, rather than using it,
and this, once acquired, is hard to break. Every additional pound
tempts to the formation of lazy or sluggish habits because of the
additional weight that has to be carried around. Everyone knows how
hard it is to walk a few blocks a little briskly carrying a suit case
that weighs thirty pounds. Even twenty pounds soon proves to be a
burden. Fat in the tissues, though it seems to be a portion of the
individual, is really quite outside of him and consists of extra food
material that the body is carrying round, having accumulated it for
the purpose, apparently, of using it at some time when it should be
necessary. While carrying this burden, people have little inclination
to an active life. Inactivity lowers oxidation processes and leaves
them with an additional tendency to fat accumulation because of lack
of oxidation. In a word, a vicious circle of cause and effect is
formed. Accumulation of fat prevents the taking of proper exercise,
and lack of exercise leads to further accumulation of fat!

Not only should the treatment of obesity begin early in a particular
case, but, in families where there is a recognized tendency to take on
fat, it should begin early in life.

Children should not be so fed that they become mere specimens,
illustrative of how early fat accumulation may occur, and to what a
degree it may go. Just as soon as baby shows signs of an accumulation
of fat above its normal weight for age and size, there should be just
such a regulation of its diet as would be considered necessary if it
were an older person, and showed the same unfortunate tendency. This
is particularly important if the parental relatives on either or both
sides of the house show tendencies to fat accumulation. We are sure
that in diabetes the over-eating of starchy and sugary substances
produces what is, at the beginning, an alimentary or so-called
physiological glycosuria, though it is doubtful whether any glycosuria
is ever absolutely physiological. This may lead to a pathological
glycosuria and the production of a true diabetes. So, also, the
tendency to accumulation of fat, as the result of what might be called
alimentary obesity, may lead eventually to the production of an
essential obesity in which even the proteid materials of the food may
be changed into fats, just as in the case of diabetes they are changed
to sugar. This fat is then stored up in the tissues though there is no
need at all for such an accumulation, and the food stuff is wasted
quite as much as in diabetes.


The Will in Treatment.--The important element in the treatment of
obesity is the readiness of the patient to follow directions. Nine out
of every {293} ten stout people are thoroughly able to control the
accumulation of fat and even to bring themselves down to about normal
weight, if only they _will_ to do so. This is no easy matter. It is
not an affair of a few weeks, or even a few months. Just as in the
case of over-indulgence in alcohol, it will probably be a life
struggle. It is well worth the while, however, for life is longer and
is larger without the accumulation of fat, which is not only so
uncosmetic, but is so preventive of real enjoyment of life.
Unfortunately, the cosmetic side of it, that is, the absurdity of
going round among one's friends with a very prominent abdomen, or with
noticeable protuberances, is the particular motive that appeals to
most people. While women may be quite ready to stand many discomforts
for cosmetic effect when dictated by fashion, they are not ordinarily
persistent enough in their efforts to prevent fat accumulation to be
successful in this much more important purpose.

Such patients make the rounds from physician to physician, and from
quack to quack, and go from patent medicine to patent medicine, to
find something that will enable them to lose weight without the
necessity for their taking any trouble. It is the old, old story that
the nerve specialist who is known occasionally to treat his patients
by hypnotism has so often presented to him. Patients who are sufferers
from alcoholism, or drug addiction, or some other vicious habit,
present themselves and ask if they cannot be hypnotized and then lose
their tendency to fall back into the old habit. There is no
possibility of this. If they are willing to cooperate, all of these
habits may be overcome, but a constant effort will be required and,
even after the habit is broken, there always remains a distinct danger
of relapse. Patients suffering from obesity want to transfer the
burden of working it off to someone else's shoulders, or they want
some specific remedy that will bring about reduction in weight yet
permit them to indulge in all the pleasures of their artificially
excited appetite. They follow directions for a few weeks, often
half-heartedly, and then give up the struggle.


_Food Temptations_.--With obesity, as with indulgence in alcohol, the
main difficulty is the occasion. Most of these fat people are placed
in circumstances in which tempting food passes them three times a day,
and it is hard to refuse it. If a hot punch or a fragrant cocktail
were several times every day passed under the nose of a man with a
tendency to inebriety it would be beyond the bounds of reason to hope
that he should withstand his craving. Just as soon as those who want
to reduce in weight are put in conditions in which only simple food,
though there may be a reasonably good variety of it, is presented to
them, the difficulty of limiting the amount they eat is comparatively
easy. This necessitates, as a rule, refusing invitations to dinner at
friends' houses, especially at the beginning of a reduction cure,
avoiding hotel _menus_ and giving up various social functions. It may
even involve changing home customs from those of luxury back to
simplicity. The question is whether this is worth while or not. When a
husband is likely to indulge over much in alcoholic liquors a wife is
apt to consider it easy to deny herself the privilege of such liquors
on her table and of avoiding places where he is likely to be tempted.
The rest of the family are usually quite satisfied to stand some
self-denial so that unfortunate results may not follow.

Where father or mother are suffering from obesity this same thing may
be necessary with regard to rich and highly seasoned foods. This would
be a {294} hardship to inflict on the family were it not for the fact
that the health of all the members will be distinctly benefited and a
return to simple food, nutritious and with a variety that makes it
eminently wholesome, will be good for them as a prophylactic measure.


_Motives for Self-Control_.--The task of keeping the weight down is so
difficult that very few people with a tendency to over-weight are
equal to it. They need the help of every motive possible for
encouragement. It is well to make these persons realize that
over-weight, according to the statistics carefully gathered and
collated by the large insurance companies in recent years, is a
serious bar to great expectancy of life. In a large series of cases it
was found that not a single individual recorded as being more than
twenty per cent. over the normal weight that he should have for
height, died of old age. Furthermore no one of over-weight attained
the age of eighty years, though 44 under-weights passed this age, and
two of them even reached the age of ninety. Death from nearly every
known cause is more frequent among the over-weights than in the normal
population, except in the single instance of tuberculosis.

What was thus demonstrated from statistics, carefully gathered in
modern times, has been a commonplace in medicine since the earliest
days. Hippocrates summed up Greek experience in the aphorism "persons
who are naturally very fat are apt to die earlier than those who are
slender." Practically all the commentators since his time have agreed
with him. In early years thinness may be quite as dangerous.

If there were no other reason but the greater frequency of _diabetes_
among the obese, this of itself would be sufficient to act as a strong
deterrent motive. It may well be used as such, especially in families
where a tendency to diabetes has been manifest. Diabetes figures as a
cause of death in life insurance statistics five times more frequently
among those who are over-weight than in the general population. Those
who are under-weight suffer from the disease in fatal form less than
one-half as frequently as the average. Hence, obesity and diabetes are
evidently closely related. As we have suggested, the disturbance of
metabolism due to the failure to use sugar properly in the system and
to its consequent elimination, corresponds in some, as yet not well
understood, way to the other metabolic disturbance by which
unnecessary fat is accumulated in the system. It is probable that the
over-eating of starchy foods and fats which leads to obesity, causes
in some people a breakdown of metabolism in the matter of the proper
disposal of sugar, and this initiates diabetes which becomes a
pathological condition, after a time quite beyond control.


Sleep and Exercise.--After the reduction of diet, the most important
feature of any successful treatment of obesity must consist of an
increase in the amount of exercise. Both of these can be accomplished
only through the patient's will, and by frequently repeated
suggestion, and auto-suggestion, of the necessity for constant
surveillance in both these matters. Any form of exercise that is
pursued faithfully is beneficial. Exercise in the open air, because it
encourages oxidation, is preferable to gymnastic exercises, but the
care of a trained instructor, the influence of example, the habit of
taking it at regular hours, make gymnastic exercise of value in this
condition. A regular walk every day is invaluable if it can be
secured. Women can be tempted {295} to walk even three or four miles,
if the habit is gradually formed, and if they realize the necessity
for it. It is important that too much sleep should not be indulged in.
One of the difficulties with pet animals is that they sleep so much
more in domesticity than in the state of nature. Sleep must be
absolutely regulated for the obese. The old monastic rule "seven hours
for a man, eight hours for a woman and nine hours for a hog" must be
emphasized.


Heredity.--There always remains in these cases the influence of
heredity. Many people are sure that because they come from families
with the tendency to obesity, it is impossible for them to overcome
this assumed heredity, and that the only thing for them is to bear the
affliction with equanimity. They usually do this while indulging their
taste for the luxuries of the table rather freely. This question of
heredity, however, has come in recent years to occupy a very different
position in the minds of biologists from that which it held a
generation ago. We know now that the evidence for acquired characters
being transmitted is so trivial as to be quite negligible.

The children of stout parents are likely to acquire their parents'
habits as to the consumption of food, in such quantity and quality as
will almost inevitably put fat on them. It is this habit much more
than any hereditary element, which is the underlying cause of the
obesity. There may be some influence of heredity, but it is much less
than has been thought, and even where it exists, it is not so
inevitable as has been considered. There are cases in every
physician's experience where the children of stout parents who, for
some reason, have been brought to habits of spare eating, have been
thin all their lives. On the other hand, anyone who has seen the
change that has come over the sons of spare, lanky farmers, in whom
both father and mother were of the thin type, yet who in the midst of
the luxury of city life have taken on weight, will be convinced that
personal habits mean much more than any influence of heredity in the
production of obesity.

Where there is normal occupation of mind and body with strict
regulation of the hours of sleep, and simple though abundant food,
there is little tendency for people to become obese, even though there
may seem to be hereditary tendencies. In a considerable experience
with religious communities I have often noted that the member of a
family who enters a religious order often goes but slightly above
normal weight, even though other members of the family may become
distinctly fat. This is not because of rigid self-denial in the matter
of food, that is to such an extent as to take less food than is
necessary, for most members of the religious communities work too hard
for this to be possible, but because they live the regular active life
and have the simple food of the community. This is true in spite of
the fact that their indoor life would seem to predispose them to the
accumulation of fat. After fifty most of them put on weight because
this is the physiological accompaniment of that period of life, but it
is not this form of fat accumulation that the physician is called upon
to treat as a rule, but that in people between the ages of twenty and
forty.

If the prevention of over-weight is taken up in time, if habits are
broken before they become tyrannous, if proper self-control is
cultivated early in life, there are very few people that need fear the
oncoming of obesity. There are some pathologically obese families in
which this will not be true, but they are as rare as diabetic
families. The most important element in any {296} treatment is the
rousing of the patient's mind and his will to take up seriously the
task of unlearning habits of overeating and not allowing sluggishness
of life to gain control. This can be done best, not by removing all
sorts of articles for which there is special taste from the diet, but
by a general reduction in the quantity of food eaten, by the
introduction of food material that does not put on weight yet
satisfies the craving, by the replacing of many of the starchy
vegetables by greens of various kinds, by replacing many of the
desserts by gelatine products and cheese, and by additions to the
exercise. But there must be no extremes in the reduction of food or
the taking up of exercise. Patients should not be permitted to lose
five pounds a week--at most two or three pounds--and they should be
made to understand that it is a life work and the formation of lasting
habits that they have before them. They should be made to understand,
also, after a time the satisfaction that comes from a more active life
will give them even more pleasure than the satisfaction of their
appetite did before.


Principles of Treatment.--Many systems of treatment of obesity have
been invented. All of them are supported by cured cases. Some of them
are founded on a reduction in the amount of fluids, some on a
reduction of the amount of vegetables eaten, in some cases going to
the extreme of an almost exclusively meat diet. Most of them modify
the diet very extensively. It is doubtful, however, whether any of
these systems, when successful, have owed their success so much to the
physical effect as to the suggestive influence exercised on the
patient's mind, that he must at the same time limit his eating and
increase his exercise. In the matter of fluids particularly, some of
the systems are absolutely contradictory of one another, yet success
follows their application. There is one serious difficulty in the
application of these systems. After a time the patient becomes very
tired of the monotony of diet suggested, and growing discouraged,
relapse into old habits. If suggestion can be used with as much force
without such extreme modifications of diet, the results are as good,
and are always more lasting. The important factor is a reduction in
the amount eaten, without necessarily denying any but the very rich
foods. In this way patients can very soon be induced to take half
portions of what they have been previously eating and thus secure a
prompt reduction in weight.

It is important that the bowels of obese patients be kept freely open.
Tendencies to constipation seem to disturb metabolism in the direction
of fat deposition, and even fatty degeneration. Many of the cures at
watering places include the taking of laxative salts, or waters of
various kinds, and undoubtedly this is helpful at the beginning. But
the continuance of such treatment may seriously disturb peristalsis so
that it is important to have intervals of rest for the bowels, during
which, while there is a regular daily evacuation, there are no
tendencies to diarrhea. The suggestive influence of the taking of
salts has meant much for a great many so-called obesity cures. They
should be employed carefully, but must not be abused.

For fat already accumulated, only exercise will serve as a sure
remedy. For fat within the abdomen, the various leg exercises which
may be gone through in bed, and the trunk movements, especially those
of sitting up from a lying position, when frequently repeated, will
soon serve to dissipate accumulated fat. They will also encourage the
taking of outdoor exercises, as {297} well as relieve the patient from
many muscular discomforts, difficulties of breathing and heart
palpitation, which were not only annoying before, but discouraged the
taking of exercise.



CHAPTER IX

WEIGHT AND GOOD FEELING


Probably the most important single condition for the maintenance of
good health and _good feeling_ is the carrying of weight normal for
the height and age of the individual, or slightly in excess of normal.
Popular expressions contain many proofs of this. The proverb "laugh
and grow fat" is undoubtedly due to the recognition by all the world
that stout people are nearly always laughers, and as a consequence,
perhaps placing the effect for the cause, laughing has been regarded
as a factor in putting on flesh. [Footnote 27]  There is no doubt that
the exercise for the diaphragm afforded by hearty laughing, with the
stimulation of the intra-abdominal circulation consequent upon
vigorous diaphragmatic movements, is an important element in producing
a healthy state of the important organs of the human economy contained
within the abdominal cavity. Dr. Abrams in his book, "The Blues,
Causes and Cure," attributes this disturbing condition of depression
so familiar to those who have much to do with nervous patients, to a
disordered blood and nerve circulation in the splanchnic area, and
calls it scientifically, splanchnic neurasthenia. This undoubtedly
sums up one important element in the causation of a great many
depressive conditions. Most of them are banished by frequent hearty
laughter which, with its exercise of the diaphragm, tends to stimulate
splanchnic blood vessels and nerves.

  [Footnote 27: Those who are interested in fossil words will find many
  curious confirmations of the connection between weight and good
  health and good humor. A typical illustration is the word _buxom_,
  derived from the German _biegsam_, which means "ready to obey," from
  the original significance of being ready to bend, that is bendsome.
  In our day it has come to have quite a material rather than an
  ethical significance. A buxom woman is one who is round and full of
  form and while she usually also is cheerful and tractable, the two
  ideas are not necessarily connected. It is curious that what was
  originally the obedient wife should now have become the stout and
  healthy wife, as if stoutness and healthiness were somehow
  inseparably connected with the preceding idea so that gradually one
  portion of the meaning was lost sight of and now only the physical
  significance remains.]


Thinness and Discontent.--In general, it is well understood that thin
people are likely to be more gloomy and discontented than those of
stouter build. The pessimists of the world have usually been lank and
lean. Shakespeare, in "Julius Caesar," has the great Roman declare
that he likes not "the lean and hungry Cassius," and that "discontent
is bred in such bodies." The issue shows his prophetic power.
Discontent with life is much more likely in thin people than in stout.
Most suicides are under-weight. Where nutrition is under the normal,
digestion is sure to be poor because the digestive organs themselves
suffer even more than others from lack of food, apparently giving up
some of their own substance at the call of other tissues; sleep is
nearly always disturbed, constipation is almost the rule, and muscular
action becomes distasteful. While in our day we hear much of people
overeating, the nervous specialist finds that many of his patients are
undereating. {298} These patients grow out of many discomforts,
dreads, and symptoms that often seem, even to the physician, to be due
to organic change, when they take on enough weight to relieve them
from the incessant calls for more nutrition to which insufficient food
has made them subject.


Physical Disadvantages of Thinness.--There are many dangers that go
with thinness besides the tendency to that irritability of the nervous
system which we have come to associate with neurotic symptoms. It has
long been known that a person who is under weight is much more likely
to contract tuberculosis than a normal individual. From carefully
selected statistics, the large insurance companies have determined,
that it is far more dangerous to insure a man who is twenty pounds
under weight and who has no family heredity of tuberculosis than to
insure a man with a family history of tuberculosis on both sides of
the house, provided he is well up to or above the normal weight, and
is not living in special conditions of danger from contagion. It is
contagion and not heredity that plays the most important role in
tuberculosis, and the element that is still more important is that of
vital resistance. Every adult of thirty years or over has probably at
some time had tuberculosis, for traces of its presence are found in
the bodies of all adults who come to autopsy. Seven-eighths of the
human race are, however, able to resist, and among these seven-eighths
by far the greater proportion are those who are above normal weight.

Of course, this matter of the relation of normal weight to good health
did not escape the acute observation of the old physicians.
Hippocrates, to take the first and greatest of them, realized that
while excessive eating and drinking was serious, there were many
people who suffered from not eating enough. One of his aphorisms runs,
"A slender and restricted diet is generally more dangerous [manifestly
he means to both the well and the ill] than one a little more
liberal." He appreciated, too, the fact that while the old may
restrict their diet with more or less impunity, this practice may be,
and indeed is likely to be, more serious in young people. He has
marshaled the ages and stated the effects of a low diet on them very
definitely:

  Old persons endure fasting most easily, next adults; young persons
  not nearly so well, and infants least of all, especially those who
  are of a particularly lively disposition.


_Discomfort Due to Lack of Fat_.--Many of the vague discomforts of the
internal organs seem to be due to a lack of fat cushions round them,
and fat blankets to keep them from being too much subjected to the
vicissitudes of external temperature. Anyone who has noted in a series
of cases the difference between the condition of patients suffering
from a slightly movable kidney when they are well up to weight, and
when, on the other hand, they are considerably reduced in weight, will
have the significance of the first of these conditions brought home
very clearly. Most of the people who suffer much from cold in winter
are greatly benefited, as might be expected, by a blanket of fat. It
is rather easy to grow accustomed to carrying ten additional pounds of
fat when ten additional pounds of clothes would be an insupportable
burden. Some fat people are prone to complain of the cold. These are
not the plethoric but the anemic. This latter class often have a
sluggish circulation, besides a lack of hemoglobin. As a consequence
of this their {299} oxidation processes are slow and imperfect, and
this is one of the reasons for the over-accumulation of fat. The
healthy individual with normal heart and normal blood-making apparatus
will always be ever so much more comfortable with a reasonable
panniculus adiposus and fat cushions and coverings for the internal
organs.


_Muscular Weakness and Discomfort_.--There are a number of pains and
aches occurring in lean persons that are due to nothing else than the
weakness of muscle consequent upon the poor nutrition of their
muscular tissues. Muscles which do not receive as much nourishment as
they should, must necessarily be weak, and if asked to do much work
they will resent it. Ordinarily it is not realized how much work is
required even for such common muscular efforts as those that are
needed to hold the body erect, or to keep it in a stooping position at
a definite angle, or to move around on the feet.

I have seen patients lose their aches and pains, and become quite
capable of standing weather changes and ordinary hard muscular labor
without discomfort, simply as the result of a decided gain in weight.
All that was needed was the persuasion to eat more, and especially to
eat a full breakfast, the meal likely to be neglected. In some
persons, appetite will only return after the correction of
constipation and insistence on a certain amount of outdoor air every
day, not necessarily exercise--for bus riding or the open cars are
excellent appetizers.


Eating Enough.--It is very difficult to persuade some people to eat
enough! They have all sorts of excuses. They rather pride themselves
on the fact that they do not eat much. Persons who are twenty pounds
under weight will calmly tell you that they do not need more than they
eat. They are actually in debt to that extent to their tissues, yet
they are persuaded that they are paying nature's claims in full.
Sometimes the excuse is that they have heard, or read, of how much
harm is done by overeating; they have taken to heart the phrase that
people are digging their graves with their teeth, and so they are
actually cultivating the habit of undereating instead of allowing
their instinct for food to manifest itself. Many are found to be
following the good old saw of getting up from the table hungry. The
inventor of it is not known, but quite unlike the inventor of sleep,
it would have been a great blessing if he had kept it to himself by
patent right.

After a time habit for these people becomes second nature, and it is
hard to get them to eat enough. When people undereat it is the
digestive organs that, in my experience, always suffer the most. As a
consequence, the appetite decreases because of gradually acquired lack
of vitality in the digestive system, its nutrition having been lowered
by drafts upon it from other portions of the body. Quite contrary to
what is told in the old fable, the stomach apparently is not selfish
and does not keep the lion's share for itself. The decrease in the
amount of food brings on a decrease in digestive power.


Weight for Height.--The physician who wants to help patients by
suggestion must keep before him weight tables for height, as they have
been determined by statistics. When people are under weight, it
matters not what they may be suffering from, improvement will come if
they are made to gain in weight. To be able to show them that they are
considerably below the normal and to point out what this probably
means in lack of surplus energy, suffices of itself to make many
people understand the necessity for {300} effort in the matter and to
give them a strong suggestion as to probable relief of their symptoms.
The following tables are the best-known averages for men and women:

ADJUSTED TABLE OF WEIGHTS FOR INSURED WOMEN, BASED ON 58,855 ACCEPTED LIVES

         15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Combined
                                                                     Ages
4' 11"   111   113   115   117   119   119   122   125   128   126   118
5'  0"   113   114   117   119   122   122   125   128   130   129   120
5'  1"   115   116   118   121   124   124   128   131   133   132   122
5'  2"   117   118   120   123   127   127   132   134   137   136   125
5'  3"   120   122   124   127   131   131   135   138   141   140   128
5'  4"   123   125   127   130   134   134   138   142   145   144   131
5'  5"   125   128   131   135   139   139   143   147   149   148   135
5'  6"   128   132   135   139   143   143   146   151   153   152   139
5'  7"   132   135   139   143   147   147   150   154   157   155   143
5'  8"   136   140   143   147   151   151   155   158   161   160   147
5'  9"   140   144   147   151   155   155   159   163   166   165   151
5' 10"   144   147   151   155   159   159   163   167   170   169   155
Combined 123   126   129   132   136   136   139   142   145   142   133
Heights


The average shoes of the average woman will raise her about 1-1/2 to 1-3/4
inches.


DR. SHEPHERD'S TABLE OF HEIGHT AND WEIGHT FOR MEN AT DIFFERENT AGES

        15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

5'  0'  120   125   128   131   133   134   134   134   131
5'  1'  122   126   129   131   134   136   136   136   134
5'  2'  124   128   131   133   136   138   138   138   137
5'  3'  127   131   134   136   139   141   141   141   140   140
5'  4'  131   135   138   140   143   144   145   145   144   143
5'  5'  134   138   141   143   146   147   149   149   148   147
5'  6'  138   142   145   147   150   151   153   153   153   151
5'  7'  142   147   150   152   155   156   158   158   158   156
5'  8'  146   151   154   157   160   161   163   163   163   162
5'  9'  150   155   159   162   165   166   167   168   168   168
5' 10'  154   159   164   167   170   171   172   173   174   174
5' 11'  159   164   169   173   175   177   177   178   180   180
6'  0'  165   170   175   179   180   183   182   183   185   185
6'  1'  170   177   181   185   186   189   188   189   189   189
6'  2'  176   184   188   192   194   196   194   194   192   192
6'  3'  181   190   195   200   203   204   201   198



Correction of Underweight.--Underweight is undesirable for many
reasons, and gain in weight is often the solution of many problems in
ill feeling. It is well to bear in mind that most patients who are
under weight can be made to gain in weight by an appeal to their
reason and by proper directions and care in seeing that those
directions are carried out. Patients have told me that they could not
eat more and yet I have been able to persuade them that they must eat
more, and they have done so. Anyone who has much to do with
tuberculous patients knows that utter repugnance for food can be
overcome by will-power, when it is once made clear to the patient that
they {301} must eat if they want to live. The most interesting event
in the process is that with the increase in the amount of food taken,
instead of the appetite becoming more and more satiated, as patients
are likely to anticipate, and instead of the repugnance for food
growing, the appetite grows stronger, and the repugnance gradually
disappears. There is only one way to gain in weight; that is by eating
more than one has been accustomed to eat. Persons who are twenty
pounds under weight ought easily to gain three pounds a week, half a
pound a day, if seriously intent on doing so, but in order to do this
they will probably have to increase the amount they eat by double this
quantity. That means that a solid additional pound of food, quite
apart from the watery elements of the food, must be taken every day.

In the correction of under-weight details are all-important. Patients
must be given specific directions as to what and how much of the
various foods they should take. With regard to supposed idiosyncrasies
against such nutritious substances as eggs, milk and butter, enough is
said elsewhere to make it clear that, as a rule, these are merely pet
notions, beginning in some unfortunate incident and cherished until
they have become a mental persuasion strong enough to disturb the
digestion of these substances. What is true for quality of food is
true also for quantity. People must be made to understand that the
amount of food is to be increased. The results attained by this method
are well worth the efforts required for it. Of course, the bitter
tonics, especially strychnin and cinchona, will do much to help. Just
as soon as patients begin to gain in weight many of their neurotic
symptoms leave them. Their tired feelings are no longer complained of
and when they are up to normal weight they are quite other
individuals, both in good humor and efficiency.

If for years patients have been eating less than they should, then
they will have discomfort when they begin to eat more. They will have
no more discomfort, however, than would be occasioned if they took
more exercise than they had been accustomed to. The stomach and
intestines must be gradually accustomed to the new task of disposing
of more food. Unfortunately, the usual impression among these patients
is that discomfort in the abdominal region, by which they mean any
sense of fullness, proceeds from indigestion, and indigestion
signifies developing dyspepsia with all the horrors that are supposed
to go with it. In reality the slight discomfort which comes from
increased eating is usually not manifest whenever the patients are
occupied with something reasonably interesting. After a time the
organs will become accustomed to it, and then the discomfort will
cease.


_Nervous Patients_.--One of the strongest suggestions that we have in
our power for thin nervous patients, suffering from many and various
ills, is to have them gain in weight. Many of them will be found to be
distinctly under weight for their height. They insist that they cannot
eat more, that they are eating as much as they care to, and that they
have no appetite, that when they eat more they have discomfort, etc.
It must be made clear to them that their one easy road to health is to
gain in weight. If they are under weight this makes a very definite
purpose to put before their minds. The objection so often urged, that
they come from a thin family, must not be listened to. The unalterable
purpose to make them gain in weight must be insisted upon. If they can
be made to eat more than they have been {302} eating before, they will
surely gain in weight. To see themselves gaining in weight is a daily
renewal of the suggestion that they will be better when they get up to
their normal weight. It is much better than electricity or the rest
cure, or anything else that I know; it is perfectly natural and, above
all, because it may be made an auto-suggestion, it does not leave the
patient after a time dependent on anyone else.



CHAPTER X

VAGUE ABDOMINAL DISCOMFORTS--LOOSE KIDNEY


After the vague pains around joints so commonly called rheumatic, and
which occur so frequently that probably there is no one over forty who
is quite ready to confess that he has not had rheumatism, the most
important source of vague discomfort is the abdominal region. This
occurs particularly in people who are engaged in a sedentary
occupation which prevents much exercise, keeps them indoors, and gives
them abundant opportunity as a rule for introspection and dwelling
upon their sensations. There are few people who live the intellectual
life who have not suffered from some of this abdominal discomfort,
which they presumed must mean some definite lesion, or portend some
serious development, and yet, as a rule, they have lived for years
afterward without any of their fears proving true.

Physicians are not spared from this source of worry and discomfort.
They suffer from it even a little more than others. Their knowledge of
the possibilities of serious pathological developments within the
abdomen, especially after the age of forty, makes them a little more
concerned as to the significance of these vague discomforts.

At least half a dozen times a year, for the last ten years, I have
heard physicians say that they were sure that some organ or other
within was not performing its function properly, and that there was
probably some organic lesion. The thought has usually been in their
minds for months, sometimes for years, and they have come to be
thoroughly examined. Sometimes they rather expect to be told that they
should go to a surgeon. They are usually half concealing a question as
to how soon they should set about putting their affairs to rights and
how serious the outlook is. As a rule, I am able to dismiss them
without any further treatment than the injunction not to think so
persistently about certain obscure feelings which they are allowing to
occupy their consciousness. Sometimes I know they take the
advice--even oftener, perhaps, I know they do not. Once it has got
hold of us, it is hard to get away from morbid introspection, and I
sometimes hear of them consulting others. All of these patients are
improved for a time after their consultation by the reassurance that
so long as they have a good appetite--which is the case with all of
them--and their bowels are regular--which unfortunately is not the
case with most of them--and so long as they sleep well and have no
acute pain, there is little likelihood of any serious latent abdominal
condition.

Such reassurance cannot be given until the abdominal region is
carefully palpated, and especially the right side explored as
thoroughly as possible. {303} Here lies the appendix, the head of the
colon, which is sometimes the seat of trouble not necessarily
originating in the appendix. Just above them one may find a loose
kidney, for the right kidney is more likely to be movable than the
left, because of the overhanging liver, and finally the gall-bladder,
and the bile passages, so likely to be the seat of serious trouble. If
none of these organs are tender on deep palpation, if the kidney does
not come down when the patient is examined in the standing position,
if there are no serious derangements of digestion, except such as can
be attributed to nervous indigestion, and if there is no dilatation of
the stomach, and no enlargement of the spleen, there is no reason why
one should do anything but try to get the patient's mind off himself.

There is always the danger of overlooking an abdominal cancer, in
these eases, though with the care in diagnosis I have suggested this
is minimal. The best therapeutic test that I know to determine this,
if there should be any doubt, is to put the patient on an increased
diet and watch the scales. If he is able to digest the added food
well, and without trouble, and if he proceeds promptly to gain in
weight, there is much less than one chance in a hundred that he is the
subject of latent cancer in the abdominal region. The old farmer's
maxim is: "A sick hog don't get fat." When human beings properly
respond to increased feeding, it is probable, not only that there is
nothing serious the matter with them, but that the symptoms of which
they complained before may very likely have been due to lack of
nutrition. The digestive organs not having enough to occupy them, were
tempted to digest themselves, or at least to have their function
disturbed by the short circuiting of nervous energy looking for
something to do.

I have seen a number of these cases that had been operated on for
vague discomfort--some whose appendices had been removed, some whose
kidneys had been fastened up because they were slightly movable, some
whose gall passages had been examined for adhesions that were supposed
to exist, or perhaps for a stone that it was thought might be found
there, and except where some actual organic lesion was found and
relieved, none of them was materially improved when seen several years
after operation. I have heard reports of cures of these cases by
surgeons who felt that the removal of an appendix presumed to show a
catarrhal process, or a hyperemia, or an adhesion at its tip, had
meant the cure of vague abdominal discomfort which had continued for
many years and made the patient profoundly miserable. But these
reports were founded on the patient's condition at the end of
convalescence after the operation, and not on the condition that
established itself some months, or perhaps a year, later. Operations
on the abdomen, except for very definite indications, have, in my
experience, always done more harm than good, and I have seen serious
conditions--hernia, displacement of organs and disturbance of the
peristalsis of the intestines--develop subsequent to them.

I have in mind two typical cases. One was a physician whom I had seen
on a number of occasions, and who complained of vague discomfort,
mainly in the right side of the abdomen, though never acute, never
accompanied by fever, nor even by any disturbance of pulse when he was
not in an excitable mood. His bowels were not always regular, and he
had had some disturbance of circulation as the result of thrombosis of
veins on that side after an {304} attack of typhoid fever. My opinion
was that his discomfort was entirely due to the disturbance of
circulation. There was probably some interference with the normal full
circulation to the large intestine, in its ascending portion, that
gave him a feeling of uneasiness, or of consciousness of its function.
Eventually he became convinced that he was suffering from a chronic
form of appendicitis. After considerable persuasion he convinced a
surgeon friend that his appendix should be removed, and the operation
was done. I saw his appendix afterwards. It was supposed to be
thickened, but considering the normal limits of size of the appendix,
I could not think that it was beyond them in any marked way. At most
there was but a slight catarrhal inflammation.

For a time after operation he was much improved. He felt confident
that all his trouble has disappeared, and he took some pains to
impress me with the supposed fact that in these vague cases of
discomfort there was always some underlying organic lesion that needed
surgical treatment. During convalescence he had gained in weight, and
was looking very well. When I met him a year and a half later he said
that some of his discomfort had returned. He had grown thinner and was
feeling discouraged. Six months later he was about to submit to
another operation, this time for the breaking up of adhesions in the
neighborhood of his gall-bladder. He had become convinced that this
must be the seat of the difficulty. After this operation he was sure,
beyond peradventure, that his trouble was gone never to return. Two
years later I found him preparing to have his right kidney sewed up. I
had known that his right kidney was slightly movable, but it did not
move sufficiently to cause any disturbance of kidney function, and
certainly not enough to justify serious surgical intervention.

After this operation I met him once casually and he assured me that
now everything was surely all right. I have since heard that he
submitted to an operation either for the breaking up of some adhesions
around his stomach or in order to tuck up that organ for ptosis. It
had not been quite decided whether an adhesion caused a slight
hour-glass constriction of the stomach, with some dilatation of the
splenic end of the fundus, or whether there had been some actual
sagging. I am sure that after this operation, as after preceding ones,
with the strong suggestion that he ought to be better and an increase
of weight during convalescence, he lost his vague abdominal discomfort
for a time, though I have no doubt that it either has or will return.
When he gets something to so occupy his mind that he does not dwell
too much on his discomfort, he will not increase it to the extent that
makes it intolerable. Then he will remember that most people have some
discomfort, and he will learn to distract his mind, rather than allow
it to dwell on the thought of his particular ailment until it becomes
intolerable.

It has taken twelve years or more to develop this case to the point
where it is as instructive as it now is, and it is a typical example
of what may happen even to a physician. There are other cases in my
notes that are quite as instructive, two of them occurring in
thoroughly educated men, clergymen who were of good intellectual
capacity, but who became too much occupied with themselves. One of
these had more operations done on him than my friend the physician. He
first had his appendix removed, and was better for a time. Then his
kidney was fastened up, and improvement once more took place. After
this he lost in weight considerably and suffered so much {305} from
headaches that a friendly surgeon suggested that there must be
adhesions between his dura and his brain. Accordingly a trephining was
done, and these adhesions, real or supposed, were broken up. For a
time he seemed to be better. Then he had some urinary trouble. A long
prepuce, though one that was never tight or adherent, and only
required a little attention to cleanliness to keep it from giving
bother, was removed. Some disturbance of his appetite led him to limit
his eating for a time, and then he suffered from constipation. This
was diagnosed by a specialist in rectal troubles as due to abnormally
developed valves in his rectum, and these were cut. He still
complained very much of abdominal discomfort at times. This was
diagnosed as ptosis of his organs, and an operation was done to tuck
these up. After this he developed a large ventral hernia, which had to
be relieved by a subsequent operation.

I had followed the case carefully during many years, seeing him at
times, and I was always opposed to the idea of operation and fully
confident that none of the operations were really needed. He could not
be persuaded that what his case needed most was occupation of mind
with something besides his condition. Whenever I could persuade him of
this I had seen him gain in weight, get into much better spirits and
be almost able to take up his work again. Then he would become
discouraged, and before long I would hear of another operation that
was planned, or was about to be performed. During the course of one of
his many progressive losses in weight as a consequence of depression
of mind, he developed tuberculosis. He resisted this very well, but
eventually died rather suddenly of an empyema. A careful autopsy
showed nothing but the traces of former operations, and no reason why
they should have been done.

Another case: A friend, also a clergyman, had three operations done,
one of them circumcision, the second an appendectomy and the third on
a supposed floating kidney. None were indicated, so far as I could
see, by any definite symptoms, or justified by his condition. He had
vague abdominal discomfort, and this continued to bother him in spite
of treatment by various specialists, and his mind became so much
occupied with it that he was ready to submit to anything in order to
be rid of his burden of discomfort. At no time was it an ache, nor did
he ever speak of it as a pain. He had some tendency to dilatation of
the stomach and at times, when much occupied with indoor work and
neglecting muscular exercise, there was probably some delay of
digestion. His appetite was good whenever he would let it be; his
bowels were regular whenever he was eating sufficient to stimulate
them to normal function; he slept well, except when unnerved by
something, but the presence of this abdominal discomfort disturbed
most of his waking hours. He could stand it so far as it had gone, but
he was sure that it would become so much worse in the future that it
would be unbearable. He dreaded that cancer or some other awful
development would come after a time.

As a matter of fact, the main portion of the discomfort in these cases
is the dread of what may happen. It is a dread, just as misophobia or
claustrophobia or acrophobia or any of the other dreads that we
discuss in the chapter on that subject. The constant occupation with
this dread apparently inhibits to some degree the flow of nerve
impulses to the abdominal organs, and digestion, already disturbed, is
still more impaired. Indeed, the whole {306} of the discomfort seems
to be a consciousness of stomach and intestinal function rather than
anything more serious. The stomach will take two or three pounds or
even more of mingled liquids and solids at a meal and pass them on to
the intestines without forcing itself into the field of our
consciousness. Anyone who is aware what a thin-walled membranous bag
the human stomach is--what it most nearly resembles is perhaps the
familiar bladder of the cow--may well be surprised that, though it is
supplied with many sensitive nerves, it gives so little sign of the
load that is often placed in it. It may, however, be brought rather
poignantly into the sphere of consciousness by concentration of
attention on it.

The intestines function usually with the same lack of reflex. They
proceed to pass on this quantity of food, store up two or three days'
rations, digest what is nutritious and eliminate what must be
rejected, without rising into consciousness. If either stomach or
intestines once begin to attract attention, then it will be difficult,
unless care is exercised to distract the mind from them, to replace
and keep them back in the sphere of the unconscious once more.
Peristaltic movements are constantly taking place in the digestive
tract. Various things may interfere with peristalsis, and the
disturbance of it will almost surely cause some sensation. It may not
be serious, and digestive processes may continue, yet there may be
discomfort. If there is delay in the passage of food, gas accumulates
in the stomach, presses up against the diaphragm and interferes with
the heart action. This will give rise to many bothersome sensations,
some of which are felt in the heart region itself; others much lower
down on the left side, where it is rather hard to recognize just what
the real seat of them may be. A good deal of the abdominal discomfort
of which people complain, is due to such functional disturbances,
emphasized by the fact that digestive action has come into the sphere
of consciousness and now attention is being concentrated on it, to the
detriment of digestion itself, as well as to the increase of the
annoyance which the discomfort may occasion.

Operations for abdominal discomfort are quite contra-indicated, unless
there are very definite localizing symptoms of some pathological
lesion that can surely be relieved by operative intervention. To
operate on general principles is sure to emphasize the patient's
concentration of attention on his abdominal discomfort, if it does not
relieve it, and in most of these cases it utterly fails. The strong
suggestion of an operation will relieve for the time being, just as
operations for epilepsy seemed to relieve when that procedure was
first introduced, though now, unless there are definite localizing
signs, there is no question of such an operation.


Toxic Factors.--_Tea_.--A very interesting phase of abdominal
discomfort seems to be associated with the taking of nerve stimulants.
I have frequently found that patients who complained of vague
abdominal uneasiness, sometimes rising particularly at night to the
height of colicky feelings but always on the left side, were indulging
to excess in tea or coffee. In one case, a woman was taking, she
thought, about a dozen cups of tea a day. Just how much more than this
she actually was taking I do not know, for it is almost incredible the
amount of tea that middle-aged women who are alone may take. I once
found by actual count made for me, that a woman was taking almost a
score of cups of tea in each twenty-four hours.

{307}

Just as soon as there is a reduction in the amount of tea taken in
these cases, relief is afforded the patient. This relief will not,
however, be absolutely satisfactory because the craving for the tea
stimulation makes the patients irritable, and it takes but very little
to cause them to complain that they still have their old discomfort.
In the course of three or four days they realize that the root of the
trouble has been reached. If the discomfort has continued for a good
while, a sort of habit seems to be formed, and the attention of the
mind gives a sense of uneasiness, if not discomfort, in the left
abdominal region. Usually it is in the upper left quadrant and seems
to be stomachic in origin. The discomfort is apparently due to the
presence of air, or gas, which is not properly expelled because of
some lack of co-ordination of muscles, and then the warmth of a room
or of the bed at night, or the presence of some slightly irritant
substance makes the discomfort more noticeable. In the patient's
over-stimulated condition, there is inability to withstand it
patiently. In none of these cases is there a fever, though in all
there is some disturbance of the pulse as if the heart's action were
interfered with and the organ resented it.


_Coffee_.--In some cases the same vague abdominal discomfort occurs as
a consequence of taking too much coffee. This is seen in men more than
in women. The tea topers are nearly all women, though my attention was
first called to this vague discomfort, that made life miserable for a
tea tester, who spent most of his day tasting tea, though drinking
very little of it. With regard to coffee, individual idiosyncrasy is
an extremely important matter. Some men seem to be able to take five,
six or even more cups of coffee in the day without inconvenience; some
cannot take even a small cup of coffee after six o'clock at night
without being kept awake for several hours; others cannot take a large
cup of coffee in the morning without having considerable discomfort,
which is usually attributed to indigestion. I have known large, strong
men, who were much better for not taking any coffee, or at the most a
tablespoonful of it in a cup of milk in the morning to satisfy the
taste.


Loose Kidney.--Movable kidney is responsible for many of these cases
of abdominal discomfort. Where it exists to a marked degree it may be
relieved by operation. It occurs much more frequently in women than in
men because, for physiological reasons, the kidneys are normally more
movable in women and this is particularly true of the right kidney,
which would otherwise perhaps be injured by pressure between the
pregnant uterus and the liver. It is probable that many of the cases
of the kidney of pregnancy are really due to an abnormal fixity of the
kidney to a particular place, so that the growing uterus interferes by
pressure with its circulation and its function. Slight movability of
the kidney, then, should not be considered pathological.

I have seen a number of these cases. They seem to occur particularly
in women who have lost weight. The fat around the kidney is somewhat
absorbed during the course of loss in weight, and this leaves this
organ more movable and also less protected and consequently more
liable to irritation. One sees it rather frequently in many unmarried
women who have some strenuous occupation. Many of these young women
come back from their vacation at the end of the summer having gained
fifteen or twenty pounds in weight. If there has been any kidney
sensitiveness or movability before, {308} both have usually
disappeared. The kidney is well held in place because there is much
more fat within the abdomen, all the organs are better cushioned, yet
without any interference with their function.

During the course of the year these patients, school-teachers,
stenographers, and daily workers of various kinds, lose in weight.
When they have lost ten pounds the kidney begins to be sensitive again
and somewhat movable. By the time they have lost fifteen to twenty
pounds there is serious complaint in the right upper quadrant of their
abdomen extending at times over toward the navel, and the kidney
becomes quite movable. At this time the treatment must consist in
holding the kidney as firmly in place as possible, for dragging
downward will be followed by reflex symptoms in the stomach and
intestines. Disinclination to food, loss of appetite, and even the
occurrence of some nausea, as well as some constipation, are easily
traced to kidney reflexes. During the night there is no trouble,
because while the patient is lying down the kidney falls into its
proper position. On arising in the morning the kidney drops down out
of place. If a corset is put on at this time the kidney may be forced
still further out of place, giving rise, after a couple of hours, to
considerable discomfort. New shoes can be borne at first, but after a
time the pressure they produce shuts off circulation and causes
intolerable discomfort. To a less degree this happens to the kidney if
thus compressed and this explains the course of symptoms in many
cases.


_Mechanical Treatment_.--If the corset is adjusted before the patient
rises, and fits reasonably snugly, but not too tight, the contents of
the abdomen will all be kept in place, and the kidney will maintain
its normal position. When the corset is not sufficient to retain the
kidney in place, a simple pad, a towel or a napkin or, if there is
much sensitiveness, something more elaborate, especially adapted to
conditions, can be placed over the kidney, and when held firmly by the
corset will keep the kidney in its place. At first the kidney is
usually sensitive to this on account of having been pressed upon
during the preceding weeks or months. The patient must bear some
little inconvenience at first, must get accustomed to the new
conditions in which the kidney is kept in place, and must not expect
complete relief at once. Any improvement must be considered a step
forward, and further amelioration can be confidently promised. As in
all other cases of the use of apparatus or mechanical
aids--spectacles, false teeth or crutches--the patient must be content
to grow used to the new order of things, before expecting satisfying
relief.

This is the palliative treatment. The natural treatment of many of
these cases is to have the patient maintain such weight as will hold
the kidney in place, because of the fat within the abdomen, without
any necessity for external aids. This can be done more readily than is
often thought to be possible. These patients insist that they lose
their appetite when they settle down to work, but what they really
lose is the habit of eating a definite amount at stated intervals.
Very often it will be found that breakfast, which they took abundant
time to eat during vacation, is rushed. The luncheon suffers in the
same way and is small in quantity. They take only one good meal, and
one good meal is not sufficient to maintain normal weight.


_Question of Operation_.--When a kidney is so movable as to deserve
the adjective "floating," so that it moves considerably from its place
and, perhaps, even sags and may be felt in the subumbilical region, it
should be fastened up {309} by surgical means. There is a choice
between two evils. The fastening of the kidney in the loin does not
restore the normal condition, but puts it in an artificial condition.
The kidney supports are of such a kind that it was evidently meant to
be slightly movable. When it is fastened firmly in the loin, it is
likely to feel every jar, and certain post-operative cases that I have
seen, in which firm adhesions had supposedly taken place, complained
considerably of the discomfort occasioned by this. In a certain number
of cases, even after the operation, the kidney is still somewhat
movable, because the adhesions yield and some of the old distress
returns. All this must be realized before there is any question of an
operation. There must be not merely a little discomfort, but enough of
actual ache and of reflex disturbance that can be traced directly to
the kidney to warrant the operation.

No floating kidney should be operated upon in a patient who has lost
much in weight and has developed a sensitiveness of the kidney since
the reduction of weight. Definite efforts should first be made to
bring about increase in weight, so as to see whether this will not
restore the previous condition of reasonable comfort. At times it is
said that the disturbance of the stomach, that is reflex to such a
floating kidney, prevents the patient from taking and assimilating
enough food to restore normal weight. This will be true if attention
has been called to the condition very seriously, and if the patient is
persuaded that this is the reason why there is no appetite and poor
digestion. Ordinary palliative measures, such as a binder, or a
specially made corset, will be sufficient to prevent the kidney from
producing reflex disturbance of the stomach, and will exert a strong
suggestion to this effect under the influence of which the patient
will usually gain in weight.


_Intermittent Discomfort_.--The discomfort that comes with a loose
kidney may be quite intermittent. I have known patients to be bothered
by it for months, and then quite free from it for several years, only
to have their discomfort renewed so that they become quite worried.
Some definite local or mechanical condition can generally be found for
these variations in feeling.

In thin people a jolting ride over a rough road or stepping off a car
will occasionally be the beginning of the trouble, and as this also is
likely to cause a stone in the kidney to give its first
manifestations, there may be serious suspicion of a more grave
pathological condition than is really present. If this discomfort
continues only the X-ray can absolutely decide the question.

Once the mechanical conditions which cause the discomfort are
understood by the patient, the actual ache becomes much more easy to
bear. Apprehension makes it almost intolerable. Attention exaggerates
it, and makes diversion of mind difficult. Understanding helps all the
conditions and lessens the pain, not actually but mentally, until
after a time very little attention is paid to it.


{310}

SECTION VII

_CARDIOTHERAPY_


CHAPTER I

THE HEART AND MENTAL INFLUENCE


The heart is an organ so vitally important that we might expect it to
be carefully protected by nature from any interference with its action
through mental influence, emotional conditions, or voluntary or
involuntary feelings. As a matter of fact, it is extremely susceptible
to mental influence, stimulant or depressive, and to emotions of all
kinds. Psychotherapy, that is, the removal of inhibiting influences
originating in the mind, and the suggestion of favorable mental
influences, is probably more important for the heart than for any
other organ in the body. The law of reserve energy has its most
noteworthy applications with regard to it. When we are apparently so
completely fatigued that we cannot do anything more, a purely mental
stimulus may so enliven the heart as to give the body a new supply of
strength and energy. A man wandering through a desert, or swimming for
his life at sea, may be so exhausted as to be quite ready to give up
entirely, and be brought to the conviction that he has absolutely no
strength left for further effort, when a flash in the distance, or a
sound that indicates that help is near, or some other mental
incitement, will give renewed energy. It is probably through the heart
that there comes to us most of our power to accomplish things when we
are already so tired as to seem exhausted. On the other hand, it is
the failure of circulation in muscles, because of a slacking heart,
that produces the sense of exhaustion. Muscular work is easy or even
pleasant when we are in good spirits, while, whenever exertion is
undertaken in the midst of discouragement, we cannot accomplish nearly
so much as when conditions are so framed as to give stimulus and
encouragement.

If a perfectly normal heart can be so affected by mental conditions
and emotions as to be seriously disturbed in its work on the one hand,
or greatly stimulated into new activity on the other, it is to be
expected that a heart affected by disease will be similarly affected
and probably even to a greater degree. It is clear, then, that our
cardiac patients have to be guarded against unfavorable mental
conditions, and have to have all their reserve energy called out for
them by encouragement and by the best possible prognosis for their
reflection. This is especially true as regards the removal of the many
unfavorable suggestions which, because of ignorance, have in the past
gathered round most forms of heart disease.

{311}

Emotion and the Heart.--The mental and emotional influence over the
heart's action was the truth that lay at the basis of the old fallacy
with regard to the physiology of the heart. The literature of all
countries testifies that the heart was long supposed to be the seat
and origin of the emotions. Every one has experienced how the heart
jumps when something unexpected happens. People have fainted from
excess of joy as well as of grief. The physical side of emotion is so
generally associated with some modification of the heart beat that it
is no wonder that emotions were directly connected with the organ.
When people are in depressed states the heart is apt to beat more
slowly than usual, while when in states of exhilaration, even those
dependent merely on mental factors, the pulse is more rapid.
Melancholic states have occasionally been attributed to the slowness
of the pulse, but the slow pulse seems to be a symptom connected with
the mental condition rather than a causative factor. In the maniacal
conditions, the rapidity of the pulse, which is sometimes quite
marked, must probably be explained in the same way, as due to the
mental excitement under which the patient is laboring.


The Heart and the Nervous System.--Prof. Von Leyden ten years ago
recalled attention to the fact that the heart is literally the _primum
movens_ in man, and that before the central nervous system is laid
down, or there is any possible question of impulses flowing from
center to periphery, the heart, or at least its embryonic
representative, is beating as constantly, regularly, rhythmically, as
it is to do during all the subsequent life of the individual. Oliver
Wendell Holmes has expressed it poetically by stating that the angel
of life sets this heart pendulum going and only the angel of death can
break into the case and stop it.


_Primitive Heart Action_.--The original beating of the heart is
entirely automatic, and quite apart from any nervous initiative or
stimulus. The original bend in the primal blood vessel, which is to
represent the heart in the course of development, begins to pulsate
very early in the chick and evidently does the same thing in all other
living things. Notwithstanding this fact that the heart is thus easily
demonstrated to be the _primum movens_, the first exhibitor of
vitality, and might thus seem to be one of the organs or indeed the
one which should be safe from any nervous interference, later on
powerful connections with the nervous system are made, and heart
acceleration and inhibition become familiar phenomena. Every emotion,
as we have said, has its influence on the heart and even a certain
amount of voluntary control may be acquired. Indian fakirs are said to
be able to cause the heart to slow and almost to stop. The curious
phenomenon of suspended animation which they sometimes exhibit is said
to be due to this. Certain of the well-developed muscular subjects who
exhibit themselves at medical clinics are able to cause their hearts
to miss a beat, but this is said to be rather a result of will-power
over other muscles compressing the thorax, and interfering with the
heart, than direct influence upon the heart itself.


Mental Influence over Diseased Hearts.--Worry produces much more
serious symptoms in heart patients than in others. Anxiety about the
heart itself is often a source of serious detriment to a heart
patient. Most people have such a terror of having anything the matter
with their hearts that the haunting thought of such calamity is likely
to have a definite influence in preventing the development of such
compensation as will enable the heart to {312} do its work to the best
advantage. It used to be the custom to refrain from telling patients
suffering from tuberculosis that they had the disease. On the other
hand, people with heart disease were usually informed of that fact.
The reason given for the latter course was that heart disease may in
many cases be the forerunner of sudden death, and the warning
knowledge was supposed to enable a man to get his affairs in order. No
worse policy for either disease could well have been imagined. The
pulmonary patient should be told at once, the heart patient should, as
far as possible, be saved the depressing knowledge of his condition.

Dr. MacKenzie, whose practically illuminating studies of heart disease
give him a right to express opinions with regard to it (and when those
opinions concern the influence of the mind they are doubly valuable
because of the absolute objectivity of his studies), has some rather
strong expressions with regard to the importance of modifying the
mental state in heart cases. He says:

  The consciousness of heart trouble has often a depressing effect on
  people, whether the trouble be slight or serious. When such people
  become convinced that the trouble is curable or not serious, their
  condition at once becomes greatly improved. Cures by faith, whether
  in drugs, baths, elaborate methods or religion, act by playing upon
  the mental condition. But our employment of this element in
  treatment should not be the outcome of blind unreasoning faith in
  some rite or ceremony, bath or drug, but in the intelligent
  perception of the nature of the symptoms. The reassurance of the
  patient of the harmless nature of the complaint goes a great way in
  curing him. The reassurance that with reasonable care no danger need
  be feared is extremely helpful. Even in serious cases when there is
  reasonable hope of recovery or a certain degree of recovery, the
  encouragement of the patient may and does help forward his
  improvement.


Heart Remedies and Suggestion.--Probably the best evidence we have for
the influence of the mind over the heart in diseased conditions, that
is, when there is definite organic change in the heart valves or
muscle, is to be found in the history of the many remedies that have
come and gone in heart therapeutics during the past generation.
Strophanthus, for instance, was very popular a quarter of a century
ago, and it seems as though in many cases it not only replaced, but
was more efficient than digitalis. How few there are who use it now
with confidence, and how general is the impression that it does not
affect the heart to any extent! The confidence with which the remedy
was given by the physician was conveyed to the patient and he "took
heart," as the expression is, and proceeded to get better. Even more
striking is the evidence afforded by other remedies. For a while it
seemed that cactus provided a heart stimulant and regulator of value.
Convalaria also gained a reputation as a heart remedy. Both are now
practically abandoned. Here, once more, the real remedy, when these
substances were employed, was, undoubtedly, the suggestion to the
patient in connection with the regulation of his habits of life, so
that his heart got a chance to catch up with its work. There are other
remedies with which we had similar experiences.

Even digitalis has had phases of confidence and distrust in it, that
are interesting to study in the light of what we now know with regard
to the influence of the psyche on the heart. One hears at medical
society meetings reports of the favorable action of digitalis within a
few hours of its administration. These are not examples of digitalis
action, but of mental influence. {313} Any heart patient after the
first visit of a physician in whom he has confidence is sure to
brighten up at once, heart action is ever so much better and symptoms
of mental depression, and even of circulatory disturbance, disappear.
It is this that has made the study of even the efficiency of digitalis
so difficult. There were times when most physicians employed it in
rather large quantities for all forms of heart disease. In some heart
cases it is absolutely contra-indicated. Fortunately many of the
preparations of digitalis used in the past were quite inert, and so no
harm was done. The results obtained were psychotherapeutic.


Cardiac Inhibition.--The importance of the role of the nervous system
and of the mental influences which control it in all functions is well
illustrated by what we have learned during the last half century with
regard to inhibition in the animal organism. We used to think that
while the nervous system sent down positive impulses--that is, nervous
stimuli which brought about the accomplishment of certain
activities--it had nothing to do with the stoppage of those
activities. Such interference was supposed always to be due to
external influences of various kinds, potent for the time, in the
organism. We have learned, however, that inhibition is one of the
important functions of the nervous system. The idea has now become so
familiar that sometimes we are apt to forget how great is its
significance. Lauder Brunton, in his article on "Inhibition," set
forth its role as we have come to know it.

  The recognition of the part inhibition plays in vital phenomena is
  undoubtedly one of the most important discoveries which have been
  made in physiology since Harvey discovered the circulation of the
  blood. It throws light upon an immense number of phenomena
  previously inexplicable and enables us to form theories of a
  satisfactory nature about many vital problems. It offers an
  explanation of the nature of hypnotic states, which is at least as
  satisfactory as that we have of the action of many drugs.

  The nervous mechanism of the heart affords the best and most
  commonly cited example of inhibitory action, and here it was first
  studied by Weber and Claude Bernard in 1848. The cardiac ganglia
  derived from the sympathetic preside over the movements of the
  organ, and in response to the stimulus of the intra-ventricular
  blood-pressure cause rhythmical contraction of the cavities. Their
  action is, however, controlled by the pneumogastric nerve, through
  which impulses of an inhibitory nature are constantly traveling and
  acting as a restraining force.

As noted by Lauder Brunton, the late Professor Czermak had a small
glandular tumor in close contact with the right pneumogastric nerve
and he was able by pressure on this to compress the nerve to any
extent he wished, and either "to completely stop the heart or simply
retard it." He often performed this experiment so that it is not
nearly so dangerous as might be thought. We have some instances,
apparently too well authenticated to be doubted, in which the power of
the human will to inhibit heart action has been as strikingly
manifested as this mechanical disturbance of Professor Czermak.
Sometimes these stories of cardiac inhibition through the will are
dismissed as unworthy of credence, and doubtless many of them are mere
fiction, or have been exaggerated for sensational purposes, but some
of them are very suggestive examples of the power of the will over the
heart. If only a modicum of such power were to be employed, it would
seriously hamper heart action, and it must be the aim of psychotherapy
to prevent such inhibition.

{314}

At least one instance of voluntary heart inhibition was observed by
thoroughly trained and properly accredited scientists. A report of it
has been published. As a bit of documentary evidence, on a subject
that is usually considered so vague as to be scarcely worth
considering, Dr. Cheyne's description of the remarkable power of
Colonel Tonshend over his heart should be in the hands of those who
wish to influence hearts through minds and wills.

  He could die or expire when he pleased, and yet by an effort, or
  somehow, he could come to life again. . . . We all three felt his
  pulse first: it was distinct, though small and thready, and his
  heart had its usual beating. He composed himself upon his back and
  lay in a still posture for some time. While I held his right hand.
  Dr. Baynard laid his hand upon his heart, and Mr. Skrine held a
  clean looking-glass to his mouth. I found his pulse sink gradually
  till at last I could not feel any, by the most exact and nice touch;
  Dr. Baynard could not feel the least motion in the heart, nor Mr.
  Skrine discern the least soil of breath on the bright mirror. Then
  each of us by turns examined his arm, heart and breath, but could
  not by the nicest scrutiny, discover the least symptom of life in
  him. We reasoned a long time about this odd appearance, and finding
  he still continued in that position, we began to conclude that he
  had indeed carried the experiment too far; and at last we were
  satisfied that he was already dead, and were just ready to leave
  him. This continued about half an hour. . . . As we were going away
  we perceived some motion about the body, and, upon examination,
  found his pulse and the motion of his heart gradually returning; he
  began to breathe heavily and speak softly.

Nor must it be thought that the inhibitory faculty can act only in
slowing the heart. Normally a certain amount of inhibition is
exercised over the heart's action. If by any chance this should be
decreased then acceleration of cardiac activity may take place. Lauder
Brunton called attention to that in discussing another phase of
pneumogastric function. He said:

  Paralysis of the pneumogastric, of course, does away with its
  action. And hence we have among other symptoms of this condition
  increased rapidity of the contractions of the heart from withdrawal
  of the inhibitory influence.

If slowing of the heart action can be produced through the mind by
this mechanism of inhibition, so also under other circumstances may
acceleration occur.


Shock and the Heart--How large a role emotion plays in disturbing the
action of a heart that is already diseased, is illustrated by the
story told in serious histories, on what seems good authority, of the
dwarf of the French king, who was frightened to death by what he
thought were the arrangements for his execution. While we take great
pains as a rule to impress upon sufferers from organic heart disease
the necessity for their avoiding every kind of over-exertion, or
sudden movement of any kind, we do not always impress upon them the
even greater necessity for the avoidance of shock and fright, and
profound emotions. It must not be thought that emotional shocks have a
deleterious effect only in advanced cases of heart trouble. Almost any
physician will readily recall examples where emotion had much to do
with the break in compensation which indicates that the heart has for
a time been overworked.

A case in my own experience illustrates this: The patient, a student,
had suffered from severe so-called growing pains, undoubtedly
rheumatic, when he was about fourteen, and probably had acquired a
heart lesion at that time. {315} It did not, however, disturb him in
the slightest degree. The patient had never noticed any fatigue on
running up stairs; he had no shortness of breath; there were no
symptoms pointing to his heart. One summer while his family were in
the country he came into town for the day, and missing the last train
out, he went to the family home to sleep, though it had been closed up
for the summer. He let himself in without difficulty and was preparing
to go to bed when he resolved to get a glass of water. There being no
tumbler nearer than the dining-room, he went there. As he entered the
dining-room he struck a match. With the flash of the light he found
himself looking into the barrel of a revolver and a hoarse voice said,
"Hands up!" His hands went up. The next minute he was in the hands of
two "plain clothes" policemen who had been watching the neighborhood
because of recent burglaries. Noticing the light upstairs, they had
made their way in for the purpose of catching what they thought a
burglar at work.

The young fellow, who had never before fainted, collapsed almost at
once, and was unconscious for some minutes. The next day he was rather
prostrated and tired on movement. By resting a good deal for the next
week this passed off to a considerable degree, but then his physician
found that he was suffering from a serious heart lesion, with a
decided break in compensation. I saw him several months later. His
heart had never regained its old power, and his mitral valve was quite
unable to fulfill its function. Just what the mechanism of the almost
sudden break in compensation was after he had been for so long quite
immune from any effects of the rheumatism, is hard to say, but the
lesson of the case is easy to understand.


Place of Psychotherapy in Treatment.--The role of psychotherapy, then,
in heart cases consists in the recognition of the part that the mind,
the will and the emotions play in their influence over this important
organ. These psychic factors may produce disturbed conditions of
various kinds. The more experience the physician has with cardiac
cases of all kinds, organic as well as functional, the more powerful
does he recognize the influence of the mind over the heart to be. The
expression that a man is living on his will is no mere figure of
speech. Some cases we have cited seem to show that a favorable
attitude of mind keeps up heart action, where an unfavorable attitude
would almost surely allow the heart to fail. It is this very potent
influence then that must be used to as great advantage as possible in
the psychotherapy of cardiac patients.

Undoubtedly the most important phase of it is in prophylaxis. As far
as possible we must save our heart patients from emotions. The effect
of emotion on the heart is known. When that organ is already crippled,
emotion may produce a serious strain on it. It is as important to save
heart patients from joyful emotions as from those of contrary nature.
Many a son who, after years of absence, thought to surprise a dear old
mother by suddenly presenting himself to her, has learned to his cost
that an old heart may break from joy, almost as easily as from sorrow,
and may be as unfavorably affected by the glad emotions as by terror
or fright. We must also save heart patients from the unfavorable
influence of a bad prognosis, and of too serious a diagnosis, both of
which may be quite unjustified, for the rule is that the longer a man
has been studying the heart, the less likely is he to be confident in
his diagnosis, or unfavorable in his prognosis.

{316}

The curative place of psychotherapy is in the obtaining, as far as
possible, of placid easy lives for these patients. This does not mean
that they are to give up their occupations, for very often the
internal emotional life, which develops when they have nothing to do
but think about themselves, will be more serious in its effect upon
the heart than the ordinary vocation. Exciting incidents in life work
must, however, be avoided. If men are in occupations that require
exposure to excitement, then it may be advisable to change their
occupations. Brokers, speculators, actors, sometimes public speakers,
on whom appearances in public in spite of apparent placidity are often
a severe strain, may have to be guided into quieter paths of life. In
general, in every attempt to treat heart disease, and the neurotic
symptoms which develop in connection with it, the patient's mind must
be considered as one of the most important therapeutic factors.



CHAPTER II

DIAGNOSIS AND PROGNOSIS IN HEART DISEASE


The more carefully heart disease, and particularly individual patients
affected by various heart lesions, have been studied in recent years
the more it has come to be appreciated that the most important element
in the treatment of organic heart disease is the definite recognition
of the difficulty of exact diagnosis of most cardiac conditions and
the unfortunate tendency to make the prognosis worse than it really
is. Many heart affections are quite compatible with long life. In the
past both of these problems of diagnosis and prognosis have been only
too often solved unfavorably to the patient, to the serious detriment
of his power of physical reaction against the ailment. Many a patient
has been seriously disturbed and even his power of compensation
lessened by having a diagnosis of an organic affection of the heart
made with the usual prognosis, or at least strong suggestion of early
death that goes with it, when there was no justification for such an
unfavorable opinion.


Mental Attitude of Patient.--We do not pretend to cure tuberculosis,
but we do relieve its symptoms and bring about a remission in the
progress with a shutting in of the lesions. In heart disease something
of the same kind can very often be accomplished. This does not mean
that in advanced cases of heart disease much good can be accomplished
any more than in advanced cases of tuberculosis, though in both a
change of the mental attitude may lift the patient from what seems
almost a death-bed into renewed activity for a prolonged period.
Probably heart disease is more serious in its prognosis than
tuberculosis, yet undoubtedly the lives of many patients could be
prolonged nearly as much as in the pulmonary affection and a large
amount of suffering saved through mental influence. We do not hesitate
to change the occupation and the place of abode of the patient
suffering from tuberculosis. There is even greater reason for doing
this same thing when it seems advisable with patients suffering from
heart disease.

With regard to heart disease, the best authorities are now agreed that
it is better, as a rule, not to tell the patient himself unless it is
absolutely {317} necessary to do so in order to get him to take the
precautions that will prevent further deterioration of his cardiac
condition. The depression incident to the knowledge that one has a
serious heart lesion is not reacted against, and especially not during
a threatening break in compensation, and a more favorable time must be
waited for to reveal his condition to him. The danger of sudden death
in valvular heart disease is much less than is popularly supposed.
Only sufferers from aortic heart disease are likely to die without
warning, and this form of the disease is comparatively rare. The death
of the patient suffering from mitral disease is likely to be
lingering. Mitral disease is the commonest form of heart disease, and
the prognosis of it in ordinary cases is by no means so grave as is
usually supposed. I have seen a patient still alive with a mitral
murmur who told the story of having had his affection originally
diagnosed as mitral regurgitation by Skoda, the distinguished Vienna
diagnostician, over forty years before. This patient at the time I saw
him was nearly seventy years of age, still had the mitral murmur, but
his apex beat was scarcely if at all displaced and there was neither
enlargement of the ventricle nor apparently any degeneration of the
auricle.


The Apex Beat and Heart Murmurs.--In this regard an expression of
Prof. Carl Gerhardt of Berlin deserves to be recalled. That
distinguished clinician used to say that if the apex beat was not
displaced there was no good reason for thinking that any heart
affection which might be present was serious enough to require active
treatment. Heart murmurs have been made entirely of too much
significance and any man of considerable experience is likely to have
seen a number of patients who, because they had a heart murmur, had
been seriously and needlessly disturbed by having a physician tell
them that they had heart disease, with an air of finality that seemed
to the patients to say that they might prepare for the worst very
soon. Patients suffering from diseased hearts have to care specially
for themselves, but not to the extent of living such maimed lives as
is likely to be the case if they are depressed by an unfortunate
exaggeration of the seriousness of their condition.

Our best authorities in* heart disease have at all times proclaimed
their uncertainty as to the diagnosis of heart conditions from
murmurs, while mediocre men of comparatively slight experience have
not hesitated to declare their certainty in this difficult matter. It
is not an unusual thing to hear of a supposed expert having declared
upon the witness stand and under oath that he could tell whether a man
had heart disease by _listening_ to his heart, and some have even gone
the length of making their decisions in this matter while listening
for a few moments sometimes even above the clothing of the patient!
Needless to say, this is quite unjustifiable in our present knowledge
of the status of heart affections and only men of small experience and
over-confidence in themselves make any such declarations. The more
experience a physician has had in heart disease, the more careful he
is not to make positive declarations. One or two examinations may very
easily be deceptive unless there are signs quite apart from those in
the heart itself. Indeed, it is much more the state of the individual
than the state of the heart itself, or anything that can be found out
about it, except after a prolonged and repeated study, that enables us
to make definite decisions. Probably no one during the nineteenth
century had studied hearts more carefully than Prof. William Stokes,
whose books on the subject were so widely read. He wrote:

{318}

  We read that a murmur with a first sound, under certain
  circumstances, indicates lesion of the mitral valves. And again,
  that a murmur with the second sound has this or that value. All this
  may be very true, but is it always easy to determine which of the
  sounds is the first, and which is the second? Every candid observer
  must answer this question in the negative. In certain cases of
  weakened hearts acting rapidly and irregularly, it is often scarcely
  possible to determine the point. Again, even where the pulsations of
  the heart are not much increased in rapidity, it sometimes, when a
  loud murmur exists, becomes difficult to say with which sound the
  murmur is associated. The murmur may mask not only the sound with
  which it is properly synchronous, but also that with which it has no
  connection, so that in some cases even of regularly acting hearts,
  with a distinct systolic pulse, and the back stroke with the second
  sound, nothing is to be heard but one loud murmur.

  So great is the difficulty in some cases, that we cannot resist
  altering our opinions from day to day as to which is the first and
  which the second sound.

  To the inexperienced the detailed descriptions of such phenomena as
  the intensification of the sounds of the pulmonary valves; of
  constrictive murmurs as distinguished from non-constrictive; of
  associations of different murmurs at the opposite sides of the
  heart; of pre-systolic and post-systolic, pre-diastolic and
  post-diastolic murmurs, act injuriously--first, by conveying the
  idea that the separate existence of these phenomena is certain, and
  that their diagnostic value is established; and secondly, by
  diverting attention from the great object, which--it cannot be too
  often repeated--is to ascertain if the murmur proceeds from an
  organic cause; and again, to determine the vital and physical state
  of the cavities of the heart. . . .

There are too many cases in which murmurs have no such serious
significance as was often attributed to them when first studied, and
yet it used to be almost a universal custom among physicians, and the
custom still obtains with many, to tell a patient rather emphatically
whenever a heart murmur was present, that he had heart disease. Above
all, too much significance has been ascribed to murmurs in initial
cases of heart disease and these are just the cases that should not be
disturbed by unfavorable suggestion. The louder the murmur the less
likelihood there is of there being heart disease in the ordinarily
accepted sense of the term, that is, that the heart is so affected as
to be incapable of doing its work properly, for where loud murmurs are
present this is almost never the case. A murmur that may be heard a
foot distant is usually associated with perfect compensation.

If this were remembered by those who examine hearts generally, there
would be much less disturbance of heart action by unfavorable mental
influence. A great many more who are suffering from certain
symptomatic conditions of the heart not surely or necessarily
dependent on organic lesions, are plunged into depression by
unfortunate, premature or exaggerated expressions on the part of their
physicians. It is almost a rule to have men and even women patients
say that it makes no difference to them, that they should be told the
exact truth as to what their condition is. The future has been
mercifully hidden from us in most things and there is no doubt that
this plan is the better for human comfort and accomplishment
generally.

The truth is not easy to find and oftener in these cases lies on the
side of favorable prognosis and refusal to think the worst than the
opposite. In this there has been a great difference between the German
and the Irish schools of medicine. The three great Irish physicians,
Graves, Stokes and Corrigan, insisted on the place of the individual
and upon how much depends upon the general conditions in pulmonary and
cardiac disease. Our teaching in {319} America in this matter has come
not from the conservative British schools of medicine, but from the
German school, and that has had a notable tendency to exaggerate the
significance of heart signs over the general condition.

What a great distinction there is between this mode of looking at
these diseases and the German method was pointed out by Prof. Lindwurm
of Munich, when he translated Prof. Stokes' work on the heart into
German. Prof. Lindwurm said:

  Thus our modern German works are to a greater or lesser extent only
  treatises on the physical diagnosis of organic affections of the
  heart. Stokes, on the contrary, resists this one-sided tendency
  which bases the diagnosis solely on physical signs and disregards
  the all-important vital phenomena; he lays less weight on the
  differential diagnosis of lesions on the several valves and on the
  situation of a sound than on the condition of the heart in general,
  and especially on the question as to whether a murmur is organic or
  inorganic, and whether the disease itself is organic or functional.


Broadbent on Cardiac Diagnosis.--What Stokes taught the
English-speaking world so emphatically in the first half of the
nineteenth century Sir William Broadbent was just as insistent about
in the latter half. It is evident, then, that clinical experience has
not changed its viewpoint in these matters in spite of all our study
of the heart in the interval. In his paper on "The Conduct of the
Heart in the Face of Difficulties" he has many suggestions that will
prevent the physician of less experience from taking too pessimistic a
view of heart symptoms. He said:

  Moreover, the heart has very special relations with the nervous
  system; it reflects every emotion, beats high with courage, is
  palsied by fear, throbs rapidly and violently with excitement, and
  acts feebly under nervous depression; but it is not only through the
  cerebro-spinal system that the heart is influenced, it is in
  immediate relation with the vasomotor nervous apparatus, and in a
  scarcely less degree with the sympathetic system generally.
  Normally, afferent impulses are constantly flowing from the viscera
  to the central nervous system and by this reflex process their blood
  supply is regulated, and their functional activity is governed.
  These afferent impulses when perverted by functional derangement or
  disease may become serious disturbing influences.

  The nervous system in a large and increasing proportion of people is
  unduly sensitive and excessively mobile, and the reactions to
  influences of every kind are exaggerated. In some a little emotional
  excitement gives rise to palpitation, and a piece of bad news or the
  bang of a door seems to stop the heart altogether. _There is in such
  subjects no form or degree of cardiac disease which may not he
  simulated_. [Italics ours.] Add a touch of hysteria on the lookout
  for symptoms and for someone to give ear to the narration of the
  unparalleled agonies of the sufferer, and the difficulties of the
  heart, and it may be added of dealing with them, are complete.


Typical Case.--We are prone to think that after the age of seventy the
existence of definite heart murmurs with some tendency to blueness of
the lips and of the fingers, with coldness of the hands, surely
indicates the presence of a serious heart lesion. It is in old people,
however, that such symptoms may be most deceptive. The outcome may
prove that physical signs ordinarily presumed to be surely indicative
of organic disease may be only signs of functional disorder, or at
most may represent certain organic affections for which even the old
heart is thoroughly capable of compensation. One such instance in my
own experience is so striking that I venture to give it in detail.

{320}

This was the case of an old physician friend of some eighty years of
age. His son had a summer lodge in the Adirondacks. Though for some
sixty years the father had been living at the sea level in New York
almost constantly, he went up to visit the son and be with his
grandchildren at an elevation of nearly 2,500 feet. His heart began to
bother him almost at once and he could not go up or down stairs or
take any exercise without considerable discomfort, marked shortness of
breath and a tendency to palpitation that was almost alarming. He
continued his stay for several months in the hope that he would get
used to the altitude, though there were always difficulties of
circulation manifested by blue lips and finger nails. He returned to
New York and placed himself under the care of a heart specialist who
found what appeared to be evident signs of heart deterioration of
muscular character complicated by valvular lesions. He consoled, the
old gentleman by the reflection that a heart that had served his
purposes so well for eighty years could not really be complained of if
now it should show some signs of deterioration. He also insisted that
any mental work would be almost sure to be injurious because of the
calls upon the circulation that it would make.

The old gentleman was ordered South for the following winter with an
absolute prohibition of any mental work. He had planned to revise an
historical work on which he had been engaged for many years and which
had served to keep him in good health perhaps more than anything else.
This was put away entirely and he proceeded to try to get well doing
nothing. Almost needless to say with nothing to do he did not get
well. He had been an extremely busy man all his life, had worked at
least twelve to fourteen hours a day for most of the preceding fifty
years, and for him to do nothing would be quite as impossible as for a
child to be kept in utter physical inactivity. His heart palpitation
continued and grew worse. He was waked up at night by starts that
seriously disturbed him and usually kept him from sleep for hours. As
he said himself, after he had read the morning paper and gone to
stool, there was nothing else for him to do all day except eat and
sleep, and these incidents had never occupied any of his attention in
the past. In spite of the doctor's orders he had his manuscript sent
to him and proceeded to work. At once he began to grow better. At the
end of three months he was feeling better than he had felt for several
years. When I saw him, about his eighty-first birthday, he was looking
better than he had for some time.

As he said himself in describing his case, his own experience had
taught him that the more fuss a heart made the less likelihood was
there of its having anything serious the matter with it, at least of
such a character as would terminate life suddenly or unexpectedly. The
serious heart lesions are those which give no symptoms, or but very
slight ones, and the sudden deaths in heart disease usually come from
the development of insidious symptoms that do not betray themselves to
the patient until the fatal termination is on them. The more the
patient himself has been disturbed by his heart, the less likelihood
is there of its giving out suddenly. The subjective symptoms are
usually due to the fact that the heart is actively overcoming external
interference, or resenting over-attention to it in its work. Certain
it is, that the neglect of it, so far as that is consonant with
reasonably regular life, is the very best thing and the most important
part of any prescription given for symptomatic heart disease, whether
organic or functional, is to forget it just as far as possible.

{321}

Heart Symptoms in the Young.--In young people particularly it is
important not to suggest the possibility of heart disease until there
are definite signs in the circulation apart from the heart which place
the diagnosis beyond all doubt. The psychotherapeutics of organic
heart disease that is most important is that of prophylaxis. Patients'
minds must be guarded as far as possible against disturbance from the
thought that they have heart disease, for this of itself adds a new
factor which tends to disturb compensation and adds to the heart's
labor because worry interferes with the vasomotor mechanism. In this
matter it seems advisable to repeat once more that there must be a
complete reversal of the customs that have existed until now with
regard to tuberculosis and heart disease. Consumptives have from the
very nature of their disease a tendency to hopefulness which soon
brings about a favorable reaction against the bad news, but heart
patients derive no advantage from the announcement and, indeed, if
they are of the nervous, worrying kind, the effect of it is likely to
be cumulative. A week after being told the worst a consumptive has
reacted vigorously and hopefully, and if he has a fair share of
immunity, the scare will do good by making him take the precautions
necessary to increase his resistive vitality. At the end of the same
time a heart patient will be just realizing all the significance of
the unfavorable diagnosis and prognosis of his case.

It may be urged that heart patients by knowing their condition will be
preserved better from injuring themselves by over-exertion, but what
we have said elsewhere about the value of exercise in the treatment of
heart cases shows how much patients may be injured by having their
exercise too much reduced and their activity inhibited by the dread
consequent upon the announcement made to them. It is perfectly easy to
insist with them that they shall not do sudden things, or take violent
exercise, or overdo activity, without disturbing them by the dread
words "heart disease."



CHAPTER III

CARDIAC NEUROSES


If, as all the authorities recognize, the attitude of mind toward
organic heart disease is extremely important and when favorable is a
most helpful therapeutic factor, it is easy to understand that in
neurotic conditions of the heart this is of even more significance.
The term "heart disease" is bound up with so many unfortunate and
persistently unfavorable suggestions that it seems advisable not to
use it with regard to non-organic conditions, even though it may be
associated with the epithets functional or neurotic. For these the
term cardiac neuroses, which avoids the implication of heart disease
in the ordinary sense, seems preferable. Many of the cardiac neuroses
are quite trifling. Many of them endure for years without producing
any serious effect or disturbance of the general health. Many
functional disturbances of the heart action which are extremely
annoying may disappear entirely with judicious regulation of life. The
one important condition in all of these cases is to be sure that the
patient does not worry over the condition, for that {322} hampers
heart activity and leads to functional disturbances of other organs
which make the heart's work harder.


Varieties.--There are many forms of cardiac neuroses. Indeed,
functional heart affections are so individual that it is hard to
classify them. In every case it is extremely important to study the
individual and recognize just what are the special factors bringing
about the disturbance of heart action.


_Palpitation_.--In a certain number of the cases it will be found,
indeed, that there is no real disturbance, but that in some way the
heart action has been brought above the threshold of consciousness and
has become noticeable to the patient. It must not be forgotten that
the heart is an intensely active organ. Several gallons of blood are
pumped through it every minute and yet it accomplishes its work, as a
rule, with such noiseless, frictionless regularity that most people
know nothing about it. When the action of the heart becomes conscious,
it is usually spoken of as palpitation. Patients are sure to think
that this must mean serious over-action, though, as a rule, no sign of
over-action or at most a slight exaggeration of the muscular sounds of
the heart will be found.


_Missed Beats_.--A further stage of this cardiac neurosis is the
missing of beats. This occurs particularly in those whose attention
has been directed for some time to their heart action by the presence
of palpitation. It may be due to nothing more than this
over-concentration of attention. It may be due, however, to mechanical
disturbances, an over-distended stomach, constipation, or certain
nervous factors.


_Arrhythmia_.--A third stage of cardiac neuroses consists of
irregularity of the heart action, in which not only are the beats
missed occasionally, but there may be certain heart sounds much less
vigorous than others and the spaces between the sounds may be very
unequal. This condition is usually said to be due to some serious
condition of the heart muscles, and undoubtedly it often is. There is
no doubt, however, that great irregularity of the heart may occur
entirely as a neurotic condition without any organic affection and
from factors quite extraneous to the heart itself.


Etiology.--There are three causative conditions for cardiac neuroses
that deserve careful study and that can be very much modified by
changing the attitude of the patient's mind toward his condition. The
first of these is an over-attention to self such as is particularly
induced by a life without much exercise and devoted to things
intellectual. The direct causation is probably intimately connected
with the second etiological factor in the production of cardiac
neuroses. This consists of an absence of sufficient exercise for the
heart itself, when it actually seems to disturb its own activity
because adequate calls for exertion are not made on it to use up
accumulated energy. Cardiac neuroses are seen particularly in those
who having had considerable exercise in earlier years, have settled
down to a sedentary life in which there are few calls made upon their
muscular system. The third etiological factor is the most important.
It is due to cardiac disturbance from the stomach and intestinal
tract; this will be discussed in a separate chapter.


Prognosis.--The prognosis in cardiac neuroses is always worse in the
patient's mind than it ought to be. If then the physician shows that
he is uncertain as to the real significance of the affection, some
hint of this uncertainty will be communicated to the patient with
resultant unfavorable suggestion. The {323} more carefully neurotic
heart affections have been studied, the better the prognosis becomes.
Morgagni in the olden time, Stokes and Corrigan in the early
nineteenth century, Broadbent and MacKenzie in our time, have all
emphasized the necessity for favorable prognosis. Even extreme
irregularity is quite compatible with long life without any symptoms
of serious circulatory disturbance. MacKenzie has, in his very careful
studies of heart action, shown that extra systoles may cause marked
irregularity in many forms without warranting unfavorable prognosis.

Arrhythmia may begin in comparatively early life, persist in spite of
treatment, and yet continue up to old age. Sir William Osler tells of
the case of the late Chancellor Ferrier of McGill University who died
at the age of eighty-seven after having exhibited an extremely
irregular heart action for the last fifty years of his life. He has
seen several other patients who have had heart irregularity for many
years without the slightest disturbance of their general health. His
experience is not uncommon, and probably every physician who sees many
cases of heart disease can recall a few of them. Ten years ago I saw a
man past seventy suffering from distinctly irregular heart action,
though he gave the history of having had cardiac irregularity for some
years at least, and he is still alive, past eighty, and with his heart
irregularity still present. I have a patient over seventy whom I know
to have had irregular heart action for fifteen years, and he himself
is sure that it has been present since he was about forty, at least.
It is cases of this kind, together with MacKenzie's recent studies of
the subject, that must be before the physician's mind when he makes
his prognosis for these patients. There must be no hesitancy about his
declaration. Patients think that physicians are prone to deny the
significance of heart trouble so as to avoid disturbing their
patients. The slightest hesitation, then, will be surely looked upon
as of ominous import.


The Intellectual Life and Cardiac Palpitation.--It is curious how many
people who give themselves to intellectual work and live an almost
exclusively indoor life have subjective symptoms relating to their
hearts. Many of the English literary men and women of the last century
had complaints of this kind. Sir Walter Scott described very vividly
his sensations as if his heart did not have room to accomplish its
functions, and said that he used to feel within his chest a fluttering
as if there were a bird there beating its wings against a cage too
small for it. Other literary people have told of this sense of
overfullness in the chest, as if somehow there were not room for all
the organs. This discomfort is mainly referred to the precordial
region. In oversensitive, nervous people it may be described as
painful, though analysis of what they mean by the word pain will show
that they have only a persistent feeling of pressure which is
uncomfortable and gives a sense of crowdedness in that region rather
than any genuine ache. Where the feeling is much dwelt on, however, it
may be exaggerated into pain, as, indeed, will any sensation, however
trivial, if attention is concentrated on it. On the other hand, in
practically all of these cases, just as soon as the mind is strongly
diverted by any pleasant occupation, the sense of discomfort
disappears not to reappear again until the patient has time to think
about himself.


Heart Surveillance.--Prof. Oppenheim of Berlin has in his usual direct
way expressed the power of the mind to influence the heart beat, and
he does {324} not hesitate to say that certain nervous people who have
been watching their hearts overmuch, and continually thinking about
them, are capable of playing all sorts of tricks on themselves and
sometimes even on their physicians, by this concentration of mind upon
their heart and its action. Prof. Oppenheim in his "Letters to Nervous
Patients," writing to a patient complaining of irregular heart action,
says:

  Whenever you succeed in controlling the action of your heart by
  means of introspection, there flows from your brain to your heart a
  current of innervation which disturbs the automatic movement of the
  organ. You now know what you have to thank for the irregularity in
  the action of your heart. I have frequently proved this to myself in
  your case: if I succeeded in feeling your pulse without your
  becoming aware of it, holding your attention by a conversation which
  interested you, the action of your heart was always absolutely
  regular. If, however, I tried it under your control, while your
  attention was anxiously directed to your heart, its action at once
  became irregular, and you experienced the very unpleasant sensation
  of palpitation.


Irritable Heart of Athletes.--A curiously interesting form of heart
neuroses has appealed to me very much because I have suffered somewhat
from it myself and owing to circumstances I think I have seen a larger
number of patients suffering from it than usually come to a single
individual. I refer to the tendency to irritability of the heart which
is so marked in men who have been athletes when they were younger, and
have taken a large amount of exercise during the years between fifteen
and twenty-five. If these men later settle down to a sedentary life
they almost inevitably suffer from a marked sense of discomfort in the
precordial region because of palpitation, and are apparently much more
liable than other people to have an intermittent pulse. Just what
these symptoms are due to is not always easy to discover, and in
different individuals there seem to be different accessory causes at
work. I have seen it particularly in professional men who while at
college have been on the teams and have played such hard games as
handball, hockey on the ice, and the like. I do not refer only to
those who have played an occasional game, but who every day of the
college year have had some severe muscular exercise.

Whether this irregularity of heart action has not at least been
predisposed to by over-exertion remains to be determined. Strenuous
athletics produce curious heart symptoms. Missed heart beats and
irregular heart action and even leakages at the valves are not unusual
even in the best of hearts after severe exertion. A careful
examination of the hearts of those who took part in a Marathon run at
Harvard some years ago showed that immediately after the race many of
them were irregular and some of them had leakages at the mitral valve
which lasted from one to twenty-four hours. These were probably due to
irregularity in the action of the papillary muscles as a consequence
of the fatigue. I had occasion to examine the hearts of some
theatrical dancers a few years ago, immediately after they came off
the stage. One of them is one of the most successful of modern dancers
and is able to occupy the better part of an hour in the severest kind
of exertion before an audience. Her heart was not only very rapid
immediately after she left the stage, but there were missed beats and
a distinct disturbance at the mitral valve. It was hard to determine
absolutely, but the sounds at all the valves were impure and there
{325} seemed to be imperfect closure or irregularity of action. In
another case there was a regular missed beat at every sixth or seventh
pulsation. This seemed to be due to an abortive systole. Usually
within an hour regularity of heart action is restored and the valve
sounds become normal. At times when the patient is run down for any
reason, the cardiac disturbance may persist for many hours, or even
until after long hours of sleep.

The patients I have mentioned seem to have developed their muscles to
a noteworthy degree and have enlarged and strengthened their hearts by
this exercise. Later on their occupation in life prevents them from
taking any severe exercise, or at least furnishes no opportunity for
it, and they often settle down to existence that, beyond a short,
quiet walk perhaps once a day, affords no exercise at all. Under these
circumstances the muscular development that they secured as young men
and which kept them in such magnificent health during their adolescent
years seems to prove a positive detriment to good health, or at least
to good feeling. The muscular system seems to crave to be kept up.
Occasionally I have been sure that the intermittent heart action so
often seen in these cases was due to the fact that the appetite, or as
I should rather put it, the habit of eating, which they formed while
they were accustomed to taking vigorous exercise, remains with them
during their sedentary life and as a consequence they overeat,
particularly of proteid food materials. The large consumption of these
materials gives rise to the presence of substances in the blood which
make all the muscles more irritable than usual, and this seems to add
particularly to the irritability of the heart.


_Dietetic Regulation_.--For many of these people a regulation of diet
seems to be the best possible remedy. They must be made to eat less
substantially, since they do not need the same amount of proteid
material to make up for muscle waste, now that there is no longer the
old use of muscles. Some of them become very heavy. These, however,
are mainly individuals who, besides eating abundantly of proteids,
also consume carbohydrates in large quantities. In these there is a
distinct disturbance of digestion and a tendency to dilatation of the
stomach with gas which interferes with the heart action and brings on
the intermittent pulse so often seen in them. In a certain number,
however, there are no accessory symptoms of indigestion, but the heart
symptoms are most prominent.


_Exercise_.--For these people the only real relief is afforded by a
certain amount of exercise every day. They become ever so much more
comfortable just as soon as their physician insists that they shall
have an hour's walk at least every morning and every afternoon and
that this walk shall be brisk and always have some definite purpose in
it, so that there is no mere sauntering or delaying on the way. Most
business men to whom this prescription of an hour's walk is given will
reply that it is impossible. Most clergymen will say that their duties
are such that they cannot arrange their hours for this purpose. As a
rule, it is not difficult to show the business man, however, that if
instead of riding to his business, he should walk every day, and this
will probably only take twenty minutes to a half-hour longer than if
he goes by trolley or even by automobile, this walk will provide him
with a full hour of brisk exercise in the open air. The walk back from
business will provide the other hour, whenever golf or some other
diversion cannot be provided instead. In most cities men live from
three to five miles away from their {326} business, and it is not too
much to ask them to take this walk. The muscular clergyman must be
made to understand that there shall be no trolley cars for his
ordinary clerical calls, or at least that none are to be taken unless
he has had his full two hours of brisk walk.

There is always the fear in the patient's mind that exercise, by
calling for heart exertion, is almost sure to make the condition
worse. This fear of itself further hampers heart action. When exercise
is first increased in those who have been living sedentary lives the
heart action for a time is brought more and more into the sphere of
consciousness and any irregularity that is present is likely to be
emphasized. A little persistence, however, soon shows that what the
heart actually was craving was the opportunity to expend some of its
energy and it was this pent-up force that was disturbing its action.
There is often the fear in physicians' minds lest the advising of
exercise should really do harm to the patient. They fear the presence
of perhaps a fatty condition, or of some obscure muscular condition,
or of some other heart lesion not easy to detect, yet likely to
produce serious symptoms. Stokes, who probably knew fatty heart
disease better than anyone else in the nineteenth century, outlined
his views of the therapy of it as follows:

  In the present state of our knowledge the adoption of the following
  principles in the management of a case of incipient fatty heart
  disease seems justifiable:

  We must train the patient gradually but steadily to the giving up of
  all luxurious habits. He must adopt early hours, and pursue a system
  of graduated muscular exercises; and it will often happen that,
  after perseverance in this system, the patient will be enabled to
  take an amount of exercise with pleasure and advantage, which at
  first was totally impossible, owing to the difficulty of breathing
  which followed exertion. This treatment by muscular exercise is
  obviously more proper in younger persons than in those advanced in
  life. The symptoms of debility of the heart are often removable by a
  regulated course of gymnastics or by pedestrian exercise, even in
  mountainous countries, such as Switzerland or the Highlands of
  Scotland or Ireland. We may often observe in such persons the
  occurrence of what is commonly known as "getting the second wind,"
  that is to say, during the first period of the day, the patient
  suffers from dyspnea and palpitation to an extreme degree, but by
  persevering, without over-exertion, or after a short rest, he can
  finish his day's work and even ascend high mountains with facility.
  In those advanced in life, however, as has been remarked, the
  frequent complications with atheromatous disease of the aorta, and
  affections of the liver and lungs must make us more cautious in
  recommending the course now specified.

Perhaps the most important therapeutic suggestion which Sir William
Broadbent has to make with regard to the cardiac conditions that have
come to occupy much of the patient's attention is of a negative
character. He says that "patients suffering from these functional
derangements of the heart usually make them a pretext for avoiding
exercise and often for taking stimulants or drugs, whereas exercise
and fresh air are what they need. The best way to prevent the
expenditure of superfluous energy on the part of the heart in the form
of palpitation is to give it a fair amount of legitimate physiological
work to do." Personally I have found that most of the cardiac tonics
seem to do harm, in the sense of increasing the subjective symptoms,
except in cases where the patient is run down in general health
because of failure to take sufficient food, when strychnin seems to be
of avail and in the shape of nux vomica acts as an appetizer as well
as a heart tonic. Sir William Broadbent has warned particularly with
regard to the use of alcohol in these cases. {327} Most patients find
that for the moment palpitation is lessened by alcoholic stimulation.
They pay for it afterwards, however, by an increased sense of
discomfort that sometimes lasts for 24 hours or more. As Sir William
Broadbent declared, "To relieve one attack of palpitation or fainting
by alcohol is to invite another, while the terrible danger of dropping
into alcoholism is incurred."

Lest it should be thought that even Broadbent is a little
old-fashioned and not quite to be trusted in the light of our
present-day knowledge, and above all lest it might be feared that
these older men made a better prognosis or emphasized the value of
exercise more than is compatible with our recent discoveries in the
physiology and pathology of the heart, it seems well to give
MacKenzie's opinion of these cases in full. This is all the more
important because, as I have said, the influence of German teaching
has led to the formation of rather different opinions in America,
especially among our younger physicians. Prof. Martius in this country
in his lecture for the Harvey Society gave quite a serious prognosis
for practically all heart irregularity. He almost went so far as to
lay it down as a rule of diagnosis that whenever a heart beats
irregularly there is something the matter with the heart muscle or
good reason to suspect a myocardial lesion of some kind. MacKenzie's
view is very different to this and he warns particularly against
permitting the influence of an unfavorable attitude of mind on the
part of these patients. He says:

  The most serious thing about these cases is that the consciousness
  of having an irregularity sometimes makes a patient introspective
  and depressed. He keeps feeling his pulse, and communicates his
  doleful tale whenever he find a sympathetic ear.

  As the process which gives rise to it in elderly people is the same
  as that which produces the tortuous temporal arteries, no more
  significance should be attached to the one symptom than to the
  other. I have followed cases for many years, and watched them pass
  through seasons of sickness and of stress, and have seen no reason
  to attach any serious import to this symptom. In rare instances the
  heart, from being occasionally irregular, has after many years
  become continuously irregular for short or long periods, and in a
  few the permanent establishment of the nodal rhythm has been the
  means of hastening the end. But this is infrequent, and in cases of
  cardio-sclerosis has only happened in advanced life, and the patient
  should on no account be frightened by being warned of the possible
  occurrence of this unlikely contingency. In younger and neurotic
  people I have never seen it lead to any bad results. It may appear
  in serious affections of the heart, as in febrile complaints, but it
  does not of itself add to the gravity of the condition, though I am
  not sure that when due to an acute infection of the heart, as in
  pneumonia and rheumatic fever, it may not be a sign of invasion of
  the myocardium by the diseased process.

  If the patient is aware of the irregularity, he should be assured
  that there is no cause for alarm. It is useless to attempt to treat
  the irregularity itself. If in other respects the patient is well,
  then there is no need of any special treatment. If the patient be
  suffering from conditions which seem to promote irregularity, such
  as worry, fatigue, dyspepsia, the treatment should be devoted to the
  removal of the predisposing cause. In people with temporary high
  blood pressure, who show extra systoles, I find plenty of healthy
  exercise in the open air specially beneficial, though until they get
  trained, the extra systoles may at times become more frequent by the
  exertion.

This last remark of MacKenzie's is particularly important, for at the
beginning of an attempt to relieve the symptoms by insisting on more
{328} exercise, the patient is almost sure to be disturbed by this
symptom of which he will often be conscious, and it takes a good deal
of experience on the part of the physician to reassure him that
because of the increased subjective symptoms at the beginning of the
treatment by increased exertion, he may not be doing harm rather than
good. As a rule, however, it is not long before the good results of
the exercise treatment of these cases begin to make themselves felt
and the patient is reassured. Regulated exercise of body and
occupation of mind are the two important factors even in the treatment
of organic heart disease. They are extremely important even in the
cases with alarming heart symptoms that occur in the very old, once
the acute symptoms have subsided. In all the functional heart
affections exercise is the most important therapeutic resource we
have. It would seem that in the course of muscular exercise some heart
tonic was manufactured, which in all but the cases of absolutely
failing hearts is the best possible therapeutic resource for the
stimulation and steadying of the heart action. Such an internal
secretion would not be surprising in the light of all that we have
learned of the physiological nexus of organs in recent years.

Many so-called cures for heart disease probably depend for their good
effect much more on the graduated exercise that goes with them than on
many of the other remedial measures, though it is these latter that
are usually vaunted most highly. We all now recognize how little value
there is in the Nauheim bath treatment for heart disease away from
Nauheim itself. The reason is because the resisted movements of the
early part of the cure and, above all, the graduated exercise of
walking up the hills around Nauheim, which are such important parts of
the treatment there, cannot be so well given with the baths at a
distance.



CHAPTER IV

CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE


Morgagni, whom Virchow greeted as the Father of Modern Pathology, made
a careful study of the pulse and especially of its irregularities. He
had learned from the most careful pathological studies that marked
intermission and even more decided irregularity of the heart may be
present in life, though there may be absolutely no organic affection
of the heart itself, either of the valves or of the muscle,
discoverable at autopsy. In his opinion the most frequent cause for
such irregularity is flatulency and disturbance of digestion
generally. He went still farther, however, and seems to have
understood very well that constipation was often one of the most
important links in the chain of causes leading up to such heart
disturbance, itself either a cause or an effect of other digestive
symptoms. This idea deserves to be borne in mind when there is
question of the significance of heart symptoms. What Morgagni thus
determined by precise studies in pathological anatomy had been
clinically observed by many of the distinguished old-time
practitioners of medicine, who knew the fatal tendencies of organic
heart symptoms, yet recognized that many cardiac cases associated with
gastric symptoms did not have an unfavorable prognosis.

{329}

In spite of the recognition of these conditions by old-time medical
investigators, there has always been a tendency to fear that heart
symptoms in these cases might be due to a cardiac affection. This has
invariably been true for patients themselves to whom the heart
disturbance became conscious, but has often made physicians hesitate
as to the diagnosis and rendered their prognosis more unfavorable than
is justified by actual knowledge.


Gastro Cardiac Arrhythmia.--What may be called the gastro-intestinal
cardiac neuroses usually run a typical course. As a rule, with young
folks, the beginning of cardiac unrest is found in some stomachic
symptoms. The distention of the stomach with gas is said to be a
mechanical reason for interference with the heart action. Whether this
is really gas that has formed within the stomach, or whether it is to
a great extent, at least, gas which has been diffused from the vessels
of the stomach walls in a disordered viscus, or in some cases at
least, air which has been swallowed because of certain gaspy habits of
neurotic individuals, is hard to determine. In many cases the absence
of all odor of decomposition, or of any disagreeable taste, makes for
serious doubt whether the substance is really due to fermentation.
Certainly the changes that take place in food in the stomach during
the course of an hour or two of digestion are not sufficient to
account for the volume of gas that exerts pressure upon the gastric
walls and is eructated in large mouthfuls. Fermentative processes are
slow gas producers, as anyone with experience in the chemical
laboratory knows.


_Mechanical Cardiac Interference_.--Every physician has seen the young
man who is sure that he has heart trouble when he is really suffering
from indigestion. Many of the feelings of discomfort accompanied by
palpitation and irregularity are really phenomena connected rather
with the stomach than the heart itself. The reason for this is not
always clear. In many cases there seems to be a mechanical
interference with the heart's action. This is due to the presence of
gas in the stomach pressing against the diaphragm. In many cases the
distention of the stomach by a heavy meal, especially if the heart has
been rendered sensitive by the taking of stimulants, will have the
same effect. This is particularly noticeable if the patients lie down
shortly after the meal, when there is distinct discomfort in the
cardiac region and noticeable irregularity of the pulse.

The most frequent phenomenon is a missed beat, or often simply a sense
of discomfort in connection with the heart action that makes its
beating very noticeable. This palpitation, as it is called, is usually
entirely subjective. There is nothing abnormal in the sensation
produced on the hand when the heart is palpated, nothing the most
delicate finger can detect in the apex beat and nothing uniform in the
change in the heart sounds produced in these cases. There is usually a
somewhat over-excited action of the heart, but this is not
characteristically revealed by either palpation or auscultation. The
rhythm is interfered with, but the arrythmia affects only an
occasional beat, usually rather regularly spaced, and does not
interfere with the heart's rate nor with its action in any way. This
represents the most familiar form of cardiac neurosis and may, of
course, be due to such substances as tobacco, or coffee, or tea, where
these are taken in excess. Excess is always a matter of individual
idiosyncrasy.

{330}

_Cardiac Reflexes_.--It is thought by some that this heart
irregularity and palpitation is a reflex action due to irritation of
the gastric terminal filaments of the vagus nerve reflected back along
this nerve and affecting the heart. The doctrine of reflexes is not as
popular, however, as it was, but there can be no doubt of the fact
that the vagus nerve has terminal filaments in all the large organs,
yet is so extremely important to the heart that it has a definite
physiological meaning and doubtless is meant to act in such a way as
to stimulate the heart when these important organs are overloaded or
are laboring in their functions, and, on the other hand, to depress it
or at least to inhibit it somewhat, whenever there is a tendency to
send too much blood to these parts. In any case, whether the positive
factor in the production of the heart trouble be mechanical, as it
surely often is, or whether it be reflex and due to the action upon
the vagus, it must not be forgotten that in all cases where heart
symptoms occur with considerable intervals of absolute freedom from
them and with large subjective elements in the case, the relation of
the stomach or the digestive organs in general to the heart may serve
as their best explanation.


_Gastric Dilatation_.--In dilatation of the stomach there is likely to
be an associated tendency to a cardiac neurosis. Unfortunately, enough
of these cases have not been followed up so as to be sure what the
outcome is and whether there may not really have been some affection
of the myocardium with a premature breakdown of the heart. As a
consequence of the excessive irritation of the terminal filaments of
the vagus nerve in the stomach wall, or because of the mechanical
interference with the heart's action as a consequence of the dilated
stomach pulling upon the esophagus and probably somewhat interfering
with the action of the diaphragm, an irregularity of the heart action
is established and a sense of discomfort in the precordia develops
that is often very marked. These patients sometimes suffer from
pseudo-angina and still more frequently from cardiac irregularity.
This cardiac irregularity is sometimes quite marked, and yet in 24
hours, as a consequence of the emptying of the stomach, will
disappear, so that only slight intermittency remains, which eventually
subsides. I have known a heart affected thus to be pronounced
absolutely without any lesion when examined by a competent heart
specialist within a month after it had been so irregular as to be
quite alarming to both patient and physician.


_Upward Distention_.--There is sometimes a tendency for the stomach to
distend upward rather than to dilate downward and toward the left.
Perhaps this is due to the fact that in certain individuals the
gastric ligaments are much stronger and more unyielding than they are
in others. One thing is sure--that there are great individual
differences in these cases. In some that are without any demonstrable
gastric dilatation, except that gastric tympany extends higher than
usual, there is marked interference with the heart action. The
physician needs to see these cases when they are so irregular that
there would seem to be absolutely no doubt of the existence of a
myocardial lesion and then to examine them some months afterwards when
the stomach had been restored to good conditions, before he is able to
realize how much interference with heart action is consonant with
complete return in a comparatively short time to the normal, at least
so far as heart function goes. This is a very different opinion from
that held by many heart specialists and {331} especially certain
German authorities, who insist that any irregularity of the heart must
be considered as probably representing a muscular lesion; but the
evidence of careful observers may be adduced in support of it, and it
is an opinion that very much reassures the patients.


Old-time Clinicians--Morgagni, Lancisi.--In this subject it has always
seemed to me wise to recur to the opinions of some of the old-time
clinicians who noted symptoms very carefully and studied out
particularly the connection of symptoms with prognosis.


_Morgagni_.--Morgagni, for instance, whose clinical remarks are always
precious, said:

  Now that mention is made of the intermission of the pulse which
  approaches more nearly to the nature of an asphyxia than even its
  slenderness or weakness (for what else is the intermission of the
  pulse but a very short asphyxia, or what is an asphyxia but an
  intermission which lasts very long?) the causes of this disorder in
  the pulse are not to be passed over without examination in this
  place, as the greater part of physicians are very greatly terrified
  thereby, often with good reason, yet frequently without any; as when
  there is some cause of it in the stomach or intestines, which may
  even vanish away of itself, or be easily removed by the physician.
  For in what manner a palpitation of the heart may sometimes be
  brought on by flatus distending these parts, and again carried off
  by the dissipation of such flatus, I have already said; and in the
  same manner, or one not very dissimilar, it is also evident, that an
  intermission of the pulse has sometimes generated, and gone off of
  itself, in many whom I have known. At another time, in these very
  same viscera, there is a matter which produces the same effect, by
  irritating their nerves, with which you know how easily the nerves
  of the heart consent. And this matter is sometimes of such a nature
  that it may readily be prevented from harboring itself there. Thus I
  remember, when I attended to the cure of a young girl who had a
  fever, and an intermission of the pulse was added to the other
  symptoms contrary to my expectations, I was not at all deterred from
  giving such a medicine as I had before determined upon, that the
  stomach and intestines might be well cleansed; and even that I gave
  it so much the more boldly; and that on the same day after these
  parts had been deterged, the pulse returned to its former standard.
  But you will read even in the _Sepulchretum_ that Ballonius had not
  only seen this disorder of the pulse, but also that of a languid and
  small stroke, removed in the same manner. "According to the degrees
  to which the purging was carried," says he, "the pulse was
  restored." And, indeed, there is an intermission of the pulse, that
  is of a far longer continuance as that with which Lancisi says he
  had been troubled "for the space of six years"; yet if this
  intermission should be, as it was in him, "from a consent with the
  hypochondria," it may be entirely and perfectly taken away, by
  perfectly restoring those parts.


_Lancisi_.--Lancisi was another distinguished clinical observer who
made special studies in neurotic heart disturbance. These studies are
all the more interesting because he himself was a sufferer from this
affection for many years. He was inclined to think that his heart
intermittency was due to disturbance in his digestive organs and
especially those lying in the upper part of the abdomen. He attributes
it himself to sympathy with these and said that it came _ex
hypochondriorum consensu_, as it were a reflex from his hypochondriac
regions. As Lancisi lived to a pretty good age in spite of noting this
symptom in early middle life, the significance of it will be well
understood. It would be perfectly possible to gather a series of such
cases from among the distinguished physicians of history, and as for
our contemporaries and colleagues, at least one out of four of them
will tell you that at some time he has suffered from an affection of
this kind and has been much worried {332} about it, yet has recovered
without incident and without any serious development.


English Opinion.--The role of the stomach in disturbing the heart is
only less important than that of the nervous system itself. Of course,
individual peculiarities, as I have said, are extremely important.
Some people seem to suffer very little cardiac disturbance from a
distended stomach, while in others all sorts of heart affections may
be simulated as the result of the mechanical interference with the
heart action by the pushing up of the diaphragm. Sir William Broadbent
in the article on "The Conduct of the Heart in the Face of
Difficulties," already quoted from, does not hesitate to say that
heart symptoms secondary to gastric disturbance probably cause more
suffering than does actual heart disease. Expressions of this kind
need to be borne in mind when we reassure patients who have all sorts
of queer, uncomfortable, often even painful, conditions in their
cardiac region, "Heart disease" has been, perhaps, mentioned casually
to them and as a consequence worry is adding a nervous element to
hamper a heart already seriously disturbed by gastric distention. Sir
William Broadbent's own words are given because they carry so much
weight in this matter:

  The difficulties arising out of flatulent distention of the stomach
  or colon or intestinal canal generally, will require some attention,
  since they are the cause of most of the functional derangements to
  which the heart is subject, and give rise to the heart complaints
  which occasion in the aggregate perhaps more suffering than does
  actual heart disease. The heart often tolerates a considerable
  degree of upward pressure of the diaphragm, and it is not uncommon
  to meet with stomach resonance as high as the fifth space, and to
  find the apex beat displaced upwards and outwards to the fourth
  space and outside the nipple line, without conspicuous symptoms. But
  the heart behaves very differently in different subjects in the
  presence of flatulent distention of the stomach. It partakes of the
  general constitutional condition of the individual; in the strong,
  therefore, it is vigorous; in the weak it cannot be anything but
  weak.


Prognosis.--Nothing sends a young person sooner to a physician than
this cardiac unrest and functional disturbance. He comes all
a-tremble, as if to hear the worst. Even in middle age and in those
whose education might be expected to steady them somewhat in the
matter, even in physicians of long experience, there is a tendency so
to exaggerate the condition and its possibilities of fatality as a
consequence of emotion that inhibitory action on the heart becomes
noticeable. It is a rule with very few exceptions that in these cases
when the heart is complained of by young persons who have no history
of rheumatism, the causative condition will be found in the stomach,
or at least in the digestive tract.

I know a number of physicians who have suffered in this way and who
have been badly frightened about themselves, yet who have had no
serious difficulty once they took reasonable care of their diet, and
paid attention above all to regularity of meals and slowness in
eating. Indeed, it is rare to find a physician of a nervous
temperament who has not had some trouble of this kind, and the demands
made on a busy professional man foster this. Some of them are sure
that if their cardiac uneasiness does not signify an actual heart
lesion, valvular or muscular, at least it portends a premature wearing
out of the heart. There are many evidences to show that this is {333}
not so. I have had a distinguished physician, now well past his
seventy-fifth year, tell me of distinct irregularity in his heart
action as a young man which had rather alarmed him, and as this had
been preceded by an attack of acute articular rheumatism there seemed
to be every reason to think that he was a sufferer not from functional
but from organic heart disease; yet he has lived well beyond the span
of life usually allotted to man, has accomplished an immense amount of
work and is now in excellent general health almost at the age of
eighty. The case is all the more striking because, while rest and care
of the health and regular life and conservation of energy are usually
supposed to be essential for these cases, this colleague is noted for
having made serious inroads on the hours which should have been
devoted to sleep in order to accomplish certain medical literary work
while devoting himself to the care of a most exacting practice.

That the good prognosis of these cases which I suggest is not forced
and is not over-favorable nor the result of the wish to soothe
patients may be judged from recent studies of the heart as well as
from the older ones. In discussing extra-systole, MacKenzie in his
"Diseases of the Heart," [Footnote 28] says:

  [Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D.,
  1910, Oxford Medical Publications.]

  Dyspeptic and neurotic people are often liable [to suffer from
  them]. That other conditions give rise to extra-systoles, is also
  evident from the fact that they may occur in young people in whom
  there is no rheumatic history and no cardiosclerosis and whose
  after-history reveals no sign of heart trouble.

It is well to note the frequency of such annoying symptoms in those
who have gone through rheumatic fever, and where patients have a
history of this it is well to be cautious, but even in these cases he
says that the trouble is often entirely neurotic and the one important
preliminary to any successful treatment is to get the patient's mind
off his condition, improve his general nervous state, and above all
relieve as far as possible the gastric symptoms that may be present.

He says further:

  Some patients are conscious of a quiet transient fluttering in the
  chest when an extra-systole occurs; others are aware of the long
  pause, "as if their hearts had stopped"; while others are conscious
  of the big beat that frequently follows the long pause. So violent
  is the effect of this after-beat, that in neurotic persons it may
  cause a shock, followed by a sense of great exhaustion. Most
  patients are unconscious of the irregularity due to the
  extra-systole until their attention is called to it by the medical
  attendant. Both being ignorant of its origin, and its being
  characteristic of human nature to associate the unknown with evil,
  patient and doctor are too often unnecessarily alarmed.


Cardiac Stomach Disturbance.--On the other hand, as a word of warning,
it seems necessary to say here that later in life acute conditions
manifesting themselves through the stomach are often of cardiac
origin. Most physicians have been called to see some old man who had
partaken of a favorite dish which did not, however, always agree with
him and who suffered as a consequence from what at first was thought
to be acute gastritis. The severity of the symptoms and the almost
immediate collapse without any question of ptomaine poisoning,
however, usually make it clear that some other organ is at {334} fault
besides the stomach itself. The real etiological train seems to be
that a weakened heart sometimes without any valve lesion but with a
muscular or vascular degeneration hampering its activity is further
seriously disturbed by the overloading of the stomach. The result is a
failure for the moment of circulation in the digestive organs with
consequent rejection of the contents of the tract, nature's method of
relieving herself of substances that cannot be properly prepared for
absorption. Unfortunately, the condition sometimes proves so severe a
shock to the weakened heart that it stops beating, and the physician
is brought face to face with a death from "heart failure."

In these cases it is important to remember that the gastric
disturbance may so mask the heart symptoms as completely to deceive
the physician. The prognosis of these cases, however, is most serious.
It seems worth while to give a warning with regard to these cases,
because anything that we may have to say as to the relations of the
stomach and the heart and the possibility of lessening the cardiac
depression due to unfavorable mental influence when palpitation occurs
as a consequence of gastric distention, has nothing to do with these
acute cases in older patients where the condition is serious and the
prognosis by no means favorable.


Treatment.--The rôle of psychotherapy in this form of cardiac
disturbance associated with gastro-intestinal affections is, after the
differentiation of neurotic from serious organic conditions, to give
the patient such reassurance as is justified by his condition. It is
surprising how many people are worrying about their hearts because
their stomachic and intestinal conditions give rise to heart
palpitation, that is to such action of the heart as brings it into the
sphere of their consciousness, sometimes with the complication of
intermittency or even more marked irregularity. The less the
experience of the physician the more serious is he likely to consider
these conditions and the more likely he is to disturb the patient by
his diagnosis and prognosis. Until there is some sign of failing
circulation, or of beginning disturbance of compensation, the
attachment of a serious significance to these conditions always makes
patients worse and removes one of the most helpful forms of
therapeusis, that of the favorable influence of the mind on the heart.
On the other hand, unless the patients' own unfavorable
auto-suggestions as regards the significance of their heart symptoms
are corrected, these people not only suffer subjectively, but bring
about such disturbance of their physical condition as makes many
symptoms objective.

While there are serious affections in which heart and stomach are
closely associated, these are quite rare and usually manifest
themselves in acute conditions and in old people. In the chapter on
Angina Pectoris attention is called to the fact that there are may
forms of pseudo-angina due to cardiac neuroses consequent upon gastric
disturbance and without heart lesion. Broadbent has not hesitated to
say that these forms of angina cause more suffering or at least
produce more reaction on the part of the patient and are always the
source of more complaint than the paroxysms due to serious cardiac
conditions which present the constant possibility of a fatal
termination.

Where the stomach is the cause of the cardiac neuroses psychotherapy
is an extremely important element in the treatment. The continuance
and exaggeration of their symptoms is often due to a disturbance of
mind consequent upon the feeling that they have some serious form of
heart disease. Without {335} definite reassurance in this matter all
the experts in heart disease insist that it is extremely difficult to
bring about relief of symptoms in these patients. Whenever the general
health of the individual has not suffered from his heart affection, it
is quite safe to assume that no organic disease of the heart is
present, no matter what the symptoms, for, as Broadbent and many other
authorities emphasize, gastric cardiac neuroses can simulate every
form of heart disturbance. The older physicians insisted that what
they called sympathy with the hypochondriac organs might produce all
sorts of heart symptoms. The patient must be told this confidently.
The slightest exaggeration of the significance of his symptoms can do
no possible good and will always do positive harm.

After reassurance, the most important thing is, of course, regulation
of the diet and of the digestive functions generally. Unfortunately,
regulation of the diet to many patients and even to many physicians
seems to mean the limitation of diet. I have seen sufferers from
cardiac symptoms have these increased by excessive limitation of diet.
If they are lower than they ought to be in weight they must be made to
regain it. Above all, there must be no limitation of meat-eating
except in the robust. Very often the heart seems to crave particularly
that form of nutrition that comes through meat. It is especially
important that the bowels should be regular. Fast eating is very
harmful. Occupation with serious business immediately after eating is
almost the rule in these cases.

All of these elements of the case need special study in each
individual patient. The needed suggestions can then be made. Above
all, the patient is made to realize that his case is understood and
that it is only the question of a gradual acquirement of certain
habits, including proper exercise, that is needed for the restoration
of his heart to normal.



CHAPTER V

ANGINA PECTORIS


The two forms of this affection, known commonly as true and false
angina, are characterized by pain or anguish in the precordial region
with reflected pains in other portions of the body. It used to be said
that whenever the precordial pain was accompanied by reflected pains
in the neck, or down the arm, or, as they may be occasionally, in the
jaw, in the ovary, in the testicle, sometimes apparently in the left
loin, this was true angina and the patient was in serious danger of
death. We know now that false angina may be accompanied by various
reflex pains and that, indeed, a detailed description of the anguish
and its many points of manifestation is more likely to be given by a
neurotic patient suffering from pseudo-angina than by one suffering
from true angina. True angina occurs in most cases as a consequence of
hardening of the arteries of the heart or of some valvular lesion that
interferes in some way with cardiac nutrition. The definite sign of
differentiation is that in practically all cases of true angina, there
are signs of arterial degeneration in various parts of the body.
Without these, the "breast pang," as the English {336} call it, is
likely to be neurotic and is of little significance as regards future
health or its effect upon the individual's length of life.

Besides the physical pain that accompanies this affection there is, as
was pointed out by Latham, a profound sense of impending death. It
used to be said that this was characteristic of the organic lesions
causing true angina pectoris. It is now well known, however, that the
same feeling or such a good imitation of it that it is practically
impossible to recognize the true from the false, occurs in
pseudo-angina. It is this special element in these cases that needs
most to be treated by psychotherapy and which, indeed, can only be
reached in this way. Where there are no signs of arterial degeneration
and no significant murmurs in the heart, it should be made clear to
these patients that they are not suffering from a fatal disease, but
only from a bothersome nervous manifestation. Especially can this
reassurance be given if the angina occurs in connection with
distention of the stomach or in association with gastric symptoms of
any kind. In young patients who are run down in health and above all
in young women, the subjective symptoms of angina--the physical
anguish and the sense of impending death--are all without serious
significance.


Differential Diagnosis of True and False Angina.--In the diagnosis of
angina pectoris the main difficulty, of course, lies in the
differentiation between the true and false forms, that is, those
dependent on an organic affection of the heart muscle or blood vessels
and those resulting from a neurosis. The neurotic form is not uncommon
in young people and is often due to a toxic condition. Coffee is
probably one of the most frequent causes of spurious angina, though
the discomfort it produces is likely to be mild compared with the
genuine heart pang. It must not be forgotten, however, that neurotic
patients exaggerate their pains and describe their distress in the
heart region as extremely severe and as producing a sense of impending
death, when all they mean is that, because the pain is near their
heart it produces an extreme solicitude and that a dread of death
comes over them because of this anxiety. Coffee and tea, especially
when taken strong and in the quantities in which they are sometimes
indulged in, may be sources of similar distress. Tobacco will do the
same thing in susceptible individuals, or where there is a family
idiosyncrasy, and especially in young persons.

For the differentiation of true and spurious angina Huchard's table as
given by Osler is valuable:



TRUE ANGINA

Most common between the ages of forty and fifty years.

More common in men. Attacks brought on by exertion.

Attacks rarely periodical or nocturnal.

Not associated with other symptoms.

Vaso-motor form rare. Agonizing pain and sensation of compression
by a vice.

Pain of short duration. Attitude: silence, immobility.

Lesions. Sclerosis of coronary artery.

Prognosis: grave, often fatal.

Arterial medication.


NEUROTIC FORM

At every age, even six years.

More common in women. Attacks spontaneous.

Often periodical and nocturnal.

Associated with nervous symptoms.

Vaso-motor form common. Pain less severe; sensation of distention.

Pain lasts one or two hours. Agitation and activity.

Neuralgia of nerves and cardioplexus.

Never fatal.

Antineuralgic medication.


{337}


True Angina and Psychotherapy.--One of the most frequent occasions for
the development of true angina is vehement emotion. The place of
psychotherapy then in the affection will at once be recognized. A
classical example of the influence of the mind and the emotions in the
production of attacks of angina pectoris in those who are predisposed
to them by a pre-existing pathological condition, is the case of the
famous John Hunter. He was attacked by a fatal paroxysm of the
affection in the board room of St. Thomas' Hospital, London, when he
was about to begin an angry reply with regard to some matter
concerning the medical regulation of the hospital. He had previously
recognized how amenable he was to attacks of the disease as a
consequence of emotion or excitement, and had even stated to friends
that he was at the mercy of any scoundrel who threw him into an attack
of anger. Some of the deaths from fright or sorrow at a sudden
announcement of the death of a relative, or even the deaths from joy
are due to angina pectoris precipitated by the serious strain put upon
the heart by the flood of terror or emotion.

Men who are sufferers from what seems to be true angina pectoris must
be made to understand without disturbing them any more than is
absolutely necessary that strong emotions of any kind--worry, anger,
exhibitions of temper, and, above all, family quarrels, must be
avoided. Not a few of the serious attacks of angina pectoris which
physicians see come as a consequence of family jars, owing to the
persistence of a son or daughter in a course offensive to the parent.
A part of the prophylaxis, then, consists in impressing this fact on
members of the family and making them understand the danger. The
disposition that causes the family friction is, however, often
hereditary and will, therefore, prove difficult of control. It is one
of the typical cases of inheritance of defeats.


_Solicitude and Prognosis_.--The distinguished French neurologist,
Charcot, had several attacks of what seemed to be true angina
pectoris. His friends were much disturbed by it. Physicians who saw
him during the attack feared that he was suffering from an incurable
heart lesion. He himself, as his son, Dr. Charcot, told me, refused to
accept this diagnosis, and preferred to believe that what he was
suffering from was a cardiac neurosis--and, of course, he had seen
many of them. He was unwilling to have a heart specialist examine him
very carefully for he did not wish to be persuaded of the worst
aspects of his condition.

What he said in effect was, "This is either a neurotic condition, as I
think it is, or it is an organic condition. If it is organic, my
physicians would be apt to tell me that I must stop working so hard,
and I am sure that if I should do that I would do myself more harm
than good by having unoccupied {338} time on my hands. I want to go on
doing my work. If I am wrong some time I shall be carried off in one
of these attacks. That will not be such a serious thing, for after all
I must die some time and my expectancy of life cannot normally be very
long. I prefer, then, to go on with my work and think the best, for it
does not seem that I could do anything that would put off the
inevitably fatal issue if I am to die a cardiac death." He was found
dead one morning, but he had passed into the valley of death without
being seriously disturbed and without any of the neurotic symptoms
that so often develop in discouraged patients. Curiously enough, one
of our most distinguished heart specialists in this country went
through almost the same experience and preferred to live "the brief
active life of the salmon rather than the long slow life of the
tortoise."

The best possible factor in therapy is secured if patients can be
brought to the state of mind of these distinguished physicians who
calmly faced the future, refusing to disturb themselves or their work,
because they feared that the worry that would come down upon them in
inactivity would aggravate their disease. Where men are occupied with
some not too exacting occupation, that takes most of their attention
and at which they have been for years, it is best to leave them at it,
though the harder demands of it must be modified. If they can be
brought to persuade themselves, as did the two physicians--though
probably only half-heartedly--that their affections may possibly be
merely neurotic and not true angina, it will always be better for
them. Death may come, and commonly will, suddenly, but, after one has
lived a reasonably full life, that is rather a blessing (and not in
disguise) than the terror which it is sometimes supposed to be.


Pseudo-Angina.--The neurotic form of angina is quite compatible, not
only with continued good health but with long life, and even after a
long series of attacks, some of them very disturbing in their apparent
severity, there may be complete relief for years, or for the rest of
life. Exaggeration of feeling due to concentration of attention plays
a large role in these cases, and it is evident that the dread of
something the matter with the heart connected with even a slight sense
of discomfort may readily become so emphasized as to seem severe pain,
though many people have similar feelings without making any complaint.

In spite of reassurances attacks of pseudo-angina are likely to worry
both patient and physician. The only working rule is that in younger
people discomfort in the heart region, even though it may be
accompanied by some sympathetic pain in the arm or in the left side of
the neck, is usually spurious angina. Broadbent goes so far as to say
that this is true also in many older persons. His method of making the
differentiation is interesting because so easy and practical that it
deserves to be condensed here. The earlier attacks of true angina are
practically always provoked by exertion, while spurious angina is
especially liable to come on during repose. Any cardiac symptom or
pain that can be walked off may be set down as functional and due to
some outside disturbing influence, or to nervous irritability. When
palpitation or irregular action of the heart, or intermission of the
pulse, or pain in the cardiac region, or a sense of oppression follows
certain meals at a given interval, or comes on at a certain hour
during the night, there need be little hesitation in attributing the
disturbance, whatever it may be, to indigestion in {339} some of its
forms. Nightmare from indigestion, Broadbent thought, is not a bad
imitation of true angina.

In Broadbent's mind acute consciousness of any heart disturbance lays
it in general under the suspicion of being neurotic in origin. He was
talking to some of the best clinical practitioners in the world and
some of the most careful observers of our generation, when, before the
London Medical Society, he said: "The intermission of the pulse of
which the patient is conscious and the irregularity of the heart's
action--though this can be said with less confidence--which the
patient feels very much, is usually temporary and not the effect of
organic heart disease." This is particularly true, of course, in
people of a neurotic character, and Broadbent went on to say that
"speaking generally, angina pectoris in a woman is always spurious,
and the more minute and protracted and eloquent the description of the
pain, the more certain may one be of the conclusion."

I had the opportunity to follow the case of a young woman who had a
series of attacks of angina pectoris some twenty years ago, so severe
that a bad prognosis seemed surely justified, and though at times the
attacks were rather alarming to herself and friends, nothing serious
developed and for the past ten years, since she has gained
considerably in weight, they have not bothered her at all. She used to
be rather thin and delicate, trying to do a large amount of work and
living largely on her nervous energy. At times of stress she was
likely to suffer from pain in the precordia running down the left arm
and accompanied by an intense sense of the possibility of fatal
termination. With reasonably large doses of nux vomica, an increase in
appetite came and a steadying of her heart that soon did away with
these recurrent attacks. These came back later several times when she
neglected her general condition, but there never were any objective
symptoms that pointed to an organic lesion. After twenty years she is
in excellent health, except for occasional attacks of a curious
neurotic indigestion that sometimes produces cardiac disturbances. Of
course, such cases are not uncommon in the experience of those who see
many cardiac and nervous patients.

For the treatment of pseudo-angina, mental influence is all important.
Of course, the conditions which predispose to the mechanical
interference with heart action that occasions the discomfort, must be
relieved as far as possible. The severity of the symptoms, however,
are much more dependent on the patient's solicitude with regard to
them, they are much more emphasized by worry about them, than by the
physical factors which occasion them. Reassurance is the first step
towards cure. After relief has been afforded from the severer attacks,
the patient's solicitude as to the future must be allayed and the fact
emphasized that there are many cases in which a number of attacks of
cardiac discomfort simulating angina pectoris have been followed by
complete relief and then by many years of undisturbed life. It is
important to make patients understand that, in spite of the fact that
their attacks occur during the course of digestion, as is not
infrequently the case, this constitutes no reason for lessening the
amount of food taken. Nearly always these attacks occur with special
frequency among those who are under weight, and disappear rather
promptly when there is a gain in weight. Solicitude with regard to the
heart must be relieved wherever possible and then with the regaining
of general health the heart attacks will disappear.


{340}


CHAPTER VI

TACHYCARDIA

Etymologically tachycardia means rapid heart. There are two forms of
rapid heart, that which is constant and that which occurs in
periodical attacks. It is for this latter that the term tachycardia
has been more particularly used, though occasionally the adjective
paroxysmal is attached to it to indicate the intermittent character of
the affection. With regard to the persistent type of rapid heart
something deserves to be said, however, because patients' minds are
often seriously disturbed by them. Often it has existed for years,
sometimes is known to be a family trait and probably has existed from
childhood, yet the discovery of it may be delayed until some
pathological condition develops, calling for the attendance of a
physician who may be needlessly alarmed and in turn alarm his patient
by his recognition of it. The cause for this persistent rapid pulse is
not well known and is difficult to determine. Heredity, as has been
suggested, sometimes plays an important role in it. Certain families
have one or more members in each generation with rapid hearts.
Whenever persistent rapid heart is a family trait the patient can be
assured, as a rule, without hesitation, that the general prognosis of
the case is that of the lives of the rest of the family. Usually the
symptom seems to mean nothing as regards early mortality or any
special tendency to morbidity.


Favorable Prognosis.--While a rapid pulse often and indeed usually has
some serious significance, it must not be forgotten that it may be an
individual peculiarity and be quite compatible with long life and hard
work. One of the first patients that I saw as a physician had a pulse
between ninety-six and one hundred. As there was a slight tendency to
irregular heart action also, I was inclined to think that there must
be some cardiac muscle trouble. There was apparently no valve lesion.
He told me that a physician ten years before had noted his rapid pulse
and had made many inquiries about it which rather seriously disturbed
him. He had been an extremely healthy man during his fifty-five years
of life and there seemed no reason to conclude, since his rapid pulse
had been in existence for ten years, that it meant anything serious.
He has now lived well beyond the age of seventy and still has a pulse
always above ninety. Contrary to what might be thought, he is an
extremely placid, unexcitable individual, who, under ordinary
circumstances, will probably live for many years to come. He has no
family history of tachycardia, though there is a history of rather
nervous irritable hearts in other members for two generations.

An interesting case of this kind came under my observation about
fifteen years ago in a clergyman whose pulse was never below ninety,
and who on slight excitement, or after a rapid walk, or after a heavy
meal, would have a pulse of 120. He knew that it was a family trait,
his father having had it yet living to be past seventy. He gave a
history of its having been recognized in his own person more than
twenty years before. His general health, however, was excellent. He
took long walks and, indeed, pedestrian excursions {341} were his
favorite exercise. He was able to go up flights of stairs rather
rapidly without discomfort. He was the pastor in a tenement house
district so he had plenty of opportunity for such exertion. Infections
of any kind, colds and the like, disturbed his pulse very much, if the
ordinary standard was taken, but it was not irregular and the increase
in rapidity was probably only proportionate to the original height of
the pulse in his case. After all, as the normal pulse of sixty to
seventy rises to between ninety and one hundred even in a slight
fever, it is not surprising if a pulse normally above ninety should
rise fifty per cent. to one hundred and thirty-five under similar
conditions. He is now well past sixty, after over thirty-five known
years--and probably longer--of a pulse above ninety, yet he is in
excellent general health and promises, barring accident, to live
beyond seventy.

Some ten years ago I first saw another of these cases of fast heart,
with a family history of the affection in a preceding generation. He
was a man who had not taken good care of himself and had been
especially over-indulgent in alcohol. This indulgence consisted not in
rare sprees but in the persistent daily taking of large quantities of
straight whiskey. In spite of warnings, he has not given up this
habit; yet at the age of sixty-five he is apparently in good health
and is able to fulfill the duties of a rather exacting occupation.

Persistent rapid pulse often occurs in connection with some
disturbance of the thyroid gland. The larval forms of Graves' disease
occur particularly in young persons, though they are sometimes seen in
those beyond middle life. They seem to be due to a lack of development
of the thyroid in consonance with the rest of the tissues, though
occasionally, especially after the menopause, they seem to be
connected with some degenerative process out of harmony for the moment
with other forms of degeneration. When they occur in young persons
they may, of course, represent the beginning of incipient Graves'
disease, but they are often only functional and the symptoms may pass
away entirely. The rapid heart action may come and go, though usually
the attacks last for some days and oftener for a week or more at a
time.


Paroxysmal Tachycardia.--A rapid heart may not only exist continuously
in an individual for many years without any impairment of general
health or shortening of life, but there may be spasmodic attacks of
this condition with the pulse running up so high as to deserve the
name of paroxysmal tachycardia; yet the patient may live for many
years and die from some affection not connected with his heart.
Perhaps the most remarkable case of this kind on record is that
reported by Prof. H. C. Wood of Philadelphia. The patient was a
physician in his later eighties when he came under Dr. Wood's
observation. His first attack of paroxysmal tachycardia came in his
thirty-seventh year. These attacks had apparently always been similar
to those he then suffered and were abrupt in onset and the pulse would
rise rapidly to 200 a minute. The original prognosis had been, of
course, very unfavorable. The physician had outlived all the prophets
of evil in his case, however. When large numbers of these cases were
studied, it was found that they always last more than ten years, and,
while heart failure in such cases is reported, it is doubtful if this
occurs with more frequency in these patients as the result of strong
reflexes than in the general run of patients, for it must not be
forgotten that there is a certain average number of deaths from
so-called heart failure in people supposed to be in good health.

{342}

In connection with these attacks of paroxysmal tachycardia, there
often come intense feelings of depression and even local disturbances
of circulation. It is probable that in many cases there is a serious
factor at work. MacKenzie has suggested that they are due to nodal
rhythm of the heart in which the heart beat does not start at the root
of the sinus as is usual, but in some other portion of the musculature
and as a consequence there is serious interference with the regular
rhythmic action. In a number of cases of heart failure, tachycardia
becomes a prominent feature and it is probably due to some such
disturbance as this. Such cases often look very serious for a time,
yet frequently recover completely after a brief interval. This must
not disguise the fact, however, that many of these cases, especially
where acute dilatation of the heart can be demonstrated, are extremely
dangerous and may end in a sudden fatal termination. The patient seems
so much prostrated that occasionally the physician may doubt whether
it is worth while to put him to the bother necessary in order to
diagnose the acute dilatation of the heart. It always is, however. If
it were nothing else but the occupation of the patient's attention
with the doctor's manipulations, as far as that is possible, the
effect would be good, besides whatever irritation may be caused to the
heart muscle itself by percussion of the heart area will probably do
mechanical good.

The most important element evidently is that the patient shall not be
allowed to lose courage or to think that nothing can be done for him.
Something must be done, and a combination of swallowing movements and
deep breathing, as far as that is possible, with counter-irritation
through the chest wall should be carried out. Drugs also should be
employed and the aroma of strong coffee with the irritating effect of
ammonia upon the nostrils should be employed. These act upon the vagus
so as to stimulate the heart, but above all they act upon the mind,
and nothing so stimulates the heart as reawakened hope.



CHAPTER VII

BRADYCARDIA


Bradycardia, or persistent slow pulse, is much rarer than the
persistent rapid pulse discussed at the beginning of the chapter on
tachycardia. Cases are, indeed, sufficiently rare to be medical
curiosities. Prof. Clifford Allbutt has called attention to the fact
that the status of bradycardia or brachycardia, as Osler (following
Riegel because of the analogue tachycardia) prefers to call it, is
very different from that of tachycardia. In the latter, especially, in
the specific sense of the term, the symptoms occur paroxysmically,
endure for a definite length of time and then there is a return to the
normal pulse rate. For this, or at least for the condition known as
essential tachycardia, there is no well-defined cause and no definite
pathological lesion. Bradycardia or brachycardia, however, is usually
present as the result of some known physiologic or pathologic
condition; it endures as long as the cause continues to act and then
ceases, usually not to return unless the same cause gives rise to it
again.

{343}

There are some cases, however, of slow pulse that cannot be traced to
any definite lesion and in which the pulse is much slower at certain
times than at others, though without its being possible to trace any
definite immediate cause. These cases seem to be physiological
analogues of tachycardia. In tachycardia there is an irritation of the
accelerator nerves to the heart, in brachycardia of the inhibitory
nerves.


Depressed Mental States.--Occasionally the reason for this can be
found, though it is rather vague. In depressed mental states, for
instance, a pulse between fifty and sixty is common. In people who
suffer from periodic fits of depression it is not unusual to find that
in the early morning the pulse is not more than fifty-five. I have
seen patients who were worrying about their hearts present records of
early morning pulse before they got up that were always below sixty.
This is probably in a certain number of people quite normal. I
remember a series of observations made on the attendants in the
Charite Hospital in Berlin in which it was clear that the normal
German morning temperature at seven a.m. was below 97 F., while the
pulses were always below sixty. A reassurance of this kind is helpful
to patients who have acquired the bad habit of taking their own pulse
and have been disturbed by finding it so much below what they consider
normal.


Illustrative Case.--A number of cases of persistent slow pulse seem to
be congenital or produced by some definite pathological lesion, yet do
not prove serious for the patient. Some years ago I described one of
these cases in a paper read before the Section on Medicine of the New
York Academy of Medicine [Footnote 29] and I have had the opportunity
to follow it for about fifteen years. Though the patient's pulse is
usually below forty and even after a rapid walk does not rise above
fifty, she is in reasonably good health and during those years has
buried two husbands. When I saw her she was compelled to go up and
down stairs frequently and yet did not experience much difficulty.
While patients suffering from palpitation would find it impossible,
because of the discomfort produced, to make the journeys up and down
stairs that she did, she felt only about as much respiratory
discomfort as would come to a woman of her size. Her respirations were
somewhat hurried--22 to 24 to the minute--but her general health was
very good. Her urine was normal, her liver not enlarged, her ordinary
organic functions were not disturbed and there was no sign of arterial
degeneration.

  [Footnote 29: _The Medical News_, November 10, 1900.]

With the pulse rate as low as this one might expect to find the
patient phlegmatic, slow of movement and not readily moved to emotion.
On the contrary, she has always been rather nervous and high-strung
and inclined to be excitable. Her cardiac condition was first noted
just after the first grip epidemic in this country, though her
attention was not called to it during the course of the grip. It seems
probable that the heart condition was acquired as a consequence of
some irritative lesion affecting the inhibitory nerves to the heart
that developed at that time. After her heart condition had been
discovered she was for a time a skirt dancer and frequently danced for
the amusement of her friends. She was always lively and active and
after her first husband's death, when it became necessary for her to
earn her own living, she was on the stage for a time and danced
without any embarrassment of either {344} heart or respiration. As a
consequence of running down in weight and general health, owing to
conditions since her husband's death, she noticed that dancing proved
exhausting to her and she gave it up.

In general, she considered herself quite as capable as any of her
friends for the ordinary duties and amusements of life. When I first
saw her her digestion had been somewhat disturbed by worries and
unsuitable nutrition taken at irregular intervals and this, I think,
accounted much more than her heart for her complaint of tiredness on
exertion. Later, after her second marriage, when she was in better
circumstances, all her symptoms disappeared and even her heart rate
rose so that it was seldom below forty, and after exertion always went
to fifty. What was needed in her case more than anything was a change
of environment, the satisfaction of mind that comes with freedom from
worries and the cares of making her own living, and the improvement in
digestion due to regular meals of good, simple, nutritious food.


Compatibility with Health and Activity.--The above case is interesting
as illustrating mental influence upon such a serious condition as
bradycardia. Most people who suffer from it are likely to be
over-depressed and this reacts to disturb digestion and also further
to disturb the heart itself. What these patients need above all, then,
is reassurance with regard to their condition. There are some striking
examples in history and in medical literature of bradycardia or
persistent slow pulse in persons who are able to accomplish a large
amount of work and whose general health and capacity for
accomplishment were not at all disturbed by this physical condition.
Above all, they were not depressed and did not lack initiative.
Napoleon I, whose pulse is said normally to have been about forty,
rising during the excitement of battle to fifty, is a typical example.
Medical literature records a number of patients with congenital slow
pulse without any discernible heart lesion who lived long and
successful lives. One of these was a very successful English athlete.
The prognosis of these cases is not as bad as it might seem to be and
the mental state of the patient is more important than anything else
in the treatment.


{345}

SECTION VIII

_RESPIRATORY DISEASES_


CHAPTER I

COUGHS AND COLDS


Cough under most conditions is so completely a natural reflex due to
irritation from material which demands expectoration that to talk of
the application of psychotherapeutics to its treatment would seem
almost an abuse of words. This is true if we think of the curing of an
ordinary catarrhal or bronchitic cough by suggestion. We know now,
however, that, as a rule, we do not cure diseases, we only relieve
their symptoms and thus enable nature to overcome the affection. The
ordinary cough remedies do two things: they cause more liquid to exude
into the lung tissues and thus soften and liquefy thick mucous
material so as to make it easier to expectorate, or they lessen
irritation and soothe the cough by making the nervous system less
reactive. This second function of our remedial measures directed
against cough can at least be assisted very materially by
psychotherapeutics. Direct suggestion may be of great help, while the
first function, that of softening the cough by liquefying the sputum,
can be materially aided by certain suggestions to the patient of
natural means and ways by which his cough may be relieved, its
secondary symptoms modified, and its course abbreviated.


Cough and Suggestion.--Much of the coughing indulged in is quite
unnecessary and might well be dispensed with. At many of the German
sanatoria for consumption there is a rule that patients must not cough
at dinner, and no coughing is heard in the refectory. Without such a
rule the midday meal, if taken in common by the large number of
consumptives present, would be a pandemonium of coughing. Cough is
largely influenced by suggestion. Most of the respiratory reflexes
follow this same rule. To see another yawn tempts us to yawn; to hear
another cough tempts us to cough. In church or in a theater after an
interval of interest one cough will be followed by a battery of
coughs. People who have colds think they have a right to cough, and so
they often cough much more than is at all necessary. Of course, when
material accumulates in the lungs it must be coughed up, but not a
little of the coughing might easily be dispensed with--it is
unproductive coughing. A distinguished German medical authority who is
accustomed to talk very plainly once said that it is quite as impolite
and injustifiable to cough unproductively as to scratch the head
unproductively. Only results justify either procedure.

Dry coughing, when persistent, is greatly a matter of habit acquired
by yielding to slight irritation. When children scratch their heads we
train them {346} not to, and the same thing should be done with regard
to yielding to reactions from slight irritations of their lungs.

Even when material has to be expectorated there is often much more
fuss and effort made over it than is needed. Most men a generation ago
insisted on their right to expectorate in public because it was better
for them to rid themselves of offensive material than to retain it.
The difference between men and women in this respect has always been
distinctive. Women practically never expectorate in public, men do it
frequently, or rather, let us hopefully say, used to. It seems to be
thought the exercise of a manly privilege to spit and the boy learns
the habit. It seemed almost a necessity in the past, yet now we have
come to a point where, by legal regulation, we prohibit spitting in
public and it seems likely future generations, not far off, will hold
it as a rule that instead of the sexes being essentially different by
nature in this respect, the habits formed by the enforcement of recent
legal regulations will show their essential similarity and we shall
have no "expectorating sex."


Unnecessary Coughing Harmful.--Coughing, unless it is necessary,
always does harm. It irritates the mucous membrane, already rendered
somewhat hyperemic and tender by the inflammatory process at work, to
have the breath pass over it in such an expulsive way. This is one
case where nature's indications are not to be followed. It is like
itchiness in eczema: it needs to be restrained. The cold will get
better sooner, the inflammatory process will run its course with less
disturbance and in briefer time than if it was not disturbed in this
way or disturbed only as little as possible. This is a point that is
not often explained to patients and most sufferers from colds are
inclined to think that the more they cough the better, even though the
cough, like the scratching in eczema, evidently produces a roughening
and sensitizing of inflamed tissue. Of course, this principle of the
limitation of cough may be carried to excess and indeed sometimes is
when opium is administered to quell coughing. This is not the idea,
however, of the suggestion made here, which is only to restrain the
cough within the limits necessary for the removal of material that
should be evacuated.

The history of most of the tuberculous patients who suffer from
hemorrhage for the first time shows that they had been coughing
unproductively, and then, after coughing in this way rather severely,
there came the flow of blood due to the rupture of a minute artery. In
these cases the tuberculosis process has been at work for some time
and has prepared the tissue for this arterial rupture, but there is no
doubt, however, that the coughing itself, far from doing good, rather
helped in the destruction of lung tissue, or at least made it more
difficult for natural processes in the lungs to wall off the bacilli
and prevent further damage. Practically every adult is in some danger
of lighting up an acute tuberculous process in his lungs if he racks
them by coughing. There are many similar examples in nosology of this
possibility of some habit predisposing to or favoring the development
of disease.

After measles and whooping cough tuberculosis is especially likely to
develop. In both of these diseases, but especially in the latter,
coughing is an element of the affection that probably predisposes to
the implantation of the tubercle bacillus so commonly present in the
air of our cities. The lesions produced in the extreme expulsive
efforts of the paroxysm form favorable niduses for the micro-organism.
Children particularly, if at all encouraged, are likely {347} to cough
more than is good for them. On the slightest irritation they cough. It
is almost impossible to restrain them from scratching when they are
suffering from eczema, yet we take rather elaborate means to do so,
and quite as much must be done to prevent them from coughing when
there is no special reason for it. This does not refer to cases in
which material is being abundantly expectorated. Elimination can only
be secured by a proper expulsive effort. Very often, however, children
notice how much solicitude their little dry cough arouses. They like
to be the objects of attention. They are dosed with various cough
remedies, more or less pleasant, whenever they cough. Instead of being
told that they should restrain their cough except when it is
necessary, they are rather encouraged to cough whenever there seems to
be the slightest occasion.


Reflex Coughs.--There are a number of coughs that are said to be
reflex because they are not induced by any lesion of the lungs or of
the larynx, or, indeed, of any of the air passages. In these cases
some pathological condition is often found in another organ or set of
organs, usually one of those connected with the vagus nerves. The wide
distribution of these pharyngo-laryngo-esophago-pulmano-cardio-gastric
nerves gives ample opportunity for reflexes. We hear much of reflex
cough. There is a stomach cough and an intestinal cough, a uterine
cough, an ear cough, etc. These coughs are always dry, though often
very irritating to patients, and especially may be a source of dread
and disturbance of mind and health because they seem to signify some
serious pathological condition. As a rule, these coughs can be
restrained to a great degree and frequently suppressed entirely by
suggestion and discipline. In many cases there is some temptation to
cough consequent upon irritation of nerve endings communicated through
some devious paths to the nerve supply of the respiratory tract, but
this tendency is not very strong and can be easily overcome. It may be
said that this is asking too much of human nature, and that, just as
sneezing carries with it a certain satisfaction and so is apparently
worth the trouble of indulging in, coughing should be permitted, at
least, if not encouraged, but the reasoning is fallacious.


Habit Coughs.--An interesting cough that comes to the physician is
that in which there is absolutely no pathological reason to account
for it. There is an irritation of the mucous membrane somewhere along
the respiratory tract but it is very slight and somehow the habit has
been acquired of yielding to the reflex that it occasions. I have seen
these coughs in children in cases where I was sure that they were
nothing but tics. I have seen so-called hacking coughs in girls of
twelve to sixteen that were explained as ovarian, or sometimes as
puberty coughs, that were really nothing more than habits. A slight
hyperemia of the mucous membrane in the upper respiratory tract due to
an ordinary cold began in a very slight degree the irritation, and
then the habit of coughing was not given up. Of course, I know the
danger of treating such cough as habit coughs. Tuberculosis in its
initial stage may exist for a prolonged period before it produces any
increase of secretion and at a time when none of the ordinary physical
diagnostic signs are present, except possibly a little prolongation of
expiration over the affected area. At this stage tuberculosis will
sometimes produce gastric disturbance, and, as I have already said,
these are spoken of as stomach coughs when there really is something
much more serious than them at work. When there has been no running
down in {348} weight, and, above all, no special opportunity for
contagion, then, if there are no physical signs in the lungs, these
coughs will be best treated as habits and gradually be made to stop by
suggestion. The limitation of coughing will do good in any case.


Coughs as Tics.--Some coughs are not really due to any difficulty in
the respiratory tract, but are caused by nervous irritability. There
are certain habits in the matter of clearing the throat that sometimes
become pronounced and apparently impossible to stop. As I have said,
these are tics rather than true coughs. Many of these neurotic coughs
very seriously alarm patients and also their friends. They are dry, as
a rule, rather harsh and inclined to be brassy. Occasionally they are
only what is known as "hacks," as if the patient were trying to clear
the throat of some offending material. Of course, at no time must the
significance of cough be made light of unless a careful investigation
of the patient's condition has been made.


Diagnosis.--Names for these coughs should not be too readily accepted
which, by satisfying legitimate curiosity and lessening proper
apprehension with regard to them, will stop further investigations.
Besides stomach coughs, one often hears of intestinal and even uterine
or ovarian coughs. In many cases the real condition is one of an
incipient tuberculous condition and there may be no sign of this
except a disturbance of the pulse and perhaps a slight variation of
the temperature range for the day (two degrees or more Fahrenheit in
the twenty-four hours). Such coughs should always be carefully
investigated for the possibility of incipient tuberculosis. At once
the patient should be warned about coughing without necessity, since
this only tends to disseminate the tuberculous process and may help to
break down nature's wall of protective lymph.

Where there is no disturbance of pulse or temperature and the patient
is not under weight and there are no signs in the lungs, then the
cough is merely a habit and partakes of the nature of a tic. Sometimes
these habits are rather difficult to break; always, however, much can
be done by suggestion, by a habit of self-control, by self-discipline,
and by thorough persuasion of the patient. Drugs are likely to
inveterate the condition if not allied with suggestion.


Removing Unfavorable Suggestions.--For the ordinary coughs and colds
of the winter time there are many unfavorable suggestions that deserve
to be eliminated. For instance, most people are sure that exposure to
the air will inevitably make their cold and cough worse. This is a
relic of the olden time when the confinement of patients to their
rooms was supposed to be the best remedial measure for all respiratory
diseases. Tuberculosis patients were kept in and died without any
chance. Now these patients, even while running a temperature, or
suffering from pleurisy, or the intercostal painful conditions that
are often serious complications because of the irritability and
discomfort produced, and which are so often supposed to be due to
drafts, are put out on the porch, or on the roof of a hospital, or
allowed calmly to lie in bed between two open windows, without the
slightest hesitation. They begin to improve under such treatment much
sooner than if they were confined, and indeed the whole prognosis of
tuberculosis has been completely changed by the modification of the
old-time habit of confinement to that of perfectly free access of
outer air and even cold air that has taken its place.

This principle of treatment must be applied for coughs and colds.
While {349} patients are running a temperature they must not take
exercise, they must not be allowed to work, above all they must not be
allowed to get in crowds nor tire themselves in any way. The room in
which they are, however, must be thoroughly aired, the window must be
open all night and, if possible, they must sit in the sun for several
hours a day. This will cure a cough or a cold quicker than anything
else. Many coughs that hang on when treated by remedies of various
kinds, yield at once if the patient is given an abundance of fluid
diet and gets freely into the air. There is no danger of catching
another cold, because a cold is not due to a low outdoor temperature,
but to dust and microbes, and is a real infection.


Irrational Remedies.--There are an innumerable number of supposed
remedies for colds. Scarcely any one who has reached the age of forty
apparently feels that he or she is doing the whole duty to humanity
unless they have some remedy for colds to recommend. Most of the
popular remedies that are employed probably do as much harm as good
and many of those that are very popular and are sometimes recommended
even by physicians have no rational standing in present-day
therapeutics. Perhaps the most popular is a combination of quinin and
whisky. The effect of this is to give patients, who are unaccustomed
to whisky and who are susceptible to quinin, about as uncomfortable a
twenty-four hours the day after they take the remedies as can be
imagined. Quinin now has no possible specific therapeutic significance
in the cure of the series of infections called colds. In the days when
we did not understand malaria and considered it in some way as an
essential fever due to the absorption of miasmatic material, quinin
seemed to have a specific influence upon several conditions.
Accordingly it was employed in all sorts of fevers and, because it is
comparatively harmless, also in that short infectious fever which we
call a common cold. No physician now employs it (except in small doses
as a general tonic) for febrile conditions, unless in malaria. There
we know that it acts by killing the plasmodium and is a real specific.
We do not think of it any more, however, as a general febrifuge and
there is no justification for its use in the slight infective
conditions we know as colds.

As for the whisky, if taken in stiff doses as it often is, the
reaction is likely to make the patient quite miserable the next day.
It seems to be the rule for him to think that if, notwithstanding the
taking of the quinin and whisky, he feels thus ill, he would have been
ever so much worse without it. Colds, however, when left untreated so
far as drugs go but managed by natural means often run a mild course.
Some of the reputation of quinin and whisky is due to the fact that
not infrequently persons suffer from chilly feelings that seem to
portend a cold and take quinin and whisky and the cold does not
develop. The remedies are then supposed to have aborted or to have
inhibited the development of the cold. Anyone who has seen a number of
these cases treated expectantly, however, knows how often it happens
that the chilly feelings that seem to announce the cold pass off
without incident after a good night's rest.


Rational Treatment.--The old rule of getting the emunctories at work
must be the basis of any rational therapy of colds. A mild opening of
the bowels, especially if there is some constipation, a hot drink on
going to bed so that there is some sweating and perhaps the use of a
mild diuretic will almost surely affect these cases favorably.
Patients have to be careful, {350} however, next morning to stimulate
the circulation in their skin to activity so that the cutaneous
muscles shall react upon the capillaries and the capillaries
themselves tonically contract in order that there may not be too much
blood near the surface of the body, or the patient may easily be
chilled in cold weather. This chilling of the blood when much of it is
near the surface seems to lower its vitality and the patient easily
reinfects himself or, if he goes into dusty or crowded places, catches
a fresh dose of infectious material. This is the process which is
called catching a fresh cold.

The removing of the unfavorable suggestions of remedies that do harm
rather than good and the giving of favorable suggestions founded on
our present-day knowledge of what a cold is and just what we need to
do in order to benefit it, is the most important element in the
treatment. Above all, however, the patient must sleep in an airy room
and must be sure that he is neither breathing his own expired air nor
that of anyone else. With thorough ventilation, however, and the
stimulating effect of the cold air and the confidence due to proper
directions, colds rapidly get better.

There can be only one reason for keeping patients indoors who are
suffering from cold. That is, if they are suffering from fever, the
being out involves exertion. In that case, of course, patients must
rest and must avoid exertion, but there is no reason why they should
not have all possible fresh air. The unfavorable state of mind towards
fresh air and especially night air in these patients was cultivated by
the profession up to a generation or two ago, but is quite unjustified
by our present knowledge. Night air is probably a little better than
day air because it is freer from dust. It is because of malaria that
night air was supposed to be detrimental, but we have found that the
only good reason for this was that the mosquito travels at night.
There are no other constituents of night air that produce any serious
effect.

As a rule, patients suffering from colds need more sleep than other
people and above all need more sleep than they ordinarily take, for
this will increase their resistive vitality and enable them to throw
off the infection. A good rule is to add two hours of sleep to the
usual quota. The unfortunate habit of keeping people indoors and of
keeping fresh outdoor air away from them, because it is feared they
will catch a fresh cold, often seriously disturbs sleep and delays
recovery. In a word, many a cold that hangs on does so mainly because
of unfortunate suggestions of one kind or another that have come to
occupy a place in the supposed therapeutics of the condition. The
removal of these and the insistence on just as much recourse as
possible to the therapeutic means at nature's command constitute the
basis of successful therapy of these very common infections, which
probably are the source of more morbidity in the community because of
their wide diffusion and frequent recurrence than all the other
infectious diseases put together.



CHAPTER II

TUBERCULOSIS


Tuberculosis, in spite of all our efforts against it, remains in
Defoe's striking phrase the "captain of the men of death." Pneumonia
has preempted its {351} place in the statistics of mortality, but this
is to a considerable extent because tuberculosis at the end
masquerades as an acute pneumonic exacerbation. Not less than one in
eight, probably more, of all those who die, die from tuberculosis. It
is the most serious of diseases. In spite of its eminently physical
character it probably affords the best possible illustration of the
place of mental influence in therapeutics. We have had any number of
new cures for tuberculosis, introduced by serious physicians who were
sure from the results they had secured that they had found an
important new remedy. After a few years each of these cures in
succession has been relegated to the limbo of unused remedies because
found inefficient. At the beginning they produced a beneficial
influence because of the suggestion of therapeutic efficiency that
went with them. When this suggestion failed because the physician who
administered the remedy lacked confidence, the real place of the
supposed specific as merely another mind cure was recognized.

Indeed, many of the remedies that have been introduced have not been
merely harmless drugs, but not a few of them have probably had rather
a detrimental physical effect than a beneficial influence. In spite of
this, the influence on the patient's mind has been sufficient to
neutralize whatever of harmfulness there might have been and to arouse
new courage and new energy. The consequence of this has always been
that the patient was tempted to live more in the open air and to eat
more. _These_ are the two efficient remedies for tuberculosis. With
the additional life in the open air and increase of food his appetite
grew, for nothing so adds to appetite as the exercise of it, and with
the gain in weight there was a cessation of cough, a reduction of
fever, a disappearance of night sweats and a definite increase in
resistive vitality which gradually helped to overcome the disease.
Manifestly, then, the use of mental influence in tuberculosis is very
significant.


PROGNOSIS AND SUGGESTION

The most important element in any treatment of tuberculosis must be
the neutralization of unfavorable suggestions which are weighing upon
the patient and preventing him from using even the vital forces that
he has for resistance against the disease. The popular impression of
tuberculosis, happily waning, is that it is an intensely fatal
disease.

Though this is true in general, tuberculosis is by no means a
necessarily mortal disease in individual cases, and, indeed, a great
many more patients recover from tuberculosis than die from it. Papers
read at the International Congress on Tuberculosis, in Washington, in
1908, showed from careful autopsy records that practically all adults
either actually had had at the moment of death, or had suffered
previously from tuberculosis. If there are not active lesions then
there are always healed lesions of tuberculosis in the body of almost
every human being who has passed the age of thirty. Most people have
quite enough resistive vitality to enable them to recover from the
disease. It is only those who are placed in very unfavorable
circumstances during the initial stage of the disease, or who have
some serious drawback against them, who succumb to it. The fact that
the bacillus finds a lodgment in so many individual tissues shows that
it is not insusceptibility that makes the difference {352} between
people, since we are all susceptible, but it is the lack of resistive
vitality, and that most of us have, under ordinary circumstances, and
all of us can have under favorable conditions, quite sufficient
immunizing power to prevent serious developments.

Even in advanced cases it is perfectly possible for the progress of
the disease to be stopped and for many years of useful life to be
gained. Probably patients who have gone beyond the incipient stage, in
whom there has once been a breaking down of pulmonary tissue never are
entirely cured, but they may be so much improved that all their
symptoms disappear and they are able to follow an ordinary occupation
for many years. There is no disease in which the unfavorable prognoses
of physicians have been more frequently disappointed than in
tuberculosis. In any city hospital dispensary one finds many cases of
tuberculosis turning up as relapses of previous conditions, with the
story that when they were seriously ill before, some prominent
physician, since dead, said they had only a few months to live. The
fact that the physician who made the unfavorable prognosis has since
died himself adds greatly to the zest with which patients tell their
story. Neither the severity of the symptoms nor the amount of lung
tissue attacked is quite sufficient to justify an absolutely
unfavorable prognosis in the majority of cases of pulmonary
tuberculosis.


No Incurable Cases.--Above all, it cannot be insisted on too
emphatically that there is never a time in the course of the
tuberculosis when a physician is justified in saying to a patient
suffering from any form of tuberculosis that his case is hopeless. One
is never justified in saying "You are incurable." Practically every
town of any size in this country has a number of cases in which
patients were told by physicians that there was no hope, and yet they
have recovered to chronicle as often as they get the chance the fact
that they have outlived their physician. To say that no case of
tuberculosis can be confidently declared incurable will seem to many
an exaggeration. There are patients in whom the prognosis is so
unfavorable as to be almost hopeless. There are never cases of which
it should be said there is no hope. When patients are told, as they so
often are, that they are incurable, absolutely no good is done and
harm is inevitable.


Heredity of Resistance.--When the disease has developed very rapidly
in patients in whom there is no previous history of tuberculosis, and
in whom there is no history of previous cases in the family, the
outlook is always serious. These cases come as near being incurable as
any the physician sees. But the most apparently hopeless of these will
sometimes recover, contrary to all anticipation. In spite of the
opposite impression so commonly accepted, the most helpful element in
these cases is the presence of a trace of tuberculosis in the family
history. This always means the existence of some immunity against the
disease and there may be a turn for the better even when the case
looks absolutely hopeless and when it seems to just be verging on its
fatal termination. Probably the most discouraging are the cases in
which miliary tuberculosis is at work and conditions are about as
unfavorable as possible. There are cases of this kind on record,
however, with the most startling contradiction of anticipation, in
which undoubted miliary tuberculosis produced high fever for weeks and
even months, then gave rise to pleurisy, to peritonitis, to various
cutaneous abscesses and to abscesses of bone, in which patients lost
one-third of {353} their weight or even more, and yet after the
external lesions began to discharge freely, recovery occurred.


Slow Cases.--As for slow-running cases in which there is a distinct
history of tuberculosis in the family, not even the most experienced
physician can state with any certainty that a fatal termination is
inevitable and that recovery cannot occur. Some of the most expert
diagnosticians have been deceived in these cases. After half a dozen
physicians have given a man up, some gleam of hope has buoyed his
feelings and a turn for the better has come. Men with cavities in
three lobes, even in four lobes and occasionally it is said in all
five lobes, have survived acute stages, have recuperated to a
considerable degree and have been able to return to work or at least
to take up some useful occupation for a time. Where the lung lesion
progresses slowly it is surprising how small an amount of healthy lung
tissue is needed to support life. Only those familiar with many
autopsies on the tuberculous can appreciate this. Ordinarily we are
apt to think that when more than half the pulmonary tissue is involved
so as to be of little or no use for respiratory purposes, death must
be inevitable. On the contrary, one-fourth the ordinary lung capacity
will serve and all of one lung may be quite out of commission and only
a portion of a single lower lobe be available, yet the patient may
survive for a prolonged period.


The Specter of Heredity.--The most serious contrary suggestion that
patients suffering from tuberculosis are likely to have is that their
affection is hereditary and that, therefore, there is little hope of
its cure. It is in the family strain and cannot be obliterated. This
idea, fortunately, does not carry the weight it used to. It should,
however, have no unfavorable influence at all and this needs to be
emphasized. We discuss the subject more fully in the chapter on
Heredity. We know very definitely now that the hereditary element in
tuberculosis is so small that it is quite negligible. There are good
authorities who do not hesitate to say that heredity plays no role in
the causation of tuberculosis and does not even produce a
predisposition. Some remnant of the old superstition (for
superstition, from the Latin, superstare, means a survival from a
previous state of thinking, the reasons for which have disappeared)
always remains, and predisposition is the last rule of outworn
opinion.

We know now that contagion is the important element. The possibilities
for contagion vitiate all proofs of the predisposition idea.
Especially is this true when we recall that thirty years ago
practically no one took proper precautions to prevent the
dissemination of tuberculosis, and very few took them even fifteen
years ago. Even at the present time many tuberculosis patients cough
around the house with open mouth, spreading tubercle bacilli all
around them. We are caring for the sputum, but many other avenues for
the diffusion of the disease are open. Children acquire the infection,
overcome it, but retain the seeds of it in them and then in some
crisis in life, as after puberty, or when they are over-working and
over-worrying, or during the first pregnancy, an opportunity is given
to still living tubercle bacilli to find their way out of sclerotic
confinement. Other forms of contagion count in the absence of a case
in the immediate family. We can trace the contagion only too easily,
even if there is no consumptive member of the home circle.
Scrub-women, laundresses, those who are careless in their attendance
upon the tuberculous, workers in dusty places or in factories, where
there are others who cough, all {354} these get the disease.
Predisposition counts for so little that it is a vanishing factor.

Patients can be assured at once then that they need not worry that the
hereditary factor will make their affection less curable. On the
contrary, our recent careful studies in tuberculosis show just the
opposite of the old false impressions. The children of parents who had
tuberculosis are much more likely to possess resistive vitality to the
disease than those whose parents never had it. As we emphasize in the
chapter on Heredity, the nations that have had the disease the longest
among them are the most resistant to it. When the affection is newly
introduced into a tribe or race it carries off a great many victims.
This immunity, however, is not a function of heredity or of the
increase of resistive vitality by the inheritance of an acquired
character from the preceding generation, but tuberculosis takes the
non-resistant, weeds out all those who have not some immunity against
it, and consequently those that are left possess some immunizing
power. Tubercular heredity, then, instead of being a source of
discouragement should rather be a source of hope. It is surprising to
note what a relief to many patients' minds is the explanation of this
newer view of heredity in tuberculosis; it lifts a burden from many
and makes them eat and sleep better for days.


ANNOUNCING THE DIAGNOSIS

Friends and especially near relatives sometimes come to a physician
when there is suspicion that a young person is suffering from
tuberculosis and ask that, if there is a ground for a positive
diagnosis, it shall not be communicated to the patient. They usually
urge that they fear the discouragement will kill the patient. The
young are not so easily killed and the reaction on being told the
truth and the facing of it bravely is such a magnificent help in
therapeutics that the physician should always refuse for the patient's
sake alone, quite apart from any ethical obligations in the matter, to
enter into any such arrangement. The assurance may be given that the
patient's condition will be so stated that, far from the patient being
discouraged after due consideration, he or she will look forward with
confidence to overcoming the affection.


EARLY DIAGNOSIS

Mental treatment is most valuable in the very early stage of incipient
cases of tuberculosis. The time is past when the diagnosis of
tuberculosis was made only after the recognition of definite physical
signs in the lungs and a considerable loss in weight.

In the _Medical News_ for April 9, 1904, I called attention to the
question of "Early Diagnosis of Tuberculosis" from the pulse and the
temperature in these cases, and pointed out that a disturbance of
temperature need not necessarily be a febrile temperature of over 100
degrees, but that any increase of the normal daily variation of
temperature, usually considered to be about a degree and a half,
should suffice to arouse serious suspicion at least. If the morning
and evening temperatures differ by two degrees, this would indicate
the presence of some pathological condition, usually tuberculosis. If
in addition to this and the pulse disturbance there is any localized
area of prolongation of {355} expiration, then tuberculosis is almost
certainly present, even though there may be no other physical signs,
no cough, no tubercle bacilli in the sputum, nor any other signs of an
active process.

It is in these cases particularly that patients can be benefited. Very
often they have a slight hacking cough, frequently repeated, with some
disturbance of appetite and of digestion and sometimes some loss in
weight. Indigestion is recognized now as one of the early stages of
tuberculosis. The cough in these cases, as has been said, is often
spoken of as a stomach cough and is supposed to be due to the nervous
reflex from the pneumogastric nerve carrying irritative impulses from
the stomach to the lungs. It is much more likely to be due directly to
irritation of the terminal filaments of this same nerve in the lungs
themselves.


FAVORABLE MENTAL ATTITUDE

The most important element in any cure or successful treatment of the
disease is a favorable attitude of the patient's mind. He must be told
at once that consumption takes away only the "quitters." People who
give up the battle or who, though still hoping, do not hope
actively--that is, do not make the exertion necessary to get out into
the open air and to eat heartily--inevitably succumb to the disease.


Eating.--Eating is often more a question of exertion than appetite or
anything else for consumptive patients. They have no active appetite
and they simply must force themselves to chew and swallow. Their
fatigue from chewing is, indeed, likely to be so disturbing that it is
advisable to furnish patients as far as possible with such food as
requires no chewing. Milk and eggs and the thin cereal foods, like
gruel, and rather thin puddings are the best for this purpose.
Patients must be persuaded that they must take these whether they care
for them or not. Occasionally they may cough after a meal and vomit it
up. The rule in the German sanatoria for consumptives is that whenever
this happens they must, after a short interval, repeat the whole meal.
Only rarely does it happen that a tuberculous patient vomits without
some such mechanical cause as coughing. They must be made to
understand that any food that stays down does them good no matter how
they may feel toward it.

The actual state of affairs as regards their future must be put before
them. It is a question of eating or of death. They face these two
alternatives. Eating is objectionable but, as a rule, death is more
so. The kinds of food they do not care for, if they are good for them,
must be insisted on. Most people who think that they cannot take milk
can do so, if it is only presented to them insistently, with at first
such slight modifications of taste as may be produced by a little
coffee, or tea, or vanilla, or by some other flavoring extract, which
modifies its taste. Butter and the meat fats will be taken quite
readily if it is only once made perfectly clear to patients that they
must take these or else lose in the conflict with the disease.

It deserves to be repeated here that in many of these cases the
disinclination to eat is due to the fact that patients find it almost
intolerably wearying to make the effort necessary for mastication.
This is particularly true if they are asked to eat meat frequently,
and especially if asked to eat underdone beef, {356} which usually
requires vigorous chewing. Such meat is excellent for them once a day,
but it may be made much easier to take by chopping or scraping so that
practically no exertion is required. Besides, it is by no means
necessary that these patients should eat much meat nor that they
should have to chew laboriously at their food. Raw eggs may be the
basis of the diet, especially eggs beaten up, and these will be found
not only to be very tasty, but eminently digestible. Their vegetables
may be taken in purees, so that they require very little chewing
effort, though patients must be warned to mix starchy substances well
with saliva so as to facilitate their digestion. Their bread may be
taken in the shape of milk toast, or in some other soft form--bread
pudding for instance. All this helps, without demanding too much
effort, to prevent loss of weight and to regain it when it has been
lost.


Air and Comfort.--Next to food, the most important adjuvant is fresh
air. Often patients find many objections to this. It is too cold for
them; they are shivery and become depressed. Most patients need to be
dressed much more warmly than is the custom at present, and hands and
feet should be covered with woolen gloves and socks and even a woolen
hood worn around the head if necessary. There is usually too much
covering worn on the chest and too little on the extremities. With
fleecy wool garments next the body and sufficient clothing, properly
distributed, many a patient who complains of the cold will at once be
more comfortable. They must be made to understand that fresh air is
absolutely essential. Every extra hour they spend in the air is that
much gained; every hour they spend inside is just that much lost in
the curative process. If they are uncomfortable, however, they become
discouraged, and a discouraged tuberculous patient never resists the
progress of his affection. Not only does he not improve, but he
inevitably retrogresses. It must not be forgotten, however, that the
thin anemic patients who complain bitterly of the cold, when they
first take up the habit of living outside, will grow used to it after
a time and then will from habit and the accumulation of a ten-pound
blanket of fat be able to stand the cold much better than many healthy
persons.


Stimulating Examples.--Tuberculous patients need to have their courage
kept up. It is true that the toxin of the tubercle bacillus has the
definite effect of stimulating its victims so that they are likely to
be hopeful, but very often this hopefulness is vague and does not
tempt them to eat and to live in the open air, the two things that
make their continued resistance to the disease possible. I find that
the knowledge of how bravely and how successfully other sufferers from
the disease resisted its invasion and succeeded in doing a good life's
work is the very best tonic that sufferers from tuberculosis can have.
Needless to say, there are any number of examples of heroes of
tuberculosis who put to shame perfectly healthy people in the amount
of work they succeeded in accomplishing in spite of the drawbacks of
their disease. The unfavorable suggestion of the number of deaths from
the disease must be overcome by the contrary suggestion of the brave,
busy lives lived by those who suffered even the very severe form of
the disease and often accomplished the full term of existence in spite
of their handicaps from tuberculosis.


_Robert Louis Stevenson_.--The best example in recent years is
undoubtedly Robert Louis Stevenson. In spite of tuberculosis in severe
form which prevented his living in the ordinary climates for the last
twenty years of his life, he succeeded in doing an amount of work that
is simply marvelous and in {357} influencing his generation more
widely than most of the perfectly healthy writers who lived in his
time. There are over, 2,000,000 published words to the credit of
Stevenson, and, when we recall that most of this, owing to his
critical care, had been written over and over many times, some idea of
the vast amount of work he accomplished will be realized. Perhaps the
climax of his cheerful nature, the utter lack of discouragement in the
face of what is usually the most depressing possible incident, is to
be found in his famous letter to a friend telling him, as he lies in
bed, that he cannot write at any great length now but that he will
write a long letter next week if "bluidy Jock," his playful name for
hemorrhage from the lungs, would only let him.

One of the most striking illustrations of his insatiable appetite for
work and his complete refusal to admit that he was being conquered by
the disease has been recently told with regard to his unfinished
novel, "St. Ives." He had been suffering from certain severe symptoms
and had been forbidden to do anything at all, even to dictate brief
notes, or anything else that would make any extra work for his
respiratory organs. The ideas for chapters of "St. Ives" were in his
head and would work themselves out in spite of the doctor's
prohibitions. He would not let the thought of his disease overcome
him, and so he dictated these chapters to a secretary in the sign
language, which he had learned so as to be able to communicate under
such conditions. I know nothing that is more likely to make people
realize how a brave spirit can overcome every discouragement of body,
and how much such a spirit is its own reward, since it secures for its
possessor a prolongation of the life of the body that would surely be
worn out by depression, by discouragement, and by worry. Undoubtedly
Stevenson's interest in his work literally gave him new life. It did
use up some nervous energy, but if his mind had been occupied by
thoughts of his disease, and its probably fatal consequences, much
more of his precious store of nervous energy would have been exhausted
in anxiety and worry.


_J. Addington Symonds_.--After Stevenson probably the most striking
example among modern literary men is John Addington Symonds.
Comparatively early in life he found that he could not live in England
owing to the inevitable advance of tuberculosis when he tried to do
so. He took up his residence then at St. Moritz and other places of
rather high altitude in Italy and continued his literary work. When we
see the row of books that we owe to Symonds' literary activity it is
surprising to think that he, too, like Stevenson, had to watch his
temperature, that every now and then there were discouraging
developments and incidents in his tuberculosis, and that a return to
the ordinary habitations of men away from the friendly altitudes of
the Italian Alps was always followed by a recrudescence of his
symptoms. Symonds' work was not merely literary, but his books are
valuable historical monographs on many subjects requiring much reading
and diligent study and consultation of authorities. There are few men
in perfect health and with abundant leisure who have succeeded in
accomplishing as much as did this hero of tuberculosis.


_Thoreau_.--There are other distinguished literary men of the
nineteenth and twentieth centuries the stories of whose tuberculosis
has a special interest and tonic quality. One of these is our own
Thoreau, another is Francis Thompson, the English poet, whose recent
death has brought him even more publicity than did his great poems
while he was alive. Both of them are typical examples of another phase
of tuberculosis that is interesting to realize. {358} It is probable
that if Thoreau had lived the ordinary, practical, everyday life,
which those who lived around him thought he should, he would have died
of tuberculosis before he was thirty. He had no use for money beyond
his present needs and when he had made enough to keep himself very
simply he refused to earn any more. He had not time, as he said, to
make money. He wanted to live his life for itself and for the
interests higher than the material that there can be in it.
Accordingly, he set himself to learn all about the birds and beasts
and the trees and plants and the waters and their inhabitants around
his country home. He introduced the modern taste for nature study in
its most beautiful way. He spent most of his time out of doors.

Undoubtedly this out-of-doors life prolonged existence for many years
beyond what would have been his term. His biographers say that
probably his being out of doors in all sorts of weather laid the
foundations of "the cold which settled on his lungs" and eventually
carried him off. Those of us who know anything about tuberculosis, as
it has been studied in recent years in the tuberculosis sanatoria, are
not likely to agree with such an opinion. Our patients in the
Adirondacks live outside ten or twelve hours a day and then sleep with
their windows open with the temperature sometimes down to zero during
the severest winter weather. Rain and dampness are not allowed to
interfere with the open air program. Colds that "settle on the chest"
so that people die from consumption are not due to exposure to cold
but to the bacillus of tuberculosis. Where this once gains a foothold
the one hope of prolongation of life is out-door air and the more cold
and stimulating that out-door air is, provided he can stand it without
discouragement, the better for the patient. Thoreau is an example of a
man whose life was prolonged by his out-door habits and by his refusal
to live the humdrum, practical existence of other men, just to be like
those other men and measure his supposed success by their standards.


CHARACTER AS A THERAPEUTIC ASSET

Recent interest in tuberculosis has taught us that the best possible
asset for a tuberculous patient is character. Resistive vitality in
the physical order and character in the moral order seem to be
co-ordinate factors. If a man will not give in in the fight, if he
insists on struggling on in spite of difficulties, discouragement and
an outlook that seems hopeless, then he will almost without exception
get over his tuberculosis, if there is any favorable factor in his
environment. We talk much of immunity inborn and acquired to the
disease, but it seems to go hand in hand with a certain capacity to
stand the debilitating symptoms of the disease without allowing one's
mind to become depressed or one's disposition rendered despondent by
them.


Courage and Constancy.--The career of Dr. Trudeau to whom we owe so
much of our knowledge of tuberculosis is a striking example of the
power of character to enable even an apparently delicate organization
to withstand the ravages of the disease. This is all the more striking
because he was an advanced case when he finally reached an environment
in which he could make head against the disease. The story of his own
personal struggle for life at Saranac, in which he both learned
himself and taught others what the modern {359} treatment of
tuberculosis should be, is one of the best therapeutic documents of
modern times. Under circumstances that were quite apt to be
discouraging to anyone of less character than he, with the bitter cold
of the Adirondacks around him and quite inadequate heating facilities,
so that even old-fashioned lamps were in requisition for heating
purposes, he yet succeeded in winning back his own way to health and
showing others how it could be done. The struggle had to be kept up
for long, it had to be renewed again and again, our greatest American
authority on tuberculosis had to learn in his own person all the
clinical details of the disease, but in the midst of it all he
succeeded in accomplishing a life work that will stand beside that of
any man of his generation and will probably mean more in the history
of American medicine than that of any of his supposedly more
distinguished colleagues in our large cities and large teaching
institutions.

This is the sort of man whom tuberculosis does not take in spite of
every advantage that the disease may seem to have. Two others of our
American authorities on tuberculosis had almost the same experience.


Persistence.--Recently I have been in correspondence with a young man
who illustrates the same power quite as strikingly. He went to Florida
and soon found that the unfortunate fear of tuberculosis that has so
unwarrantably come into many minds in recent years made it extremely
difficult--indeed, almost impossible--for him to live under such
circumstances as he hoped for when he went there. In any
boarding-house he went to just as soon as there was question of his
having tuberculosis the landlady would either insist on his leaving at
once or else plead with him to take his departure, lest her other
boarders should desert her. He was coughing, he had some fever, his
disease was advancing in the midst of all this disturbance, physical
and mental, and the outlook seemed hopeless. His picture of this
selfishness of humanity, scared about nothing (for there is
practically no danger if tuberculous patients take reasonable
precautions, as even nurses in sanatoria do not acquire the disease,
though living in the midst of it), constitutes one of the most
poignant indictments of human nature in its worst aspect that I have
ever had presented to me.

Finally he made up his mind that there was nothing for him to do but
to tent out and live by himself. Fortunately he was able to do that
and just as soon as he was settled under circumstances where human
nature did not bother him, nature began to do him good. He feared that
he would die during the first month in the tent, for he was having
fever up to 102-1/2 and sometimes more every afternoon; but he laid in
a store of provisions which with the milk and eggs delivered to him
every day enabled him to stay in bed for a week, opening up the flap
of the tent in the middle of the day. Then he went out and got another
stock of provisions and stayed in bed for another week. His thoughts
were gloomy enough, he had only some old illustrated newspapers to
give him a few fresh thoughts every day, he had no one to visit him,
but he hung on and kept up his habit of rest and forced feeding in
spite of disinclination. At the end of two weeks he had no temperature
in the afternoon. At the end of the third week he made for himself a
reclining chair and sat in the sun outside of his tent wrapped in a
blanket. At the end of four weeks he had gained five pounds in weight.
From that on all was plain sailing. It was his character that
conquered his tuberculosis.

{360}


SUGGESTION AS TO SYMPTOMS

Besides the value of suggestion for the general condition in
tuberculosis many of its symptoms can be treated best by changing the
mental attitude of the patient towards them and giving him a proper
appreciation of their significance. Most symptoms are likely to
produce exaggerated reactions, especially in patients who are
over-solicitous about themselves. Not a few of the symptoms are really
nature's attempts at compensation, or the result of conditions which
show a natural disposition to bring about a cure. Fever, for instance,
produces lassitude and great fatigue on exertion, and patients are
prone to think that this means weakness or exhaustion. It is really
only an indication of the necessity for rest, and is brought about by
nature's refusal to supply all the demands of the muscles for
nutrition, at a time when the febrile condition is burning up a lot of
extra material. Far from being a disadvantage, weakness is a decided
advantage in this condition.


Hemorrhage.--Probably no symptom that occurs in connection with
tuberculosis is more influenced by the mental attitude than
hemorrhage. It is a most disturbing incident. Even in quite small
amounts it upsets the patient seriously and, of course, in large
amounts it is a source of profound disturbance even to the most placid
of patients. Excitement always adds to it. Probably no physical means
that we have at command can be depended on to control it. Ergot used
to be popular, but such physiological action as it exerts, so far as
we know the drug, would seem to be likely to do as much harm as good.

Other remedies have gradually lost favor in the hands of those who
have had most experience with the symptom and gallic acid and
supra-renal extract, the older and newer remedy, are now little
depended on. Two things are important--to secure lower blood pressure
and lessened pulmonary activity. For these opium in some form is
undoubtedly the best drug; and then a placid state of mind on the part
of the patient must be secured as far as possible. The scare in these
cases, in so far as it is relaxing, is rather favorable than
unfavorable for the patient. In addition, it is necessary to insist on
absolute quiet and silence and then to allay all reactionary
excitement. It is important to make patients realize that while
hemorrhage is a serious complication, it is by no means so serious as
is usually thought.

Many cases of tuberculosis that eventually run a slow course are
ushered in by hemorrhage, or have it as a very early manifestation. It
is surprising how many people have had hemorrhage as a symptom and
live to tell of it thirty or forty years later. This was not due to
any mistake of diagnosis, for a generation ago tuberculosis was more
likely to be missed when actually present than to be diagnosed when
absent. Indeed, this tendency for the cases in which hemorrhage
occurred to run not so fatal a course as others was a fact that seemed
to an older generation of physicians to require explanation. They
suggested that possibly the hemorrhage swept out with it some of the
virulent elements from the lungs and so lessoned the infection. From
what we now know this is a doubtful explanation, but it seems not
unlikely that a frank hemorrhage might reduce the amount of toxins in
the circulation and so in an early stage of the disease give nature a
fresh start in resistive vitality.

{361}

What is much more likely, however, is that the occurrence of early
hemorrhage made it easier for the patients to appreciate the
seriousness of the affection and brought them to accept advice as to
proper precautions. Under ordinary circumstances it is difficult and
used to be even more so in the past to make the patient understand at
the beginning of the affection the necessity for giving up indoor
occupations and living the outdoor life with the care for nutrition
that is so important if the case is to be improved. Hemorrhage scared
them into submission. In the old days it was the first positive
symptom of consumption. Now we have many others, and instead of
following the advice of over-solicitous relatives that we should not
tell patients what is the matter with them, we tell them frankly and
secure such care of the health as will bring about improvement.
Probably nothing illustrates so well the necessity for thus
influencing the patients' minds into caring for themselves as the fact
that the hemorrhagic cases, as a rule, do better than the others. All
of this can be used to make the minds of patients much less disturbed
than they would otherwise be by this alarming symptom.


Cough.--In the chapter on Coughs and Colds we have outlined how much
coughing may depend on suggestion, or habit, or on the tendency to
yield to slight bronchial irritation when there is no real necessity
for it. Most tuberculous patients cough much more than is necessary.
This is always somewhat dangerous for them since it disturbs their
lungs, has a tendency to distribute tubercle bacilli in their lungs,
or in the air around them, and may by efforts at expulsion lacerate
affected blood vessels and produce hemorrhage. Whenever cough is
productive it should be indulged in, for it removes material that
should not be allowed to accumulate. Unproductive coughing, however,
can usually be controlled by training.

It is particularly at the beginning of phthisis that the control of
coughing by suggestion is important. There are many little coughs,
"hacks" as they are sometimes called, frequently repeated by those in
a very early stage of pulmonary tuberculosis and which are consequent
upon irritation either of pulmonary nerves or of pulmonary tissues,
but that are quite unnecessary, as a rule, if a little attention is
paid to suppressing them. As a warning sign they are excellent, but
the patient should be taught not to indulge in them. Coughing tends to
prevent nature's curative reaction and the contraction of pulmonary
tissues which may take place around a lesion. In beginning
consumption, even where there is but slight infiltration, we know from
the observation of the movements of the diaphragm either by the X-ray
or directly by Litton's method that its excursions on the affected
side are shortened. Coughing is in direct opposition to this setting
of the lung at rest and therefore should be controlled; however, as
our drug remedies are likely to disturb the stomach, whose healthy
function is so important in these cases, the use of the mind in the
control of the cough is of the greatest value.


Thoracic Discomfort.--Complaints are often made by the tuberculous of
pains in the thorax. Ordinarily the discomfort is supposed to be due
to the lung condition, and it is assumed that it is either actually in
the lung itself or in the pleura, or communicated from them by reflex
to the muscles. In most cases, however, patients complain of pain on
the side that is either not affected at all or least affected. If they
have been told that the other side is suffering most from
tuberculosis, they are prone either to think that now the {362} well
side is being invaded or else that their physician is making a
mistake, and both thoughts are seriously discouraging. The reason for
the pains on the well or the better side, however, are easy to
understand. As far as possible, as can be readily demonstrated by the
X-rays or seen in the observation of the so-called Litten's
phenomenon--the excursions of the diaphragm--nature puts the ailing
lung at rest and the diaphragm moves much less on that side than on
any other. In order to make up for the lack of breathing in this side
the other lung does compensatory work. This over-stretches the muscles
of the thorax on the well side and causes some over-work in them. The
consequence is a tiredness which may become fatigue; in damp weather
this may be even painful. Just why damp weather has this particular
effect on muscles is not surely known. Muscular action is probably
accomplished with more difficulty in damp weather because of the
relaxing effect of moisture on tissues and circulation. Reassurances
may be given them, then, that will keep them from thinking seriously
of the significance of these pains except as an index of nature's
compensatory efforts. The painful conditions instead of causing
discouragement will, then, be a source of encouragement. It must not
be forgotten that rubbing with some gentle stimulant, soap, liniment,
or the like, will greatly improve the thoracic muscles in these cases,
but the rubbing must be done gently and by someone else beside the
patient, for it is only beneficial if done from before, backwards, in
order to help the return venous circulation which runs in that
direction in the external respiratory muscles.


Altitude.--There is a marked difference between the amount of water
which finds its way out through the lungs at varying altitudes. At sea
level an ordinary patient will lose during the night about 300 cc,
that is, something more than half a pint of water, through his
respiratory tract. At an altitude of 5,000 feet, however, this amount
is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet
it is half as much again as it is at sea level. This copious giving
off of water has a marked effect on the lungs. It constitutes one of
the reasons why altitude is a favorable element in the treatment of
tuberculosis. Only beginning cases of tuberculosis, however, are able
to stand the additional work thus put on them, though a slight
elevation, up to 2,000 or even 3,000 feet, rather seems to be of
benefit to all cases. How far-reaching the effect of this extra loss
of fluid is, is appreciated from the concentration of blood which
takes place and which produces a blood count of 8,000,000 red cells at
a mile of altitude in patients who, at the sea level, have no more
than 4,500,000. Such patients, of course, need much more water and
fluids generally to be comfortable than when living lower down.


Suggestion and Treatment.--There are many accessory suggestions with
regard to food that serve to confirm the patient in the idea that
abundance and variety of food must be taken if the battle with the
disease is to be won. To patients who find milk difficult to take, it
must be explained that a copious amount of fluid in the system is
needed in order to make coughing easier. So milk serves a therapeutic
as well as a nutritional purpose. In the same way it may be explained
that fats, such as bacon and cream, help to keep the bowels from
becoming constipated and constipation inevitably disturbs the
appetite.

Explanations as to the advisability of being out of the city and in a
portion of country not very thickly populated, in order to avoid the
possibilities of secondary infection with other respiratory diseases
and bacteria of various {363} kinds, will make a patient understand
the necessity for leaving town. It may be helpful, also, to insist on
the value of living at some elevation above sea level as an aid to
expectoration.

Cough is the symptom that many of these patients fear most, and a
promise of any amelioration of it by a simple change of location helps
them to make the sacrifice of city life for a while. Some patients who
have been benefited by a stay in a sanatorium come back with a relapse
of their symptoms. They dread to return to the sanatorium and think
they can care for themselves as well at home, since they know what the
regulations are, though it may be evident to the physician that they
are losing ground in their city environment. It is well worth while to
give them a careful explanation of what we know of the effect of
altitude upon consumptives who have sufficient reactionary power to
stand it.


_Negative Suggestions_.--Some suggestions are valuable for the
prophylaxis of complications. For instance, tuberculous patients must
be warned not to indulge in breathing exercises without the express
consent of the physician. So much is said in popular literature as to
the value of breathing exercises that many a patient suffering from
tuberculosis thinks that, not only may they be indulged in with
impunity, but that they will surely do good and can do no possible
harm. Nothing could be more erroneous. Many localized lesions have
been diffused in this way and there is always danger that the strain
will cause hemorrhage. Patients must be warned also to avoid any
possible condition in which they might have to over-exert themselves.
Because of the dust inevitably breathed during automobile riding, this
pleasure must be denied to tuberculous patients as a rule, but even
when they have recovered sufficiently so that this may be permitted
they must be warned not to take long rides into the country lest the
breaking down of the machine should place them under the necessity of
walking a long distance. This idea should also be emphasized for
rowing excursions, or trips by motor boat, for occasionally they lead
to serious and exhausting exposure.

One negative suggestion should be given at the very initial stage to
every patient in whom the presence of pulmonary tuberculosis has been
recognized. This should be a warning to exercise the greatest care
against permitting the development of constipation. Tuberculous
patients must never strain at stool. Almost necessarily a certain
number of tubercle bacilli are swallowed every day whenever pulmonary
tuberculosis is at all active and they are constantly present in the
digestive tract. If tuberculous patients then strain at stool, little
abrasions of the mucous membrane of the rectum are caused in which
tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are
common among the tuberculous and rectal fistulas often give much
bother. When a tuberculous patient develops such a condition, a period
of depression and discouragement will follow, for there is a curious
tendency to depression associated with all lesions of the rectum. A
pulmonary patient who has been doing well will often fail to make
progress for months after the development of even a small
ischio-rectal abscess.

{364}


CHAPTER III

NEUROTIC ASTHMA AND COGNATE CONDITIONS


For the consideration of its psychotherapy asthma may be divided into
two forms--symptomatic and essential, or neurotic, asthma. Symptomatic
asthma is a difficulty of breathing, the result of some interference
with the circulation, as by heart disease, or with the oxidizing power
of the blood, as by kidney disease, or various blood conditions, or
from direct interference with respiration from some pulmonary
affection. Essential asthma is not dependent on any organic condition,
but is an interference with breathing without any distinct
pathological condition in the lungs themselves or in the general
circulation. There may be some emphysema, but not enough to account
for the respiratory difficulty. It is spoken of as neurotic asthma,
and the most careful investigations made of individuals who have died
during a seizure has failed to give any sure pathological basis for
the affection. Certain accompanying phenomena are worthy of note. The
most interesting of these are Curschmann's spirals, which usually
occur in the form of translucent pellets very characteristically
described by Laennec as pearls. They are evidently formed in the finer
bronchioles and show that the affection extends to the terminal
portions of the bronchial system. In connection with these the
so-called asthma crystals first described by Charcot and Von Leyden
and sometimes called by their combined names are often found. Besides,
there are a large number of eosinophiles in the sputum itself
entangled within the filaments of the spirals and an eosinophila of
the blood.


Etiology.--Not only are we ignorant of the reasons for these phenomena
but there is even some doubt as regards the mechanism of the
respiratory spasm itself. There is a general impression that the
paroxysm is due to incapacity to inspire because of a paroxysmal spasm
of the respiratory muscles. Gee in his "Medical Lectures and
Aphorisms" [Footnote 30] rather leans towards the explanation that
suffering is due not to any inability to fill the lungs but to
incapacity to empty them when they have become over-distended with
air. He tells the story related by Dean Swift of the old man whose
barrel-shaped chest was fixed in spasm so full of air that the patient
could not find room for the slightest additional breath. "If I ever
get this air that is in me out," the patient declared to the Dean, "I
will never take another breath."

  [Footnote 30: Frowde, Oxford Univ. Press. 1908.]

It is important to differentiate symptomatic from neurotic or
essential asthma. In symptomatic asthma the only assured treatment of
the condition must come through amelioration of the organic condition
causing the symptoms. Cardiac and renal asthma respond promptly to
remedies which relieve critical conditions that may be present in the
heart or kidneys. It must not be forgotten, however, that respiration
is readily disturbed by mental influences. Where cardiac or renal
disease causes interference with respiration this is much emphasized
by the patient's unfavorable mental attitude toward it, or much
relieved by keeping him from worrying over his condition. Even
symptomatic asthma, then, has a definite place in psychotherapeutics,
though {365} it would be serious not to recognize the underlying
conditions and treat them. If the patient's attitude of mind is one of
discouragement, the respiratory difficulties will continue to be a
marked symptom of the case, even though the proper remedies for the
relief of cardiac or renal conditions are administered.


Symptomatic Picture.--What is likely to be one of the most disturbing
experiences of the young physician early in practice, especially if he
has not before seen a typical case, is to be called to a patient
suffering from a severe attack of asthma. Often the sufferer is
sitting up in bed so as to get all the air possible, and, though the
windows are wide open, he is gasping for breath, usually pleading for
more air with a tense, anxious expression, starting eyes, and the
sweat pouring from his forehead, while the accessory muscles of
respiration, deeply engaged in moving his thorax to move air enough to
keep him from stifling, emphasize his dyspnea. Occasionally a degree
of cyanosis develops that is quite startling for the untrained
observer. Most of those who see the symptomatic picture for the first
time think that death is impending, and the patient himself, if he has
not had a series of attacks, will fear a fatal termination. It appears
impossible to believe that the next morning, within six or seven hours
of this, the patient will, as a rule, be quite well and walking round
in the enjoyment of apparent good health.

As a rule, the worse these cases seem in their intensity and the more
the patient is anxious, the more surely are they merely of functional
nervous origin; above all, the more complaints of lack of air and of
fear of impending death that are made, the more likely is the patient
to be all right within a few hours. Asthma looks as though it must be
due to some serious organic condition. Of course, in many cases of
difficult breathing, even with asthma-like attacks, there are
underlying serious conditions of heart and kidneys that are extremely
dangerous. As a rule, however, these do not produce the woeful
pictures of purely neurotic asthma. Even when the basis of the asthma
is an emphysema, which of itself is not dangerous and is quite
compatible with long life, the attacks, though frequent and severe,
are usually not so serious looking as those in which absolutely no
pathological condition of the lungs, or heart, or kidneys can be
found, and, indeed, in which there is absolutely no organic change to
account for the extremely uncomfortable and even terrifying symptoms.


Mental Influence.--In the medical literature of asthma there are
abundant proofs that the attitude of mind of the patient towards his
affection means very much. There is the story, thoroughly vouched for,
of the two friends stopping at a little country hotel late at night.
One of them was a neurotic subject, who, whenever he remained for some
time in a stuffy atmosphere, was likely to have a severe asthmatic
attack. The quarters assigned to them proved to be one of the cramped
little rooms with a single small window that occasionally are found in
the attics of country inns in England. During the night the patient of
asthmatic tendencies had one of his attacks and begged his friend to
open the window. The friend, suddenly roused from sleep, did not
remember the position of the window and, the night being very dark, he
felt for it and finally found it. He could not raise the sash and he
could not move it either inward or outward and there seemed no way of
getting it open. His friend was insistently clamoring for air with
that tone of despair and {366} dread of impending death so
characteristic of the young, inexperienced asthma sufferer. Unable to
get the window open, the sympathetic companion finally took his shoe
and smashed the glass. The relief was immediate. Scarcely had the
crash of the broken glass been heard before the patient gave an
audible sigh of relief. When his friend went over to him he felt so
much better that it was rather easy for the sufferer to persuade him
that nothing more would be needed and that he should go back to bed.
In the morning, when the friend awoke, his first glance, directed by
the sunlight that came streaming into the window, was toward the
broken panes of the night before. To his surprise it was not broken.
Wondering what had happened, he looked round the room to find that he
had smashed two panes in an old bookcase set into the wall, and that
it was the breaking of the glass with the suggestion of free ingress
of air that it involved and not any real provision of fresh air that
had cured his friend's asthma so promptly.


_Suggestion_.--When much-vaunted cures for asthma are analyzed, many
of them are found to depend more on suggestion than on any other
element. Various forms of cigarettes are used, comparatively innocuous
in themselves, and certainly of no strong therapeutic action, yet they
work marvels in loosening the spasm that comes over the lungs in
asthmatic attacks. Any sort of a cigarette will do at the beginning. I
have seen dried grape-vine stems work very well in the country,
especially in young women to whom the idea of smoking anything was
strongly suggestive. Cubebs cigarettes have the same effect on older
people. Doubtless there is some relaxing action in the smoke. This is
not enough, however, to account for the effect produced without mental
influence. After cubebs have been tried for a period and begin to lose
their efficacy, then other materials that produce a pungent smoke or
have a certain sensory action, as stramonium leaves, may be used, and
will also have the marvelous power of cubebs. After a time, however,
they, too, lose their efficacy, and, as a rule, each successive
cigarette that is tried has less power than the first to control the
difficulty of breathing.

The more one hears of cures for asthma, and the longer one has
experience with these cases, the clearer does it become that there is
a large suggestive element in every successful treatment. If a piece
of ordinary blotting paper be dipped in a strong solution of saltpeter
and allowed to dry, it will, if touched by a lighted match, burn
slowly without flame, but with the production of heavy, thick smoke.
The therapeutic elements in this are not very strong, but the
suggestive element, when a room gets full of it, is intense and is
cumulative. Very probably the thick smoke, rich in nitrites, has some
tendency to relax the spasm in the lungs which causes the asthmatic
seizure, but after a time the remedy fails and something else has to
be tried. In many cases, when first used, it almost works a miracle.
This is the simplest type of suggestive treatment for asthma.


_Mental Shock_.--Any strong mental influence, especially if
accompanied by the suggestion of assured relief, is likely to do much
for asthma of essentially neurotic character, and indeed is more
powerful in dispelling the symptoms of the seizure than almost any
other means that we have. Sometimes even things absolutely indifferent
which produce a profound mental impression, prove curative. There are
many stories of men in the midst of a severe asthmatic seizure being
suddenly roused by the cry of fire, or an alarm of some {367} kind
near them, having the spasmodic conditions disappear as if by magic.
Occasionally where attacks of asthma recurred regularly on successive
nights for a considerable period, travel on a railroad train or
anything else which occupied the attention much, prolonged the
interval between seizures and sometimes put an end to the series of
attacks. The more one knows of asthma the more one realizes how much
its occurrence depends on mental influences of many kinds in
association with various reflex irritations, some of them very distant
from the respiratory tract and comparatively trivial in their effects
on other people.


_Loss of Control_.--Occasionally in elderly neurotic people
over-fatigue induces an attack of asthma about the time that sleep
becomes deep. This usually occurs after the first hour or two of
sleep. The inhibitory power of the nervous system over spasmodic
contraction of the lung tissues seems lost in deep sleep and then the
asthmatic condition develops. The greater the effort to breathe the
more intense does the contraction become, until the antispasmodic
effect of the presence of a lessened amount of oxygen and an abnormal
quantity of carbon dioxide in the blood makes itself felt. In many
cases these patients will be relieved of the tendency to such spasm by
taking a cup of coffee. This stimulates the general circulation and
minimizes the reflex tendency which centers in their respiratory
tracts. Such patients after taking an amount of coffee that would keep
ordinary people awake all night, sink in the course of half an hour
into a quiet, restful sleep and awake quite refreshed. This is not
entirely suggestive, but suggestion plays an added role in the relief
of all the symptoms.


Treatment.--_Varied Cures_.--We do not mean to say that asthma is
entirely amenable to suggestive treatment, but we emphasize the mental
influences in its production and its cure. A new and almost infallible
cure is announced nearly every year for asthma, as for tuberculosis.
Sometimes this is some new treatment for the nose, occasionally it is
a novel method of treating the throat, but reflexes from a great many
other organs not at all in touch with the respiratory system have also
been supposed to be productive of asthma, and their treatment has been
followed by relief from this trying condition. Washing out the
stomach, for instance, has been followed by prolonged cessation of
asthmatic attacks. In children it is claimed that occasionally the
correction of eye-strain by the proper glasses has cured neurotic
asthma. There are those who have had cases where the relief of
long-continued constipation had a like therapeutic result and there
are other and even more curious claims for curative effect in this
affection.


_Negative and Positive Suggestion_.--Any condition in the human body
that sets nerves in tension and requires constant inhibition may lead
to such a cumulative effect of repression that reaction follows and
explosion takes place. In particularly susceptible individuals,
irritable respiratory centers may be affected with consequent
asthmatic seizures. The direct treatment of the respiratory tract to
secure ease of respiration often does away with the liability to
asthma by direct prevention. If patients, especially young patients,
are mouth-breathers the clearing out of the throat and nose so as to
insure normal breathing can naturally be expected to lessen any
tendency to asthma. In the same way treatment of irritative or
degenerative conditions in the throat and larynx, as well as in the
nose, may be considered directly curative. On {368} the other hand,
there is no doubt that many of the slight ameliorations of intranasal
conditions suggested by enthusiastic specialists as curing asthma do
not have any direct therapeutic influence but owe their efficacy to
the strong suggestion of the operator's assurance on the patient's
mind that this treatment has cured asthma in many cases and will
surely cure him.


_Drugs and Suggestion_.--The medicines that are especially effective
in asthma of neurotic origin are those which also have a large
suggestive influence because of their taste or their effects upon the
system. Hoffman's anodyne is an efficient antispasmodic and is
wonderfully effective in relieving the tendency to asthma. I have
always felt, however, though I have given it freely, that a large
element in its effectiveness was its particularly disagreeable taste
and odor and then its excretion through the lungs with a certain sense
of well-being allied somewhat to the intoxication that comes from the
inhalation of ether. I have seen asthmatic tendencies in young women
greatly relieved by the use of valerian. Undoubtedly this remedy, like
the compound spirits of ether, is antispasmodic in action, yet to a
much less degree than Hoffman's mixture, and over and over again I
have noted that in pill form, though given in large doses, it was not
as effective as if given in liquid form when its nauseating smell
added distinctly to its suggestive influence. The drug itself does
good but it is distinctly helped by the influence upon the patient's
mind of its taste and, above all, of its aroma. The elixir of ammonium
valerianate being particularly unpleasant is likely to be more
beneficial to these patients.


_Climatotherapy and Suggestion_.--The climatic treatment of asthma has
received much attention. Change of scene and environment nearly always
does good. Different patients, however, require very different
conditions. Of two cases of neurotic asthma in which no diagnostic
differences can be found, one will improve at the seashore or on a sea
voyage, while the other will be made worse by such a change though
probably the asthma will be improved in the mountains or in some dry
climate. Even moving from one part of a city to another has brought
great improvement in asthma. Sometimes there were good reasons for
this, as, for instance, when an investigation showed that the patient
had previously been living above a bakery from which there came a good
deal of hot air and flour dust. Some people are actually improved by
close contact with human beings in rather crowded quarters. I have
known a settlement worker to experience great relief from asthma when
living in the slums. Where there is intense occupation of mind,
especially if combined with the suggestion that now the asthma ought
to be better, seizures will be less frequent and less severe. All
sorts of places in the mountains and by the seashore have acquired
reputations as relieving asthma which were justified by many cured
cases and yet they have lost this reputation. Whenever there are many
sufferers together, the expectancy of relief seems to do great good.



CHAPTER IV

DUST ASTHMA, SEASONAL CATARRH, HAY FEVER


Grouped under the term "hay fever" there are probably as many
different affections as there are under the term "chronic rheumatism."
There are {369} people who, in the springtime, as soon as the weather
gets warm, suffer from what is popularly called hay fever. This is
often called "spring catarrh" or "rose cold" and seems often to be
associated with the pollen of flowers. Then there are people whose hay
fever, as it is called, develops about the first of June and continues
to be bothersome until the middle of July, when there is a remission
of symptoms, though in dry prolonged hot periods after that the
affection may recur. It seems as if, at the beginning of the heated
term, the warm, dry dusty air irritates their nostrils very much,
while after some weeks they gradually become used to this and the
reaction is not so violent. Then there are the regular hay-fever
patients whose affection occurs principally in haying time, during
August and September, though most of them have not been near hay
pollen, and the disease is an affection of dwellers in cities rather
than in the country, of indoor livers more than of farming people, who
might be expected to suffer most from the supposed cause, hay pollen.
Even where pollen is directly concerned in its causation it is
probably oftener the pollen of the rag weed rather than that of hay
that is responsible for it.

There are two elements in the disease apparently of equal importance.
One of these is a strictly local condition interfering with
respiration in some way, or with the circulation to the mucous
membrane of the nose and the lachrymal ducts. The other is an
individual over-sensitiveness so that there is an exaggerated reaction
to irritation. Some of this is mental, that is, is due to expectancy,
or to the persuasion that this reaction is sure to occur under certain
circumstances. As a consequence, attacks of hay fever are reported
even after a distant view of a hayfield, or of rose cold due to the
sight of an artificial rose, and of other recurrences that show the
power of the mind to bring about at least a beginning of symptoms.

While the first or physical element in the etiology of dust catarrh
can be treated successfully by various means, it is important to get
the mind of the individual in a favorable state so as to enable him to
obtain better control over his vaso-motor system which is so much
influenced by emotions and thoughts. It is this latter element in the
causation of the disease that has been successfully treated by the
many remedies that for a time have had reported success in the cure of
hay fever yet afterwards proved to be of no benefit because they had
lost their influence over the patients' minds.

In a review of Morell MacKenzie's book "Hay Fever, with an Appendix on
Rose Cold," Dr. J. N. MacKenzie   [Footnote 31] has some paragraphs on
hay fever which, though written twenty-five years ago, are worth
recalling for a proper understanding of the disease. He preferred to
call the disease rhinitis sympathetica or coryza vaso-motoria
periodica, names which are much better descriptive terms and have no
unsubstantiated suggestions of etiology in them.

    [Footnote 31: _American Journal of Medical Sciences_, 1886.]

  According to our conception, the so-called nasal reflex neuroses,
  whether taken singly or collectively, as the cause of the _ensemble_
  of phenomena known as "hay fever," may be regarded as the protean
  manifestation of a morbid condition to which we have given the name
  rhinitis sympathetica, and which is characterized by a hyperesthetic
  condition of the vaso-motor nerve centers linked to a peculiar
  excitability of the nasal cavernous tissue. For, if we inquire what
  condition or conditions is common to them all, and what morbid
  process is capable of producing them, either singly or in
  combination; how phenomena apparently {370} so widely different in
  character and anatomical sphere of operation may be traced to a
  solitary source, we find the answer in certain more or less clearly
  defined changes in the nasal apparatus and in a certain exalted
  state of the sympathetic nervous system, to which latter we
  instinctively turn as the organ most conspicuously concerned in the
  evolution of purely reflex acts. In whatever relation the local
  nasal affection and the condition of the sympathetic stand to each
  other in the matter of cause and effect, they must both be regarded
  as inseparable factors in the production of the phenomena under
  consideration. It matters not to what hypothesis the path of
  speculation may lead. Of this we can be reasonably sure, that in the
  production of the characteristic symptoms of this disease, a certain
  excitability of the nasal passages is necessary, plus an exalted
  state of the central nervous system.

Dr. MacKenzie calls attention particularly to the erectile character
of the tissues mainly involved in all these forms of dust catarrh and
dwells on the rôle that mental influence always plays in the phenomena
noted in such tissues. This with the vaso-motor elements in the
affection which are so largely also under the control of the emotional
nature make it clear that the pathology of the affection must be
considered from this standpoint and, therefore, its therapy also.

Dr. MacKenzie continues:

  From our present knowledge of the disease, it seems difficult to
  escape the conclusion that its pathology is intimately interwoven
  with a morbid condition of the vaso-motor sympathetic, and probably
  a hypersensitive state of the nerve centers themselves. When we
  recall the fact that in the famous section of the sympathetic in the
  neck by Claude Bernard, symptoms similar to, or closely allied to,
  the phenomena of hay fever were produced; when we reflect upon the
  results reached by Prevost in his experiments on the spheno-palatine
  ganglion, is there not a clue to lead us through the labyrinth of
  our difficulties to a rational solution of the question? . . .

  . . .In the human body, wherever erectile tissue is found, it is
  intimately related to reflex or sympathetic acts; there seems to be
  connected with it a certain receptivity to reflex producing
  impressions, a certain power of reflex excitability dependent upon
  its structure and functions. It is thus peculiarly a tissue of
  sympathy in which we may most satisfactorily study the mechanism of
  purely reflex or sympathetic acts. Now it seems to us that, as the
  nasal corpora cavernosa belong to this class of sympathetic tissues,
  there will be little difficulty in explaining the rôle which they
  play in the paroxysms of an affection which is probably connected
  with, if not dependent upon, an excitation of the sympathetic nerve
  centers, and in more clearly defining the intimate relation which
  its erection bears to the reflex manifestations of the disease under
  review.

These considerations explain the heredity of the affection in many
cases, since it is dependent on defects that may be family traits, yet
they also enable us to understand how slight lesions of the nasal
mucous membrane may be the center from which radiate the underlying
pathological conditions of the disease.


Railroad Asthma.--There is a form of dust asthma which deserves
special attention here because it is due to modern conditions and
helps to an understanding of the etiology. It occurs in sensitive
persons when they travel on railroad trains in warm weather,
particularly if it has been dry for several days and dust is abundant.
It has been called railroad asthma or railroad catarrh by the English
and the Germans, but the condition has no necessary connection with
the railroad. It occurs as a consequence of the infiltration into
railroad cars of fine dust during the passage of the train. {371} I
have seen it in those who had made long trips over dusty roads in
automobiles, though the dust of the railroad seems finer and more
penetrating. It develops just as much at the end of a long train as if
the passenger spent most of the journey in the car next the engine and
apparently it makes no difference whether the engine burns hard or
soft coal. They use soft coal almost exclusively in England and
Germany, but one sees cases of it here after travel on roads that burn
hard coal and are especially cleanly in this respect. Soft coal adds
somewhat to the amount of dust and therefore this increases the
irritation, but there is nothing specific about coal dust. It is
surprising how severe the symptoms may be. I have seen a patient who
had traveled continuously for four days across the continent who had
so much photophobia when he alighted from the train, that he was
almost unable to open his eyes, and it was not until twelve hours had
passed that he could open his eyes with any comfort, yet at the end of
two days practically all the symptoms had passed off.

Prof. Fraenkel, professor of laryngology and rhinology at the
University of Berlin, who was one of the first to classify the
condition among the affections related to "hay fever," described
certain features of it very well in a clinical lecture reported in
_International Clinics_, Vol. II, Ninth Series, 1899. As a rhinologist
he insists on the nasal conditions that underlie the affection yet
suggests that the nasal hyperemia may be due to reflexes of one kind
or another. The basis of these is undoubtedly very often an emotional
condition of the patient, a dread of dust, an expectancy of symptoms
and a consequent exaggerated reaction. Unorganized dust produces
asthma, but organic materials bring more severe and lasting effects,
partly because of the mental effect of odors and other sensory
conditions in connection with them.


The Personal Element and Power of Suggestion.--The history of these
asthmas and other symptoms produced by odors and dust make it clear
that the more that is known about the disease the surer it becomes
that there is a large personal element, usually dependent on a certain
frame of mind, in the cases. Some people are affected by one form of
irritant, some by another, some by pollen, others by animal
emanations, and not a few by a persuasion of the likelihood of
suffering from these things, since occasionally the sight of an
artificial product produces a like result. Certain classes suffer much
more than others. Those who are much confined to the house and who are
especially prone to reflection upon themselves and their feelings form
the great majority of the patients. In old days the monks were
favorite victims, in modern times literary folk, students, and those
who have the time and the inclination for reading and introspection
are particularly likely to suffer. How much the mental element may
account for in these cases is not clear, but it stands for much more
than has been thought and there seems no doubt that more relief of
symptoms is afforded by diversion of mind and change of dwelling quite
apart from external conditions than in any other way. It is important
to remember that no specific dust but almost any kind of dust produces
these conditions in sensitive persons.

Dr. MacKenzie describes an interesting case in which all the symptoms
were produced by the presence of an artificial rose. The story is so
striking and he has told it so well that I prefer to tell it in his
own words. I may say, however, that the clinical history of the case
was typical. About the end of {372} May or the beginning of June every
year the patient suffered from a coryza preceded for a few days by an
indefinite sense of general depression with a disagreeable feeling of
heaviness in the head. Sometimes there were chilly feelings and
general malaise. The catarrhal stage commenced with profuse watery
discharge from the nostrils, copious flow of tears with redness of the
conjunctiva, itching of the puncta lacrymalia and photophobia. The
exterior of the nose, especially at the tip, became intensely red and
toward the close of the attack the cuticle desquamated. There was a
short, dry, hacking cough relieved by sneezing, an intense tickling
sensation in the throat, the voice became husky, the pharynx dry, the
ears stopped up and tinnitus occurred. Her attacks continued most of
the summer and were always brought on by the pollen of any plant and
above all by the smell of a rose. It was, indeed, an example and of
the most aggravated form. She was brought to Dr. MacKenzie in
consultation and I leave him to tell the rest of the story.

  Decidedly skeptical as to the power of pollen to produce a paroxysm
  in her particular case, I practiced the following deception upon
  her, which still further confirmed me in that belief. For the
  purpose of the experiment I obtained an artificial rose of such
  exquisite workmanship that it presented a perfect counterfeit of the
  original. To exclude every possible error, each leaf was carefully
  wiped, so that not a single particle of foreign matter was secreted
  within the convolutions of the artificial flower. When the patient
  entered my consultation room, she expressed herself as feeling
  unusually well. The evening before she attempted to wear some roses,
  but had been obliged to remove them from her dress, as they had
  produced a great deal of discomfort. Apart from this incident she
  had been perfectly comfortable for several days and nights. Her
  conjunctivae were normal, the nasal passages free, and there was
  nothing to indicate the presence of her trouble. She conversed with
  me for some time about her case and on general topics, speaking in
  the most encouraging manner concerning the progress she was
  apparently making toward recovery. I proceeded to remove the slight
  slough from the cautery operation, which lay loose in the nostril,
  and made an application to the mucous membrane, and all without
  exciting the slightest tendency to reflex movements. After I felt
  sure that such tendency was absent, I produced the artificial rose
  from behind a screen, where it had been secreted, and, sitting
  before her, held it in my hand, at the same time continuing the
  conversation. In the course of a minute she said she must sneeze.
  This sensation was followed almost immediately by a tickling and
  intense itching in the back of the throat and at the end of the
  nose. The nasal passages at the same time became suddenly
  obstructed, and the voice assumed a hoarse nasal tone. In less than
  two minutes the puncta lacrymalia began to itch violently, the right
  and afterward the left conjunctiva became intensely hyperemic and
  photophobia and increased lacrymation supervened. To these symptoms
  were added, almost immediately, itching in the auditory meatuses and
  the secretion of a thin fluid in the previously dry nasal passages.
  In a few minutes the feeling of oppression in the chest began with
  slight embarrassment of respiration. In other words, in the space of
  five minutes she was suffering from a severe coryza, the counterpart
  of that which the presence of natural roses invariably produced in
  her case. An examination of the throat and nasal passages was then
  made. The right nostril was completely obstructed by the swollen,
  reddened, irritable, turbinated structures; the left was only
  slightly pervious to the air current; both were filled with a
  serous-looking fluid. The mucous membrane of the throat was also
  injected, but did not exhibit the same amount of redness and
  irritability found in the nasal passages. As the discomfort was
  rapidly increasing, and as I considered the result of the experiment
  sufficiently satisfactory. I removed the rose and placed it in a
  distant part of the room. When told that the rose was an artificial
  one, her amazement was great, and her incredulity on the subject was
  only removed upon personal examination of the counterfeit {373}
  flower. She left my office with a severe coryza, but also with the
  assurance that her disease was not altogether irremediable. A few
  days later she called to see me again, and on that occasion she
  buried her nostrils in a large, fragrant specimen of the genuine
  article and inhaled its pollen without the slightest tendency to the
  production of reflex acts.

There is but one conclusion that can be drawn from this: that
suggestion plays a large rôle in the relief of the symptoms of the
disease. If patients once become persuaded that something will do them
good, then it surely does. It is true that this good effect will
usually not persist, but that is because after a time conditions
conspire to make the suggestion fail of its purpose. This does not at
all imply that hay fever, or just catarrh as I prefer to call it, is
imaginary. The relief of our most serious and fatal diseases with
profound pathological lesions, such as tuberculosis, may well be
brought about by suggestion. After all, just the same story is told
about consumption and its many remedies as of hay fever and its many
"cures." However, the most important therapeutic element so far
discovered for the treatment of hay fever is evidently suggestion. If
the patient's mind can only be brought to a favorable attitude in
which the discouragement incident to imperfect oxidation can be
greatly lessened, then relief of many of the symptoms will be afforded
and under favorable conditions the patient will deem himself cured.
Undoubtedly the large amount of attention given to hay fever, the
gathering of these patients in particular localities, the repetition
of the story of their symptoms to each other, the body of literature
that has gathered around hay fever and is read with such avidity by
those who are pleased to call themselves its victims, adds to the
unfavorable suggestions and inveterates the symptoms, exaggerates the
nasal hyperemia and makes the general condition worse.

I am the more positive about the influence of suggestion, favorable
and unfavorable, in the affection after having carefully noted the
conditions in certain patients from year to year for a number of
years. I became interested in it because it is a family affection and
several sisters as well as myself are sufferers from it. At the
beginning, when the real nature of the trouble is not recognized,
there is a year or two of considerable general discomfort, though not
much local disturbance. Then comes the realization of what the
recurrent affection is and a period of distinct depression during its
continuance. Eventually it begins to be appreciated that a number of
local applications will lessen the symptoms from day to day and that
there need be no apprehension of serious sleep disturbance, or of any
lasting effect upon the general health, the affection becomes quite
bearable and, while still annoying, is no longer the object of
particular solicitude.



CHAPTER V

DYSPNEA--CAT AND HORSE ASTHMA


There is a class of cases of difficulty of breathing allied to asthma
and often called by that name, the study of which throws light on the
origin and the relief of neurotic asthma. These cases are usually
accompanied by such a sense of oppression on the chest that breathing
becomes labored and, to some {374} extent at least, the accessory
muscles of respiration have to be called into play. The most typical
cases are connected with the mental influence produced by the presence
of some particular animal, the cat being the most frequent and the
horse not rare, or with emanations from these animals, when there
seems to be some physical nexus between the animal and the symptoms.


Cat Asthma.--The symptoms associated with cats are rather common, and
they occur at the sight or touch of the animal, but may be the result
only of its presence which in some way the patient is able to
recognize without sight of him. Shakespeare's expressions in a number
of places, such as "I could endure anything before but a cat" and
"some that are mad if they behold but a cat," shows that the affection
was commonly recognized at that time and that the reason for it was
considered unknowable, for Shakespeare says, "There is no firm reason
to be rendered why he cannot abide ... a harmless necessary cat."

Dr. Byron Bramwell in his "Clinical Studies," Vol. I, page 107, has an
interesting paragraph with regard to these curious asthmatic
conditions which develop in the presence of animals of various kinds.
He sums up many of the curious features of this affection as reported
by various good observers. Many more people than we would be apt to
think are affected by it. He says:

  In some persons the smell of a horse or of a cat produces an attack
  of asthma. Some years ago I repeatedly saw a young gentleman who
  invariably had an attack of asthma if he went near a stable or a
  horse. He was so susceptible that he was unable to drive in a cab or
  a carriage; when traveling from place to place, while sending his
  traps from the station to the hotel in a cab, he himself was obliged
  to walk.

Dr. Goodhart mentions a similar instance which occurred in the
practice of Prof. Clifford Allbutt. Dr. Goodhart also mentions a
remarkable case of "cat asthma":

  I have known of two cases of cat asthma. In one of them the
  existence of cats is the bane of life, for before accepting an
  invitation she is obliged first to ask, "Is there a cat?"
  [Footnote 32] An attack of urticaria and coryza followed by asthma
  has been noticed to come on within ten minutes of having stroked a
  cat. At other times, sitting in a room in which there was a cat,
  without any actual contact with it, was sufficient to produce a bad
  attack, beginning within ten minutes of entering the room.

    [Footnote 32: A case of this kind came under observation as this
    book was nearly ready for the press. The patient, a young woman in
    an office, had to refuse a vacation with a wealthy friend in
    Florida, because she knew that friend could not be separated from
    her pet cats, five in number, and the patient would have been
    intensely miserable were she near them, so that even the joys of
    Florida in the winter did not make up for the constant,
    intolerable discomfort they would have caused her.]

There are two forms of this intolerance of a cat. One of them takes on
the character of a dread and is discussed in the chapter on Dreads.
The other is accompanied by dyspnea or asthma with a sense of
discomfort and tightness of the chest that cannot be overcome. It is
not merely an imagination, for sometimes even when they cannot see the
cat, or at times when friends have been careful to exclude cats from
the room, these people become impressed with the idea that a cat is
near and a search usually shows that their impression is true, though
just what was the means through which they came to know it is
difficult to understand.

{375}

Dr. Weir Mitchell's review of the subject of "Cat Asthma and Allied
Conditions" in a paper read before the Association of American
Physicians brought out many curious details. There is no doubt about
the power to recognize the presence of the unseen cat. Besides the
respiratory oppression, some patients develop urticarial lesions and
occasionally even conjunctivitis and a catarrhal condition of the
nasal mucous membrane. These seem to be due to the direct irritant
effect of animal emanations. As the symptoms of rose cold or hay fever
have sometimes developed after the sight of an artificial rose, or
even, it it said, the picture of a hay field, so, in some of these
cases, the sight of a picture of a cat has produced at least some of
these symptoms. Probably the most interesting feature of the affection
is that the large cats, the tiger and the lion, do not have any effect
on the patient. There seems to be no doubt, then, that the mind plays
an important role in the matter and that relief must be secured
through mental influence.

In some of these cases a careful searching of the past of the patient
will show that there has been some terrifying incident connected with
the cat. In one case in my own experience the patient's earliest
recollection, and the first time that death was brought home to her,
was when a favorite bird was killed by a cat. Ever after that she had
a horror of the animals, the family cat had to be disposed of, and her
family never had another. She used to suffer from a severe dyspnea at
the sight of a cat and was sure that she could recognize its presence
without having seen it. She mentioned a number of occasions on which
that had been true. The very idea of living where a cat could come
near her was appalling. She was sure that she was even waked by the
mere propinquity of a cat if by any chance one got into her room at
night, though without any noise.

A change in her material circumstances compelled her to teach in
private families. Under these circumstances her cat detestation made
difficulties for her. I suggested, since she had had no feeling toward
cats before the bird incident, that probably her symptoms were due to
suggestion and an acquired habit of mind and that she might by
discipline overcome them. She was sure that would be impossible. With
determined effort, however, and practice in withstanding her feelings
in the presence of cats she finally learned to overcome practically
all of her feelings so that though it still requires an effort she can
even pick up a cat and stroke it. I have had several other patients
with less marked forms of the affection who have by self-discipline
overcome their feelings to a great degree. It is always well to search
the past of these patients in order to find out whether there may not
be a dominant idea derived from some unfortunate experience, which
acts as an auto-suggestion in the production of their symptoms of
constriction of the chest and sometimes even the recurrence of the
swelling of the mucous membrane of the nose that produces difficulty
of breathing. Whenever this can be found, contrary suggestion can be
given and the patients can be persuaded to try, by frequently repeated
auto-suggestion, to relieve themselves of the trouble.

Occasionally these curious manifestations of a catarrhal or asthmatic
character in the presence of cats occur in people who like cats. Dr.
Taylor in his "Types of Habit Neuro-Psychoses" published in the
_Proceedings of the Massachusetts Medical Society_, 1896-98, tells the
story of a young woman in whom he saw conjunctivitis developing while
she was fondling a cat. In many cases {376} besides the hyperemia of
the nose and of the respiratory mucous membrane generally there is
marked injections of the ocular conjunctiva. It is rather difficult to
understand the phenomena of asthmatic attacks in connection with cats
and other animals in terms of a habit formed, because at some time
asthmatic or hyperemic manifestations occurred in association with the
handling of these animals and that then, somehow, suggestion works to
reproduce the same symptoms in the presence of the animals later; but
this is undoubtedly the only rational explanation that we have for
many of these cases. It represents the most helpful explanation, so
far as treatment is concerned, for by means of suggestion either in
the waking state or in the first stage of hypnosis, in many cases
relief can be brought to these patients. Repeated profound hypnotism
is a vaunted remedy for these conditions in the hands of professional
hypnotists, but serious physicians who have tried hypnotism do not
recommend it. It helps for a time but relapse follows. Only continued
suggestion and a carefully cultivated habit of self-discipline and
control succeed.


Horse Asthma.--The cases of dyspnea in connection with horses are not
less interesting. Occasionally, even when all aversion is absent,
emanations from horses are capable of producing a curious effect on
certain individuals. How much of this is psychic is not clear. I was
once consulted with regard to a patient who suffered from asthma
whenever she went to a dance. It mattered not how careful she was in
not exposing herself to night air, or in wrapping herself up warmly;
invariably a few hours after her return home, she was wakened from
sound sleep by an attack of difficult breathing that required the
opening of windows and the use of the accessory muscles of respiration
in order to satisfy her air hunger, and even then her symptoms were
quite alarming to herself and her friends. At first, her asthma was
thought to be due to sudden changes of temperature in going out into
the air after the dancing, and various devices were tried to lessen
the shock of the cold to the respiratory mucous membrane. None of them
had any effect. Then it was thought that the dust of the ball-room
made the difference and so she was forbidden to dance. After a time it
was found, however, that if she went out in the evenings to social
functions, whether she danced or not, or though she avoided completely
being in dusty rooms or where many people were moving, she still had
the attacks a few hours after she returned home.

Finally it was noted that these attacks of asthma also occurred on
several occasions after she had been out riding during the day in a
carriage. Then one evening after a rather long intermission free from
attacks, in spite of directions and her fears, she went to a ball, but
owing to circumstances went and returned by trolley instead of, as
usual, in the family carriage. That night she had no attack of asthma.
Experiments were made then and it was found that whenever she rode
behind horses she suffered from an attack of asthma during the
following night. The attack was evidently not due to suggestion. The
story illustrates the necessity for carefully analyzing all the
circumstances of an asthma patient and making sure that some one of
these curious and unusual conditions are not at work, for if they are,
the only possible curative treatment is by influencing the patient's
mind, first by demonstrating the cause of the affection and then by
training in self-control to reduce the reaction.

{377}

Recently I have been consulted with regard to a physician who has
developed in a rather curious manner a sensitiveness to the presence
of horses. As an interne at a hospital during an epidemic of
diphtheria he took a dose of diphtheria antitoxin for immunizing
purposes. The amount injected was 750 units, the remainder of the dose
of 1,500 units contained in the phial being given to the nurse who had
charge of the cases. She suffered absolutely no ill effects, so that
the manifestations in his case were entirely due to idiosyncrasy and
not to anything in the serum itself. Within fifteen minutes after
taking the injection the mucous membrane of his nose became so
congested as to make it impossible for him to breathe through his
nostrils and the mucous membrane of his soft palate was seriously
disturbed in the same way. His face became much swollen, the edema
affecting particularly his eyelids and his lips and hundreds of wheals
appeared all over the body. Fortunately the edema did not affect the
larynx, or the issue might have been fatal, or would surely have
required intubation. His pulse became extremely rapid and weak, there
was marked dyspnea, and whenever the patient sat up there was fainting
or a distinct tendency to it.

Under active stimulation and elimination the symptoms rapidly passed
off so that the only noticeable edema the next morning was in the
eyelids and lips, which, however, also disappeared within twenty-four
hours. Up to this time the physician had never been bothered by any
tendency to hay fever or to asthma and there is no history of either
of these affections in his family. Thereafter, however, though quite
without his anticipating it, and, indeed, the first symptoms were
incomprehensible, he became extremely sensitive to emanations from
horses. When he rides behind a horse for some distance his
conjunctivae become injected, the nostrils become congested and
difficulty of breathing sets in with a sense of constriction of the
chest. These subside as soon as he gets away from the presence of the
horse and has washed himself thoroughly. He suggests that he has
become sensitized to horse serum and, as it did not exist before his
experience with diphtheria serum, he, of course, connects that
incident with the present tendency. It is easy for such a case to have
its real significance entirely missed and, of course, treatment by
prophylaxis, the most efficient form, would then be out of the
question.


Other Forms.--Apparently at times human emanations or some peculiarity
of odor seems to influence asthmatic conditions. I have been told by a
good observer--a physician--of two brothers who had an attack of
asthma whenever they visited each other. At first this was attributed
to something in the air or some other condition of the visit. After a
time it was found to occur under varying circumstances, but that the
one essential was the association with each other.


Treatment.--The more one knows about asthmatic conditions the more
does it become clear that special study of individual cases is
extremely important for any definite knowledge of the causation in a
particular case. Without a knowledge of the cause the treatment is
very unsatisfactory and in the meantime the unfavorable suggestion of
the recurrence of the attacks acting upon the patient sometimes
disturbs the general health. To remove this unfavorable influence must
be the first care of the physician and then if the real cause can be
found, favorable suggestion and modifications of the mode of life,
with self-discipline and control of the mental attitude and of the
{378} nervous system, may greatly aid in the reduction not only of the
number of attacks and of the severity of the symptoms, but finally
lead to complete eradication of the affection.

Mental control to some degree can be obtained and it has even been
suggested that if the emanations from an animal cause physical
symptoms, gradually increased dosage of them, beginning with very
small amounts, that is, short periods of association with the animals
in question, may gradually lead to the production of an immunity to
them as it does even to the much more serious results of snake poison.
Certainly some patients seem to have succeeded in bringing relief to
themselves by this means and it is worth while remembering in the
therapy of the affection, if for no other reason than the strong
suggestion that goes with it.

{379}

SECTION IX

_PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM_


CHAPTER I

PAINFUL JOINT CONDITIONS--PSEUDO-RHEUMATISM.   [Footnote 33]

  [Footnote 33: The position here taken, that acute articular
  rheumatism never leaves a mark after it, is entirely due to the
  observation that whenever cases were seen in which sequelae were
  noted, there always seems to the writer to be question of something
  else besides simple acute articular rheumatism--a complication.
  Subsequent pathological investigation may show that occasionally
  acute articular rheumatism does to some extent disorganize joint
  tissues. Personally, however, I have the feeling that there are a
  number of different kinds of acute arthritis, probably three or
  four, and that most of them leave no pathological condition in the
  tissues. Perhaps we shall be able to differentiate the severer forms
  and recognize them from the beginning, as we have already done with
  regard to scarlatinal, gonorrheal, influenzal and other so-called
  rheumatisms. For practical purposes it certainly seems better to
  emphasize the fact that chronic rheumatism following an attack of
  simple acute arthritis is so rare as to be negligible.]

Many painful conditions in connection with joints give rise to more or
less continuous or frequently repeated discomfort, which often leads
patients to think that there are serious pathological factors at work,
or that some progressive disease condition has obtained a hold of
them. Many of these painful conditions are due entirely to local
causes: to over-exertion, to the wrong use of muscles, to the exercise
of joints under unfortunate mechanical conditions and the like. Just
so long as people are assured that an ailment is local, is not likely
to be followed by serious impairment of function, that the discomfort
of it is only temporary, and, above all, just as soon as they get rid
of the notion of a progressive constitutional malady, they are content
to bear even annoying pain without much complaint, and, what is more
important, without such discouragement and worry as may impair the
general health. Unfortunately, it is the custom to call most of these
vague painful conditions "rheumatism," unless there is some other
patent cause for them. Especially is this done if the symptoms happen
to be worse in rainy weather, or in damp seasons. Rheumatism is always
thought of as a progressive constitutional disease, and the very idea
of it produces an unfortunate sense of depression.


Exaggeration of Significance.--Toothache, for instance, unless it is
allowed to nag for a long time, awakens no dreads and consequently
fails to produce the corresponding depression and discouragement, seen
so often in connections with conditions much less painful, but
associated with the thought of the possibility of serious
developments. _"Omne ignotum pro magnifico,"_ what is not well
understood is always exaggerated, was Cicero's summing up of the
tendency of the human mind to make the significance of misunderstood
things greater than they really are. It is particularly true of
painful {380} conditions of the body, and the tendency must be
combated if patients are to be relieved. This must be done not alone
because along this way lies relief of suffering, since not a little of
the discomfort is due to the mental concentration consequent upon the
dread, but because, also, the discouraged state of mind interferes
with the trophic influences that go down from the central nervous
system to the periphery to keep it in good health and to restore
function when there is anything out of order. In a word, the
exaggeration of significance so likely to influence such patients for
ill must, as far as possible, be removed for their immediate relief as
well as ultimate cure.


Rheumatism, Gout, Catarrh.--There are three words in popular medical
language which can be made to include more diseases and explain more
symptoms than any others. Their meaning has become so indefinite that
they now convey very little information, though they are much
used--and abused. They are: rheumatism, gout and catarrh. Curiously
enough all three of them when their etymology is studied mean the same
thing as far as their derivation goes. Catarrh from [Greek text] the
Greek word to flow down and rheumatism from [Greek text] the Greek
verb to flow are terms that correspond exactly in etymology to gout,
which is probably derived from _gutta_, the Latin word for
drop--referring to the excess of secretion that is supposed to occur
in the disease. All of these have for their basic idea, in etymology
at least, an increase of secretion. A generation or two ago, the word
rheumatism included a host of disparate painful affections, and was
even more sadly abused than now, though its abuse has not ceased. The
word catarrh is now at its acme of abuse. Gout has been pushed
somewhat into the background by the other two. Any one of these three
terms carries with it, in the popular mind, a connotation of
progressive constitutional involvement which is not justified by
anything that physicians know with regard to these diseases.


The Uric Acid Diathesis.--The usual supposedly scientific explanation
of a decade ago for many of these vague pains and aches classed as
chronic rheumatism was that they developed on the basis of an excess
of uric acid in the system. Advance in chemistry has completely
obliterated the significance of the observation on which the theory of
a uric acid diathesis, as it was so learnedly called, as an
explanation for these conditions was founded. After uric acid there
came for a time the theory of an excess of lithic acid, the so-called
lithemia or American disease of a few years ago. These are, however,
merely pseudo-scientific hypotheses and the more physicians know of
chemistry the less they talk about them. Many practitioners, however,
continue to accept this universal explanation which makes diagnosis so
easy and which is supposed to be so suggestive for treatment. There
are various remedies that are claimed to reduce the uric acid content
of the blood or the system, and then there are various changes of diet
that are supposed to do the same thing. These two systems of treatment
and the combination of them have constituted the main therapeutic
resource of many physicians for these so-called rheumatic cases,
though their success has been anything but what they hoped for.


Diet Tinkering.--Tinkering with diet has been particularly harmful in
these cases. Over and over again I have seen patients who had lost
considerably in weight because they had had all the supposed
acid-forming elements removed from their diet. In many physicians'
minds this seems to include most of the starches, as well as the
fruits and many meats. Without any {381} potatoes, with only a limited
amount of bread, with a warning as to red meats, and occasionally even
some distrustful remarks with regard to butter, it is not surprising
that the patients lost weight, that muscles became weaker, that
painful conditions became severer, and that, above all, the patients'
minds became less capable of bearing whatever discomfort is present.
Besides, constipation intervenes with its train of consequences and
patients become miserable, lose sleep often because of insufficient
nutrition and actual clamoring on the part of their gastrointestinal
tract for food. I have seen a man who was not much over normal weight
to begin with lose twenty-five pounds, nearly one-sixth of his weight,
while being dieted for vague pains (worse on rainy days) that were
really due to his occupation, but that had been diagnosed as
"rheumatic," consequent upon the uric acid diathesis, for which coal
tar products were prescribed over a long period and his diet
strenuously regulated. This has become as much of an abuse as the
old-time purgings and bleedings.


Irregular Treatment.--As we have said, this group of cases constitutes
the most frequent and abundant source of profit for quacks and
charlatans and irregular practitioners generally. The naturapath, the
osteopath, whom we have already mentioned, for to these cases he owes
most of his success in appealing to legislatures for recognition, the
irregular electropath, many supposed diet specialists, and even the
special shoemaker, have reaped a rich harvest from these patients. The
reason why they have done so is that, as a rule, they have at once
reassured the patients that their condition was not seriously
progressive and have promised them certain relief from their ailment.
Usually various local measures, such as St. John Long's liniment of
one hundred years ago and many of its successors, or the
mechanotherapy and the massage and the manipulation of the osteopaths
of the present day, have been employed with consequent restoration of
circulatory disturbances to normal conditions and, in general, the
setting up of better mechanical employment of muscles than was
possible before. If so-called chronic rheumatism is to be treated
successfully and this opprobrium of medicine, as it has been called,
is to be removed, it can only be done by a careful analysis of the
ills of each individual patient and a definite determination as to
just what local pathological condition is at work and not by a
slip-shod diagnosis of rheumatism with immediate recourse to a
supposed or assumed theoretic diathesis for the explanation of its
etiology.


Differentiation of Joint Conditions.--The local conditions that give
rise to painful conditions of joints are most diverse in character.
There was a time when all of the infectious joint affections had the
term rheumatism applied to them. Even at present it is not unusual to
hear of scarlatinal or gonorrheal or influenzal rheumatism. What is
meant, of course, is that the microbes of these specific diseases have
for some reason found a lowered resistive vitality in one of the
joints, or perhaps several of them, and have set up an inflammatory
disturbance. These specific arthritises are now definitely separated
from the rheumatism group and it seems clear that in the near future
we shall have rheumatism itself divided up into a series of diseases.
By this I mean that even where there is the redness, the swelling and
the fever of true inflammation of joints, it is not always due to one
microbe, but to various microbic agents, and so we shall have various
forms of rheumatism. At present we are prone to speak of many of the
neuritises as rheumatic, but it is probable that {382} here a series
of varying microbic infections will be found, some of them much more
serious than others, most of them capable of complete cure, though
some of them will tend to leave pathological conditions in nerves that
are more or less crippling.


Painful Joint Affections.--These pains and aches occur particularly in
the old and those who have been hard muscle workers, in those who have
been exposed much to the elements and especially in the subjects of
old injuries. All of these conditions, one way or another, have left
their mark upon tissues so that the nerves do not receive proper
nutrition, especially when there is considerable exertion or in rainy
weather.

There are a number of reasons why rainy weather produces this effect.
The humidity of the atmosphere lessens evaporation. This disturbs heat
conditions in the tissues, for evaporation is the most important
element in heat dissipation. This leads to the accumulation of heat in
the parts and conduces to congestion. Any tissue of lowered vitality
will be affected by this and nerves become oversensitive. Besides, it
seems probable that the fall in the barometer with the lessened
pressure from without makes a difference in the circulation. There is
a general feeling of depression in wet weather and apparently the
circulation is not so active. It is particularly slow at the surface
of the body and in the terminal portions, so that the hands and feet
are likely to be cold. Just as soon as the barometer goes up somewhat
these conditions cease to be active and there is restoration of the
circulation to its previous condition. Besides, it seems not unlikely
that dampness produces some relaxation of muscles, so that it is more
difficult to make them contract, and consequently they are used at a
greater mechanical disadvantage and painful tiredness more readily
ensues. All sensitive tissues become more sensitive in rainy weather,
though in the case of toothache or neuralgia, for instance, we do not
think of connecting this with the word rheumatism.


_Classes of Sufferers_.--In persons who are over-thin or over-stout
complaints of joint discomfort are not uncommon. In the first case
they are due to the fact that muscles working around joints are not
strong enough to accomplish their normal purposes. In the other cases,
owing to the weight of the body, the muscles are overstrained. In a
number of stout people the muscles do not increase proportionately to
the size of the frame, much of the extra weight being in the shape of
adipose tissue that constitutes a grievous burden. In people who run
rapidly to either of these conditions of disturbed nutrition--thinness
or stoutness--complaints are particularly likely to be heard. Familiar
examples are often seen in the tuberculous who have lost weight
rapidly or in convalescents from typhoid fever who are much thinner
than they were before they took to their beds. On the other hand,
those who gain in weight rapidly after typhoid fever or some other
such pathological incident, or who, as the result of careful
sanatorium treatment, put on twenty pounds in the initial stage of
tuberculosis, may have similar discomforts to complain of in and
around their joints.


Heredity of Rheumatism.--The strongest unfavorable suggestion which
most patients have is that their ailment, whatever it is, is
hereditary and therefore not amenable to treatment. Nothing is more
amusing to one who knows the present-day status of opinion in biology
with regard to heredity than the frequent declaration that rheumatism
is hereditary. Probably {383} nothing is commoner than to have a
patient who is suffering from some vague, painful condition in muscles
or joints, especially if that condition is worse on rainy days,
declare that it must be rheumatism because father or mother suffered
from rheumatism. I took the trouble to analyze in more than a dozen
cases the rheumatism that was supposed to exist in the preceding
generation, and found that it consisted of everything from pains due
to old injuries and especially dislocations or fractures, through the
various deformities connected with flatfoot, up to and including the
worst manifestations of arthritis deformans. The condition in the
parents supposed to be hereditary is never genuinely rheumatic.

There is just as much sense in talking of hereditary pneumonia as of
hereditary rheumatism. Perhaps there is an hereditary lack of
resistance in the pulmonary tissues of some people that predisposes
them to pneumonia. It must not be forgotten that a century ago, or
even less, it was not uncommon to hear that certain people had
hereditary tendencies to lung fever. We know now that these were
tendencies to tuberculosis and not to true pneumonia. We know,
besides, that tuberculosis itself is not hereditary and that probably
even the predisposition to it is not specifically hereditary.

As can be readily understood, the question of heredity in rheumatism
is extremely important for psychotherapy, since the persuasion that
their affection is inherited always produces an unfavorable effect
upon patients' minds. In the old days, when tuberculosis was
universally considered to be hereditary, a patient was likely to think
himself the victim of an hereditary condition which could not be cured
and which inevitably led to a fatal termination. Something of the same
idea, though the immediate outlook is not so gloomy, is likely to
follow the persuasion that rheumatism is hereditary. The question of
heredity, of course, is bound up with that of rheumatism being a
constitutional disease dependent on hyperacidity or some other
pathological condition of the blood. Acute rheumatism, that is, acute
arthritis, is an acute, infectious disease due to a microbe. This
ought to dispose of any question of heredity in it. Chronic rheumatism
is supposed to be related to acute rheumatism and to represent, as it
were, a low-grade enduring condition such as in sudden accessions
gives rise to acute rheumatism.


So-called Chronic Rheumatism.--In these cases it is always a question
whether the condition which causes the pain and discomfort is genuine
chronic rheumatism or not. I am one of those who doubt whether we have
any genuine, definite symptom-complex that should be termed chronic
rheumatism. I have seen many ailments called chronic rheumatism. Any
painful condition in the neighborhood of the joint that is worse on
rainy days is likely to be labeled rheumatism and, because the
salicylates are supposed to be a specific for rheumatism, treated with
large doses of these drugs. These relieve the pain, as do any other
coal tar products, but it is hard to understand how they are ever
supposed to do any good for the underlying pathological conditions.
The most noteworthy characteristic of acute rheumatic arthritis is
that it leaves no mark upon the joints that were affected by it. These
get completely better and the patient has no disability, no deformity,
and there usually remains not even the slightest sign of there having
been a serious inflammatory condition within the joints.

In this it resembles pneumonia rather strikingly. True lobar pneumonia
{384} clears up completely and the man has no symptoms once he has
come through the convalescence. There are certain diseases affecting
the joints, especially the arthritises in connection with various
infectious diseases and the arthritis which accompanies acute
arthritis deformans, in which there are serious sequelae and sometimes
even complete disorganization of the joint. It is by these
after-effects alone that we are sometimes able to differentiate
genuine rheumatic arthritis from these other very different affections
which resemble it so closely. Just the same thing is true of
pneumonia. There are pneumonias that run a course at the beginning
strikingly like true lobar pneumonia but which do not have a frank
crisis and in which the lungs are seriously affected afterwards. We
know now that in these cases it is not an uncomplicated pneumococcus
pneumonia that has been at work, but either some other infection or
else true pneumonia with a complication. Very often a dormant
tuberculosis causes true pneumonia to run a different course from that
which it ordinarily follows, and this, as a complication, leaves its
serious mark upon the lungs.

_Recurrence_.--In some cases there seems to be a tendency for the
"rheumatic" disease to recur. This also is true of pneumonia. This
does not so much indicate, however, any loss of special tissue
vitality as a certain loss of vital resistance to a particular
microbe. Certainly this tendency is not sufficient to make us think of
chronic rheumatism or use that term any more than we would, under
similar conditions, talk of chronic pneumonia or of chronic
diphtheria, though both of these affections have a tendency to leave a
lack of resistive vitality. In a number of cases, subacute rheumatism
runs a course that is very bothersome and annoying and that is quite
intractable, with relapses and sequelae, but even this is entirely
different from the ordinary idea of chronic rheumatism. It is probable
that these cases, like the pneumonias that do not end by crises, are
complicated by some other condition in the joint that leads to
reinfection.


Unclassified Forms.--It is possible that in a certain number of cases
for which as yet we have no name but rheumatism, there is a virulence
of the microbic factor that brings about some joint disorganization.
This, however--and the cases are very rare--is probably an affection
to which the name of rheumatic arthritis will not be given when we
know more of the disease and its cause. There are probably many forms
of acute rheumatic arthritis due to varying microbes which will
eventually be divided into groups, as we have made groups in the
typhoid series of diseases and in the scarlet fever group and hope to
do with other diseases.


The Individual Case and Reassurance.--The main role of psychotherapy
in these affections is to set patients' minds at rest as far as
possible, by pointing out exactly what is the matter with them and
keeping them from worry, discomfort, and even interference with their
physical condition by over-solicitude. It is important to know every
detail of the patient's occupation, of his habits, of his environment,
of his exercise, and, above all, of his individual peculiarities of
structure in the neighborhood of joints, so as to decide exactly what
is the matter with him, and not be satisfied with the easy but
unscientific diagnosis of rheumatism, which may mean much but usually
means nothing.

Unless such reassurance is given, and especially if the ordinary drug
treatment for so-called chronic rheumatism is persisted in, after a
time these {385} patients, unimproved by salicylate treatment, wander
off to all sorts of irregular practitioners and form the greater part
of the lucrative clientele of quacks and advertising specialists in
the cure of chronic diseases. More probably than any other class of
cases do they support the irregulars. Osteopathy has particularly
appealed to a great many of these patients. It has done it in two
ways. The first and most important probably by its effect upon the
mind of the patients. Osteopaths immediately proceed to reassure the
sufferers that their affection is not rheumatism, but some local
condition dependent upon either a subluxation of the vertebra which,
according to the founder of osteopathy, constitutes the basis of
ninety-five per cent. of all the ills to which human nature is heir or
upon some joint or muscle condition which can be corrected by
manipulation or massage. These patients have, as a rule, been
suffering a good deal before this from the thought that they were
afflicted with a progressive constitutional condition which would
almost inevitably cripple them. Often they have seen patients who were
suffering from arthritis deformans in its worst forms and advanced
stages; they have heard this called rheumatism and they have concluded
that it was only a question of time when they would be in the same
condition. There is no good reason to speak of such conditions as
rheumatic. They are entirely local, the hope of relief between attacks
is by properly applied massage and passive movements which facilitate
the blood supply in the neighborhood, and the best applications at the
time of discomfort are the various rubefacients which stimulate the
circulation in the parts, call the blood to the surface, and prevent
that congestion in the neighborhood of small nerves which is the cause
of the aches or pains. These affections take on a much more serious
character in the minds of patients as soon as the word rheumatism is
mentioned. To tell them that the condition is entirely local, has no
tendency to spread, has nothing to do with any constitutional
condition, and can be relieved by local measures and the improvement
of the general health, will often bring the patient a good measure of
relief.


SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS

How much the treatment of these so-called chronic rheumatisms depends
on suggestion, in spite of the apparent improbability of anything so
materially discomforting being under the influence of the mind, is
best appreciated from a consideration of the many inert materials that
have been used for the cure of rheumatism. There is, of course, no
more virtue in red flannel than in any other colored flannel, but many
people suffer from rheumatism or rheumatic discomfort whenever they do
not wear red flannel and are sure that it means much for them. Then
there are all sorts of supposed electrical contrivances that do not
generate an ion of electricity. They are effective only through the
appeal they make to the mind. Some men wear electric belts and
attribute their freedom from rheumatic pains to them. Others wear
so-called electric medals or electric shields or electric insoles. Any
number of people in this country wear electric rings on the little
finger of one hand and get marvelous relief from it for their chronic
rheumatism. Some have noted good results from even less likely
objects. There are thousands in this country who carry horsechestnuts
as a preventive against rheumatism, and some of {386} them,
intelligent men and women, are persuaded it lessens their pains and
aches.

In another place I have told the story of the woman who was a sufferer
from rheumatism and who found great relief from carrying a
horsechestnut. As her husband was also a sufferer, she wanted him to
carry one, too, and when he would not, she carried one for him. It is
to be hoped that her conjugal tenderness in this matter had as good an
effect on him as she was sure the propinquity of the horsechestnut had
on her.

The patients' occupations must be regulated by proper advice and
detailed directions, and distractions of various kinds must be
provided to keep their minds from becoming concentrated on certain
portions of their body, emphasizing whatever discomfort is present and
preventing nature's curative processes. Finally, local treatment of
various kinds must be employed suitable to each individual case, that
will remove all mechanical difficulties, disperse congestions, relieve
fatigue and over-tiredness, and make conditions favorable for the
healthy, normal use of joints and muscles.

Many painful affections of joints, sometimes complicated by
immovability, are really psycho-neuroses. Sir Benjamin Brodie once
said that four-fifths of the joint troubles that he saw among the
better classes were hysterical. Sir James Paget thought this an
exaggeration, but confessed that he saw many of them and among all
classes of people. One-fifth of those that he saw in hospital and in
private practice were entirely neurotic. He emphasized the fact that
they must be looked for not only among women but that they are often
found in men and that they are by no means confined to those who are
nervously inclined, the silly young women or the foolish old women,
but that they may be found in special circumstances among the most
sensible people. They are often initiated by an injury which makes it
quite difficult to differentiate them from real joint affections.
Usually, however, there is no redness, nor swelling nor heat with
them, though sometimes one of these symptoms at least may occur with
the redness. The connection between the trivial accident and the large
reaction is usually hard to find and causes a suspicion as to the real
process at work. Often, too, there is a delay of several days or
sometimes weeks after the accident before the neurosis declares
itself. In the meantime it has been getting on the patient's mind.

In general, it must be remembered the patient's attitude of mind in
these cases of pain around joints and in muscles is extremely
important. They have furnished a goodly proportion of the patients on
which quacks and charlatans have fattened. Greatrakes in the
seventeenth century, Mesmer and Perkins, St. John Long, the early
electrotherapeutists, the blue glass faddists, all the various
liniment makers, many of the manufacturers of blood purifiers, and
Eddyism and mental healing besides osteopathy in our day have all
benefited these sufferers for a time and the patients have often been
men and women of education and influence in their communities and have
exerted their influence for the benefit of their supposed benefactors.
The methods of treatment come and go. The promise of the physician or
the healer and the confidence of the patient are the only factors that
are common to all the supposed "cures." If people stay at home without
the air and exercise they should have, if they nurse their ills and
consider that they are sure to get worse, because they labor under
hereditary or constitutional ailments, nothing will benefit them.
{387} If they are convinced that their disease is only local and begin
to go out to see their friends once more, a change comes over the
whole aspect of their disease.



CHAPTER II

OLD INJURIES AND SO-CALLED RHEUMATISM


As people advance in years, it is a common experience that tissues
injured years before are the source of no little discomfort and are
particularly prone to be bothersome during changeable seasons and in
rainy weather. A bone broken when the patient was young may twenty or
thirty years later continue to give warnings of the approach of change
in the weather and be a source of annoyance. A dislocation, especially
if complicated in any way by considerable laceration of the tissues in
the neighborhood of the luxated joint, is sure to be a source of
discomfort of this kind. These painful conditions are generally more
noticeable when patients are run down, or when they have been recently
affected by exhausting disease of any kind, during convalescence from
severe ailments or injuries, or when they are undergoing a special
mental strain. These conditions, like nearly all others worse in damp
weather, are sometimes grouped under the term rheumatism and have been
treated by internal medication. Almost needless to say, such treatment
is sure to fail or to be of only temporary anodyne benefit. As
rheumatic remedies are usually coal-tar products they may even be
distinctly harmful, especially for old patients. It has been shown
that the salicylates, for instance, are much less rapidly eliminated
in the elderly than in the young, in those with defective circulation
or kidney insufficiency than in the well. Their accumulation in the
system causes anemic tendencies and disturbs nervous control.

Just what is the underlying pathological condition in these cases is
not easy to say. In the case of luxations with laceration of tissues
there has undoubtedly been such a disturbance of venous and lymphatic
circulation by the break in continuity of tissues and the resultant
scar tissue, that lymphatic if not also venous congestion occurs
whenever there is any circulatory disturbance. For the maintenance of
normal nutrition of nerve endings a constant flow of blood past them
and a proper action of the lymphatic channels to carry off waste
products is essential. It is easy to understand how much these may be
disturbed in the injuries under consideration. When a bone is broken
there is usually laceration of the surrounding tissues. Owing to the
fixation required to procure proper bony union, the circulation to the
part is much more defective than usual and so the repair of torn lymph
and venous vessels is not as complete as would otherwise be the case.

This seems to explain why such injuries are especially called to the
attention of the patients in damp weather. It is not so much during a
rain storm as some hours before it, about the time when the barometer
begins to drop, that these old injuries become sensitive. Indeed, it
is often said that old persons who have suffered one of these injuries
earlier in life carry a barometer around with them.

Not a few of the lesions called sprains, especially those of the
ankles and {388} wrists, though also of other joints, are often really
breaks of small bones, or at least laceration of ligaments and other
structures. These may long afterward prove a source of pain and
discomfort, worse always in unsettled weather, or after the feet have
been wet, and may seem to be due to some constitutional condition,
though they are merely local. These occur more commonly in women than
in men and the condition needs careful investigation and must not be
put under the vague diagnosis of rheumatism, or the patient will
probably not be improved by the treatment suggested. In all these
cases the general condition must be looked to, and it must not be
forgotten that fat may not mean health, and that increased weight may
be a prominent factor in the production of symptoms in these cases,
especially when individuals live a sedentary life.

There is an important therapeutic method for the prophylaxis of these
conditions that has been attracting attention and yet probably not all
the attention it deserves in recent years. Prof. Lucas-Championnière
of the University of Paris has pointed out that when fractures and
dislocations are treated by the open method with easily removable
apparatus and the employment of massage within a few days after the
fracture, the subsequent discomfort of these lesions is much lessened.

It seems worth while to emphasize this treatment by manipulations and
massage, because it represents a psychotherapeutic factor in the
treatment of these injuries. The hiding away of a limb or a joint for
days and perhaps weeks, while they wonder whether it is getting better
or not is most discouraging to patients. To have the physician see it,
to have him declare that it is getting on well, to have the evidence
of their own senses that conditions are gradually improving, is of
itself a valuable factor for that satisfaction of mind which conduces
to the regular functioning of tissues. Repair undoubtedly goes on
better under such circumstances. Besides, the lack of constriction or
at least its rather frequent periodic relaxation, the airing of the
skin, the regulation of the circulation by massage and manipulation,
all react upon the mind and prevent it from inhibiting trophic
impulses and encourage it to stimulate them in every way.

As to the after-effects of fractures and dislocations as with regard
to all this series of vague pains and aches, the patient's attitude of
mind is of great importance. As they get older their aches and pains
grow worse, partly because circulation is more defective and partly
because they are prone to be much more in the house and the nerves of
patients who are much within doors are always more sensitive than
those of people who are much in the open. If their attention becomes
concentrated on their pains and aches, because of lack of diversion of
mind, then the condition may become a source of serious annoyance.
When these painful conditions develop patients are almost sure to keep
much to themselves and to nurse their ills, and consequently to
increase their discomfort. The circulation to the affected parts must
be stimulated by local treatment, by rubbings, by the milder
liniments, by massage and manipulations, and by local hydrotherapy.
Douches, as hot as can be borne, on the limb followed by cold,
especially if patients are otherwise in good health, will do much to
relieve the stagnant circulation.

Active and vigorous movement while the affected part is supported at
_skin pressure_ (there must be no constriction) is even more valuable
than {389} massage, liniments or douches in the treatment of all these
painful conditions of joints in which there is any scar-tissue.
Wonderful results may be obtained in an old sprain of the wrist, knee
and ankle by covering in the part completely (taking care to surround
the limb) with strips of adhesive strapping simply laid on at skin
pressure, but following exactly every fold or angle of the part, and
then with the part completely covered in this way to urge immediate
and constant exercise. The maintained pressure prevents any tendency
to venous congestion or exudation and favors absorption of fibrous
tissue, and exercise, which should be immediate, is now possible
through the support furnished by the strapping. The re-assumption of
normal active movement molds the old scars, strengthens the muscles
and ligaments and improves the patient's general condition. The relief
afforded _is immediate_, and the cause of relief, a simple mechanical
device, is apparent. Rheumatism is forgotten as the old crutch is
discarded and the patient is able to use the limb with confidence.

Recent sprains or bruises treated in this way recover perfectly and do
not leave old scar tissue to be a future seat of pain.



CHAPTER III

MUSCULAR PAINS AND ACHES


Whenever exposure to cold causes a period of discomfort in almost any
organ, except the teeth and certain definite nerves (for neuralgia has
been taken out of the rheumatism group in recent years) we are sure to
hear the word rheumatism employed in connection with it. To add to the
confusion, the various "specialists" have taken to assuring their
patients that local manifestations in the eyes, in the ears, and in
the nose, for which they can find no good reason, especially if they
are worse in damp weather, are signs of the rheumatic diathesis.

Unfortunately, our supposed knowledge of the uric acid diathesis
became widely diffused, and it is not surprising in the light of the
widespread acceptance of this theory, that muscular pains of all kinds
should have the word rheumatic attached to them, and that patients are
sure that the discomfort is only one manifestation of a severe
constitutional disease, which they cannot but infer will probably make
still more serious trouble for them in years to come, since it seems
to be dependent on conditions beyond their control, such as heredity
and general constitutional traits and their special mode of nutrition,
rather than on local or passing conditions.


Local and Constitutional Conditions.--It cannot be repeated too often
that it is this persuasion as to the constitutional character of the
disease that has in recent years proved a very unfavorable suggestive
element in these cases. Patients think themselves the victims of a
serious diathesis, a deep-seated pathological condition, and attribute
a host of feelings to it that are sometimes rather seriously
disturbing but are really only sensory manifestations of various kinds
in the organs and in the skin and muscles, which would be attributed
to simple local causes--fatigue, faulty mechanical conditions,
etc.--but for the concentration of attention on them.

{390}

_Individual Cases_.--The careful study of these cases is thus
extremely important. They are eminently individual and not to be
grouped together. The exact diagnosis of the various conditions from
which each patient is suffering is of itself a precious factor in
psychotherapeutics. The precise recognition of the condition present
is of immediate avail in helping him to dismiss many of his symptoms,
or at least to keep him from thinking as much of them as he did before
or inevitably will if the older ideas as to the constitutional nature
of his affection are allowed to remain.

Nearly every large group of muscles in the body may be the subject of
these painful conditions. In recent years, perhaps, the muscles most
affected in this way are those that pass around the ankle and give so
much discomfort in cases of flatfoot, or beginning flatfoot
(euphemistically called weak foot), when the plantar arch is yielding.
The manifestations are not only in and around the ankle, but occur in
the calf muscles and even above the knee. These painful conditions
always develop unless the arch is supported. Until recent years it was
rare to discover a bad case of flatfoot in which the patient had not
taken many rheumatic remedies and had not come to the conclusion that
he was the subject of an incurable and probably hereditary
constitutional disease. Flatfoot is likely to cause considerable
deformity in the old, the toes becoming bent and twisted up, and the
subjects of it complain very much of their feet. Flatfoot runs in
families. When the father and mother have complained of what they
called rheumatism in their feet which got worse every year, then the
son and daughter, when they have their first manifestation, conclude
that they are inevitably bound by the stern laws of heredity.


Occupation Aches.--Flatfoot is taken, however, only as an extreme and
therefore striking illustration. Whenever a particular group of
muscles has to do an excessive amount of work, practically always
there is a development of an uncomfortable condition worse on rainy
days and therefore likely to be called rheumatic. Over-use of the arm
at any occupation, in writing, in the use of a file, at an
ironing-board, in sewing, or at anything requiring repeated movements,
will produce it almost inevitably. Especially is this true if the
occupation is carried on without such careful attention to muscular
action as enables the muscles to do their work to the best advantage.
These painful conditions are much more likely to occur in run-down
individuals of nervous temperament, above all if they have been or are
subject to worry. Men who have lost money and now have to do hard
physical work, after previously having lived sedentary lives, and
women whose previous source of support has been withdrawn and who have
to work for a daily wage after former gentle conditions of living, are
especially likely to suffer in this way. The conditions develop on a
neurotic basis or an exhausted nervous system.

Other groups of muscles may also be the subject of these painful
conditions. The large group in the loins, called the lumbar muscles,
which are so important for stooping, for the erect posture and for
lifting, are so commonly the subject of discomfort that a special name
has been applied to their affection--lumbago. In the leg the large
group of muscles supplied by the sciatic nerve are likely to be
affected, and this affection is so common in men who have to bend the
knee and flex the hip at their work that it, too, has received a
special name--sciatica. Besides the arm muscles the groups of muscles
around the shoulder girdle are often unfavorably affected and though
we have not invented {391} a name to cover their conditions, it is so
common that we think of it as a separate entity almost in the same
manner as we think of lumbago and sciatica. In the neck the group of
muscles that rule the movements of the head, especially those at the
side may be affected and the special name of torticollis has been
given. Practically all of these affections are thought of at times as
rheumatic and the ordinary rheumatic treatment is given for them.
There is no doubt that the salicylates will relieve the pain almost at
once, but so will any other coal-tar product and phenacetin,
acetanilid or even antipyrin may be used with good effect. There is no
evidence, however, that these drugs make the underlying condition
better and, indeed, after patients have tried them for a while, unless
the affection is merely passing, they try some other physician and
perhaps are treated the same way with a different form of the drug.
These are the cases that make their way around to a number of regular
practitioners of medicine and then eventually go to some irregular or
quack and sometimes obtain relief where the regulars have failed.

When the irregular succeeds it is always because he has done three
things. First he has persuaded the patient that it is not rheumatism,
with all the unfavorable suggestion that goes with that word, that is,
the matter with him; secondly, he has treated the local condition;
and, thirdly, he has diverted the patient's mind. Local treatment is
often the real secret of his success, though the psychotherapeutic
element is not without distinct benefit.


Mode of Occurrence.--These muscular conditions present themselves
under two forms, acute and chronic. The acute condition occurs almost
suddenly and is accompanied by spasmodic pain and acute discomfort.
Muscles go into spasm to avoid the movement that would necessarily
bring pain with it. A typical example is found in torticollis in which
the patient wakes up some morning to find a stiffness in the muscles
of his neck with limitation of movement much more pronounced on one
side, and this usually gets worse as movements are attempted during
the day. This spasmodic painful condition usually lasts for some days
and suggests all sorts of topical applications and often requires
anodyne drugs. A similar acute condition may be observed in some cases
of lumbago. In this the pain in the loins comes on suddenly, usually
during movement, often in the midst of lifting something that one has
been able to lift without difficulty before. This pain is so sudden,
so unexpected, usually comes entirely without warning and seems so
mysterious in its origin, that it is no wonder the Germans speak of it
as _Hexenschuss_--"witches' shot"--a remnant of the superstition that
a witch, by means of the evil eye or some other maleficent power, or
by sticking pins in a wax image of a victim that had previously been
devoted to the devil, might produce effects upon the person at the
part where the thought was directed or the pin inserted.

These painful conditions, especially when acute, are, as a rule the
consequence of exposure to dampness, or to a draft blowing directly on
the part, usually in damp and changeable weather, and often when the
patient has been sweating just before. The train of events that brings
about the painful condition is not difficult to understand. There is a
disturbance of the normal smooth-running, indeed almost frictionless,
mechanism by which muscles glide over one another. There are
practically a series of joints in all muscular groups so as to permit
just as free a play as possible of muscles over one another. Each
muscle is covered with a glistening membrane so familiar {392} from
our dissecting room days, which secretes a substance resembling a
synovial fluid, to enable muscles to move upon each other without
friction. When, because of exposure to drafts or the evaporation of
moisture on the surface, there is a disturbance of the circulation in
these intermuscular planes, the secretion which prevents the friction
of muscle movements is disturbed. The blood is driven from the surface
and some congestion and consequent heat accumulation occurs in the
muscles, affecting particularly their contiguous layers. As a result,
the muscle surfaces are no longer smooth and the muscles now have not
as free play over one another as before. It is not surprising that,
owing to this, sensitiveness occurs and some spasm develops. This,
however, is thoroughly conservative in character since nature's idea
is to set the part at rest so as to allow the normal condition to be
restored.

This is the pathological condition that underlies these so-called
muscular rheumatisms which develop suddenly. It is important to note,
however, that these conditions develop nearly always in people who
have been over-using or wrongly using the groups of muscles which
become thus affected. The history of a torticollis patient will
usually show that there is some contortion of the muscles of the neck
familiarly practiced by him. Sometimes it will be found that the
patient has the habit of sitting on a particular easy chair in a
special relation to the light and that in order to accommodate himself
to his chair and the light in his reading, the head has to be placed
in such position that the neck muscles are constrained. It is this
that predisposes the patient to the development of the condition which
seems to be so acute and yet is really only an exacerbation of a
chronic condition. Lumbago will develop in men who have been stooping
much, especially for heavy lifting, or in women who scrub or have to
stoop much while cleaning, dusting and the like.

Some interesting muscle pains occur as a consequence of the jostling
movements of various modes of transit. They are particularly
noticeable if an uncomfortable position has been maintained for a
number of hours. People who travel on railroad trains often come with
the story that they _must_ have caught cold on the trip for they have
been sore and achy in many of their muscles since. I have known people
who went on a crowded excursion and had to stand for several hours
confident that, standing in the drafty aisle of the car on their way
home, they had acquired rheumatism. All that had happened was
over-tiredness of muscles on the jolting train which required constant
balancing and unaccustomed muscular exertion. On board sea-going
vessels people often suffer from pains in the loins and in various
trunk muscles, due to the roll of the vessel, especially while they
are asleep. These, too, are likely to be attributed to drafts, or to
some form of rheumatism, or at least to the catching of cold. I have
even seen people sure, because of pains in their loins, that they must
be developing some kidney trouble. After a time they get used to the
swinging motion of the vessel and then their achy muscle tiredness is
relieved.

One now sees affections of the same kind in connection with the
automobile. People who ride for many hours, especially if the riding
is rapid and over a rough road and they are not used to it, are likely
to develop pains and aches which they may attribute to the catching of
cold or to rheumatism or to something of that kind. The muscles of the
trunk are especially likely to {393} suffer. The abdominal muscles may
be quite sore and then later the lumbar muscles develop aches. The
arms suffer if they are held in unusual positions because of the
jolting. The discomfort may be relieved by any of the coal-tar
products, though gentle rubbing with a stimulant such as soap
liniment, always in the direction of the return circulation in the
muscle, will help to relieve the painful condition. The salicylates
are often given for these conditions and relieve the discomfort but
because of their value as anodynes, which they share with the coal-tar
products, and not because of any genuine antirheumatic effect.


Treatment.--Counter-irritation of various kinds, especially the milder
forms, always seems to do good. The underlying therapeutic principle
seems to be that the attraction of blood to the surface lessens the
hyperemia or at least diverts the circulation and permits the
restoration of function and encourages the reintegration of normal
conditions. Rubbings are especially helpful if accompanied by rather
deep pressure from the periphery of the circulation towards the
center. The leg muscles must be rubbed upward, the arm muscles upward,
the neck muscles downward, the trunk muscles generally in the
direction of their return circulation. This would seem to indicate, as
might be expected, that it is the venous circulation especially that
is disturbed in the tired condition of the muscles, that a venous
congestion with interference with the nutrition of nerves accounts for
the aches; hence, a mechanical helping of the circulation is of
benefit. There are some whose opinion is not to be put aside lightly,
who think that the rubbing alone is the most important part of these
external treatments and that the liniments and counter-irritants are
only of secondary importance. Indeed, some consider that the tingling
of the surface is mainly beneficial in making the patient feel that
now that part of the body at least _ought_ to be better.

Liniments for these conditions, however, though introduced on merely
empirical grounds, are very old and have the testimony of many
generations as to their therapeutic efficiency. Whenever that is the
case, it is a serious question to doubt the conclusions that have been
arrived at. The experience of a single generation, and, above all, of
a small group or school of men, no matter how learned or how
scientific they may be, is often fallacious. The experience of many
generations, however, even though no good reason for the benefit
derived from the treatment they suggest can be found, is almost
inevitably correct. After all, though it is usually forgotten, the use
of mercury, of iron, of quinin and of most of the tonics depends on
nothing better than empiricism. In our day the liniments have been
neglected, more perhaps than was proper, considering how many
generations of physicians found them beneficial.

Where it is a neurosis rather than a real disturbance of the
circulation, however, that is involved, the use of a counter-irritant,
by attracting attention more and more to the part, may really do more
harm than good. In nervous people it must be remembered that local
neurosis may occur almost anywhere in the body and that subjective
discomfort alone in these cases must not be taken to signify a
pathological condition, unless the localization is such as to indicate
that a particular group of muscles is affected. The differential
distinction between a pure neurosis and a discomfort due to a true
pathological condition in the intermuscular planes is, that in the one
case a group of muscles is affected, while in the other a locality is
complained of, and {394} while local tenderness is likely to be a
marked source of complaint in the neurosis it is comparatively slight
as a rule in the muscular condition.

For the more chronic soreness and discomfort of muscle groups,
manipulations with massage are of great importance. Undoubtedly the
discomfort and soreness is due in most cases to a disturbance of the
venous or lymphatic circulation of the parts. This interferes with the
nutrition of nerves and leads to nerve sensitiveness from lack of
nutrition, or actual nerve irritation from pressure upon sensitive
nerve endings while in a state of congestion. These conditions may be
relieved by gentle manipulation and by massage, provided always these
measures are not painful. These encourage the circulation and very
soon tend to restore functions. Just as soon as the pain of these
remedial measures or of any mechano-therapy becomes noticeable, it is
not likely that they are doing any good. Pain, of course, must be
judged from conditions and not from the patient's complaints, which
may be due to fear lest pain should be inflicted.

The main point is that local treatment, gentle, simple, yet directed
with the proper therapeutic purpose so as to create a favorable
expectancy in the patient's mind, will do much for these conditions,
which have in many ways been the opprobrium of modern medicine. The
rule has almost been to call them rheumatism, because they were worse
in rainy weather. The word rheumatic instinctively calls up in most
physicians' minds some cut-and-dried formula of internal medication.
So these patients go the rounds of the regular practitioners in
medicine taking a series of these formulae in succession and, as a
rule, not getting any better. Then they go to an osteopath or to a
naturapath, or some other kind of path, have some local massage and
manipulations performed, which restores the circulation of the part,
to some degree at least, and as a consequence they are encouraged to
look for further relief. Not a few of them find the relief they look
for, and it is these cured patients that in many parts of the country
have insisted on securing for the osteopaths legislative recognition
and actually obtained it for them in many cases, just because the
regular physicians have neglected methods of cure ready to hand, but
not made use of, because drugs are allowed to occupy their attention
too exclusively.


Disuse, Atrophy and Pain.--I have seen a striking example of atrophy
and pain due entirely to disuse in the upper part of the leg as the
consequence of a fall. No bone was broken, the man was laid up for
nearly a month from the wrench, and then continued to be somewhat halt
for many years. After nearly twenty years his attention became
concentrated on this limb and then he spared it more and more in his
walking, tilting his pelvis and merely swinging that leg, until there
was a difference of nearly two inches between the size of the thighs.
Of course, under these circumstances any use of the limb brought
fatigue and pain with it. To walk was painful, and he had some
twitchings at night. There was no disturbance of sensation, however,
anywhere and no reaction of degeneration. His knee jerk was slighter
than on the other side, but it was present and the weakness was due to
the loss of power in the muscles. It was only weak in proportion to
the atrophy of the muscles. This atrophy was not trophic in the sense
of any failure of nerve impulses from the central nervous system, but
was due to disuse, that is, it did not come from any nervous lesion,
central or peripheral, nor from any disturbance of circulation, but
from the dwindling of muscles that inevitably {395} comes when they
are not employed for their proper purpose. Power to use depends on
continuance of function.

All sorts of remedies had been employed in his case, but he did not
improve until he was made to understand that there was no bone lesion,
no lesion of nerves or muscles, and that what he needed to do was to
re-exercise his muscles gently but persistently and confidently back
to their normal strength. This was accomplished by exercise and
resisted motion, with care never to fatigue the muscles, but at the
first sign of tiredness to stop, taking up the exercises at first
twice, and then three and four times a day.

As can be readily understood, these curious atrophic muscular
conditions from disuse occur more frequently in the legs than in the
arms. They may, however, occur in the upper extremities and are noted
sometimes in the trunk. After all, certain of the stooping postures of
men as they get old are due to lack of use of the large muscles at the
back with consequent atrophy of them to the extent that makes standing
up straight an effort very fatiguing and even painful. To attempt to
straighten an old man by means of braces will lead to the development
of painful conditions of tiredness if the correction is emphasized. In
the arms the atrophic conditions are not so noticeable because the
arms may be used without having to do the hard work required of the
trunk and leg muscles in holding the man erect. It is the fear of the
strain put upon them by this weight that makes the disuse continue,
since there has come into the mind the thought that the muscles cannot
be used to bear the weight and the burden is thrown on other muscles
with unfortunate results.

Many of these atrophies from disuse are cured by mental influence of
one kind or another. They are the best sources of profit and
reputation of the "healers." Once the patients become persuaded that
they can use a group of muscles if they will, they begin to improve,
and it is only a question of six or eight weeks until they are so much
better that they persuade themselves that they are as well as ever. It
is easy to understand that if a person who has been lame for five to
fifteen years, vainly going to physicians of all kinds, is cured by
some new form of treatment, all the non-medical world is perfectly
sure that there must be much in the new method of treatment.



CHAPTER IV

OCCUPATION MUSCLE AND JOINT PAINS


There is one variety of painful conditions of muscles and joints,
often spoken of as muscular rheumatism or as chronic rheumatism and
frequently the source of so much discomfort that patients feel that
occupations must be given up, even at a great sacrifice. These deserve
a special chapter. They occur in persons who have some occupation
which requires them to use a particular group of muscles a great
number of times during the day. They are most frequent in the arms,
but they may be seen in the muscles of the neck, they occur very often
in the legs and are not at all infrequent in the muscles of the trunk.
Whenever a patient comes complaining of a painful condition in a
particular group of muscles, careful inquiry must be made as to his
{396} occupation, with details of the movements required. These pains
are, of course, as are all human discomforts, worse on rainy days and
in damp seasons, so that this has come to be known as rheumatic
weather. It is easy to assume without further inquiry that they are
rheumatic and this has been done frequently in the past.

There is scarcely any occupation involving frequent and habitual use
of muscles which may not be the source of discomfort if the actions
necessary for it are done in such a way as not to use the muscles to
the best mechanical advantage. In other words, there are a whole group
of occupation fatigues which may take on a character of painful
discomfort if the individual has not been properly trained in the use
of his muscles. This refers not only to the use of muscles in the
accomplishment of rather difficult tasks, but especially for those
that require nice co-ordination for their accomplishment, though they
may not demand the exertion of much muscular energy. In other words,
what we have to deal with are rather painful occupation-neuroses than
muscular fatigue in its proper sense.


Writers' Ache.--Perhaps the most typical example of these is the
painful conditions that may develop in connection with writing.
Writers' cramp is well known and consists in a contraction of muscles
which makes it increasingly difficult to hold the pen properly for
writing and may eventually make it impossible to do so. This is
accompanied by a certain amount of distress, but the writer's
discomfort that is much more common than writers' cramp does not occur
in the fingers, but in the large group of muscles just below the elbow
and may extend even to the shoulder. The pain is of a vague achy
character and as it is worse on rainy days and in damp weather, the
temptation to think of it as rheumatism is very great. It occurs in
people who write very much and rapidly, but especially those who write
in a bad position. Now that the typewriter has come in much less is
heard of it than before among reporters, but it used to be common with
them. There is very little hint that it is due to writing, unless one
makes careful inquiries.


_Gowers' Rule_.--Its occurrence can be lessened to a great extent by
following Sir Wm. Gowers' directions as to writing. Gowers was a
parliamentary reporter before becoming a physician and he learned the
difficulties of much writing and studied out the causes of the
discomfort as well as of the cramp and of the best methods to avoid
it. His rule is to sit on a rather high chair before a rather low
table so that the elbow swings free of the table and the writing is
what is called free-hand. The extent to which Gowers demands this
freedom of the elbow carried may be best appreciated from his
direction that the writing must be done in such a way that if a second
pen were fastened to the elbow, it would write exactly the same thing
that is written by the pen held in the hand. There must not be any
movements of the fingers nor of the muscles of the forearm. All the
movements required from writing must be accomplished from the
shoulder. Just as soon as sufferers from vague aches and discomforts
from much writing learn this method of writing, their aches disappear
to a great extent. My own experience in the matter, when, as a medical
reporter, I often wrote ten thousand words a day, taught me the value
of the suggestion. During one winter I suffered so much from
discomfort in the shoulder that I was sure that I had a progressive
rheumatic affection. Just as soon as I learned to write properly the
trouble was minimized to such {397} a degree that I realized that it
was merely a question of faulty writing. I have noted over and over
again, as is true in my own case, that if there has previously been
any injury in the arm, this discomfort is much more likely to develop
than otherwise.


Occupation Pains and Habitual Muscle Movements.--What is true for
writing is true for any habitual movement of groups of muscles
requiring careful co-ordination. I have seen it in marked form in the
makers of cigars and the strippers of tobacco. I have seen it in men
who do much filing and whose working bench is so high, that pressure
direct from their shoulders cannot be brought into play to supply any
force that is needed in carrying on the filing process. If such a
series of movements as filing is to be accomplished with comfort, then
the arms must be held straight, the force being applied from the
shoulders and not by the exertion of the muscles of the forearm, which
are meant only to guide and not to supply the needed pressure. The
Sloyd methods of working at benches are particularly important for
workmen if they are not to develop these curious painful conditions
which are due to habitual wrong use of muscles, and not to any
diathesis. Any and every form of work must be looked at from this
standpoint. Women often iron at a table or ironing board placed too
high for them, and as a result apply the pressure necessary through
their forearm muscles. If they are at all of nervous constitution they
will suffer rather serious discomfort from this after a time and this
will always be worse in damp weather. I have known women ready to give
up because of the discomfort thus occasioned, who found that they
could work without muscle discomfort for much longer periods, if the
ironing board was placed low enough.


_Arm and Shoulder_.--The occupation aches and discomforts in the arm
and shoulder are very frequent and their variety presents an
interesting study in the individual and his history. I remember once
having three cases present themselves at a dispensary service of the
Polyclinic Hospital on the same day, all presumably suffering from
rheumatism. One of them was a motorman suffering from the occupation
pains that so often come to those who use their arms overmuch, and the
pains seen so frequently, for instance, in baseball pitchers. These
pains are always worse on rainy days and in damp weather. There is of
course a large individual element as the basis of these. Why can one
man pitch nearly every day all season and not suffer with his arm
while another man cannot? We can no more tell the reason for this
difference than we can tell why one man is right-handed and another
left-handed. One individual has a store of nervous energy that serves
him very well. Another has a store of nervous energy that serves him
well enough for his left hand but not for his right hand. The mystery
would seem to be the original endowment of nerve force according to
the individual's constitution. The motorman who suffers severely from
putting on the brake of a heavy car will probably never be able to
continue his occupation with comfort to himself unless his sore arm is
due to some temporary condition, easily recognizable.

A second of my patients with rheumatism complained of his shoulder. He
had been first easily fatigued, then it was painful when he moved
much, most so on rainy days, and finally he had practically lost power
in it entirely. His occupation was that of finisher in a molding
works. He lifted a heavy hammer many hundreds of times a day with his
right arm, striking quick short {398} blows and using mainly his
deltoid muscle in the lifting process. It was just his deltoid that
was affected and the nerve supply had evidently given out. The third
man complained not of his right hand, but of his left and of his
forearm, not his shoulder, having lost power especially on the ulnar
side of his hand. He was a stonecutter, who held a chisel firmly in
his left hand, grasping it mainly with the under or ulnar side of his
hand, and consequently overusing the group of muscles supplied by his
ulnar nerve, leaving that structure open to pathological conditions.

There was just one feature in the history of all three that was the
same. They did not drink alcohol to excess often, but they did take
some whiskey straight every day. The easiest explanation seemed to be
that there was a neuritis set up in the nerves, which their
occupations caused them to use so much, and that, as a consequence,
the low grade neuritis finally developed to such a condition as to
make further use of the muscle supplied by the affected nerves
practically impossible. Just why alcohol will select certain nerves
and not others upon which to exercise its deteriorating influence and
why lead usually affects an entirely different set we do not know. In
the ordinary man of sedentary occupation who walks occasionally, as
his only exercise, his most used nerve is his anterior peroneal. Those
of us who are not used to walking much, know how soon this nerve
complains of fatigue when we take some forced ambulatory effort. It is
this nerve then that with most people is affected by alcohol. But any
nerve that is overused will apparently be affected the same way, and
as many outdoor workers take some whiskey straight pretty regularly,
it is not surprising to find that some of them have an idiosyncrasy
and develop a low grade alcoholic neuritis.

Alcohol, however, is not the only substance that acts thus
insidiously. I was once asked to treat a painter who was suffering
from intense tired feelings in his right forearm. They were always
worse on rainy days, and he had been treated for rheumatism without
avail. He had no signs at all of wrist-drop, there were no suspicious
signs on his gums and he had never suffered from constipation or
anything like lead colic. It seemed far-fetched, then, to say that his
muscles were fatigued mainly because of the irritating presence of
lead in the nerves supplying his right forearm. He slipped on the ice,
however, and sprained his wrist, and the next day turned up with a
typical lead wrist-drop. This fact of having lead poison develop
shortly after an accident is not unusual, just as a sprained ankle may
sometimes be the signal for an outbreak of alcoholic neuritis in the
lower leg which has been preparing for some time, the accident itself
being at least partially accounted for in many cases by the
awkwardness of muscles with disturbed nerve supply.


_Leg Occupation Pains_.--What is true of the arm is also true of the
leg. If a man uses his leg muscles very much and especially at any
mechanical disadvantage, he usually suffers painful discomfort that is
always worse on rainy days. Before the invention of the electric
dental engine, dentists used to suffer from this and the profession
talked about the "dentist's limp." This was also more painful in damp
weather and many of them were treated for rheumatic conditions, though
it was really only over-fatigue.


Neurosis and Neuritis.--There are many cases of painful conditions in
the limbs where it becomes difficult to diagnose between a neurosis
and a neuritis. The usual differential characteristic of tender points
along the course of the {399} nerve cannot be used in many patients
with confidence, because they are prone constantly to respond to the
question "is that tender" in the affirmative. Besides in a neurosis
there always seems to be a hypersensitiveness of the nerves involved
that may simulate the tenderness of neuritis. In a number of obscure
cases I have felt that the condition was a real neuritis when the
development of a corresponding condition on the other side, or relief
on one side followed by development on the other, has led to the
diagnosis of neurosis. Of course, a double neuritis may well occur in
the same nerve on both sides of the body under certain toxic
conditions. Double sciatica nearly always indicates glycosuria.
Diabetes may cause double neuritis in any other much used pair of
nerves. Alcoholic neuritis may manifest itself on both sides.
Ordinarily, however, the transference of symptoms or their spread to
the other side of the body means a neurotic condition.

In some of these cases where it has been difficult to distinguish
between neuritis and neurosis, a change of occupation or some strong
diversion of mind for a considerable period or a change of residence
has proved the beginning of a cure. I have seen what was considered by
experienced physicians to be a chronic low-grade neuritis of quite
intractable form clear up completely as the result of the young woman
being compelled to take up a wage-earning occupation, when it had
always seemed before as though life was going to be smooth and there
was no necessity for her to labor. I know of cases of so-called
neuritis that had been very obstinate to treatment that were cured by
Eddyite treatment. What really happened in these cases was that a
group of muscles used considerably more than usual had produced a
painful tired condition referred to a particular nerve. Just as soon
as the mind's inhibitory action was taken off them by the persuasion
that there was nothing the matter with them the patient proceeded to
get well, gradually progressive use bringing back the normal trophic
condition.


Discomforts of Bursae.--In any consideration of painful conditions in
and around joints, especially in connection with occupations, the
question of the formation and of the inflammation of bursae must be
insisted upon because many of these inflammatory incidents are
confused with joint affections and not infrequently treated as if they
were due to constitutional disturbance. Practically everybody is
familiar with housemaid's knee. Most people know that bunions are
inflammations of the bursae which form over the metacarpo-phalangeal
joint of the big toe whenever there is pressure and irritation of it.
Very few realize, however, that frequently repeated irritations, when
pressure is exerted over other joints and bony projections, will
produce a bursa, and then, if the irritation continues and an
opportunity for infection occurs, there is bursitis. Some of these are
mistaken for other conditions and often have been thought by the
patient to be serious developments of one kind or another with regard
to which there has been much solicitude. An interesting case of this
kind in my experience was that of an Italian organ-grinder who
suffered from the occupation bursa which so often forms over the
anterior superior spine of the ilium because of the frequently
repeated rubbing of the hand and arm as it passes this region while
turning the handle of his instrument. It had finally become inflamed,
and the Italian was much disturbed and he feared that it was
appendicitis.

Other bursae are not commonly seen in America. I have seen bursae over
{400} the elbows of miners, and in one case saw one of these inflamed
so that miner's elbow became a concrete entity. This case had been
taken for an acute inflammatory arthritis with the suspicion of
tuberculosis.



CHAPTER V

PAINFUL ARM AND TRUNK CONDITIONS


Cervical Ribs.--Some interesting cases with painful conditions of the
arms develop as a consequence of the presence of cervical ribs. It
would be more or less naturally expected that trouble of this kind
would occur early in life, but, as a matter of fact, many of the
patients are well on toward thirty or even beyond middle life when the
painful symptoms develop. Cases are practically always at the
beginning diagnosed as rheumatism because the first symptom is likely
to be pain followed by weakness. Even when this quite fruitless
diagnosis is not made, the affection is often declared to be rheumatic
neuritis, though it is really a traumatic neuritis and entirely a
local condition, as are so many of the painful conditions spoken of as
rheumatism. Usually the pain is referred to the inside of the arm and
is described as resembling slight toothache at first and even severe
toothache after a time. It will often be many months or even several
years after the first symptoms before wasting of muscles occurs, but
this practically always follows after a time and even at this stage
some physicians still talk of rheumatic neuritis as affecting the
trophic nerve fibers and causing the muscles to waste. Almost a
differential diagnostic sign in the case of cervical ribs is that
raising the arms above the head nearly always relieves the pain.
Patients usually learn this for themselves because they have been
tempted to place their arms in many positions in order to get relief.
The reason for it is easy to understand as the elevation of the arms
changes the relative position of tissues in the neck and so relieves
pressure.

The direct reason for the late development of the disease is probably
the ossification of the cervical rib and the pressure of this hard,
bony substance upon the roots of the brachial plexus. When the disease
occurs as early as the age of 30 there is likely, for some reason, to
have been a preceding loss of weight. Patients are run down and then,
either because there is a precocious calcification as a consequence of
deterioration of tissue, or because the loss of substance in the
muscles in the neighborhood makes the nerves more likely to be pressed
upon, the first symptoms develop. There is only one way definitely to
decide the diagnosis. That is to have a careful skiagraph, or, in case
of negative results, several of them taken, in order to determine the
presence or absence of cervical ribs. Not all the cases of cervical
ribs give symptoms and in one recently published series of 26 cases
just one-half presented symptoms and the other half did not, but all
these vague cases of pain in the arm, especially if any tendency to
atrophy manifests itself, should be examined from this standpoint.


_Local Conditions_.--The subjective symptoms in these cases often
include {401} much more than pain. There may be numbness and the hands
often feel cold, though they do not become blue. As a rule, indeed,
the arms are more affected than the hands, though not infrequently one
of the hands becomes more sensitive to injuries than the other and, as
a rule, both hands do not heal well after injury. Even scratches take
a long time to heal and slight abrasions cause skin lesions that are
more or less indolent for some time before healing. Any fresh injury,
even of slight degree, puts back healing much more than would
ordinarily be the case. In fact, most of the so-called tendency not to
heal is local rather than constitutional. When a patient complains
that though his or her tissues used to heal rapidly now they are very
slow to heal, it is well to think of nephritis or diabetes but it is
especially important to know the local conditions.


Pleural Adhesions.--Another interesting cause of pains in the arms is
the possible contraction of adhesions of the pleura and surrounding
tissues at the apices of the lungs and the spreading by continuity of
a low-grade inflammation even to the lower roots of the brachial
plexus. A certain number of cases of this kind have been reported in
which there seems to be no doubt of the diagnosis. In these, the early
symptoms were pains or aches in the arm followed by some weakness of
muscles and even some trophic disturbances. Ordinarily the condition
has been very acute as, for instance, a pneumonia when the first
symptoms were noticed. In the course of the exudation and the
contraction of the inflammatory exudate the brachial plexus is
interfered with. This, like the cases referred to the presence of a
cervical rib, emphasizes the necessity for thoroughly studying local
conditions in order to understand the meaning of painful conditions in
the arms. It is easy to say the word rheumatism, while it requires
time and careful investigation to find the real pathological factor at
work; but the difference in the value of the two diagnoses for both
patient and physician can be readily understood.


Other Conditions.--Besides these, there are the various conditions
discussed in other chapters of this section--old injuries, breaks and
dislocations, so-called sprains with laceration of tissues, and any
serious pathological condition that has affected the tissues deeply.
An old periostitis, for instance, will leave an arm rather easily
liable to the development of various painful conditions. Of course, a
tuberculous process anywhere in the arm will produce a like effect. An
arm that has had a lead neuritis will often be uncomfortable in rainy
weather for long after and a crutch palsy may, in the same way, leave
the arm sensitive. The musculo-spiral palsies that occur from lying on
the arm when drunk, or that are seen sometimes in coachmen who wrap
the reins around their arms--a Russian custom--or the nerve conditions
seen in patients who have suffered from an anesthetic nerve-pressure
disturbance, may all be at the bottom of subsequent painful
conditions, worse in rainy weather. The only sure rule is to
individualize the cases and make an exact diagnosis. The etiology will
probably suggest itself if the history is carefully taken.

In these cases the most important treatment is to disabuse the
patient's mind of the idea that there is rheumatism, or any other
constitutional ailment present, and to make him realize that the
trouble is entirely local. After this, the strengthening of the
affected muscles must, as far as possible, be secured by local
measures and exercises.

{402}


CHAPTER VI

LUMBAGO AND SCIATICA


Any affection involving discomfort, pain, ache, or disability of the
large muscles in the lumbar regions is likely to be called lumbago,
not only by patients but by physicians. Any condition that makes it
painful to use the upper part of the lower limb and especially the
group of large posterior leg muscles just below the nates is called
sciatica. These are commonly supposed to be typical "chronic
rheumatisms." Anything in this region that is the source of discomfort
on rainy days and comes especially to the working man who has been
exposed to the elements, or that follows a wetting or the wearing of
damp clothes, is confidently classified as a chronic rheumatic
condition. Almost needless to say any such conclusion as to the
heterogeneous groups of symptoms that occur in these regions, far from
adding to our knowledge, rather confuses the situation. There is an
assumption that we know something about them when we call these
conditions either lumbago or sciatica, but unless each individual case
is carefully investigated and its conditions studied so as to get at
their true etiology, it is almost impossible to treat them
successfully. While the general practitioner of medicine of the
regular school often fails in his treatment of them, these affections
are among the most fruitful sources of revenue for the irregular
practitioners.

It was particularly for pains and aches in the back that St. John
Long's liniment proved so efficacious about a century ago. So-called
lumbago and sciatica patients were among the most frequent callers on
Perkins in the days of the famous tractors and many of them received
great relief. In our own time these constitute a class of patients who
go from physician to physician and who finally are cured or relieved
by some irregular practice which we know contains nothing especially
remedial, but the advocates of which somehow succeed in persuading
these patients that they must be better than before. Most old people
have some aches and pains in either the lumbar muscles or the large
muscles at the back of the thigh. Many of them are relieved by
massage, but still more of them find relief in the rubbings and
manipulations of the osteopaths, and they are great advertisers of the
relief that has been afforded them and they have helped much in
securing such state recognition as has come to the systems they
thought curative in their cases. Eddyism has been helpful to a certain
number of them. Fads of various kinds catch still others. Evidently
these intractable cases deserve to be studied from the standpoint of
what mental influence can do for them.


Conditions Mistaken for Sciatica or Lumbago.--Needless to say, a large
number of conditions occur which may be called sciatica or lumbago,
but which are due to the most varied causes. An affection of any of
the joints in this neighborhood will produce pain to which is often
added tenderness and occasionally swelling, and nearly always
disability. Disease of the lower part of the lumbar spine due to
tuberculosis is often in its earlier stages called lumbago. Indeed,
without careful investigation showing that there is a special point of
tenderness, some irregular fever and that the muscles are in spasm
{403} to protect the underlying joints from use, it is difficult to
decide just what is the affection in a particular case. I have seen
three physicians diagnose a one-sided tenderness and pain in muscles
with disability as lumbago, when the course of the disease proved that
it was tuberculosis of the sacro-iliac joint. Any of the bones or
joints in this neighborhood may give rise to pain, tenderness and
spasm of muscles and it is important not to make the facile diagnosis
of lumbago, unless careful investigation has eliminated all underlying
organic conditions.

There are other conditions not infrequently mistaken for lumbago or
sciatica which are interesting. Needless to say unless they are
definitely recognized there will be no relief afforded for any
discomfort of a permanent character, though the coal-tar products will
give temporary surcease of pain. Occasionally internal hemorrhoids
produce an achy discomfort in the lower part of the back that is
described as lumbago, and unless the physician is careful to
investigate he may tentatively accept that diagnosis. Proper
regulation of the bowels and the use of gluten suppositories will
often practically cure the condition, though there will be relapses
whenever constipation returns. Chronic posterior urethritis sometimes
simulates painful conditions very low down in the back or in one hip
or the other. Usually in that case there is a chronic inflammatory
condition in the seminal vesicle on the side to which the symptoms are
referred. Occasionally over-distention of the seminal vesicles, as
seen in widowers who have been accustomed for many years to regular
evacuation of them, may cause so much pain and disability in the
region of the hip on one side as to be mistaken first for lumbago and
then even for tuberculous hip joint disease. Artificial emptying of
the seminal vesicle by milking through the rectum will usually afford
relief. In all of these cases as soon as the exact diagnosis is made,
the patient's mind is relieved of a serious burden of anxiety and it
is usually not difficult to bring a great measure of relief.


_Old Injuries and Discomfort_.--Many of the painful conditions
described as lumbago are due to old injuries, to wrenches and sprains
in this region due especially to heavy lifting and to the laceration
of ligaments from over-exertion.


_Typhoid Spine_.--Protracted cases of typhoid are sometimes followed
by pain in the lumbar or sacral regions, developing usually after a
slight jar or shock, sometimes after a fall or even following a severe
injury, which are really the result of the physical condition of the
patient. Stiffness, aching discomfort on movement and sometimes
tenderness on pressure are present. Often there are associated
neurotic symptoms of various kinds. This used very commonly to be
considered rheumatism and occasionally one still sees cases so
labeled. On the other hand, much more serious conditions, as Pott's
disease, abscess of the liver, or some form of spondylitis, may be
suspected. Absence of temperature is almost the rule and usually is
the pathognomic differential against these. The whole condition is
usually a neurosis though there may be some perispondylitis. The
treatment is to increase the patient's nutrition, which has usually
suffered to a marked degree, and get the mind off the condition in the
back. Concentration of attention on it will make it very
uncomfortable, so that even heavy doses of opiates will scarcely
relieve the discomfort, and this emphasis of attention will further
disturb the mind and develop neurotic {404} symptoms. Diversion of
attention, gentle movements, plenty of air, and regulation of the
functions of the body will bring about a cure.


Stooping Occupations.--Occupations are especially important in lumbago
and people who have to stoop much, above all those who do hard work in
a stooping position--lifting, pushing, sawing, planing, and the
like--are particularly prone to suffer. Miners working where the
height of the vein does not permit them to stand up are commonly
subject to it. Any one who has to assume, or has the habit of
assuming, a stooping posture for long hours may suffer from lumbago.
Constrained position predisposes more than hard work. Tailors, though
in a sedentary occupation, often suffer from it.


SCIATICA


Etiology.--What has been said of lumbago applies to a great extent
also to sciatica. There are a number of different affections which
have come to be grouped under the term sciatica. Here, much more
frequently than in the lumbar region, the cause of the pain is a true
neuritis. This may be of many forms. Occasionally it is syphilitic in
origin; whenever the sciatica is double it commonly develops on a
basis of diabetes, while in many cases it is of an infectious nature.
There is no special reason to think that there is a rheumatic
infection of the nerve, though inasmuch as rheumatic arthritis is
probably due to infections by many different kinds of microbes, it may
well be that some of these play a role in sciatica. There is no good
reason, however, why the word rheumatism or the term chronic
rheumatism should be applied either to lumbago or to sciatica.
Certainly there is no reason in any definitely known etiology of the
affections. Each individual case must be studied carefully. Always
these are local and not constitutional conditions, and usually
something in the patient's occupation, or in his habits of life, helps
us to understand the development of sciatica or lumbago and gives the
most valuable hints for treatment.

Men who shovel much and who bend one knee as they stoop in shoveling
will often suffer, though more frequently in the leg which they do not
bend than in the other. The same thing is true for men who use one
foot to run a lathe or a small printing press, or anything of that
kind. They must be taught to alternate in the use of their limbs.


_Pressure_.--Occasionally direct pressure upon the nerve is the cause
of the disturbance. I once was asked to see in consultation an elderly
lady who had complained very much, first of discomfort and then
numbness in her legs, until finally she lost all power in them below
the knees. The affection was considered to be some sort of creeping
paralysis. I found that her favorite chair, an old-fashioned cushioned
easy chair, allowed her to sink down so that the edge of the wood seat
frame pressed upon her just where the sciatic nerve comes closest to
the surface. As soon as the habit of sitting on this chair was changed
her numbness and inability to use her limbs began to disappear.


_Alcoholic Neuritis_.--In both lumbago and sciatica one underlying
factor is often present. This is the consumption of undiluted whiskey
in considerable quantities. Outdoor workers are prone to take an
occasional glass of whiskey, especially in the winter time, and a
copious quantity of malt liquors in the summer. Both of these
predispose to the development of a low-grade {405} neuritis in
susceptible individuals. Alcohol is said to have an idiosyncrasy for
the anterior tibial nerves. That only means, as a rule, however, that
these nerves are more frequently affected by alcoholic neuritis than
others in the body. The reason for this special location of the
affection is that in people who stand and walk much, this constituting
their main form of exercise, these nerves are much used. They are
probably in such people (that is, if the intensity of impulses that
pass through them be taken into account) the most used nerves in the
body. It is this that makes them most susceptible to alcohol. In
people who stoop much or who have to work hard in stooping postures,
the nerves in the lumbar region and those that make up the sciatic
trunk are over-used. This makes them more susceptible to pathological
influences than others, hence the tendency for neuritis to develop in
them.


_Intrapelvic Causes_.--Sciatica may be due to various pathological
conditions within the pelvis. Women with fibroid tumors are
particularly likely to suffer from it. Their removal by operation does
not always assure against the occurrence of sciatic troubles. I once
saw an obstinate case of sciatica in which there was a story of a
fibroid having been removed years before and, though there were no
signs of any recurrence of the growth of another, there were some
adhesions in the region, and there was an obstinate constipation
particularly likely to have as one symptom an accumulation of fecal
material in the rectum until it was very hard. The keeping of the
bowels open meant more than anything else for the relief of the
sciatica. This patient subsequently died from what was diagnosed by a
well-known French surgeon as rupture of the bowels. This was probably
due to the adhesions that occurred after the old operation, done
without any regard to the possible development of such a sequela, some
twenty years ago. The sciatica was undoubtedly connected with the
group of disturbed conditions within the pelvis.


_Position at Work_.--In this case, as in others that I have seen, the
position assumed while at work seemed to have been an appreciable
factor in the production of the pain in the limb. The lady made her
living by writing and often wrote on a board resting on her knee--a
feminine, not a masculine habit. This brought pressure to bear upon
the right limb a little more than the other and then, when she crossed
her knees in order to put the writing board on top of the knee, this
side seemed to be used more than the other.

This question of the position in occupation, even though sedentary, is
very important. I have seen a strikingly typical case of the so-called
_neuralgia paresthetica_, the achy condition of the outside of the
thigh with some anesthesia and paresthesia, occur in an old lady who
still retained the girlish habit of sitting on her foot while she did
crocheting. I have often seen achiness of muscles of the trunk develop
in persons who read much in a cramped position because of the reading
light being too low or otherwise wrongly placed for group reading.
Whenever a patient has to stand much on one foot while doing
something, it is important to remember that there should be
alternation in the use of the limbs; otherwise sciatica and lumbar
pains will often develop, usually on the side corresponding to the
limb that is kept rigid.


Treatment.--_Mental Persuasion_.--The patient must be made to realize
that his affection is not rheumatism, but is due to local conditions.
Just as soon as a patient's mind is relieved by being made to
appreciate that certain habits in his occupation, or certain local
conditions that can be corrected, {406} are responsible for much of
his discomfort, then that discomfort is much easier to bear. Even in
cases where actual neuritis has developed, or where there have been
changes in the intermuscular planes bringing considerable disability,
the aches caused by these will be much more bearable if the patient's
mind is set at rest as to the real significance of the condition. No
condition should be called rheumatic unless at some time in the
history of it there was an acute inflammatory condition with Galen's
classical symptoms--_tumor, color, rubor_ and _dolor_. Pain alone is
never sufficient to justify the diagnosis. Painful disability is
usually due to local causes.


_Treatment of Acute Symptoms_.--For acute symptoms, the coal tar
products may be used and usually afford distinct relief. They include
all the old-fashioned salicylates as well as certain more recent
compounds, such as aspirin. Phenacetin, however, though usually not
thought of in this connection, is an excellent remedy for the
discomfort. These drugs should be used freely so as to give relief
from the painful condition. The fact that they afford relief, however,
should not be taken as an argument that the condition is rheumatic.
Rheumatism, as we know it, is an acute infectious disease and there is
no reason in the world for saying that the salicylates or cognate
drugs are specifics in this affection. They relieve the pain, but just
in the same way they would relieve the pain of toothache or of any
other painful condition. After the acute symptoms are removed, the
condition that remains may be treated in various ways, by massage, by
local applications, and by such manipulations as will restore the
normal circulation of the part. Care must be taken, however, to
distract the patient's mind from the local condition after a time, or
mental influence, by interfering with the capillary circulation, may
inveterate the symptoms. It is not good to keep patients at rest,
though rest, of course, is always indicated if there is much
discomfort. Sometimes, however, the discomfort is really due to the
fact that muscles have not been used for some time and so are easily
fatigued and may ache even under ordinary use. In this case, a gradual
restoration of the muscles to normal strength by progressively
increased exercise is important.


_Counter-Irritation and Its Suggestive Value_.--Personally, I have
found the use of turpentine particularly efficacious in connection
with suggestion. The old-fashioned system of ironing seems to do more
good than any ordinary application of turpentine. For this a piece of
flannel wrung out in warm water has some turpentine scattered over it
and then is placed on the affected loins or back of the thigh and
covered by another piece of flannel, and a hot flat-iron is rubbed
over it. The physical effect is a considerable hyperemia, but the
effect upon the patient's mind is especially interesting, the
unusualness of the mode of application adding decidedly to the effect.
It must not be forgotten, however, that there are some people who are
over-susceptible to the influence of turpentine, and its use is
followed by a rash.


_Lumbar and Sciatic Psychoneuroses_.--Many cases of lumbago and
sciatica are really psychoneuroses. They develop exactly as
psychoneurotic conditions do in the abdomen or in joints. Not
infrequently there is some accident or injury, some sprain or strain,
or exposure to dampness or draft, that serves as the occasion. The
Germans group all these occasions together under the word "insult."
The "insult" produces little physical effect but after some days or
sometimes weeks, the slight discomfort present secures the center of
{407} attention and then the patient suffers from what seems to be
severe pain and often inability to move or use muscles. Even when
there is true sciatica or lumbago, that is, a genuine low-grade
neuritis of the lumbar or sciatic nerves, most of the symptoms may
come from the associated psychoneurosis. This is proved to be so by
the fact that such patients are often cured, for the time being at
least, by some shock or fright or sudden excitement, that makes them
move, forgetful of the pain and inability from which they suffered
just before. Besides, such cases are often cured by inert remedies of
many kinds, by local applications that have no specific effect, and by
various methods of treatment which cannot be responsible for the
recovery. The amelioration of the condition is due to the mental
influence accompanying the methods of treatment and the reassurance of
the patient's mind.


_Diversion of Attention_.--Almost anything that produces a continuous
succession of sensations on the surface of the affected area that
attract and hold the attention of the patient may prove a valuable
therapeutic suggestion and even eventual relief from symptoms that
have proved obstinate to more rational treatment. Liebault, the
well-known founder of the Nancy school of hypnotic therapeutics, tells
in his "Thérapeutique Suggestive," that he has frequently cured
lumbago by the simple recommendation of a rather stiff piece of paper
to be applied over the patient's loins. The rationale of this
treatment seems to be that the patient's attention is attracted to the
skin surface by the sensations constantly produced by it and attention
is distracted from other feelings deeper in the muscles. It often
happens that after an acute lumbago has run its course, there is left
a chronic achiness only partly physical and largely psychoneurotic.
Some of it is undoubtedly due to the habit, formed during the acute
period, of keeping the muscles quiet, in order to avoid the spasmodic
pain that occurs on movement. Patients cannot, as it were, let go of
their muscles, and their discomfort is largely due to holding them in
a cramped position. The sensation produced by the paper on the
cutaneous nerves distracts the attention and brings about relaxation
of the muscles with decrease of discomfort and gradual relief of all
symptoms.

The paper acts as a constant source of suggestion for the cure of the
psychoneuroses when the affection is purely psychoneurotic. The mind
has become concentrated on the idea of pain and discomfort in this
region and needs another thought to occupy itself with so as to
neutralize this. Wearing the paper with the assurance, for instance,
that because of its impermeability to air it keeps the part more
thoroughly protected from variations of temperature and from such
possibilities of transudation as have before been possible, serves to
lift patients out of themselves and affords relief. Whenever the
sensation produced by the paper is noted, there is a renewal of the
suggestion and its curative effects. There are many plasters that have
obtained the reputation for curing lumbago. It is doubtful whether any
of these have sufficient medicaments on them to be of any serious
pharmaceutic significance. They are mostly rubber plaster. The
presence of this and the consciousness of the sensation produced by it
acts as favorably as does Liebault's sheet of paper.


_Mechanical Agents_.--It must not be forgotten, however, that a large
sheet of adhesive plaster firmly applied may act as a mechanical
therapeutic agent, somewhat in the same way that strips of adhesive
plaster relieve the pain of pleurisy, or are helpful in a sprained
ankle or a knee. The muscles may be {408} held rather firmly together
and so there is no necessity for constant attention to prevent
spasmodic pain. Undoubtedly some of the newer large-sized adhesive
plasters produce an excellent effect in this way. If, besides, the
patient has the feeling that they must be doing him good because of
materials in their composition, the psychoneurotic elements are more
readily relieved. The old idea was that such plasters drew out the
pathological elements to the surface whence they were dissipated.
There is no truth underlying this thought.

In the old days blisters were applied rather freely to these regions
and the actual cautery was often employed. Both of these therapeutic
processes are likely to do good in chronic cases, but much more from
their psychic than their physical effects. The actual cautery is not
used nearly so much as it ought to be in chronic muscular and neurotic
conditions, for the mental effect of its application and the
distraction of attention to the skin surface while the cauterized
areas are healing are excellent remedies.

There are other counter-irritant procedures of the same kind that have
been used with reported successes in many cases. Hot needles, for
instance, if pushed deeply into the muscles, often have an excellent
effect. Some years ago a distinguished surgeon insisted that both
lumbago and sciatica might be cured in many cases by the insertion of
needles deeply into the muscles. He argued that what happened was that
these needles brought about an equilibrium of electricity in the
muscular structures which had somehow been disturbed. Deep injections
of water into the muscles also do good. Stretching of nerves has been
applied with reported success. After a time all of these measures
fail, however, because somehow after the novelty of the treatment
wears off for the physician, the patient's mind is not sufficiently
impressed and then the former results are not secured. Where there are
actual neuritic processes present they will almost surely fail. So
many of these cases are almost pure psychoneuroses, however, that it
is little wonder that anything which produces a strong impression on
the mind and leaves after it some condition that attracts attention
and so furnishes favorable suggestion will almost surely cure even
chronic conditions for which all sorts of physical remedies, employed
on rational grounds, have failed.

Anything that modifies the circulation, even to a slight degree, or by
causing a reaction in the local vaso-motor state, alters previous
conditions, tends to enable the patient to control the affected part.
These psychoneurotic conditions in large muscles help us to understand
what happens in organic diseases. There is a physical element that
must be modified, but unless a strong influence is brought to bear
upon the mind so as to arouse all its capacity for control, the cure
will not come. Anyone of a dozen things, however, may be used in this
way and often when one fails another will succeed. In obstinate cases
of lumbago and sciatica if necessary a number of these forms of
treatment should be used successively.


_Hypnotism_.--How much pure psychotherapy may mean for many of these
obstinate cases of lumbago and sciatica can be appreciated from the
many reports of cures by hypnotism or by suggestion in a light
hypnoidal state, or occasionally, under favorable circumstances, even
in the waking state. One of these cases, indeed, is responsible to
some extent for the French interest in hypnotism which attracted so
much attention in the last quarter of the {409} nineteenth century.
Prof. Bernheim of the University of Nancy had seen a case of sciatica
in which every therapeutic means at his command had failed. As the
result of disuse the leg was emaciated and possessed little muscular
power. It looked as though the man would never be able to regain the
use of it properly. Dr. Liebault succeeded in curing the patient by
light hypnotic sleep, in which the suggestion that he would be better
was given while the physician stroked the limb. After the first seance
the patient was able to use the leg better and the discomfort was
greatly decreased. Further seances with Dr. Liebault brought further
improvement until finally the condition was cured. Prof. Bernheim, who
knew how intractable these cases are, had the case called particularly
to his attention and naturally wanted to learn more about the method
by which it had been brought about. Liebault's methods had been quite
contemned by the regular faculty before. After a series of experiences
under Dr. Liebault's direction Prof. Bernheim became enthusiastic over
the use of hypnotism as a curative agent and this led to the
publication of his well-known work "De la Suggestion et ses
Applications dans la Thérapeutique."   [Footnote 34] It was the
interest aroused at Nancy that led Charcot to take up hypnotism, and
while he came to very different conclusions, there is no doubt that
the work at Nancy meant much for our knowledge of suggestion in both
waking and hypnotic state in therapeutics.

  [Footnote 34: On Suggestion and its Applications in Therapeutics.]



CHAPTER VII

PAINFUL KNEE CONDITIONS


Most of the painful knee conditions of which patients complain are not
directly due to true pathological conditions either of the knee joint
itself or of its neighboring structures, but rather to affections of
other portions of the leg that set a special strain upon the knee and,
above all, to various kinds of foot disturbances. The erect position
is maintained principally by a nice balance of nervous and muscular
energy in the knee joint and its surrounding structures. Any irregular
sensory or motor impulses to the knee-joint or to the muscles of the
thigh will disturb the absolute equilibrium of the flexors and
extensors and will make standing painful or even impossible. Whenever
a morbid condition requires a different use of the muscles and tendons
around the knee from that to which they are accustomed, fatigue
readily ensues, and aches and even tenderness in muscles and tendons
develop as the result of the over-exertion. These collateral
conditions must not be overlooked in the diagnosis and treatment of
painful knee conditions.


Etiological Factors.--Even a slight sore on one foot will give rise to
considerable achy fatigue of the knee of the opposite leg, because,
consciously or unconsciously, we stand much more on that leg, use it
more in walking, and spare the other because of the pain induced by
use of the foot. Above all, throwing more weight on the other leg
causes us to use muscles a little abnormally with consequent soreness.
This painful fatigue is most likely to be felt around the knee, though
it may extend to the hip and even the lumbar {410} region of the well
side if the foot continues to be spared for a number of days.
Particularly will this be true if there is anything the matter with
the big toe, on which so much of the use of the foot depends. An
ingrowing toenail will not infrequently give so much discomfort to the
well knee and hip as to make the patient sure that there must be some
rheumatic or other condition at work in these joints. The serious
affection of the joint which the patient apprehends is found to be no
more than a sympathetic fatigue induced by having to use his feet, or
one of them, a little differently from usual, perhaps because of some
condition that leads him to spare them. To call the patient's
attention to this is of itself therapeutic.


_Inequality of Legs_.--The effort required for standing and the
accurate balance of the muscles involved in it is such that any
mechanical disturbance of the feet or legs or even a trivial
pathological condition causes painful fatigue. It must not be
forgotten, for instance, that the presumption that human limbs are of
exactly the same length is not confirmed by accurate measurements.
There is an average difference of probably half an inch in length
between the limbs of normal persons, and there may be even a
difference of more than an inch before deformity is said to be
present. The longer limbs are likely to do more work and are,
therefore, more subject to fatigue and consequent complaint. One of
the reasons why we can distinguish persons by their gait even at a
distance is that the difference in the length of their limbs makes
noteworthy characteristics in their walk.


_High Heels_.--People who are used to walking in a natural manner and
who don a pair of high-heeled shoes for the first time are sure to
complain of pain in the calf and knee, because the high heels require
them to hold the knee more rigid and in a somewhat different position
from that required when the persons stand under ordinary
circumstances. It is the unusual in muscular effort that gives rise to
the extreme fatigue which becomes positive pain if it is allowed to
continue. It is curious how small a raising of the heel will cause
discomfort. Over and over again I have known the careless putting on
of rubber heels to be responsible for pains around the knee, which in
damp weather were the source of so much discomfort that it was hard to
persuade the patient that he was not suffering from rheumatism or some
serious incipient pathological condition.


_Unusual Occupations_.--Joint pains often develop after the patient
has been doing something quite unusual and putting an unaccustomed
strain upon his muscles. I have often seen dispensary patients whose
knee pains began after there had been a family moving. In the course
of the removal of household goods, both men and women are likely to
help in hanging pictures, in taking them down, in moving heavy
furniture and other occupations of this kind which make them extremely
tired. If there is any tendency to relaxation of joint structures the
tiredness may manifest itself as a sense of painful discomfort. The
knees are particularly likely to suffer if there is a relaxed
condition anywhere in the leg. It must be remembered that the laxity
of tissue which predisposes a patient to weak or flat feet will have a
tendency to produce some looseness of fiber, at least, also in the
tissues around the knee. The patient may not have a wabbling knee, nor
may he be able to overextend the limb, but still there will usually be
some noticeable relaxation of the tissues which will help in the
production of the painful condition by {411} making exaggerated calls
upon the muscles in order to keep the joint in proper position in
spite of the over motion in it.

The disturbance is most frequent in waiters, store clerks, tailors'
cutters and fitters, bench men in the trades, and in all those who
have to spend much time on their feet. I have seen many such ready to
give up their occupations, though they had no other resource and the
future looked very blank, indeed, away from their work. It was
difficult at first to persuade them that a slight yielding of the arch
had so changed mechanical conditions in the use of the muscles of the
leg as to produce such pains. But as soon as they were put in a
condition where their arch was not allowed to sink, they were at once
relieved of their discomfort to a great extent. The question of
treatment is discussed more fully in the chapter which follows on Foot
Troubles.

An interesting set of painful conditions around the knee develops in a
class of people in whom it might least be suspected of being due to
over-exertion connected with their occupations. These are lecturers,
clergymen, teachers, and others who, for several hours each day, are
on their feet in a position from which, as a rule, they do not move,
but stand almost perfectly quiet. A distinguished laryngologist has
pointed out that not infrequently men who come to be treated for the
chronic laryngitis, which is known as clergymen's sore throat, but
which is seen so frequently in those who have to talk in the open air,
auctioneers, cart-tail orators about election time, and in lecturers
to large audiences who do not know how to use the voice, also complain
of grievous discomfort from painful knee conditions which often makes
the ascent or descent of stairs a painful task. He attributes the
simultaneous occurrence of these conditions to some blood dyscrasia,
uric acid, or the like, affecting the two most used sets of muscles
and organs, the legs and the vocal cords. Whenever I have seen this
condition--and circumstances have brought me into intimate personal
relations with many clergymen and lecturers--the trouble at the knee
has been due to some yielding of the plantar arch, while the laryngeal
condition, if present, was due to an erroneous mode of using the voice
consequent upon lack of proper training.

Sufferers of this kind must be warned not to stand absolutely
immovable while addressing an audience. Some men stand without moving
during a whole hour's lecture. This is unfortunate, for it obstructs
the return circulation through the tense muscles, for the venous
circulation was intended to be helped by muscular contraction. Many a
man finds, as he comes down from pulpit or platform, that his knees
are stiff and sore, though a moment before he knew nothing about it.
The failure to notice any discomfort before is of itself an example of
the influence of the mind over the body for the relief of pain.


Associated Lumbar Discomfort.--The painful condition around the knee
which develops when high heels are worn is almost sure to be
accompanied by pains, or at least a tired feeling, in the back. If we
convince the patient that the trouble is due merely to a derangement
of the mechanism involved in maintaining the erect posture we shall
have scant need of medicine or even of local treatment. But as the
pain is much worse on rainy days, owing to the relaxation of the
muscles, we must be careful to remove the patient's suspicion that the
pain must have a rheumatic origin. The restoration of normal
mechanical conditions with the removal of the cause will prevent the
{412} recurrence of the affection, and if some discomfort remains, the
patient will not worry, and the muscles will gradually grow accustomed
to the strain upon them. Of course, these conditions of discomfort are
more common in those who are not naturally strong, who are run down,
who are under-weight, or whose neurotic tendency will make any
irritation seem worse than it is.


Heavy and Light Patients.--Two classes are likely to suffer more than
others from these conditions. They are the people who are overweight
and the people who are underweight. Those who are overweight exert
much more effort to maintain the erect posture than ordinary people,
and, besides, in most adipose persons the distribution of weight is
such that a disproportionate amount of it is carried forward of the
normal center of gravity. High heels cause a further tilting forward
that has to be counter-balanced, and that, at least at the beginning,
gives rise to muscular discomfort. In people who are underweight the
nutrition of the muscles has suffered, and, as a consequence, they are
not able to support the frame as well as before. In them the
additional effort necessitated by the tilting tendency of high heels
is particularly felt because such people are nearly always among the
neurotically inclined.


Muscle Disuse.--Sometimes treatment of these conditions seems to lead
up to the disuse of certain muscles and the over-use of others. I
followed for several years an interesting case of this kind in which
the course of the affection was so typical as to deserve to be
recalled. A fuller account of the case occurs in my paper on
"Rheumatism versus Muscular and Joint Pains" in _The American Journal
of the Medical Sciences,_ August, 1903.

In that case the joint symptoms caused by the pinching of a loose
cartilage within the joint occurred suddenly on two or three
occasions, so that a surgeon deemed it wise to put the knee in
plaster. As a consequence, some atrophy of the muscles of the leg
occurred, and a halt became habitual in the gait. Through this halting
gait, the muscles of the back on the same side were also spared and
thus became somewhat atrophied. Painful conditions developed in the
muscles of the other side of the back from the over-use necessary to
compensate for the condition on the less-used side. All of the muscles
on the affected side became painful, apparently because of the
atrophic condition to which they were reduced.

The young man, though with the best of good will, was utterly unable
to conquer the tendency to halt in his gait, and so the muscles
remained under-exercised and were used at a mechanical disadvantage,
with the usual painful result. He went to at least two prominent
orthopedic surgeons, who assured him that all he needed was confidence
in himself to walk straight, and that then the normal condition of the
muscles and absence of pain would result. But their directions were
absolutely without result. He went through the hands of masseurs, of
osteopaths, of rubbing quacks of all kinds, and suffered at least two
attacks of artificial eczema as a consequence of the use of turpentine
liniments, but he remained after it all in what he considered to be an
intensely miserable condition. These cases are practically always
cured by definite exercise of the muscles of the affected limb so as
to bring them back to their normal tone. It requires special attention
for this purpose, however, and the patient's mind must be brought to
understand that at first the unaccustomed use of muscles will cause
discomfort, but that this will disappear after a time. These patients
are persuaded that they must be "cured" to get well.

{413}


CHAPTER VIII

FOOT TROUBLES


The more physicians see of affections of the feet and of painful
conditions of the legs due to foot troubles the more they realize that
the human faculty of the erect position becomes the source of many
discomforts unless care is taken of the muscular apparatus of the
legs. There are few people engaged in standing occupations who do not
suffer from their feet. These achy sensations are especially
bothersome if the patient is run down in health, or is in the midst of
worry or irritation from physical or mental stress. Even under
favorable conditions there are few who reach old age without serious
foot troubles or without, at least, some deformity of the feet, which,
by preventing or limiting exercise, have an important influence upon
the general health. Careful analysis of the conditions that develop
will convince an observer that yielding of the joints of the foot has
much to do with the deformities and that the wearing of unsuitable
shoes rather than any internal pathological condition is responsible
for the foot troubles that are so common.


Foot Deformities in All Classes.--An Englishman who visited this
country, and who had ample opportunity to observe our people, declared
after seeing the bathers at Newport, that there were two interesting
peculiarities of American masculine anatomy--the deformity in their
feet and the appearance of having swallowed a watermelon whole and
retained it within them. The latter condition has doubtless much to do
with the causation of the former. Inactive lives, overeating, and the
overweighting of flaccid limbs that are not capable of bearing even
their normal burden, complicated by tight and ill-fitting shoes, give
rise to the deformities of the toes that are so common--hammer toes,
over-riding toes, bunched toes, twisted toes, bent toes. Examples of
most of these are sure to be seen wherever we observe our men and
women bathing. The Englishman's observation was of our so-called
better class--at least, our leisure class. Ordinarily, it is assumed
that clerks, waiters, and others, who have to stand upon their feet
are the principal sufferers from foot deformities. They are, but they
are not alone, and a goodly proportion of the population suffers in
this way.


Mechanical Factors.--The most important deformity in these cases is a
yielding of the arch of the foot with consequent flattening of the
instep and lengthening of the foot. This overstretches especially the
flexer tendons which run underneath the arch, produces bunions, and
gives occasion for the development of corns. The pull upon the flexor
longus hallucis which runs along the inside border of the foot, gives
rise to the bunion by pulling the big toe outward--in the direction of
least resistance. The pressure upon the tendons of the flexor longus
digitorum pedis causes the smaller toes to bend somewhat, and this
gives rise to projecting angular points on which corns readily form.
Besides, the imperfect action of the muscles of the foot consequent
upon the fall of the arch gives rise to plantar corns and callouses
that are often painful. The living cushion of muscle which is the best
protection against injury, while walking or running, has its vitality
interfered with by {414} the fall of the arch and the consequent
blocking of the return circulation through the thin walled veins. This
gives rise to cold feet and, in those who stand much, to the tender
feet that are now so much complained of and for which so many foot
powders and appliances are advertised.


Confusion of Rheumatism and Foot Troubles.--Most foot troubles are
reflected up the leg because muscles have to be overused or used at a
serious mechanical disadvantage. This combined discomfort of foot and
leg is readily referred to rheumatism. Some of the pains produced by
yielding of the arch are in the ankle, some are in the calf, some in
the tissues around the knee, and some even in the muscles and tendons
above the knee. It is much easier to say "rheumatism" than to
investigate carefully and differentiate the conditions that may be
present. Out of forty successive patients who came to the dispensary
of the Polyclinic Hospital of New York complaining of rheumatism,
eighteen were suffering from flatfoot. Out of twenty-four who thought
they had rheumatism in the feet or legs eighteen proved to be cases of
flatfoot. Of the others, one was suffering from that rare disease
meralgia paresthetica, two were suffering from sciatic neuritis, one
was suffering with sub-acute joint trouble consequent upon pinching of
a cartilage within the knee joint, and one had a painful condition
consequent upon an old dislocation of the ankle due to a fall,
accompanied by considerable laceration of the soft tissues. Analyses
of the cases left no room for the so-called chronic rheumatism which
had so easily covered all the cases at the beginning.

It was not unusual to see patients who had consulted many physicians
and taken all sorts of internal and external remedies for the
rheumatism that they supposed was causing their discomfort, yet who
had nothing more than flatfoot. Their condition had become so bad that
some of them had actually given up occupations that required them to
stand. Merely following the advice to wear flatfoot braces in their
shoes relieved these patients almost as if by magic. There was no need
to measure them particularly; all they needed was an ordinary set of
flatfoot braces. Some of them needed only a pair of good shoes, but
the metal braces were advised to make sure that there would be a firm
support for the arch of the foot. No wonder the "magic shoe-maker" had
such success in New York a few years ago.

Nearly always the shoes worn by dispensary patients are of the worst
kind, considering the condition. The patients' feet are often cold,
and they think this is nature's demand for heavy shoes, so they buy
heavy shoes and large sizes so as to be sure they will not hurt their
feet. This clumsy footgear allows the arch to drop still further
because no proper support is furnished, and the foot-trouble becomes
more poignant. Then working people nearly always wear older shoes on
rainy days, and this makes two elements for discomfort instead of one.
The yielding arch is already a source of discomfort which is more
noticeable in rainy weather because any affection around a joint is
more bothersome at such times. The support that a new pair of shoes
affords to the arch is lacking when what are so aptly termed "sloppy
weather shoes" are worn, and the consequence is that the patient is
particularly miserable in damp weather.


Unfavorable Disease Suggestions.--Of the cases in my experience of
so-called rheumatism in the legs, over one-half are due either to
flatfoot or to the incipient yielding of the arch which is called weak
foot. Rheumatism is {415} most commonly held accountable for the
condition, though gout comes in for its share of blame with quite as
little justification. Occasionally some even more serious pathological
condition is appealed to. I have seen the tendency to passive
congestion in the feet with slight swelling around the ankle
consequent upon the yielding of the arch called kidney trouble in
spite of the fact that there was nothing in the urine to justify any
such diagnosis. I have even known the coldness of the feet, which is
likely to be a symptom of the disturbed circulation consequent upon
the yielding of the arch, attributed to heart disease. As we shall
see, most of the curious deformities of the old that make locomotion
so difficult and so painful are due to a breaking down of the arch
just after middle life and then to a progressive deformity of the
foot. The mechanics of the support of the body are sadly interfered
with when the arch yields, for bones are pushed out of place and
ligaments and tendons are lengthened in order that the foot may
accommodate itself to the new conditions. In nearly all these cases
the patients are prone to say that they are sufferers from rheumatism.
This diffuses and inveterates the notion which is a source of many
unfavorable suggestions, that rheumatism is a curious progressive
crippling disease which begins insidiously but advances remorselessly
and eventually leaves its victim a prey to deformity.


Gout and Flatfoot.--Bunions consist originally of an enlargement of a
bursa over the proximal end and the inner side of the big toe in order
to protect the bone and joint from friction. If the irritation is
continued, the proximal end of the first phalanx may enlarge, though
usually this is preceded by a series of attacks of more or less acute
inflammation of the bursa, when the bunion is said to "become
sensitive." I have seen these attacks called gout so often that I feel
sure that much of the gout reported in this country is nothing more
than bunions. There is true gout, and it is probably almost as
frequent with us as it is in England, but many of the so-called cases
are really flatfoot associated with development of the bunion that so
commonly occurs as the arch yields.

I was once asked to see a physician's wife who was thought to be a
sufferer from gout. Long ago Oliver Wendell Holmes said that, as the
shoemaker's children are likely to wear the worst shoes of the
village, so the doctor's family is likely to take the least medicine,
that is, be subjected to the least formal medication. The physician
had seen the more or less acutely swollen and red enlargement of the
base of the big toe, and heard his wife complain of the severe pain
associated with it, and had suggested the possibility of gout. After
rest in bed and the administration of salicylates and colchicum, the
pain subsided and the redness and much of the swelling disappeared.
This was a typical illustration of one event following another without
causal relation. The succession of events was taken as a therapeutic
test of the diagnosis of gout, and the patient was advised to regulate
her diet so as to prevent the further accumulation of urates or uric
acid in her blood. She was warned about eating red meat, about taking
acid fruits, and about the acid fermentation of starchy vegetables.
The main result of eating only white meat is apt to be simply a
limitation in the amount of meat eaten, because white meat is less
savory and after a time palls on the appetite. In the same way fruit
was largely eliminated and sweets were taken out of the diet and
vegetables were limited.

{416}

As she did not escape recurrent attacks of soreness in her bunion,
while at the same time there were achy feelings in her foot, she took
up the careful study of the dietary for gouty patients which she found
in the books in her husband's library. So many things have seemed
possibly deleterious for gouty people that it is not surprising that
after a time nearly everything worth eating except a few cereals and
milk and eggs had to be eliminated and she began to suffer from
inanition. Then, after a time, came constipation, due to the
insufficient amount of residue in her intestines, and this, partly by
physical action but largely by mental suggestion, still further
diminished the appetite for food, and a loss of over twenty pounds in
weight was the result. The weakening of the general muscular system
consequent upon this loss emphasized the trouble with the foot and the
painful condition at the base of the big toe became more marked.

The supposed necessity for more exercise in the open air led her to
walk long distances and in order to prevent her feet from hurting her,
as she thought, she wore roomy shoes, distinctly too large. This is
one of the common mistakes of people whose feet bother them, and it is
just the wrong thing to do, since a snug, well-fitting shoe provides
both support and protection. It is not surprising that the attacks of
sub-acute bursitis became more frequent and more painful.

It was then that I saw her, and, as I feared to disturb the family
harmony by suggesting that the whole trouble was a bunion and
flatfoot, I compromised by saying that, while there might be some
gout, there was undoubtedly flatfoot, and if she would wear the proper
sort of shoe and stop limiting her diet so strenuously, and cease
suggesting to herself that she had a progressive gouty affection that
would lead to deformity and decrepitude, she would soon be much
better.

It required tact to make her look favorably on this advice, after all
that she had gone through during months of limited diet and enforced
exercise. Though not quite convinced, she was ready to try the new
method. She began to be better as soon as she was fitted with a pair
of shoes that supported her arch and as soon as her increased
nutrition began to make itself felt. At the end of two weeks she was
able to give up the remedies for constipation that she had been using
for nearly a year, while at the end of four weeks she had regained ten
pounds of weight and felt much better.

Several years have passed since I saw her professionally and
occasionally I hear from her only to be told what a great measure of
relief it afforded her and how much better she has been as a
consequence of a few simple directions with regard to her feet. I have
seen at least a dozen of cases of so-called gout in educated people
which followed almost exactly the same course and yielded promptly to
the same treatment. The hardest symptom about these cases to cure is
the cherished mental conviction that they are the victims of
constitutional disease, either gout or rheumatism, to which all their
symptoms are attributed. They are cases for psychotherapy more than
any other form of therapeutics and need for a considerable period to
have repeated assurances of the entirely local character of their
affection.


Bunions and Flatfoot.--The etiology and preventive treatment of a
bunion has always seemed to me to bear a closer relation to a flat
foot than to anything else. The flatfooted man has nearly always a
tendency to bunions. The {417} explanation of this is not difficult if
one traces the relation between the tendons that run around the arch
to the big toe. The usual etiological explanation, however, is that in
youth short shoes were worn which initiated a tendency to divert the
big toe inward toward the other toes. But there are many reasons
against this explanation. Anyone who tries will find that it is
practically impossible to wear shoes that are so short that the big
toe is crowded back. Women are more apt to shorten their shoes than
men, yet women suffer both from flat feet and from bunions much less
than men. The reason for this seems to be that the forward position
with the elevation of the heel of the shoe supports the arch and gives
the shoe a shape more fitted to the normal foot than is found in the
masculine flat-heeled shoe. Besides, this form of shoe maintains its
shape better, and then, too, women are not so prone to wear old
so-called comfortable shoes as are men.

The mechanism of the formation of the bunion in many cases seems to
be, that the large toe, instead of lying straight along the inner edge
of the foot, is pushed or pulled toward the other toes. If this
process began from the wearing of pointed shoes, especially if such
shoes did not have a straight line on the inside, conditions within
the foot would soon tend to emphasize it. If the adductor hallicis
once gets the habit of contracting rather strongly, as it is likely to
do through the irritation set up by the yielding of the arch, it will
be hard for its opposing muscles to counteract it. More important than
this, however, is the fact that the tendon of the flexor longus
hallucis runs along the inner border of the foot and is particularly
affected by the yielding of the arch. For it works at a decided
mechanical disadvantage under the new conditions and is stretched in
such a way as to pull forcibly and constantly upon the big toe,
necessarily turning it more and more outward as the arch continues to
yield. The dropping of the arch makes the distance from the heel to
the toe longer than before and the tendon pulls the toe as far outward
as possible to compensate for this, as the distance to its insertion
is thus made somewhat shorter.

The yielding of the arch lengthens the foot and puts the tendons of
all the flexors on the stretch. All of them have a tendency to bend
the toes, and as this action is constant, gradually the tendons of the
extensors become over-stretched and these muscles are not capable of
exerting their full force in overcoming the action of the flexors. The
flexor longus digitorum has a tendency to cause a bending of the small
toes, and as it also runs across the foot it pulls the toes somewhat
inward, that is, toward the big toe. This crowding leads to hammer
toes and over-riding. The big toe, however, is maintained in a state
of extension by its firm, full contact with the sole of the shoe and
with the floor when walking barefoot. The one direction in which it
can yield rather readily is outward toward the other toes because this
shortens the distance between the end of the toe and the heel. The
pressure put upon the flexor longus hallucis will have a tendency to
cause this, for it is over-stretched by the yielding of the arch and
keeps constantly pulling on the big toe until that member has a
distinct flexion outwards.

This makes the metacarpo-phalangeal joint prominent and then nature
proceeds to protect it by a water cushion, a special bursa due to the
formation between layers of connective tissue of a pocket in which
some serum is constantly present. One can scarcely admire enough this
provision of nature by {418} which she protects prominent bony points
whenever they are subject to much irritation or to such use as would
cause injury to important structures below. If continued pressure
continues to be irritating, however, the water cushion proves
unavailing and an inflammation of the overlying skin occurs with
occasionally a spreading of infectious agents from the surface into
the serum pocket below. This serum is such a good culture medium that
an acute abscess is likely to form--the acute bursitis of the
surgeons.


Rarer Foot Troubles.--Besides bunions, a number of other deformities
of the feet occur as a consequence of the yielding of the arch. All
the toes are likely to bend rather acutely, and the points of them are
pressed against the shoe, while the knuckles, so to speak, are made
prominent and are more likely to be subject to corns than would
otherwise be the case. Besides, the displacement of the big toe toward
the little toes leads to a crowding of the toes together, and this
gives rise to soft interdigital corns and to a lowered resistive
vitality which may be the predisposing factor to slight infections of
various kinds that will make the patients miserable. Such affections
may appear negligible, a matter for the chiropodist, and not deserving
the physician's attention; but they mean so much for the comfort of
the patient and the prevention of exercise through sore feet reacts so
deleteriously on the general health that these minor ailments become
important and merit careful attention. Dr. Emmet tells the story of
the old family servant, always grumpy and complaining, who, when he
had the many blessings of life pointed out to him, confessed that the
Lord had been very good to him, but said, "The Lord knows He takes it
out of me in soft corns."


_Hammer Toes--Clam Toes_.--Nature has provided a wonderful mechanism
in the arch of the foot and the anatomical relations of the toes to
support the weight of the body firmly, gracefully, and comfortably;
yet any yielding of any part of it leads to a disturbance of its
delicate mechanical relations and, consequently, to ever-increasing
deformity. Hammer toes are typical examples of what such a disturbance
may lead to. One of the toes becomes pressed downward between two
others. This over-stretches the extensor muscles and tempts the
unbalanced flexors to contract. As the extensor muscles become, after
a time, unable to work in the constantly bent toes, they atrophy to
some extent and then the flexor muscles pull the toe farther and
farther down until there is no possibility of its being straightened
at all. Now, if the flexor tendons are cut and the toe straightened
the atrophic extensor muscles will not hold it in that position, and
when the flexors grow together the old condition will reassert itself.
In the meantime, muscle changes in the neighboring toes have also
taken place. With no resistance on one side of them, they become bent
sidewise over the hammer toe, and so their muscles on one side are
overstretched and on the other side become contracted. After a time it
is impossible to correct this series of deformities which are being
constantly increased and emphasized by the weight of the body above.


Present-day Shoes.--In recent years we have heard much more than
heretofore about foot troubles. As the old-fashioned shoes were
carefully made by skilled shoemakers to fit the feet of one individual
and not to conform to some supposed ideal pedal extremity, they
supported the feet much better than do the modern cheap machine-made
shoes. These custom shoes lasted a long time, and, after they were
once molded to the foot, the wearer was not {419} disturbed for many
months by the process of having to become accustomed to another shoe.
The many advertisements in quite recent times of foot powders and
other artificial relief for the foot show that people are suffering
much more than before, or, at least, are less able to bear the
discomfort. These powders, however, are not likely to do good in the
long run, since they tempt the wearers to stand the discomfort against
which they do furnish a certain amount of soothing. It is much better,
however, for the sufferer to find the cause of the discomfort and to
remove it if possible, for otherwise it will lead to constantly
growing displacement of bones and muscles and may eventually even
bring on actual and ever-increasing deformity.   [Footnote 35]

  [Footnote 35: How much deterioration of the tissues of the foot may
  be brought about by improper footwear and, above all, by sedentary
  life and the substitution of the trolley car for the exercise of
  walking, is well illustrated by the functions that are lost. The
  child can use its adductor and abductor muscles for the toes quite
  as well as for the fingers. Those who go barefooted retain those
  muscular powers. Some time we will be able to influence young folks'
  minds enough to keep them from sacrificing all the more delicate
  muscular powers of their feet to the fashion of small or curiously
  shaped shoes. Armless men learn to use their feet almost as hands,
  they write, pick up small articles, oven play musical instruments.

  Some people have special muscular faculties, as, for instance, the
  power to displace certain tendons and bring them back with a snap
  which makes a distinct sound. The Fox sisters, to whom we owe the
  origin of modern spiritism, confessed that this was the way they
  produced their spirit rapping. Some mediums can, it is said,
  dislocate the tendon of the flexor longus hallucis onto the edge of
  its grove and then bring it back with a snap. Others can produce
  partial toe dislocations which by muscular power are suddenly
  reduced with a dull noise like the sound of a gloved hand rapping
  beneath the table.]


Prophylaxis.--The most important means of prophylaxis in these cases
is to have patients who must assume the standing position for some
hours each day, exercise their legs rather vigorously. If teachers,
lecturers, and the like, have to stand for a long time, it is
important that on the way to and from their occupations they should
not have to stand up in cars nor assume cramped and uncomfortable
positions. It would be better for them to walk rapidly for several
miles rather than ride in a standing or a constrained position. If
they are convinced of the necessity for exercise, there is much less
likelihood of the development of the severer discomfort that is
sometimes very discouraging. It is particularly difficult to make
women understand this; yet, once they have found how much relief is
afforded by vigorous exercise, they are likely to overdo it and thus
run the risk of incurring ills quite as serious as those consequent
upon not taking enough. In nervous people the nagging discomfort of a
yielding arch will sometimes (just as eye strain does) produce reflex
headaches, constipation, lack of appetite, and apparently predispose
to the frequent recurrence of migrainous headaches. I have, in not a
few cases, seen these conditions relieved by rational treatment of the
foot condition.


Circulatory Disturbances Due to Flatfoot.--An interesting direct
consequence of flatfoot is the disturbance of the venous circulation,
which is likely to bring about some swelling of the feet and nearly
always considerable coldness and numbness, particularly in the winter
and, above all, on damp days during cold weather. The swelling of the
feet makes the patient think--sometimes at the suggestion of his
physician--of kidney trouble or heart trouble, and sometimes it is
hard to persuade him that there is nothing serious the matter with
these important organs. The disturbance of the circulation further
leads to numbness, to some anesthesia, and to paresthesia. Corns and
especially callouses grow more readily between the toes, and patients
who are prone to read about such ailments may conclude that they are
suffering from hypesthesia {420} and hyperesthesia due to some serious
progressive organic nervous disease. I once had a woman patient
discourse learnedly to me about these things who was sure that she had
the beginning of some incurable spinal disease. Locomotor ataxia was
the least she might expect from her description of her feelings. What
I found was flatfoot. Raising her arch cured her.

The cold feet and the numbness, to call them by simple Saxon names
which will not disturb patients, may sometimes keep them awake. In the
chapter on Insomnia we suggest that the best thing for this is to
secure a return of the circulation either by exercises, or by wearing
a flatfoot brace during the day, or by putting the feet in water as
hot as can be comfortably borne and keeping them there for a quarter
of an hour. Of these means exercise is the best. Raising up on the
toes after the shoes are off and coming down on the outside of the
foot strengthens the muscles, pulls the bones of the arch firmly
together and encourages the circulation. For beginning flatfoot this
is a curative measure and it is the natural mode of treatment for the
coldness and numbness of the feet. Rubbing, also, is good for the feet
in order to restore the circulation, but patients are inclined to rub
downwards while they should rub upwards in order to help the hampered
venous circulation. The thin-walled veins are more likely to be
compressed by any disturbance of tissues than are the firm-walled
arteries, and it is to help the veins that our remedial measures must
be directed.


Secondary Consequences.--The secondary consequences of flatfoot are
interesting. It is surprising how many people who frequently suffer
from sprains of the ankle have some yielding of the arch as a
predisposing factor to that condition. Two classes seem to suffer
frequently from sprained ankle--those with yielding arches and those
with high insteps. Apparently there is weakness in the excess in both
directions. Very flatfooted people apparently do not suffer so
frequently from sprained ankles as those in whom there is only an
incipient yielding of the arch. They seem to have learned to walk more
circumspectly. Perhaps, too, their well-known tendency to toe outward
lessens their liability to turning on their ankle. The effects of
sprains of the ankle in people with weak foot last, as a rule, longer
and leave more weakness after them than they do in ordinary cases.
This, of course, might be expected, but it is surprising how often the
significance of beginning flatfoot fails to be noticed even by the
physician. I have seen rather frequently cases of so-called chronic
rheumatism in which there is a series of stories of sprained ankle
because of the assumed weakness of the ankle from supposed rheumatism,
when the whole case can be summed up in a yielding arch.


Exercises.--If the arch has not yielded much, it is often unnecessary
to prescribe flatfoot braces or arch supports of any kind, unless
perhaps at first. After the first soreness has passed off, exercises
may be employed to strengthen the muscles. As we have said, the
patient should rise on his toes and then come down slowly on the
outside of his feet. He may be instructed to sit with his feet--not
his legs--crossed, the feet resting on their outer edges. He may be
shown how even various slight movements of his toes, almost without
moving his shoes at all, will strengthen the muscles that pass around
the arch, which, thus strengthened, will hold the bones of the arch
firmly together and prevent further yielding. There is, at the present
day, a tendency to recommend too freely the wearing of flatfoot braces
or arches. After all, these are {421} only crutches and should not be
worn unless absolutely necessary. If the arch can be strengthened--as
it can be in many cases--so as to bear the body weight without
discomfort, then this is much the better treatment. If the arch is
restored the feet are in a more natural condition, while artificial
support leaves the muscles without that exercise which will preserve
their functions. Flatfoot braces may be necessary, but only if
absolutely necessary should they be advised, and palliative measures,
such as exercise, manipulations, and rubbings, should be given a fair
trial after the unfavorable suggestions as to his foot condition have
been removed from the patient's mind.


Significance of Foot Troubles.--We have devoted much space to foot
troubles--more, perhaps, than will seem justified to the minds of many
physicians. We have done so, however, because of the firm conviction
that the feet are the source of more discouragement and depression of
mind than any other part of the body. Life very often takes on another
aspect when foot troubles are relieved. In the old, progressive
deformities of the feet consequent upon mechanical disturbance are
probably the source of more discomfort, and by their interference with
exercise and outing, the cause of more ill-feeling and even
disturbance of health than any other single factor. Even life may be
shortened by the confinement or limitation of movement consequent upon
bad feet. Above all, the idea that any constitutional trouble, or
hereditary disease, is at the bottom of their affliction must be
removed, and then these patients are encouraged to live their lives
more fully and with more happiness for themselves and others. Hence
this long chapter.



CHAPTER IX

ARTHRITIS DEFORMANS


Arthritis deformans has unfortunately been called by several names
besides the descriptive term which, in the present state of our
knowledge, is the most suitable for it. We do not know its cause. We
do not well understand even the predisposing factors in its causation.
Hence, the term arthritis deformans, which declares simply that it is
an inflammatory condition of the joints producing deformities, exactly
fits it. It has often been spoken of by such names as "rheumatic
arthritis," or "rheumatoid arthritis," and, above all, by the
unfortunate term "rheumatic gout." Many of the worst suggestions that
attach to the word rheumatism are founded on these ill-chosen
designations. Arthritis deformans was supposed to be connected with
rheumatism or with gout, or perhaps to be due to a combination of the
two. In a majority of the cases there is no history of either true
gout or rheumatism to be obtained from the patient, and where a
rheumatic or gouty history does occur, it is either quite indefinite
or it is clear that arthritis deformans developed in a gouty or
rheumatic subject, that is, following genuine gout or rheumatism, just
as it might develop in any other individual without any causal
connection between it and the other affections.

Supposed under the old theory to be a constitutional, probably a
blood disease, patients who saw the ugly, crippling deformities
produced by it and {422} then heard the word rheumatism used in
connection with it were prone to think of this as the terminal stage
of all the severe rheumatic conditions. As a matter of fact no
evidence that we have shows that the disease has any connection with
chemical modifications of nutrition or metabolism; nor, above all, has
the so-called uric acid diathesis or any other superacidity of the
blood any etiological connection with it. It has always seemed to me
to be clearly a nervous arthropathy, as the lesions are almost without
exception more or less symmetrically distributed. The joints that
suffer are commonly the smaller ones in corresponding positions on
opposite sides of the body, and they run a definite atrophic course
sometimes with the preceding phase of hypertrophy that is so
characteristic of the trophic lesions of an affection produced by a
disease or defect of the nervous system. This symmetrical distribution
constitutes the best possible evidence that arthritis deformans is not
a nutritional disease and, above all, is not due to chemical changes
in the blood.

The affection exists in at least three forms and there is a growing
persuasion that there are even more varieties of it that will have to
be separated by clinical observation.

There is a good study of the three types of the disease in _Guy's
Hospital Reports_, Vols. 56-57, London, 1902. The article is entitled
"Acute Rheumatoid Arthritis," but there seems no reason for applying
the word rheumatoid to the group, especially since there is no proved
connection with rheumatism and no similarity, except in the case of
acute deforming arthritis in which at the beginning it may be
difficult to differentiate the two affections.



HEBERDEN'S NODES

The most familiar form is named Heberden's nodes, from the great
English physician who first made a special study of it. The affection
is characterized by an enlargement of the sides of the distal
phalanges with small, hard nodules, "little hard knobs", as Heberden
called them, developing at these points. They are more frequent in
women than in men. Evidently neither hard work nor exposure nor
excesses in eating or drinking occasions them. They occur in all
classes, the poor and rich, manual workers as well as professionals.
It is rare to find them on one hand alone, though it is not at all
rare to find them affecting solely the little fingers of each hand. I
have seen several cases where surgical intervention had been attempted
on one little finger because of the deformity produced when the node
originally appeared. When I asked if there was not some trace of a
similar condition on the other hand I was told there was not, yet I
have been able to show that the first signs, at least, of a
corresponding growth already existed on the little finger of the other
hand. In the two cases in which my attention was called to a slight
enlargement on one side before anything developed on the other, my
tentative prophecy that corresponding nodosities would grow on the
other side was fulfilled during the following years.

While this form of the disease is a true arthritis deformans it seems
to be entirely separate from the progressive forms which we shall
speak of later. The nodes increase in size and occasionally develop on
all of the fingers, but usually never spread beyond the phalangeal
joints. There is a tradition in the {423} medical profession of
England, where this affection has been observed with care for some two
hundred years, that sufferers from these nodes commonly live to long
life. This is not founded on any theory, but is an actual observation.
There is also a tradition, though I cannot vouch for its truth, that
the people who are thus affected have some sort of immunity to
tuberculosis, or at least good resistive vitality against a rapidly
running tuberculous process.

I have had at least a score of Heberden's nodes cases under
observation for more than ten years and some of them for nearly twenty
years, and have been surprised at the slowness with which the process
develops. A year often makes no change in the size of the nodes, and I
have seen cases where after five years the photograph showed no
difference. The lesions are often exquisitely symmetrical so that the
question of the origin of the affection in the spinal cord constantly
crops up, for that is the symmetrical influence in the body. There
are, however, no other symptoms that point to involvement of the cord
in any way. Most of these patients have suffered more from worry about
it than from their affection. It is another case of "having many
troubles most of which never happen."

Some of my patients are physicians, and all of them have consulted
other, some many other, physicians. As a consequence, many of them
have taken to various diets, especially eliminating certain foods and
liquids with the idea that this might stop the progress of the
disease. I have never known any change of diet or any abstinence from
liquids or solids that seemed to make the slightest difference, though
I have seen a number of cases that were considerably worse than they
would have been if the diet had not been tinkered with to such an
extent as seriously to disturb nutrition.

The main disturbing feature of the affection is the dread of the
development of serious crippling conditions in the hands or in the
large joints.

As a rule, after a time the nodes cease to grow, and then a period of
remission sets in that lasts for many years and there may be no
recrudescence of the affection. This remission is delayed if the
patients allow themselves to run down in general health. It is
apparently hastened by getting the patients up to normal weight and
removing any factors that disturb their general health. If the
patients' minds are properly disposed, the neurotic symptoms that
sometimes develop as the result of over-solicitude about their
condition are done away with, the patients are more comfortable, and
even the progress of the disease is inhibited.


ACUTE PROGRESSIVE ARTHRITIS

The second variety of the affection is a general progressive arthritis
which usually begins with fever, redness, and swelling, involving
especially the smaller joints. The diagnosis of the disease can almost
be made on the fact that its favorite locations are the jaw and the
joints of the spine. It is a much more serious affection than
Heberden's nodes. In its beginning it often simulates acute
rheumatism. It occurs particularly in people who are run down for any
reason, in young women who have recently come to the country and are
working as domestics, in young men who have recently changed their
occupation from indoors to outdoors and are not used to the
inclemencies of the weather. On the other hand, it occurs rather often
in young persons of {424} both sexes used to living and working out of
doors who take up an occupation in a damp interior.

The fever usually runs a lower course than that of genuine acute
articular rheumatism, the pain is not favorably affected by
salicylates, and the duration of the disease is generally longer. This
affection always leaves its marks on the joints and there are always
recurrences. It is, indeed, the confusion of this quite distinct
disease with acute articular rheumatism that has given the latter
affection the bad name it has in many minds as a producer of
deformities. Arthritis deformans or general progressive arthritis is
always a crippling disease; acute articular rheumatism has for its
surest diagnostic sign, when the complete history of the case is
known, the fact that it leaves no mark after it except, unfortunately,
that so often seen in the heart.


CHRONIC ARTHRITIS DEFORMANS

The third type of arthritis deformans is the chronic slow running type
which involves many joints before the process is complete. One form of
this, commonly seen in old men, called osteoarthritis, is often
confined to the hip joint, and often produces considerable deformity.
Another form is more common in women. It begins in middle life by
deformities in the terminal joints of the fingers and the
carpo-metacarpal joints of the thumbs. Bony outgrowth takes place
until the joints become almost or quite useless. It spreads from the
joints primarily affected to the elbows, the knees and occasionally
involves other joints. The disease has no favorable course, but is
progressive, and there is great discomfort, marked disability, aches
and pains particularly in rainy weather and, finally, the patient may
become quite helpless.


Preliminary Stage.--An early symptom associated with arthritis
deformans of chronic character is likely to be a distinct loss of
muscle power, which may be the first symptom in cases that have no
acute beginning. The patient notices that he is unable to hold a
satchel as he did before, or that quite unaccountably it drops from
him. There may be a loss of control over muscles and especially small
muscles that attracts the patient's attention. He finds that he cannot
hold a book as he used to, or that it is difficult to pick up small
objects. He finds it hard to turn a door handle or to pull a cork,
although the pulling action may be perfect, but the ability to insert
the corkscrew is lacking. These symptoms are prone to be intermittent.
They are most noticeable when the patient is tired, or after a damp
day, or a succession of damp days, when he is not feeling well. It
will usually be found that a joint, the affection of which is missed
unless it is carefully looked for, that between the radius and ulna
has become affected, and as a consequence there is a difficulty in
supination. The lesions are different from those which occur in lead
poisoning but at the beginning the symptom complexes may easily be
confused.

This form of arthritis deformans, in its earlier and its later stages,
is a source of unfavorable suggestion as regards other affections. Its
first symptoms may be thought neurasthenic, and if it is so called,
those who hear the diagnosis and see the later developments will
conclude that neurotic symptoms {425} can lead to serious sequelae. On
the other hand, the painful tiredness that is always worse in damp
weather may be termed rheumatism and be a correspondingly unfavorable
suggestion. Patients who develop aches and pains as a consequence of
occupations, or through the relaxation of joint tissues, are most
uneasy because of the confusion of the later stages of this disease
with rheumatism. This must be recalled by the physician if he would be
successful in treating such pains and aches; for not a little of the
discomfort is due to an exaggerated mental impression of their
significance. This of itself often proves sufficient to keep the
patients from the exercise that would relieve many of their secondary
symptoms, at least, and serve to make their discomfort more bearable.


Course of Chronic Arthritis.--The course of chronic arthritis
deformans is always interesting. It is never as serious as the
prognosis at the beginning seems to indicate, and it always has
intermissions which, in most cases, become favorable remissions with
such improvement that the patients feel encouraged, though they never
get entirely well. Six rather typical cases have been under my eyes
for from five to fifteen years. In all of them the course was slow and
the progress of the disease vague at the beginning; and it was
difficult to say how the affection began, or what was its cause, and
apparently nothing would stop its advance. After a time all of them
became discouraged and began to go the rounds. Almost without
exception the physicians told them that they were incurable, and
nearly all of them received unfavorable prognoses either directly from
the physician or from hints sometimes dropped to friends, or from the
attitude of the physician toward them. Much of this discouragement
proved unjustified by the actual progress of the disease for many
years. While they got but scant encouragement from regular physicians,
nearly all of them received hopeful suggestions from irregulars and
were, as a rule, for the time being, somewhat bettered by the
treatments suggested by these, no matter what they were.

Every one of these six cases, as was to be expected under the
circumstances, went through a period of intense discouragement, with
loss of appetite, partly from confinement to the house, partly from
thinking so much about themselves, partly from lack of exercise and,
in general, from their morbid mental condition. As a consequence of
the loss of appetite, or, at least, of failure to eat in the midst of
discouragement, severe constipation developed in five of the six cases
and this further complicated the situation. They ran down very much in
weight, and this emphasized the apparent size of the hypertrophic
nodosities in their joints and weakened their muscles to such an
extent that even under good conditions they found it difficult to
move. After a time, usually many months, sometimes a couple of years,
something happened to make them realize that while they were crippled
and were going to be deformed, they still might find much in life that
was not to be despised. Then they began to pick up in weight, their
muscles got firmer, their nodosities seemed to disappear because the
soft tissues around them filled out, though in most cases some of the
material previously laid down actually was or seemed to be reabsorbed,
perhaps as a consequence of the patient's better metabolism.


Neurotic Additions.--All of these patients are now in much better
physical and, above all, in much better dispositional states than they
were during the first year or two at the beginning of their disease.
While they allowed {426} themselves to run down in weight they were
supremely miserable, with many neurotic pains and aches that were
extremely hard to relieve, they had tendernesses and sorenesses on
rainy days, usually attributed to their rheumatic conditions but
really due to intense depression of the nervous system, with a
constant tendency to exaggerate slight pains and aches into torments,
and in general were invalids, a burden to themselves and others. They
have improved to a noteworthy extent so as to become cheerful,
reasonably happy in their power to help others, interested in many
things and, in at least two of the cases, accomplishing more actual
good for those around them than they probably would if their lives had
continued to be the conventional existences that they had been before
their arthritis came to them. This reminds one of Dean Stanley's
famous expression that life looks different when viewed from a
horizontal position. He used the expression with reference to fatal
illness, but it might well be applied to any ailment that makes people
think seriously and keeps them from occupations only with frivolous
things. One of these patients is a source of consolation to many
friends, who are much better in health than she is, who bring their
troubles to her, and who marvel at her power to make the best of
things.

The prognosis for cure is extremely unfavorable, but the prognosis for
a reasonable amount of happiness and a large amount of usefulness is,
in my experience, excellent and though, of course, new habits will
have to be formed and new ways of looking at life assumed, if this can
be quietly and persuasively made clear to the patient early in the
case, much of the more or less inevitable suffering that the patient
will have to endure may be lessened.

The older the patient, as a rule, the better the prognosis in these
cases. As with regard to diabetes, tuberculosis and many another
affection, every year after fifty adds to the prospect that the
patient's ordinary span of life will not be much shortened and that
the symptoms will not be severe. Occasionally the disease develops in
patients who have been extremely healthy until they were well past
sixty. I have in mind particularly a patient who did not begin
seriously to suffer from the disease until she was sixty-eight. Then
for two or three years she was very miserable, mainly because she had
been very active and she feared that the disease would cripple her. It
did bring about a considerable limitation of her activity. Ten years
have passed, however, and she is still able to be about, and, though
now well on the way to eighty, in good weather she still attends to
various duties that take her outside of her home and occupies herself
with many interests.

I was never able to tell her that she would be better. I assured her
from the beginning, however, that she would never be so much worse as
she imagined, and that she would never be actually crippled. During
the early stages of the disease, her discouragement and, above all,
the diminution of activity, the lack of exercise and occupation of
mind and the over-occupation with herself, made her not only mentally
miserable but seriously interfered with many bodily functions.


TREATMENT

In the treatment of arthritis deformans the most important object is
the general health of the patient. Owing to the confinement, the
pains, which {427} are often worse at night, cause disturbance of
sleep which reacts upon the general health. As a result of depression
and discouragement, patients are prone to loss of appetite. This is
sometimes looked upon as a symptom of the disease, but it is not a
direct symptom except during the acute stage when there is fever, and
is due rather to the changed conditions in which the patients live and
the mental influences that surround them. If the patient loses in
weight, as is so often the case, the effects are likely to be more
serious, for the remission is delayed and is less complete in its
consequences. Above all, it is important not to disturb the diet of
the patient in such a way as to interfere with nutrition. Owing to the
supposed rheumatic element, meat, or at least red meat, is
occasionally taken out of the diet by the recommendation of the
physician. Whenever this is done, harm results. There is a definite
tendency to anemia, which will be emphasized by an exclusively
vegetable diet, especially in those accustomed to eat meat freely. As
a rule, there is much more need to encourage the patient to eat than
to limit the diet in any way. Patients must rather be advised to take
a generous mixed diet and to consume about as much meat and the same
varieties as before. Tinkering with the diet has never been known to
do any good for arthritis deformans and often does harm. The drinking
of large quantities of water seems to do more than almost anything
else to help these patients into a better frame of body and mind.
Their neurotic symptoms are, as a rule, even more important than their
joint symptoms, and if the neurotic symptoms can be cured, as they
usually can without much difficulty, the patients feel much better.


Systematic Exercises.--As soon as the acute stage has passed patients
should be encouraged to take some systematic exercise in spite of the
discomfort that is associated with it. Unless muscles are moved
regularly deformities in bad position will result and there will be
crippling which can be avoided in most cases. It is sometimes
difficult to secure exercises for the small muscles that are involved
and definite occupations are better than artificial exercises. For the
fingers, for instance, I find that the best thing is knitting. By this
I mean using the old-fashioned knitting needles for the making of
stockings, wristlets, jackets, and the like. Crocheting is also of
some use, but it does not give employment to as many of the small
muscles as knitting. If the knitting is done with old-fashioned yarn
from which the lanolin has not all been extracted, some of this
substance comes off on the fingers during the movements associated
with knitting. This seems to do good by rendering the joints more
supple and the muscles more easy of movement. At least the suggestion
is very helpful to the patients.


Electricity and Mechano-therapy.--Electricity has been much praised,
but whatever good it accomplished has always seemed to me to be
confined to the exercise afforded the muscles. Its use, however,
serves to keep up the patient's hope.

Mechano-therapy often does good and some of the Zander machines are
likely to be useful. Pulleys and weights for the shoulders and arms
have their place and resisted movements serve to restore muscles to
function which they had lost during the time when the joints were
worst. Their use helps to bring the joint into the most available
conditions.

Something that has distinct hope in it must always be done for these
patients. For this local treatment means more than anything else.
Unfavorable {428} suggestions keep flowing in upon him from the
failure of medicine, and serve to concentrate his attention on his
condition and make him think that nothing can benefit him. Often the
physician finds that his patient has been to someone else, who did
some simple thing that brought relief of symptoms, at least for a
time, and restored his confidence to such a degree that he felt much
better for a time at least. These ailments are emphasized by advancing
years and, though we cannot prevent decay of tissue, we can keep the
patient's mind from inhibiting still further the functions of the
impaired tissue.


General Condition.--The patient's general condition must be made as
good as possible. For this outdoor air is the most important factor.
It increases impaired appetite, makes sleep more restful and easy, and
gives one of the best occupations of mind that can be obtained. Of
course, changes in the weather will bring discomfort. Where it is
possible, such patients must be sent to climates as equable as
possible. Such a change of climate during December, January and
February will often make them very comfortable, and the distraction of
mind, with the possibility of getting out in the mild climate, will
diminish their sensitiveness and be more powerful factors in the
dissipation of their aches and pains than the climate itself. Where
people cannot be sent away from home, the securing of corresponding
distractions means a great deal. The one thing necessary for the
physician is to keep the patient from brooding upon himself and his
ills and to find other occupations of mind for him.



CHAPTER X

COCCYGODYNIA

Coccygodynia, or, as it is sometimes called, coccydynia, is a painful
affection of the coccyx or bony end of the spinal column. It usually
results from trauma, as a fall on the buttocks on an icy pavement, or
particularly a fall in coming down stairs in which the main portion of
the impact is on the seat. Occasionally it follows horseback riding.
It is said to be on the increase among women who ride astride.
Occasionally it is reported after severe labor, particularly when the
head of the child was very large, or after first labor when the coccyx
has been beforehand bent inward somewhat abnormally and is pushed out
by the oncoming head. It seems to develop with special frequency in
nervous people who have to sit much, particularly if they sit on
unsuitable chairs. The chair seat with the ridge in the center which
has been introduced in recent years is sometimes blamed. Occasionally,
on the other hand, it is said to come from sitting on heavily
cushioned chairs, particularly leather chairs which do not allow of
much transpiration and cause a feeling of uncomfortable heat.

There are, indeed, so many different causes suggested, sometimes of
quite opposite or even contradictory effects, that it seems evident
that the main element in the disease is some predisposition to
sensitiveness in this region which is exaggerated and emphasized by
the cause that is blamed. It occurs particularly in women, though it
is occasionally seen in delicate or neurotic men. Sufferers from it
sometimes find it impossible to sit for any length of time. {429} Even
lying down, especially if they lie on their backs, becomes a source of
pain. Various operations, such as the reposition in place of the bent
coccyx, or even the removal of the tip of the coccyx, have been
suggested. Some reported cures are to be found in the literature.
These are mainly surgical cures, however, that is to say, the patient
recovered from the operation, was seen for a month or two afterwards,
and was then on a fair way to complete recovery. Some of us who have
had to treat these cases afterwards for painful conditions apparently
due to the scar of the operation, or to a neurotic condition closely
corresponding to the old coccygodynia, are not so confident of the
value of an operation, though probably in purely traumatic cases
surgical intervention is of value.

In most cases the sufferers are women who have little to do, who have
much time on their hands to think about themselves, and who usually
receive abundant sympathy from friends and relatives. In one case
under my observation the death of a husband and the discovery that his
estate was much less than had been anticipated, so that his widow had
to take up a wage-earning occupation, did more in a short time than
all the treatment that had been employed before to relieve her
discomfort. She had been quite unable to move around at times,
especially in rainy weather, and was something of an invalid during
all the winter, but now she was able to go out to work every day and
had very little trouble. Her affection originally dated from a fall on
an icy sidewalk and her fear to go out in the winter seemed to be
dependent on the dread of another fall. She realizes now that
practically all her former trouble was due to over-attention to a
discomfort which is still present, but which she is now able to
forget, except at times when she is alone after there have been
worries and troubles that have reduced her power to control her
nerves. In young girls an injury to the coccyx by a fall on the
buttocks will often leave tenderness for months or even years, but if
attention is distracted from this and the patient is not allowed to
concentrate her mind on it and does not hear of the awful
possibilities of coccygodynia--a mouth-filling Greek name in which we
map out our ignorance, and which seems to carry with it such a weight
of pathology--she will probably recover completely.

Coccygodynia often resembles hysterical coxalgia or the hysterical
arthritises, and seems sometimes to be due to the fact that there is a
natural or traumatic abnormal mobility of the coccygeal vertebrae
which, owing to concentration of attention, has developed into a
neurosis analogous to the corresponding condition in a joint. There
are undoubtedly cases in which a real pathological lesion exists, but
these are comparatively few. In this, as in other joint and bone
affections with vague pains likely to be worse on rainy days, the word
rheumatism is often mentioned, but it has no proper place. Treatment
that will put the patients into good general condition--never local
unless there is objective indication--outdoor air and exercise with
reassurance of mind and distraction of the attention are the important
therapeutic agents. Patients with much time on their hands do not
readily get well, while those who are busily occupied seldom suffer
for long.


{430}

SECTION X

_GYNECOLOGICAL PSYCHOTHERAPY_


CHAPTER I

MENTAL HEALING IN GYNECOLOGY


All physicians are convinced of the good that has been done by the
extension of the application of surgery to women's diseases during the
pest generation. On the other hand, there are probably very few,
except the ultra-specialists, who are not quite sure that there has
been too much surgery in gynecology, and that many a woman has been
operated on without sufficient reason and without definite
indications. In suitable cases surgery is sometimes life-saving and is
often the only means of relief for suffering that is seriously
disturbing the general conditions and is making life unbearable. Its
very possibilities of good, however, have led to abuses. From the
abuse of a thing, the old Latins used to say, no argument against its
proper use can be derived, and this is eminently true of gynecological
surgery. It will not belittle the great benefit that operative work
has been to state how much of auxiliary good may be accomplished by
the use of psychotherapy in gynecology.

Many a woman who is operated on is benefited only for the time being,
and her old symptoms return after a time. Dr. Goodell, one of our
first great gynecologists, used to warn his students insistently that
women had many organs outside of the pelvis. The individuality in
gynecology is extremely important. Some women suffer what they
describe as excruciating pain or unbearable torture from pathological
conditions that other women do not notice at all. Very often these
women either have no real interest in life and are so self-centered
that they emphasize their feelings by dwelling on them, or else their
attention has been attracted to some sensation not necessarily
pathologic and then by concentration of mind on it they so disturb
vasomotor conditions and the nutrition of nerves that the condition
does become a veritable torture and apparently demands surgical
intervention. It is possible to cause a hyperemia in the skin by
thinking about certain portions of it, and the genital organs are
particularly prone to be influenced by mental states. If for any
reason a woman gets her mind on her genital tract and becomes
persuaded that there is a pathological condition in it, symptoms will
develop until an operation seems inevitable. But the operation will
bring relief only for a while, and then her mind will find something
else to dwell on and produce similar symptoms.

{431}

Place of Psychotherapy.--To fail to try to sway the mind by all the
methods and auxiliaries outlined in the earlier chapters of this work
before suggesting an operation to a woman is to neglect a most
important means for relief in many gynecological cases. There is
scarcely any pathological condition from which women may suffer that
does not become worse as the result of the depressing influence of
much thinking about it, and that is not made better by a change in
their mind that makes them realize the possibility of being well
again. The most important preliminary to operation is the promise of
complete relief through surgery. The acme of suggestion is reached in
the preparation for operation with its constant encouragement and then
the congratulations after the operation. Then come the weeks of
convalescence during which the same strong suggestion is constantly at
work making the patient sure that she must be better. All this serves
to add tone to the system, invigorates the appetite and puts patients
in the best possible mental attitude to bring about a favorable
result. Indeed, the ten or fifteen pounds in weight that such patients
gain during their convalescence, especially when they have been under
weight before, is often the most beneficial result of their hospital
experience.

If the same patients had been given the same promise that they would
surely be cured, and then had been removed from depressing home
influences and bothersome trials and labors, and been told that what
they needed for complete recovery was to gain in weight; if they had
then been visited by friends who congratulated them on the fact that
now at least they were going to be better and their symptoms were
going to disappear, and if they had gained the fifteen pounds that
came in convalescence after their operation, most of them would have
recovered quite as completely as by the operation from many of their
vague gynecological difficulties. This is, of course, true only of
cases where there are not very definite indications for surgical
intervention. But in a certain number the symptoms are so vague that
operation is decided upon rather with the hope than the assurance of
benefit; and it is particularly in these that psychotherapy is useful
and must be given a thorough trial.


_Pain Relief_ .--It is often set down as a maxim of gynecologic
practice, that pain which cannot be relieved except by recourse to
dangerous or habit-forming drugs is an indication for operation. Pain,
however, is a relative matter and, as we have shown in the chapter on
Pain, its intensity depends not a little on the patient's attitude of
mind towards it. When there is discouragement and depression, pain
becomes insufferable, and what was borne quite well at the beginning
may now prove intolerable. Whenever occupation of mind can be secured,
however, pain is diminished in intensity.


Reputed Remedies and Suggestion.--Probably the most striking indirect
testimony to the value of mental influence and especially of
frequently repeated suggestion in gynecology is found in the recent
history of various much-advertised remedies that have been sold in
enormous quantities for all the ills of women. The composition of
these remedies is not, as is popularly supposed, a great mystery. They
have all been analyzed and their ingredients are well known. As a
rule, they contain only simple tonic drugs that have absolutely no
specific effect on the genital organs, but that are stimulating to the
general system. There has been much surprise at the definite evidence
{432} furnished by expert investigators, that the principal ingredient
in most of them--certainly their most active element--is the alcohol
they contain, which, until the passage of the pure food and drug law,
was in such considerable quantities that practically each
tablespoonful of these favorite remedies for women was equal to half
an ounce of whisky. No wonder that this gave an immediate sense of
well-being which rose in most of those unused to alcohol to a feeling
of exaltation. The patient was sure beyond contradiction that she
could feel the effects of the medicine! Of the after effects, the less
said the better, but there is no doubt that many women acquired the
alcohol habit through indulgence in these nostrums.

Illusory as was this sense of well-being, it sufficed in many cases to
relieve women of discomfort that had become so serious, to their minds
at least, that they feared an operation would be necessary.
Undoubtedly many of the testimonials given to such remedies are
founded on actual experiences of this kind in which patients were sure
that they were cured of serious ills. Where alcohol is not the chief
ingredient of these remedies, some other tonic stimulant is employed,
and it has proved sufficient to make the patients feel, or at least
suggest to themselves, that they must be better. This has given them
courage to take more exercise and get more out into the air, and
consequently relieves them of many physical symptoms that had
developed because they thought they were the subjects of some serious
ailment and must be solicitously careful of their health. The idea of
care for the health in many persons' minds seems to be to do as little
as possible of external, useful work and to occupy themselves
principally with their internal concerns. They stay in the house too
much and in so doing disturb nearly every physical function. Perfectly
well people, if confined with nothing to interest them, become
short-circuited on themselves and develop all sorts of symptoms,
physical and mental.


The Mind as a Factor in Gynecological Affections.--A gynecologic
incident of any kind may become to many women such a center of
attention that it is impossible for them to distract their minds from
it, and every symptom or feeling that can by any stretch of thought be
connected with the genital system becomes greatly exaggerated. Young
women, whose menstruation has been perfectly regular, may have it
disturbed by fright, grief, a change of environment, getting the feet
wet, or something of that kind. At immediately succeeding periods
their fear of bad effects will of itself influence unfavorably the
conditions in their genital system. They have always had more or less
discomfort, but now this discomfort becomes difficult to bear because
of the fear that there may be further serious consequences of the
disturbing incident in their menstrual life. It occupies all their
attention; instead of deliberately trying to disregard it, they fear
that, if they should do so, they would be allowing some progressive
condition to gain a hold on them which would lead to serious results.

One is apt to see this condition in young married women who have had a
miscarriage in their first pregnancy and who fear that there will be
serious results from it. If they have been much disturbed by the
miscarriage, they may lose in weight, and then a number of subjective
symptoms in their genital life will appear. Though their menstruation
appears regularly, lasts the usual time, and is neither more scanty
nor more profuse than before, and {433} though their physical
conditions are normal as ever, they suffer from bearing down pains and
feelings and backache just before menstruation begins; their ovarian
regions become sensitive and, if they are constipated, their right
ovarian region is likely to become tender, and they develop a set of
symptoms that seems to call for surgical interference. If, however,
they are put in conditions where they have some other occupation
besides themselves and their ills, it is surprising how the case will
clear up. They gain in weight, their subjective symptoms disappear and
especially they lose the persuasion, so common among them, that any
betterment of their symptoms is due to their getting used to the
pathological condition present and not to any real improvement of it.


Treatment.--In the treatment of gynecological conditions such as are
not necessarily indications for operation, the most important
consideration is to reassure the patient's mind and secure the
discipline of self-control. If patients are under weight this
condition must be corrected. If they are in an unfortunate environment
it must be modified, as far as possible. If they are without
occupation this must be provided for them. Dominant ideas and morbid
auto-suggestion must be overcome--not always an easy task, yet always
possible if patience, tact, and skill are exercised. They must be made
to realize that the women of the past, before the development of
modern gynecology, not only lived useful lives without any of the
modern gynecological operations, but that most of them were quite
happy in so doing. Even though many of them had physical symptoms, the
lack of unfavorable suggestion as to the significance of these
prevented mental exaggeration, and morbid dwelling on them was not
allowed to produce such a deterioration of the physical condition as
to emphasize the pathological conditions. This does not mean that
women may not have to be operated on, and, when that is necessary, the
operation should be determined on and performed with no more delay
than is proper to put the patients into suitable physical condition.
But many operations that are undertaken without definite indications
merely because the women complain, and it is hoped that an operation
will somehow prove of relief, would be replaced with much more final
satisfaction and relief by properly directed psychotherapy.

There are many minor pathological conditions such as slight cystic
enlargements, hyperemias with tenderness, slight displacements of the
ovary, slight dislocations of the uterus or twistings of it that can
often be successfully treated the same way. After all, what is
considered the normal condition of the feminine internal organs is
only an average reached from observation and many deviations from this
average cannot be considered abnormal. Many a woman living practically
without symptoms, or certainly without such symptoms as to justify an
operation, has pathological conditions of her internal organs worse
than those for which operations are sometimes suggested because
over-sensitive women complain of their symptoms. The rule must be
first to relieve the over-sensitiveness and then to determine whether
an operation is necessary or not. Pain alone, unless it is of a
disabling character or reacts upon the physical health, is not a
sufficient indication for operation.


{434}


CHAPTER II

PSYCHIC STATES IN MENSTRUATION


One does not need to be a physician to be familiar with the curious
psychic states which develop or are accentuated during the menstrual
period. Practically all the peculiarities of the individual are
emphasized at this time and if there are any special neurotic
conditions or psychic anomalies these become quite marked. All the
dreads, for instance, are more noticeable at this time. Women who at
all times feel uncomfortable on looking down from a height are likely
at this time to be quite overcome by fear and be unable to approach
any position from which they might look down for a distance. Women who
are afraid of horses, yet conquer their dread sufficiently to ride
behind them, cannot do so, or only with great difficulty, during the
menstrual period, and the same is true of the dread of cats or other
animals. Misophobia, the dread of dirt, may be particularly emphasized
at this time and servants are puzzled as to what has come over a woman
who was not so punctilious in the matter a short time before.


Irritability.--Dr. Charcot, the famous French nerve specialist, used
to say that for a day or two before menstruation and during the first
day or two of their period many women were not quite responsible. This
is not merely an exaggeration of French contempt for women, for
Möbius, the distinguished German neurologist, insisted that there is a
certain physiological mental disturbance with distinct hampering of
the faculty of judgment (Schwachsinn) normally associated with
menstruation.

Few physiologists or gynecologists agree with these extreme views, but
there is no doubt that many of the troubles which business men
experience with women in their employ begin with hasty words spoken at
these periods when the real reason for the irritability is not known.
The consciousness of this on the part of some women saves them from
much undesirable friction by making them more careful at these
periods. Many a domestic misunderstanding begins at these times and is
unfortunately allowed to continue because the real reason for it--the
instability of disposition due to menstruation--is not recognized.


Lack of Inhibition.--There is no doubt that, except in women of the
most stable physical and psychic character, a notable lack of
inhibition characterizes all their actions at this time. To think that
this is universal, however, would be a mistake. Healthy women deeply
occupied with something they like often pass through menstruation
absolutely undisturbed, and this is particularly true of the mothers
of families. In spite of its exaggeration, it is well to keep the
great French specialist's expression in mind, for it helps to explain
many things that produce much suffering in the world. This is
particularly true now that women are working more and more out of
their homes at occupations which often make strenuous calls on them
just at periods of the month when they should have more rest than
usual. The consequence often is the development of a highly neurotic
condition in which psychic {435} symptoms are likely to be prominent
as well as a tendency to exaggerate the significance of their feelings
which is disturbing to the patient and may even disturb the physician.


Exaggeration of Sensitiveness.--The most striking feature of this is
the tendency to exaggerate the meaning of physical symptoms which they
have often borne with for a good while without much inconvenience, but
which now appeal to them as of serious significance. Any uncomfortable
feeling is likely to be dwelt on to such an extent as to be called an
unbearable ache or even an excruciating pain, and the patient is prone
to connect it with some serious pathological process in the region in
which it is felt. If a woman has been reading about some special
ailment, or, above all, has been listening to the tale, usually
neither plain nor unvarnished, of a friend's medical woes, she is
almost sure to think that there must be something seriously wrong with
herself. Many a supposed chronic indigestion had its origin in nothing
more than the uncomfortable feelings in the stomach region during
menstruation, which call attention to that organ and then, by morbid
introspection, lead to the exaggeration of various sensations that
have always been present but have hitherto been disregarded.

It is a good rule to neglect symptoms that develop during the
menstrual period and not to treat them directly until it is plainly
seen that they persist afterwards; for symptomatic treatment at this
time will cause an over-attention to the condition. And we should be
careful not to suggest to a woman at this time that her symptoms may
be due to some pathological condition in an important organ. Such a
suggestion will almost surely be accepted seriously and dwelt on so
much as to become an auto-suggestion that may lead to the disturbance
of the function of the organ in question because of the surveillance
over it. The diagnosis must be put off until menstruation is over in
order that the exaggeration of this period may be eliminated. If this
were more commonly done and if women were advised to counteract their
feelings at this time as far as possible by occupations of interest to
them, there would be much less need of medication. As between rest and
strenuous work during the menstrual period, work is probably always
the better. Rest with nothing to do emphasizes morbid introspection to
such a degree as to make even ordinary feelings unbearable.


_Symptomatic Conditions_.--It is interesting to note how often
affections that are always present give symptoms only during the
menstrual period or just before it. Many women, however, suffer
considerably about the time of the menstrual period from an extremely
tired, painful condition of the leg below the knee which is really due
to flatfoot. At other times it gives them little annoyance. Old
dislocations and sprains are particularly likely to give bother at
this time. All the occupation pains and aches are emphasized.
Tiredness becomes a torment. This extreme over-sensitiveness extends
to physical ills of all kinds, even those that are trivial. For
instance, corns and bunions become almost unbearable, especially if
there is any change of the weather with moisture in the air about the
time of menstruation. Teeth become sensitive and often will ache when
there is little that the dentist can find the matter with them. Women
are often suffering from teeth that are supposed to be quite
intractable because of over-sensitiveness, while in reality it is only
at these certain times that the over-sensitiveness is present.

{436}

Over-reactions.--Even habitual actions which are accomplished without
much difficulty at other times are likely to be a source of annoyance
about this period. If a young woman has to call out figures or read
off lists of names, she soon becomes hoarse, her voice becomes husky
and it requires more effort to accomplish her work than at other
times. Complaint of sore throat is common about this time, and if
there have been any recent changes in the weather this is almost sure
to be a premonitory symptom of menstruation. Singers and elocutionists
are likely to find their occupations particularly trying at this time
and actresses are seldom without considerable physical discomfort that
makes playing difficult and unsatisfactory. This happens in all
occupations requiring frequently repeated use of particular muscles.
Piano-players and typewriters find that their fingers become sensitive
at this time. This sensitiveness of the ends of the fingers may become
so marked as to prevent these usual occupations, or at least may
require their limitation.


Physical Basis of Psychic States.--The physical basis of these
troubles is probably more responsible for them than has been thought,
though the mental state renders the individual more susceptible to
annoyances of any and every kind. Careful weighing seems to show that
there is a gain in weight amounting sometimes to three to five pounds
toward the end of the menstrual month. This is accompanied by a sense
of fullness that is perhaps an actual plethora, as if nature were
manufacturing a superabundance of blood in anticipation of the loss.
This produces a systemic hyperemia. It is well known that hyperemic
areas are more sensitive than tissues in ordinary condition and this
seems to be the case in menstrual life. This renders the nervous
system more active and irritable and the nerve endings more sensitive.
With the menstrual loss this physical condition is relieved and then
there is a return to normal with a loss of weight only partly due to
the actual blood loss and somewhat to increased excretion in
perspiration, in transpiration through the lungs and through all the
emunctories.


Treatment--To know that these psychic disturbances are likely to occur
at the time of menstruation is to be prepared for them so as to lessen
their effect upon one's self and others. They are much relieved by
this frank recognition and the patient understands that with the
betterment of the psychic condition by such reassurance the physical
symptoms are lessened. Many a woman gives up her occupation at such
times who would be much better if she bravely clung to it and resisted
the temptation to be moodily occupied with her condition. Above all,
she needs to be in the air. Oxidizing processes within the body are
slower and while much exercise is not beneficial and may be often
harmful, riding in the air, sitting in the air, above all, sleeping
where there is an abundance of fresh air is all-important. Every form
of exertion will be reflected in increased irritability. Shopping,
balls and parties will disturb the woman's mental equilibrium and make
it more difficult for her to stand whatever physical discomforts she
may have, and also make it hard for her to pursue her ordinary
occupation if this is somewhat exacting. Even these, however, must not
be given up if the sacrifice involves the throwing of the patient back
on self and increases introspection. Diversion of mind and
temporizing with symptoms are the basis of therapy at the menstrual period.

{437}


CHAPTER III

AMENORRHEA


No feature of menstrual difficulty shows so clearly the influence of
the mind over bodily function, and especially over those genital
functions that are supposed to be involuntary and spontaneous, as
amenorrhea. Almost any kind of mental trouble may produce a cessation
of the menstrual functions. Profound grief or a severe fright nearly
always does. Every physician of large experience has seen cases of
women who have missed their period because they were disturbed by a
fire, or a runaway, or an automobile or railroad accident within a
short time before their menstruation should normally occur. Even
slighter shocks may have a similar effect, and a profound shock of any
kind will seriously disturb menstruation. The most frequent effect is
to inhibit it, but it may be anticipated or delayed, and where there
is a tendency to too profuse a flow, it may produce menorrhagia.

Every physician knows that much less serious mental influences than a
profound shock or fright may somewhat disturb menstruation and, in
young women at least, this disturbance is nearly always in the
direction of lessened flow and amenorrhea. Home-sickness, for
instance, will often have this effect. Many of the foreign-born
domestics who come to this country have serious disturbances of their
menstrual flow, usually a diminution, during the first three or four
months after they arrive in America. This may, of course, be due in
part to change of climate, change of food and change of habits of
life. These girls while in their European homes have often been
accustomed to be much more out of doors and to have more exercise in
the open air than they have here.

That the mental state has much to do with menstruation may be
appreciated from the fact that serious changes of her state of life
may be accompanied by amenorrheal symptoms even when the patient stays
in the same climate and under conditions not different physically from
those under which she has lived. Country girls who come to the city
often suffer from such symptoms. Young women who enter convents
sometimes have these symptoms for some months, and this is so well
recognized as to be expected in a certain number of cases. Indeed,
there is danger that it should be attributed too much to the change of
mental state, and that other factors, such as incipient tuberculosis,
or disease of the ductless glands, or anemic states, which are
responsible for it, may fail to be appreciated because of the ready
explanation afforded by the mental factor. General experience shows
that the attitude of mind of a patient toward menstruation, the
expectancy of it at a particular time, and a good general physical
condition that predisposes to it, are quite as important for its
regularity as the specific physiological conditions which naturally
bring it about.


Fright and Amenorrhea.--Fright particularly may disturb menstruation
in many ways. Occasionally the disturbance of menstruation consequent
upon shock lasts for months or even years. At times when a woman
between thirty-five and forty is seriously frightened, especially by
terror that endures {438} intensely for some hours, the sort that is
said to blanch the hair in a single night--and there are
well-authenticated instances--menstruation never recurs or if it does
recur it is vicariously from some other portion of the body than the
genital tract. Among my notes is a case of a woman frightened by a
revolver which a maniac had flourished for hours at her while she
dared not make a move nor a sign. Her menstruation stopped completely
for a time and then came back irregularly and usually from the ear.
The bleeding was from the pierce in the lobule which had been made for
earrings, and before it started a large swelling of this would come on
in the course of an hour, often not subsiding for days. In another
case a woman who was frightened during menstruation by an insane
person flourishing a knife near her had for several years after an
extremely irregular menstruation, and usually only the molimina in the
genital tract, while the bleeding was from the nose. Deep emotion can
very seriously affect menstruation.


Pseudocyesis.--The mind may bring about a cessation of menstruation in
another way without any other factor interfering and in spite of the
fact that physiological conditions would all seem to be favorable to
its regular occurrence. We have many cases in medical literature in
which married women anxious to have children have concluded that they
were pregnant, and have had complete cessation of their menstruation
for months with all the symptoms of beginning pregnancy, so as to
deceive even careful physicians. The best known historical instance is
that of Queen Mary, the eldest daughter of Henry VIII of England, who,
nearly forty when she married Philip II of Spain, was very anxious to
have children. Not long after her marriage menstruation stopped and
all the ordinary symptoms of beginning pregnancy developed. Her
condition was widely heralded throughout the kingdom; then, after a
time, to the intense disappointment of the Queen and her friends, it
proved that she was not pregnant but that her mental attitude had
produced the series of symptoms that proved so deceptive. These cases
of pseudocyesis are so likely to occur that a physician in dealing
with a woman, who being rather well on in years when she marries is
anxious to have children, must be on his guard and he must always take
into account the possibility of a pseudo-pregnancy and must be careful
not to be deceived by symptoms that would ordinarily indicate beyond
doubt the beginning of pregnancy. Even experts have been deceived in
such cases, and it is in them that accurate rules for the certain
detection of pregnancy are most needed.

These symptoms have reference not only to the uterus, but also at
times to other organs. They are not merely subjective, but sometimes
become so objective as almost to demonstrate the diagnosis of
pregnancy, and yet a mental condition is the only source of the
changes. For instance, cases of false pregnancy have been reported in
which, besides the gradual enlarging of the abdomen with many of the
signs of pregnancy accompanying that phenomenon, there has been an
enlargement of the breasts and even the secretion of milk. In a few
cases the enlargement of the abdomen has been accompanied by
pigmentation and the areola of the nipple has also become pigmented.
This is not surprising, since corresponding changes take place in
connection with fibroid tumors, and the deposit of pigment is not a
symptom of pregnancy, but only a result of the congestion which takes
place in these structures during their enlargement.

{439}

Amenorrhea from Dread.--In some cases all the symptoms of pregnancy
develop, or at least there is complete cessation of menstruation, as a
consequence of nervousness and dread of the occurrence of pregnancy.
Unmarried women who fear that they may have become pregnant by
indiscretion, sometimes become so worried over their condition that,
without any physiological reason, they miss one or more periods and
thus add to their nervous state and further inhibit menstruation,
though usually two months is the limit of such amenorrhea and the
menstrual flow commonly makes its reappearance shortly before or after
the time of the third period. Occasionally, however, in the case of
anxiously expectant married women further symptoms of pregnancy may
appear and the case becomes more complicated. Every physician of
considerable experience has seen such patients, and doubtless much of
the harvest which advertisers reap from drugs that are supposed to
produce abortion comes from nervous young women who are not really
pregnant, but have inhibited their menstruation by worry, and who take
these medicines with confidence and have the menstrual flow restored
by trust in their efficacy.


Ductless Gland Disease.--Of course, in many cases of amenorrhea there
are serious underlying constitutional conditions which may or may not
be amenable to treatment, but the possibilities of which must always
be thought of. One case of amenorrhea I saw in recent years proved to
be due to a beginning acromegaly. There was no sign of enlargement of
the hands, though there had been a coarsening of the face which was
attributed to growth and to the fact that the girl was taking much
horseback exercise in all weathers. She had a headache for which no
remedy seemed to be of any avail, and when the amenorrhea developed it
was naturally thought that the headache must be due to gynecologic
conditions. Nothing was found on investigation, however, and
eventually the gradual development of the symptoms of acromegaly
showed what was really the basic cause. Occasionally diseases of other
ductless glands, as the thyroid, may have amenorrhea as one of the
first symptoms. It is seldom that any serious thyroid condition
develops without disturbance of menstruation, but this is less
frequently in the direction of diminution than toward profusion and
prolongation. In some cases, however, one or more periods is missed in
the early development of the disease. In this, however, others of the
characteristic tripod of symptoms--rapid heart, tremor,
exophthalmes--are sure to be present even though the enlargement of
the thyroid is not noticeable.


Tuberculosis.--But more important than these causes of amenorrhea is
the early development of tuberculosis. In some cases, even before
there is any cough that calls attention to the condition, or when the
cough has been considered to be one of those myths now fortunately
passing, "a cold that hangs on," the cessation of menstruation may
depend entirely on the weakness and anemia due to the growth of
tubercle bacilli in the lungs.


Inanition Amenorrhea.--Sometimes indigestion, or what is supposed to
be indigestion, may be at the root of the amenorrhea. In many cases it
really is not true indigestion that is present, but a disinclination
for food which has increased to such a degree as to bring about a
lowered state of nutrition. In nervous young women and, above all, in
nervous spinsters beyond forty, disturbances of menstruation
consequent upon lack of nutrition are not infrequent. Often their
indigestion is considered to be a reflex from their genital {440}
organs, when, on the contrary, whatever disturbance of their genital
organs is present is due to the inanition which has developed because
they have not been eating enough. Many of these women literally starve
themselves, and they, must be persuaded to eat once more and taught
what to eat, and their weight must be watched until it gets up to what
is normal for their height.


Psychotherapy and Treatment.--The treatment of amenorrhea on
psychotherapeutic principles will be readily understood from the fact
that there is a distinct psychic element in practically all the cases
touched on in this chapter. This psychic element is generally
appreciated and admitted. If a woman is accustomed to connect certain
physical incidents with disturbances of menstruation, then those
disturbances are almost sure to recur. As a rule, many an incident
said to be disturbing to the function would probably have no influence
upon it but for the dread connected with it and the anticipation of
some interference. In all cases of amenorrhea, then, the patient's
mind must be put into a favorable state and suggestions must be made
that will lead to the expectancy of menstruation at the next regular
period. If the mind can cause menstruation to cease, as is clear from
experience, any inhibition from this source must be removed and its
power set to bring relief to these patients. Drugs should not be
neglected, and general physical conditions must be improved, but if
the patient's mind continues to be unfavorably affected towards her
menstruation, its satisfactory return will be delayed until somehow
mind as well as body are co-ordinates for the resumption of the
function.

The best testimony to the value of psychotherapy in amenorrhea is
found in the success of many of the remedies used for the condition,
which, in the successive phases of medical development, have included
all sorts of home treatments, many types of quack medicines, and
innumerable proprietary combinations. Many of these have acquired a
reputation for efficacy not justified by any direct pharmaceutic
effects which we now know them to possess. From the familiar gin and
hot water, through the various combinations of aloes and the tonic
remedies of a later time, only the most general and obvious effects
could have been produced by the medicines, yet apparently specific
reactions have followed them in the menstrual cycle. But this was
because the mind of the patient was prepared by the taking of the
remedies and unfavorable suggestions as to menstruation were removed.
Above all, with amelioration of the general health, constipation being
relieved, the appetite restored and the whole tone of the system
improved, nature became capable of taking up once more the menstrual
function. What was accomplished by indirect psychotherapy in the past
can now be done much better by direct mental suggestion, when at the
same time various remedial measures in other therapeutic departments
are employed as auxiliaries. But the physician must be sure that the
mind of the patient is properly disposed or remedies may fail and
symptoms continue.



CHAPTER IV

DYSMENORRHEA


Practically every woman of menstrual age has more or less discomfort
during menstruation. In most cases this does not rise beyond a heavy
depressed {441} feeling shortly before menstruation begins, followed
by a sense of weight and discomfort in the back and then some
sensations more or less acutely uncomfortable due to congestion in the
pelvis, which begin to be relieved with the commencement of the flow
and then gradually disappear. Even in otherwise healthy women, various
achy feelings of distention are often felt in the neighborhood of the
ovaries, but these would scarcely be described as pain, unless the
patient is over-sensitive. The effect upon the disposition is more
marked and more universal. Some women are inclined to be irritable and
hard to get along with for a few days before their menstruation and
sometimes during the whole of its course. The frank recognition of
this fact by them and a consultation of the calendar when they find
that everything seems to be going against them and that everybody is
lacking in sympathy, usually leads to an appreciation of the fact that
the trouble is in themselves rather than in those around them, and
their condition becomes more bearable. It is curious, however, to note
how often this is forgotten, with consequent give-and-take of
irritation in their environment that makes the nervous and mental
condition worse and emphasizes the physical symptoms.

The term dysmenorrhea, from the Greek, means difficult menstruation
and is usually associated with painful conditions in connection with
the menstrual flow. It may be applied, however, to various
uncomfortable feelings, to superirritability, to fatigue, to lack of
energy, or even to more vague discomforts at this period. The
discomforts are usually spoken of as pains, especially after the
patient has been dwelling on them for some time and has been reading
patent medicine advertisements that tell of how women suffer in
silence, but analysis often shows that they are sensations of
pressure, of compression, of achy distress at most, and sometimes only
of unusual feelings--paresthesiae--that having got over the threshold
of consciousness, through concentration of attention upon them, are
occupying the center of the stage of mental activity to the exclusion
of all serious interests.

The serious difficulties of menstruation are due to definite
pathological conditions such as displacements of the uterus,
affections of the uterine mucosa and of the ovaries. There are,
however, many cases where the trouble is merely functional, dependent
on conditions that can be easily corrected without serious surgical or
even lengthy medical treatment, and where the patient's attitude of
mind towards the trouble is the most important factor in the medical
aspect of the case. As a matter of fact, many of the discomforts and
even serious pains complained of in connection with menstruation are
due rather to the patient's incapacity to bear even slight discomfort
with reasonable patience and without exaggerated reaction than to the
actual pain inflicted by whatever disturbance of function and tissue
may be present. People differ very much in their power to stand
discomfort and what seems quite trivial to one becomes unbearable
torture to another. With this in mind it is possible to relieve many
women who suffer from dysmenorrhea from their discomforts so that they
shall only have to bear what is every woman's heritage in the matter.
Successful management of these cases will save them from the supposed
necessity of being operated on, which is likely to be constantly
suggested to them in an age when women so often talk of their
operations.

The amount of pain suffered from any cause is dependent on two
factors, the pathological condition and the power of the individual to
withstand {442} discomfort. When we are irritated, when we are very
tired, when we have fever, when we suffer from want of food or lack of
sleep or any other condition that exhausts vitality, even slight pains
become hard to bear. In relieving pain it is as important to remember
this lessened capacity to stand discomfort as it is to get at the
cause of the discomfort itself. This habit of standing discomfort with
reasonable patience is one of the best remedies for lessening
suffering, especially when it is known that the discomfort is only
temporary and the end of it is in sight.


Physical Condition.--In the treatment of suffering incident to the
menstrual period, then, the correction of all conditions that may
increase nervous irritability and make patients less capable of
standing pain should be the first care. Young women who are thin and
anemic, especially if they are more than ten per cent. under weight,
are likely to suffer much at their menstrual periods for two
reasons--through their lack of power to withstand discomfort and owing
to the fact that their ovaries and the uterus itself are especially
sensitive, probably through lack of nutrition consequent upon their
general condition. In these cases local treatment is not as necessary
as improvement of the patient's general condition and the raising of
her general bodily tone.

The bowels must, of course, be regulated, partly for the sake of the
general condition and the fact that it is very hard to have a regular
appetite unless there is a daily evacuation, and partly also because
the presence of an accumulation of fecal material in the lower bowel
is likely to produce congestion in the pelvic region. This added to
the normal congestion due to the menstrual function may cause undue
pressure upon sensitive nerves in the ovaries and uterus. Indeed a
regulation of the function of the bowels is immediately followed by a
lessening of the menstrual discomfort as well as by a general
improvement. Many women find that the taking of a gentle purge a day
or two before the menstrual period serves to make that period a source
of less discomfort than it would otherwise be, and undoubtedly the
suggestive value of such a remedy persuades many women that their
discomfort should be lessened.

Professor Goodell's reminder that women have many organs outside of
their pelvis is important in dysmenorrhea. Almost any ailment that
drains a woman's strength and brings a series of irritations to bear
upon her nervous system will be reflected in her genito-urinary system
and will cause discomfort during the menstrual period. Over and over
again the physician finds that the true source of the menstrual
discomfort is not in the essentially feminine organs, but in the
digestive organs or occasionally even in such distant organs as the
lungs, and that proper attention to these brings relief during the
menstrual period. Just as soon as they realize that this is not a new
affection but only a reflex from their other ailment, whatever it may
be, they stand it with much better spirit and their complaints
diminish.

Anyone who has seen the difference between the reaction to menstrual
moliminia when patients are in good condition and when they are
otherwise run down will realize how much a matter of over-reaction to
symptoms dysmenorrhea may be. Teachers who begin the school year,
invigorated by their vacations, scarcely notice their periods, but at
the end of the course, when run down by months of hard teaching work
and especially by the confinement of the winter, they find the strain
extremely hard to bear. In many of these cases an examination by a
specialist seems to reveal something that might be {443} benefited by
operation. There may be various uterine displacements, sensitive
ovaries, perhaps slightly enlarged yet often not distinctly
pathological, but just as soon as the physical condition is made
normal, the symptoms given by these conditions completely disappear.
Women who have nothing particular to do, who talk much about
themselves and their ills, who have had friends operated on and heard
much talk about the subject, are soon convinced that only an operation
will do them good. Once _that_ suggestion is implanted in their minds,
the hypnotic dread of the operation and the morbid attraction of being
a center of interest and commiseration will make them exaggerate their
symptoms to such a degree that operation becomes almost inevitable.


Moral Fiber.--It is often said that modern women, as the result of
civilization, refinement, and city life, are of laxer physical fiber
and therefore cannot stand the ills that their grandmothers bore with
equanimity and considered as nothing more than what was to be expected
in this imperfect existence. Most physicians must feel, however, that
the increased laxity is not so much of the physical as of the moral
fiber. We have not weaker bodies than our forefathers, but weaker
wills. This is especially so with those who have much time to think
about themselves, and, therefore, is more true, of women than of men,
though in our generation men also have become very introspective. I
have seen--and I am sure that my experience is a common one among
physicians--delicate women who seemed unable to stand any trial or
hardship successfully, placed by unfortunate conditions--such as the
sudden death of a husband, or his failure in business--in
circumstances that were extremely hard to stand up bravely against.
Not only did they stand it, but they had better health, they had less
complaint of pains of all kinds, particularly in this matter of
dysmenorrhea, than they had before.


Pain and Occupation of Mind.--The more claims a woman has on her
attention the less likely is she to be bothered at her monthly
periods. If she does not _have_ to get up in the morning because there
are no insistent obligations upon her, she is likely to lie in bed and
worry about herself and by concentrating her attention on her ills
will make them worse than they are. But if she has to be up and doing,
if household cares cannot be put off, if she has to earn her living by
working every day, she not only succeeds in doing it, but often also
forgets her ills to a great extent in her occupation. Of course, there
are pathological conditions that cannot be put off in this way, and if
there are serious uterine changes, or if an infection has spread along
the tubes to the ovaries, there will be symptoms that cannot be
distracted away. Even where there are minor pathological conditions,
however, occupation of mind will make pain less annoying and even make
it quite negligible. We know our own experience with toothache. This
is a real pain and with a real pathological condition of the most
material kind. The congestion of the sensitive dentine or the
irritation of an exposed nerve filament causes about as severe pain as
it is given to mortals to bear. Even with toothache, however, we can
by occupying ourselves with friends, or with a pleasant book, or a
game of cards, or the theater, so diminish the annoyance consequent
upon the pain as to be comparatively comfortable. If anything
completely occupies our attention as, for instance, a fire or an
accident, or bad news from a friend, then it may be hours afterwards
before we realize that we were suffering from a toothache. Since this
will happen with a dental nerve, why should it not {444} happen to
branches of the genital nerve? There is no reason why one should be
more sensitive than the other, and whatever reason there is is rather
in favor of the dental nerve giving more bother, since it is nearer
the center of the nervous system and these nerves are usually said to
be more sensitive.


Working Women.--With regard to painful menstruation, the habits of
many country people, and of the European peasantry generally, furnish
valuable indications of the power of work to dissipate discomfort.
During my medical student days in Vienna I had the opportunity to know
rather well a group of women who were engaged in working on a
building. They carried up the bricks and mortar for the men and worked
the windlasses by which heavy materials were carried to the different
stories, and they mixed the mortar and prepared the building materials
generally. These women, living constantly in the air and working very
hard, had almost no symptoms of menstrual difficulty. They never laid
off at this time except in a few cases in which subinvolution after
pregnancies and genital infections had left conditions that made it
hard to understand how they worked at all.

I learned in addition from them, for most of them came from the
country, that the women who work so commonly in the fields in central
Europe have little difficulty with menstruation and practically do not
know that it is coming on them until the show indicates its presence.
I had known before how true this was for the Irish peasant women. This
seems to be the normal healthy condition, and the state of mind of
these women aids this satisfactory state of affairs. They rather look
down upon women who complain at this time as being of such inferior
health as to be despised. Doubtless if they were persuaded, as so many
seem to be, that a woman must expect to have a serious time, or at
least a great deal of discomfort about this period, they would have
it, too. Of course, they have some difference of feeling at this time.
They feel more tired in the evenings, and they awake in the morning
less rested, but that is no more than the changes in the weather bring
to men.

On the coast of Brittany and Normandy many of the women rake for
shellfish. Their custom is to wade into the water and, standing with
the water often above the knee and waves sometimes washing as high as
the waist, to rake all day for the shellfish that they are seeking.
They do not lay off from this occupation, as a rule, when their
menstruation is on them, but continue as if nothing were the matter,
and there are very few complaints of menstrual troubles among them.
Such occupation would seem to be positively counter-indicated, but
long years of experience have shown them that there is no need of
interruptions in their work and as they need every centime that they
can obtain in this way for the support of their families, they
continue even in very cold weather, when it would seem inevitable that
this must produce serious results.

It is not uncommon for a young woman, who, while her family was in
good circumstances, was a severe trial to everyone for a week more or
less, every month, to become quite free from trouble for herself and
others when, owing to a change in the family circumstances, she has
had to take up some occupation for a living. I have notes of cases of
this kind in which the pain was so severe that, after several years of
medication and external applications, it was decided to dilate the
cervix uteri in the hope of affording relief. The relief thus
afforded, however, was only temporary. A little later in life, {445}
however, the necessity of earning a living has in some cases quite
freed these young women from the torments that sent them so frequently
to their physicians.


We need the report of many more of such gynecological conditions which
get better as a consequence of occupation of mind without any other
treatment. We have any number of reports of benefits derived from
operation, but not infrequently these reports refer only to a few
months after the operation, when the strong mental suggestion of the
performance of the operation and the general betterment of health
consequent upon care during convalescence are still acting upon the
patient, and she has the benefit of the gain in weight and strength
that usually follows because of hope, appetite, exercise in the air,
etc. Not infrequently in these cases there are, later on, sad relapses
into painful conditions quite as severe as before, while, on the other
hand, some change in the circumstances of the individual, or some
intense preoccupation of mind a few years after, brings lasting cure,
thus showing that it was the mental state which was at the root of the
condition rather than any bodily affection.


Spasmodic Dysmenorrhea.--There are two forms of dysmenorrhea that have
been the subject of much study. One of them consists of cramp-like
pains which occur some time before menstruation, are relieved if the
flow is copious, but continue if it is scanty. This affection has
often been attributed to mechanical obstruction. Nearly twenty years
ago Dr. Champneys in his Harveian Lectures on Painful Menstruation
discussed this subject, and showed that the mechanical explanation
while very simple and popular was probably not correct. His conclusion
was that the dysmenorrhea was more frequently due to conditions
outside of the uterus than in that organ. He recommended plenty of
healthy exercise between the periods and especially riding if the
patient were not a working woman, regular activity of the bowels with
epsom salts as probably the most valuable single remedy, and then a
number of drugs such as guiacum and sulphur that are not specifics but
have a general effect. In his experience castoreum, a strongly
suggestive remedy, gave more relief than anything else. He advised
against local treatment unless there was a very definite reason for it
and frankly expressed the opinion that the complaints were often due
more to an incapacity to stand the slight discomfort that is more or
less inevitably associated with the congestive state that precedes
menstruation than to any pathological lesion.


Membranous Dysmenorrhea.--This affection like membranous colitis
remains one of the mysteries of pathology and etiology. There is no
doubt, however, that there are large nervous elements in its
production and that it is worse at times of worry, while mental
factors of many kinds influence its occurrence and also its relief. In
his Harveian Lectures Dr. Champneys discussed the questions connected
with it very well and his monograph is a classic on the subject. Many
drugs have seemed successful and then have failed. Castoreum has done
good in this as in spasmodic dysmenorrhea. A number of gynecological
methods of treatment have been successful when first applied, when
physician and patient were both confident of their value, and then
later has failed. Probably nothing does more good than getting the
patient's mind off her condition, securing such occupation as will not
permit of introspection to any extent, though of course treating
surgically whatever requires operation. It must not be forgotten that
while many of those suffering from the disease {446} complain of pain,
not a few sufferers from it have no symptoms of this kind and their
condition is discovered more or less by accident. After this there is
likely to be much more discomfort from it. All this must be borne in
mind in its treatment.


Minor Ovarian Lesions.--In many cases there is vague discomfort in the
ovarian region about the time of menstruation, and the ovary is found
to be somewhat enlarged or perhaps dislocated. In these cases if there
is continued complaint of pain, operation will almost surely be
advised and frequently cysts are found. This is considered to be
justification enough for the removal of the ovaries or at least for
their resection. It is doubtful, however, whether ovarian cysts in the
majority of cases are really a pathological condition. Those who are
engaged in spaying cattle think it almost if not quite normal for
cysts to exist in the ovaries. Whether this is not also true of women
we have not the data to determine. In a number of the patients who are
operated upon for this condition there is a relapse of symptoms, and
there seems to be no doubt but that whatever good is accomplished
comes from the expectation of relief followed by the weeks of rest and
quiet in bed and very often the gain in weight which succeeds the
operation. Whether something of this kind would not follow from the
simpler procedure of improving the general health is an open question.

It is sometimes insisted that the general health will not improve in
gynecological cases unless the offending pathological condition is
removed. This is true if the patient is persuaded that there is some
pathological condition present which must be corrected or else she
will not be better, and if favorable suggestion cannot be used to
advantage. If, however, these patients understand from the beginning
that probably the local condition, which gives the symptoms, is due
rather to their general health than to a definite lesion, there is
more probability of improvement. It is surprising how many of these
cases are relieved by an improvement of the general health, by the
relief of constipation, by the decrease of congestion by laxatives,
and by the persuasion that there is nothing which will go on to
serious developments (this is the most disturbing of dreads) but only
a condition that will probably get no worse and the symptoms from
which may yield to general treatment.

The popularity of many so-called remedies for women's diseases is due
to their success in lifting the veil of discouragement and, by
alcoholic and other tonic stimulation, helping the women into a better
general condition and a more favorable frame of mind.


The Individual.--In all cases of dysmenorrhea, then, it is important
not to be influenced too much by the complaints (for here, as
Broadbent insists with regard to angina pectoris, the more complaint
we have the less serious the condition will often be), but to
investigate the patient's condition and, where there is not some
definite and serious pathological lesion, to analyze the beginning and
the development of the individual case and eliminate the neurotic
elements. Often the menstrual difficulty is due to suggestion, as the
patient has been in contact with others who were sufferers and caught
her complaint from them by psychic contagion. Special investigation is
needed as to her occupation of mind. This must be provided for her.
Nothing else will save her from herself. Travel may do it, exercise
may be helpful, but an occupation in which she is deeply interested,
especially if it involves {447} association with other people, is the
best basis of psychic treatment. Improvement of the general health and
the relief of various symptoms are auxiliaries.


Unfavorable Suggestion.--After consulting with many women physicians,
with many women who have lived active lives, with many superiors of
religious orders in consultation about their religious women, I cannot
but conclude that painful menstruation is ever so much oftener a
result of mental and nervous states than of organic disturbances.
Unfortunately a tradition has now been established that women suffer
much at this time, so many of them give in to their feelings,
exaggerate their discomfort, dwell on their sensations, affect the
blood supply to the genital organs through the sympathetic nervous
system, actually produce functionally pathological hyperemia where
only physiological was present (the simile of the blush makes this
easy to understand), and finally set up a condition that is actually
painful, though there was only some discomforting sense of compression
and congestion before. We have been educating young girls in disease,
not in health. Plato pleaded for the opposite. After these 2,400 years
we might take it up seriously.



CHAPTER V

MENORRHAGIA


While the influence of the mind in producing painful menstruation and
a much diminished menstrual flow is well recognized, the connection
between the mind and an increased menstrual flow is not so generally
appreciated. Usually profuse menstruation (especially when it reaches
a height where it would properly be called menorrhagia) is considered
to be due to some serious pathological condition. Its most frequent
cause is undoubtedly subinvolution of the uterus after pregnancy, or
an overgrowth of the uterine mucosa because of some pathological
condition--usually an infection. While menorrhagia is often attributed
to colds or to getting the feet wet (and undoubtedly the disturbance
of the circulation consequent upon wet feet is an active factor in the
production of an increased menstrual flow) there is no doubt that in
most cases there is some more distinctly local cause at work. Another
important cause of profuse menstruation is the presence of a fibroid
tumor or other neoplasm which brings an increased blood supply to the
uterus and a consequent greater elimination at the menstrual epoch.

In most cases of subinvolution a curettage, at least, will have to be
done. Often the use of extremely hot douches, that is, just as hot as
can be borne, may accomplish much. Such quantities as a quart or two
are useless; several gallons should be taken, and that not in the
awkward cramped postures in which douching is sometimes done and in
which it cannot be expected to accomplish its purpose, but in the
reclining position and to be followed by an hour or two of rest with
the hips elevated. This treatment will be more effective if women do
not get the idea that an operation will surely have to be done on
them. Operations are now so much spoken about that some women
apparently do not feel that they have had quite all the experience
that is coming to them in life unless they have at least one to their
credit. If they can be made to realize that, in the past before the
days of operative gynecology, most such cases recovered of themselves
and that now if courage is {448} resumed, appetite strengthened
through the will, constipation relieved, an abundance of outdoor air
secured (exercise is not so necessary), recovery will probably be more
complete than after an operation, there would be much less need of
operations than at present.

The material conditions based upon pathological changes which usually
produce menorrhagia hardly seem amenable to influence by the patient's
state of mind, yet experience demonstrates that much can be done for
these patients by setting their minds at rest, by improving their
general condition, by soothing their worry as to what the profuse flow
means. Many nervous patients have quite normal menstruation, as
regards the length and quantity of flow, until some serious
disturbance occurs in their mental state. I have had patients who for
months would have a perfectly normal menstrual flow of three to five
days to whom a serious mental disturbance always brings a profuse
menstruation. The arrest of a woman by mistake just before or at the
beginning of her menstrual period will often cause a greatly increased
flow and great weakness will follow. Women approaching the menopause
already have a tendency to an increased flow though not beyond the
bounds of what might be considered normal, and at this time almost any
shock will produce profuse menstruation and lead to prostration. If
the secondary anemia from this is not overcome during the interval
profuse menstruations may succeed each other for many months.

The necessity for reassuring these women, therefore, becomes evident.
Most of us have seen women who were worried at having a slightly
increased menstruation, and who had been told that they had a fibroid
tumor which was producing the increased menstruation, and which would
have to be removed if it continued to bring on this serious condition.
Such a suggestion inevitably leads to a series of more profuse
menstruations during the following months. Such women worry over their
state and dread an operation. They do not eat well and, even though
they do not lose much in weight, they often become distinctly anemic.
This anemia adds to the tendency to a freer flow and as a consequence
the menstrual period is lengthened in time and increased in amount.
This soon brings them to operation, though very often there has been
no increase in size of the fibroid tumor and there is no more reason
for operation than there was when they were first examined.

I have had under observation during the last two years a patient in
whom the diagnosis of a fibroid brought this unfortunate result. Her
menstruation had been profuse and prolonged before but now it became
still longer and lasted nearly fifteen days each month. As she lost
much in weight, was run down in strength, became self-centered, stayed
more at home, and took less exercise, the resultant depression in her
general condition emphasized the menorrhagia. As soon as it was made
clear to her that her case had but one indication for operation--the
loss of blood and that the fibroid was so small that it might well be
allowed to remain until after her menopause, when involution would
probably prevent further unfavorable action, she took heart, began to
exercise, ate more heartily, her marked constipation was relieved, she
slept better and in three months her menstruation was almost normal.
For many months she had no menorrhagia.

I have seen other cases in which amelioration of symptoms came just as
soon as the patient learned that, by improvement in the general
health, there {449} was a possibility of lessening the tendency to
hemorrhage and thus of putting off the necessity for operation for a
time at least, if not until such natural changes occurred in the
system as to lessen the danger from the growing tumor. I have in mind
the wife of a physician whose menopause was delayed for some ten years
as a consequence of a good-sized fibroid growth. She had it when she
first came to me, and I watched the case for some seven years, and she
absolutely refused to entertain the idea of operation. I set her mind
at rest as to the seriousness of the growth provided the bleeding was
not injurious and no infective conditions occurred through the
intestinal walls to complicate the condition and cause adhesions.
Whenever she worked hard, or whenever she was much worried, she would
have alarming flooding. Under ordinary circumstances, however, when
things did not go awry, she had a menstruation somewhat more profuse
than normal and of five or six days in length. This continued from her
fiftieth to her fifty-fifth year, and then gradually subsided. She is
still alive at the age of sixty and, though she has had many trials
and hardships at the end of her life, she is healthy and considers
herself much better off than if she had had an operation. I doubt
whether this is true, that is, if the operation had been done twenty
years ago. But, after watching such a case and realizing that
operations on fibroids are more often fatal than any other of the
gynecologic operations that do not involve serious conditions, a
physician is justified in tiding women over the time to their
menopause and then letting nature dispose. Infective incidents
pointing to the formation of adhesions are a contraindication to this
policy, however.

The sufferer in this case was one of the most patient of women. She
had had to suffer much in mind and in body as the result of being left
almost destitute after a life of luxury, yet she seldom complained.
One might almost think her indifferent to hardship if one did not know
her well. She was not at all a stoic but she never allowed her
imagination to run away with her, she bore the ills of the day without
thinking of what was going to come next week and she worried as little
as possible under the circumstances. The ordinary woman, nervous and
excitable, would have broken down under the strain that was placed
upon her but she promises to live to a good age and her trials have
not hurt her vitality nor spoiled her disposition and she looks the
world in the face with surprising cheerfulness. This state of mind
modifies even fibroid menorrhagia favorably.

Fibroids have been reported "cured" by so many different
remedies--local applications, acupuncture, hot needles, electricity in
various forms, even internal treatment, which afterwards proved quite
unavailing--that it is manifest that the mind plays a large rôle in
controlling the symptoms.

Before operation it is important to put the minds of these patients
into an attitude of confidence, for operators who make it a point to
secure the confidence of their patients, or who for some reason have
their full faith, have better results in these cases than others of
equal surgical skill.

In unmarried women the development of a small fibroid with its reflex
disturbances is sure to be followed by excessive reaction in many
ways. Nervous symptoms are likely to be marked and the increase in
menstruation is usually much more profuse as a consequence of the
solicitude than because of the fibroid. Some of these tumors which,
though of small size, are so situated with regard to the nervous and
circulatory systems of the uterus as to produce {450} profuse
menstruation even in women of phlegmatic disposition. In these
patients operations will be necessary whenever the loss of blood makes
it clear that the drain on the system is producing serious effects.
There are cases, however, in which the menorrhagia is not due directly
to the fibroid, but rather to its effect upon the general system and
this may be lessened very much by reassurance, by regulation of the
general health, by resumption of exercise and toning up of appetite
and, above all, by relief of the constipation which so often
complicates these cases. Fibroids may or may not continue to grow. The
removal of one is no guarantee that others will not form, nor that
others are not present in very small form which will develop later. As
a rule, there can be no question of the removal of the uterus unless
conditions are serious.

If in spite of general treatment and the calming of the patient as far
as possible profuse menstruation continues, it is an indication for
surgical intervention. Psychotherapy may readily be abused in these
cases, but it has a distinct use, and its application is more
frequently successful than has been thought; but it must be
deliberately employed. When, however, menorrhagia is a symptom of some
serious progressive condition, psychotherapy will do harm rather than
good. I have known women whose menstruation was stopped and then
recurred and even became profuse reassured that this was only a
symptom of the menopause when it was the first symptom of a cancer. In
such cases there must be no temporizing or reassurance, but a careful
determination of the actual condition must be made and immediate
operation done if it seems necessary. Psychotherapy may have a place
in incurable cancer, but in other cases it has none at all except to
calm the patient for operation where surgery may be of service.



CHAPTER VI

THE MENOPAUSE


While the phase of feminine sexual life which involves the cessation
of menstruation is physiological and not morbid, it is so commonly
associated with physical and mental symptoms difficult to bear that,
practically always, it sends the woman to a physician. This is as true
of the artificial menopause induced by removal of ovaries as it is of
the normal process by which, in the course of time, ovarian function
comes to an end and changes are brought about in the system consequent
upon the absence of ovarian secretion. The ovaries, like many other
organs, have two functions. One, that of ovulation, is so prominent
that the other, the internal secretion, has been too much neglected.
How important this is, however, may be judged from the change that
comes over feminine nature after its cessation. Much of the
emotionality of woman disappears, not a few of her special sex
qualities are modified and even masculine physical peculiarities may
assert themselves. The physical effects of the ovarian internal
secretion may be inferred from the definite tendency to grow stout
which results from its suppression by the menopause. Certain changes
in the organism are inevitable then, and the only hope of therapy is
to keep them from disturbing life processes.


Neutralizing Unfavorable Mental Attitude.--Psychotherapy can do more
{451} for the troubles of the menopause than any other treatment. The
symptoms of the change of life in the long ago, if we can trust
traditions, were not so troublesome as they are now. Only rarely did
women suffer from it as they are supposed to suffer at the present
time. Women are so persuaded that there is to be much suffering, or at
least prolonged physical discomfort, as to make it difficult for them
to be quite themselves. They are prone to think that their physical
symptoms are noted, and that their condition is a subject of remark.
This adds to the difficulty of bearing in patience whatever symptoms
are present. The introspective attitude of our time has reacted upon
such affections as occur in the menopause, and, by creating an
abnormal susceptibility of mind, has added much not only to its
possibility but also to its actuality of suffering. Drugs or other
remedial measures will modify the conditions only partially and
temporarily. The mental prophylaxis of suggestion must alter the state
of mind both before and during the progress of the condition.


Favorable Suggestion.--After the menopause women are less disturbed by
emotional strains and troubles of any kind than before. They settle
down into more placid, easy-going lives. They are not subjected to the
monthly interruption of their routine of work or amusement, everything
comes a little easier to them, and they are not, to use the word in
its physiological sense, so irritable--that is, so responsive in
reaction. They are not so likely to respond to slight irritations, and
are often physically and mentally more content with life. This must be
insisted upon, for, at the present time, unfavorable suggestion with
regard to the menopause is the universal rule. Women look for the
worst from it, and their expectation makes conditions less tolerable
than they really are. Most women dread it as if it were the beginning
of the end of life, the first descent into old age, while it is often
the dawn of a larger and broader life free from sexual and other
irritations, and with better possibilities of accomplishment.


Definite Prescriptions.--These patients are best reassured by being
told that every woman who has lived to the age of fifty has gone
through a similar experience and that they have all, with rare
exceptions, revived with health of both body and mind. It is more
important to insist on the patients cultivating a certain gaiety of
disposition, to plan for regular diversions two or three times a week,
to see that they are not too much alone and that they find abundant
occupation of mind and body, than to try to combat their manifold
symptoms by drugs or local measures. Of course, their physical
functions must be kept normal. It is surprising, however, how much
improvement can be brought about in the menopause symptoms by definite
prescriptions as to the time to be spent in the open air--at least two
or three hours a day--with regard to having a definite diversion of
some kind in mind two or three days ahead to which they look forward
with pleasure, and by convincing them that whenever they allow
themselves to dwell much on their condition, their symptoms of
discomfort will become so severe as to be intolerable, while when they
are occupied with other things they will find them quite easy to bear.

As a rule, mothers of families with many cares and diversions of mind,
with little time to think of themselves, do not suffer much at this
period, or at least not nearly so much as do those who are without
these diversions. The more time a woman has to think about herself at
this period, the worse for {452} her. Her irritability of mind will be
reflected upon her physical condition and make it worse. In the olden
time mothers of families went through it and no one knew about it, or
even noticed that there was anything the matter with them except
possibly a little increased irritability at certain periods. Neither
menstruation nor the menopause is necessarily connected with more than
passing discomfort, if the patient is in good health. This is
perfectly true if symptoms are not brooded over, if there is not too
much expectancy of evils, and the feelings and manifestations which do
not deserve the name of symptoms are taken as a matter of course. Best
of all, let the woman keep her mind well occupied with many
duties--with care for others, the helpless, the ailing, around her,
instead of with herself and her passing ills.


Dread of Insanity.--There are few women who go through this period
without the hideous thought that possibly they may go crazy. This is
especially likely if, as a consequence of the exaggerated desire for
seclusion that many women have at this time, they do not get out into
the air nor exercise as much as they should. As a consequence, they
suffer from constipation, from lack of appetite, and capriciousness of
taste for food, and they may have a series of symptoms that, when
dwelt on during the hours of solitude, very seriously disturb the good
feeling that is so important for the normal accomplishment of
physiological functions.


Diversion of Mind.--This tendency to withdraw from social relations
with their friends and from the occupations that take them out of
doors and which are often a helpful diversion of mind is one of the
worst symptoms of this time and must be strenuously combated. It
superinduces a series of physical symptoms which are attributed to the
menopause but are really due to lack of air, to inactivity, to absence
of interest and the consequent opportunity provided for unfortunate
auto-suggestion and introspection. These superadded physical symptoms
can be readily relieved by directions for rational living and then the
genuine menopause symptoms may be so diminished as to be scarcely
noticeable. It is impossible for the ordinary human being to stay much
in the house, to lie down a large part of the time, eat irregularly
and let the bowels become sluggish without having many symptoms of
depression.


Summary of Treatment.--The treatment, not of the menopause but of the
patients passing through the menopause, then, must consist, first, in
putting them in as good physical condition as possible and keeping
them in it; second, in maintaining such normal natural habits of life
as will enable them to keep up this physical condition without
disturbance; thirdly, in putting off solicitude with regard to the
menopause and realizing that it is a normal natural process with a
definite place in human life and not at all representing a terminal
stage of human existence. Nature meant that the mature woman, formed
by precious experience, with sympathies broadened by years, should be
able to devote herself without sexual irritation to the many things
that naturally come to her at this period. There is a place in life
for the grandmother and even for the grandaunt, though a French
visitor recently declared that he thought there must be no
grandmothers in America since all the women seemed to dress in the
fashion of the young girl. If this submission to natural conditions is
recognized and accepted there are long years of happiness and
helpfulness in store for the woman of middle age and the menopause may
be welcomed as an important step towards a larger development of life.


{453}

SECTION XI

_PSYCHOTHERAPY IN OBSTETRICS_


CHAPTER I

SUGGESTION IN OBSTETRICS


In no department of medicine is favorable or unfavorable mental
influence more important than in obstetrics. Unfortunately,
unfavorable suggestion has here played a serious rôle and must be
controlled, modified, neutralized. Suggestion is valuable in its every
phase, during the course of pregnancy, in labor itself, in
_post-partum_ convalescence, and with regard to nursing. Many women in
our time are prone to persuade themselves that labor is a more serious
incident than it usually proves to be and the consequence is an
unfortunate suggestion of pain to come that so exaggerates
sensitiveness as to make the actual suffering seem more than it really
is. Sympathy expressed for women in pregnancy and in anticipation of
their labor is sure to do more harm than good. Pain instead of being
lessened by sympathy is increased and capacity to bear it is
diminished. Anything that calls attention more particularly to the
pain removes distracting conditions that might modify it favorably.
Animals have the admirable instinct of withdrawing to some quiet
corner when they are in pain, preferring to be alone. In this they
follow nature and imitation of them is worthy of consideration, at
least so far as the avoidance of opportunities for the expression of
sympathy is concerned.


PREGNANCY


Maintenance of Health.--Women must keep up their normal health and
strength during pregnancy. By not taking sufficient exercise and by
being too much indoors, many women develop a morbid mental state in
which every discomfort is less bearable than it was before. Lack of
air and of exercise, furthermore, makes them prone to constipation,
makes their sleep less restful, and reduces the appetite. For the sake
of the being within them, they force themselves to eat, but this often
serves only to make them obese, without improving their general
health. If a woman in her ordinary condition, who was accustomed to
going out-of-doors several hours every day and having reasonable
diversion of mind and exercise of body, were to adopt the habits of
life that many pregnant women form, she, too, would become morbidly
introspective, fearful of the future, irritable over little things,
restless at night, and even have certain physical symptoms, such as
constipation, tired feelings, loss of {454} appetite, etc. Many of the
discomforts and symptoms of which women complain during pregnancy are
really due to unfortunate habits and to their mental attitude toward
their conditions, rather than to any specific influence of pregnancy
on the general health. As a rule, women who live naturally are in
somewhat better physical health during pregnancy that at other times.


Obesity and Pregnancy.--It is important that women should not become
obese during pregnancy. The woman who is taking too much fat in her
diet and accumulating fat is likely to have a fat baby, and with these
there is more difficulty in labor itself, and the infants have less
resistive vitality than if they were unencumbered with useless adipose
tissue. Her will must overcome the tendency to lassitude and the
proneness to inactivity that comes over her, and she must feel that
labor and her condition after it are dependent on normal, healthy life
at this time.


Delayed Labor and Suggestion.--One phase of maternal impressions or of
suggestion for the mother's mind that I have always been interested in
has been that of the possibility of preventing delay in parturition by
frequent suggestion of the time that delivery should be expected.
There seems to be no doubt that expectation has some influence on the
time of delivery. We do not know just why, after the uterus has
tolerated the presence of the fetus for nine calendar months, it
should then refuse to do so any longer and contract and expel it. Any
number of theories have been suggested and even now our best
obstetricians are not agreed as to the reason for this action on the
part of the uterus. In some cases this contraction does not take place
normally. The due term of labor is past and as a consequence fetuses
grow too large within the uterus, greatly increasing the difficulties
of parturition and adding to the risk of both mother and child. It is
the custom to announce with pride the birth of twelve- and
fifteen-pound babies, but it is doubtful whether nature intended that
growth to this extent should take place before birth. There is in
this, as in other phases of pride with regard to children, a curiously
perverted feeling.

Many obstetricians feel that the babies who weigh much more than the
average of seven pounds have probably been delayed in the uterus for a
lunar month beyond the time when they should, or at least could have
been normally born. It is a question whether this delay would have
occurred if the mother's expectation of the birth had been directed to
a date a month ahead of that on which her mind became fixed as the
time of labor. Parturition usually takes place about the period of the
recurrence of the menstrual molimina, or at least of that monthly
cyclic feeling which many women experience, though there is no flow.
It is not always easy to say at which of two monthly periods the birth
should be expected. While physicians have warned patients of the
possibility of the child being born at the first of the two possible
periods, they have been inclined to dwell on the fact that it will
probably be delayed until the later term. Women themselves are more
prone to take the later than the earlier termination of their
pregnancy. Both physician and patient are timorous of the ridicule
that may follow if they make premature announcements. Whether we have
not in this way created a tradition tending to delay parturition by a
lunar month in many cases, is a problem that requires careful study.

The suggestion of as early a period as is compatible with the data
provided, so as to create a definite expectancy in the mother's mind,
seems well worth {455} deliberate attention. This is a role that
psychotherapy has to play in lessening the dangers and the
difficulties of parturition. With most healthy women, as indeed with
most sensible normal women in life as regards all things, no
suggestion is needed and nature will take her course promptly and
properly. It is the nervous women, over-anxious about themselves,
often of lax physical fiber because of their nervous condition, that
need this phase of psychotherapy. It is in them that the unfavorable
or mistaken suggestion may be emphasized to such a degree as to delay
labor for a lunar month or even more.


Vomiting of Pregnancy.--One of the dreaded complications of pregnancy
is serious prolonged vomiting. We know now that this is of two kinds,
toxic and neurotic. The toxic variety may be associated with kidney
changes, but is more commonly the consequence of certain rare forms of
degeneration of the liver. The pathological picture after death is not
unlike that of phosphorus poisoning. These cases are due to some
serious disturbance of metabolism or to the absorption of some little
understood poison. They are probably always fatal. The cases of
neurotic vomiting are rather common. They are exaggerations, of the
ordinary familiar vomiting of pregnancy which is exhibited by nearly
all women at the recurrence of the menstrual times in the early
portion of pregnancy. In some of these cases, however, the vomiting is
so persistent and so prolonged that the patient's nutrition suffers
severely, and there seems to be danger of a fatal termination.  The
condition has received the unfortunate name of "pernicious vomiting."
In these cases there is sometimes question of the advisability of
terminating the pregnancy lest the woman should die. Unfortunately
this question has been so commonly discussed that most prospective
mothers are likely to know something about it, so that when vomiting
begins they are fearful lest they should have to lose their child.
This becomes an obsession in some minds and an unfavorable suggestion
that helps to maintain the vomiting.

A number of remedies have been highly recommended for this at various
times. Nearly every alterative drug has had its period of popularity.
In the older time nitrate of silver was said to be efficacious. Small
doses of ipecac were highly recommended at one time. Small doses of
cocain were suggested, and the painting of the back of the throat with
cocain. Small doses of morphin had a vogue; codein had its turn after
its introduction, and heroin also had a time of popularity. Oxalate of
cerium was highly recommended. Any obstetrician of experience will
remember many other remedies that have been supposed to be
efficacious. Various gynecological procedures have been suggested: the
touching of the _cervix uteri_ with a mild caustic, with iodin or with
nitrate of silver, slight dilatation of the cervix, sometimes the
application of a tampon with just enough glycerin to produce a
reaction, but not enough to terminate the pregnancy. Occasionally
local applications over the stomach region, a mustard leaf, or certain
plasters, or finally even a piece of sized paper bound on over this
region have been known to be followed by the cessation of the
vomiting. When as many different remedies are recommended and seem for
a time to be successful and then later prove to be inefficacious, it
is reasonably clear that it is not the remedies but the effect
produced by these on the mind that is the important therapeutic
factor.

Many obstetricians of wide experience now teach that most of these
cases of vomiting in pregnancy are merely neurotic and are to be
treated entirely {456} as if they were hysterical. The patient's mind
is to be distracted from her condition; she is to be assured that even
severe vomiting is quite common in pregnancy, that it is annoying, but
never serious in its consequences, that it always ends without
unfortunate incident for mother or child, and that there need be no
solicitude. Above all, no hint of the possibility of the necessity for
the termination of the pregnancy, if vomiting continues, should be
given. Some physicians are entirely too solicitous in the matter and
have by their anxiety made the neurotic condition of their patients
worse. Some men see what they call a "pernicious vomiting" in every
hundred labors. A well-known obstetrician in New York has had 3,000
births without seeing a single case. He is known for his placidity and
lack of over-anxiety. In the great obstetrical clinics in Europe
vomiting to the extent that will put mother or child in danger is
extremely rare. The greatest obstetrician of the later nineteenth
century reports 100,000 obstetrical cases with only one artificial
labor.

In foreign obstetrical clinics these cases in recent years have been
treated expectantly, without any active interference, especially with
pregnancy, and the results have been much more satisfactory than any
other method of treatment. There are a number of cases on record now
in which pregnant women have lost from twenty to forty pounds as the
result of vomiting for weeks, yet after a time the attack has passed
and they have carried the child to full term. Where vomiting has
occurred and relief has once been afforded by the termination of
pregnancy, it is very unlikely that succeeding pregnancies will pass
without corresponding conditions in which no remedy will prove
effective, except the dreaded obstetrical intervention for the
termination of the pregnancy. It is extremely important then that
these cases should be treated conservatively and that from the very
beginning there should be nothing to arouse the patient's solicitude
with regard to herself or above all to give her any hint of the
possibility of obstetrical intervention being necessary in her case.
For some women the knowledge that a consultation has been held to
discuss such a possibility will of itself prove a persistent
unfavorable suggestion, that will surely prolong the vomiting.

This may seem a rather strong opinion from one who is not in practical
touch with obstetrics. It has been the growing opinion, however, among
the great German obstetricians for the last generation. Ahlfeld, in
the _Archiv für Gynaekologie_ (Band 18 Heft 2 page 310) said that he
had seen [in a very large obstetrical practice] three cases of
so-called pernicious vomiting (_unstillbaren Erbrechen_) in all of
which the patients wanted an abortion because they had previously
learned the success of this method of treatment, but all of them
recovered without incident and carried their children to term. Kronig,
ten years ago, in his monograph on "The Significance of Functional
Nervous Diseases for Diagnosis and Treatment in Gynaecology"
[Footnote 36] said: "The excessive vomiting of pregnant patients has
for a long time seemed to be a genital reflex neurosis. We thought
that the growing uterus irritates certain nerve tracts which are
connected with the mucous membrane of the stomach. We owe it to
Kaltenbach that this opinion was overturned and _hyperemesis
gravidarum_ set down as the result of a functional neurosis,
hysterical in character. A large number of gynaecologists have
accepted this opinion in recent {457} years (men of all nations) among
others Calderini, Charpentier, Schaeffer, Klein, and Graefe."

  [Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten
  für die Diagnostik und Therapie in der Gynakologie von Dr. B.
  Kronig. Leipzig, 1902.]


Winkel and the leading obstetricians of Germany, especially the
directors of obstetrical clinics in the large cities, must be quoted
as of the same opinion, since Winkel has collected the statistics of
100,000 pregnancies in the large German clinics in which 6,555
obstetrical operations were performed and in only one case was
artificial abortion produced. German opinion is rather strong in the
assertion that a number of cases of abortion in the practice of an
obstetrician indicates over-hastiness in coming to conclusions as to
danger, or leaves him open to the suspicion of yielding too readily to
the wishes of mothers who would prefer not to carry their children to
term. The suggestion of the possible necessity for abortion has done
much to make the hysterical vomiting of these patients continue until
this remedy is employed. Insistence from the very beginning that
vomiting, though it may injure both mother and child, never
necessitates abortion--one out of 100,000 cases is practically
never--would be the best possible contrasuggestion.

Kronig thinks that the vomiting of pregnancy is an especially
favorable subject for suggestive treatment. He inclines to the opinion
that the remedies that have been reported to do good and so many of
which have subsequently proved unavailing have really owed whatever
success they have had to the suggestion that went with them. Bumm, in
his text-book of obstetrics (Grundriss zum Studium der Geburtshülfe
von Dr. Ernst Bumm, Wiesbaden, 1902), accepts Kaltenbach's and
Ahfeld's conclusions and thinks that the consideration of
_hyperemesis_ as an hysterical neurosis is well supported by the
success and failure of our therapeutics. All sorts of remedies, any
number of drugs, all manner of gynecological procedures short of
abortion, though also including abortion, have been reported as doing
good. All of them even including abortion have failed in a certain
number of cases. Evidently suggestion plays a large role. Hypnosis
often proves an excellent remedy.


Excessive Salivary Secretion.--Bumm considers that the excess of
secretion of saliva which is so often noticed in pregnancy is of the
same nature and should be treated rather by suggestion than by any
particular remedy, though remedies should be tried because of certain
helpful physical effects, and then the psychic element that goes with
them. The less importance given to the symptom, the less attention it
attracts, the more its passing trivial character is emphasized, the
sooner it will subside. Solicitude causes it to persist and even
increase.



LABOR


Suggestion in Labor.--When the subjects are normal, expectancy has
much to do with the severity of labor pains. In recent years so much
fuss has been made and so much said and written about woman's burden
and travail in the pains of childbirth, that preliminary dread and
anxious attention have wrought young women up to such a poignancy of
expectation as to make these pains worse than they really are. In the
old days child-bearing was as much a matter of course as the husband
going out to his daily work, and the taking of the dangers and
fatigues of it was a simple matter of duty. Labor was then {458}
comparatively easy and, while never pleasant, was also never an
over-uncomfortable process. The effect of unfortunate suggestion has
been to make it seem ever so much worse than it really is. Multiparae
furnish the best proof of this. A healthy woman who has already had
more than one child does not dread labor pains very much, or only to a
slight degree, because the previous maternities have lessened the
physical pain to be experienced, though a healthy woman's tissues are
so thoroughly resilient that nature is able to bring about a return to
normal conditions so complete that it is not always easy to decide
whether a woman has given birth to a child or not. Of course, there
are many cases in which tears reveal the former labor, but there are
others in which it is not so, and the renewal of the birth process
must, therefore, be nearly if not quite as painful as before,
especially if it is recalled that succeeding children are usually
larger. In spite of this in multiparae, labor has lost most of its
terrors because real knowledge of its comparative ease has replaced
the previous unfavorable suggestion, and instead there has come a
proper appreciation of what will have to be borne, and of the positive
pleasure of the relief when it has been borne successfully.

Healthy women of the lower classes have so little difficulty in labor
that they are quite frank to confess that it means scarcely more than
a few severe muscular pains during an hour or so. Some of them mind it
so little that up to within half an hour of the birth of the baby they
occupy themselves with other things and succeed effectually in
distracting their pains away.

In their article on "Hypnotism and Suggestion in Obstetrics" Drs.
Auvard and Secheron   [Footnote 37] suggest that hypnotism can be
employed with advantage during labor, but it is more difficult to
produce it then than in the normal condition. Its only advantage is
anesthesia, and this can be obtained during the preliminary pains in
many cases. It is frequently impossible to produce complete
anesthesia, however. To replace hypnotism they advise that suggestion
in the waking state be used and they even suggest the employment of
pseudo-choloroform or other like means. This method they consider more
advisable than hypnotism, for there are no inconveniences and many
real advantages. The nervous condition of the patient after hypnotism
during labor is sometimes far from satisfactory.

  [Footnote 37: "L'Hypnotisme et la Suggestion en Obstétrique,"
  Paris, 1888.]


Nature's Methods.--In obstetrics and labor we have been finding in
recent years that we have not trusted nature enough, have not looked
sufficiently to the woman herself for assistance in its difficulties,
and have made her too much a passive rather than an active factor.
Practically all of the dangers that have accrued to the woman in
childbirth, certainly many times more than have come from any other
factor, have been due to well-meant but unfortunate attempts to help
her while preventing her from helping herself. Before the middle of
the nineteenth century most of the puerperal fever was due to
infection from over-zealous but unclean attendants. Now men are
proudly reporting hundreds of cases of delivery without even a vaginal
examination. Above all, we have failed to take advantage of the
occupation of mind that could be used to save women much of the
anxiety and suffering of labor. If the parturient woman were allowed
to change her position, as she does so naturally and frequently in a
state of unsophistication, and to help actively, as she can {459} in
many postures, in the delivery of her child, it would mean much in
diverting her mind from pain which is emphasized by inactivity. The
rule of having the woman lie on her back has been unfortunate in many
ways and has required much more external interference than if other
positions were adopted, while the pains have been more unbearable
because that is actually the position in which the woman suffers most
and in which she can do least to lessen them.

I was once told by an Irish grandmother the story of nearly one
hundred deliveries without accident of any kind, in which the only
rule had been not to touch the woman, but to allow her to change her
position and, above all, to facilitate her in getting on her knees in
a stooping bent-over posture so as to help herself. The upper mattress
was doubled over completely and the woman was encouraged to kneel on
the lower straw mattress, which was so arranged that it could be
changed completely, or destroyed immediately after labor. This seemed
old-fashioned and unscientific twenty years ago, when I heard the
story, but I have been interested recently in reading Professor King's
address on "The Significance of Posture in Obstetrics."   [Footnote
38]

  [Footnote 38: _Bulletin of the Lying-in Hospital_, Vol. V, No. IV.]


Professor King is sure that there are many advantages in following
certain natural inclinations of the mother to change her position and
that this helps her in many ways. Above all, as the psychotherapist
sees at once, it will occupy her mind, keep down anxiety and lessen
pain in many natural ways, besides encouraging concentration of
attention on muscular effort instead of on painful sensation. The
whole article is well worth reading, for in it he suggests that
certain obstetrical operations, even version, would not be so often
necessary, if the woman were sometimes allowed to assume the squatting
position in the course of birth. His illustrations make very clear the
help that changes of position are in the mechanics of many
difficulties of labor. The pressure of the patient's thigh on the
abdomen, when she was allowed to assume a squatting position, enabled
him, in a case in which the woman had been in labor twenty-eight
hours, in which ergot had been given by the midwife, in which the
waters had been discharged and the uterus was tetanically contracted
around its contents, to deliver the child without instrumentation and
without further delay. In five minutes the arm (for it was an arm
presentation) began to recede, and in twenty minutes the child was
delivered, head first, and mother and infant both did well. Other
cases with similar results have been reported by obstetricians quite
as distinguished as Professor King. Many other experienced obstetrical
teachers have expressed themselves to the same purpose in recent
years.


Postures after Labor.--Allowing changes of position after labor also
has its advantages. There is often retention of urine and this can be
relieved by allowing the woman to assume the usual position. It may be
impossible owing to the swelling and hyperemia in the neighborhood of
her urethra for the woman to pass water, and yet if she is allowed to
sit in the usual position upon a commode, she will in most cases pass
her water in a few minutes without difficulty and the risks attending
catheterization will be obviated. The power to urinate is due in these
cases partly to the pressure of the thighs upon the abdomen which
helps the bladder to contract and undoubtedly also to the suggestive
influence that the position has.

{460}


NURSING

The attitude of mind of a woman toward her milk supply is important,
as the flow of milk is closely subject to mental influence. The
presence of the child and the consequent exercise of maternal instinct
does more to bring about the prompt, healthy flow of milk than
anything else. Sometimes women in the later months of their first
pregnancy upon seeing a mother nursing her child have felt the flow of
milk to their breasts not rarely with such painful overdistention of
the milk ducts as to require artificial relief. On the other hand, a
fright may stop the flow of milk or make it scanty and a mother's
aversion to a child may prevent her being able to nurse it. The sight
of the father of the child in a state of intoxication may have a
similar result.

How much milk supply may be dependent on the state of mind, or at
least the state of the nervous system, can be realized from the
animals from which we obtain milk. Any serious disturbance is likely
to interfere with the milk supply. When a cow's calf is taken away the
animal will often refuse for a time to give milk. If a cow is scared,
as by the attack of a wild animal, or by being hit though only
slightly injured by an engine, it will often not have milk for several
days or even longer. There is an impression prevalent among farmers
that if a cow takes a dislike to a particular person they are not
likely to "give down" as much milk as would otherwise be the case.
This may be only a curious farmer tradition, that has no basis in
fact, although it is supported by so many observations reported from
many different countries that it is apparently to be taken as of
scientific value.

In modern times many fashionable women do not nurse their children
because they have not the proper supply of milk. It is easy to see how
this can be brought about through suggestion from many sources and the
sight of others neglecting their duty in this matter. Most fashionable
women would rather not nurse their children, and yet many of them feel
a bounden duty in the matter. Some of these, however, having heard
that many mothers of the better class are not capable of nursing their
children, easily persuade themselves that they come in this category,
and so their whole attitude of mind toward nursing is one of extreme
doubt. Knowing as we do how the mental state influences nursing we are
not surprised when these women prove not to have sufficient milk in
the early days of the nursing. If they are to have it they must look
forward with confidence to nursing their children and they must be
ready and willing to take such food and secure such fresh air as will
put them in the best possible condition for this function, always with
the thought that nothing can be better for a child than to be nursed
by its own mother. Nature has made exactly the form of food suited for
the particular child, and it matters not how healthy a wet nurse may
be, her milk is not likely to be so suitable. Much depends on the
nutrition of the child during this early susceptible period of its
life and there is more that passes over with the milk than merely the
food elements. It is well recognized now that the reason why nurslings
are protected from most of the so-called children's diseases and the
contagious diseases generally, is that, as a rule, their mothers {461}
have had these diseases, have acquired an immunity to them and this
immunity is transferred to the child so long as the nursing process is
continued. This has been shown to be true over and over again in
animals and holds good for human beings.

Professor Von Leyden, the distinguished professor of medicine at the
University of Berlin, points out that we are not quite sure as yet
just what may happen to the human race from the very general refusal
of mothers to nurse their children and the almost universal
substitution of the bovine mother; whether in times to come certain
bovine traits, at least as regards susceptibility to disease, may not
be stamped upon the human race, cannot be determined until this
experiment in ethnology, now being conducted on so large a scale, has
been carried to some definite conclusion.

Perhaps this view is groundless, but there is no doubt that milk is
more than merely a food and that during the period after birth when
the child's nervous system is being formed, the perfectly adapted
mother's milk is more likely to be the proper food than anything that
human ingenuity can elaborate. We have heard much in recent years of
the tendency of education and civilization to lower the birth-rate and
to make women less fitted for maternity and for such maternal duties
as nursing, but stronger than any deterioration of the physical
constitution by the mental development is the unfortunate unfavorable
effect of mental suggestion upon such functions, by which the
preparation of the organism for their fulfillment is greatly
influenced. It is in this respect that the women of to-day differ from
the woman of the past much more than in mere physical development.



CHAPTER II

MATERNAL IMPRESSIONS


"Maternal impression" is accepted as a specific designation to signify
the real or supposed influence of emotion and especially serious
trouble, which may affect the mother's mind during pregnancy and be
transferred to the child _in utero_, with the production of
deformities or mother's marks. There used to be an almost
superstitious belief in the power of the maternal impressions to
influence unfavorably the child _in utero_. With the newer
developments as to the influence of the subconscious and subliminal
there might well occur in some minds an exaggeration of these ideas
with the production of much mental suffering at least, if not of more
serious results.


Maternal Impressions in Old Literature.--The belief in the influence
of maternal impression on the child _in utero_ is so strongly fixed
that to most people it will seem paradoxical to question the whole
subject. The evidence for it, however, is quite trivial, and none of
it rises above the grade of what may be explained by coincidence. But
there are many apparently insuperable difficulties, from the
standpoint of our modern scientific knowledge, with regard to the
whole subject. If we take up the medical books and the popular
science, or rather pseudo-science, and the folk stories of a century
ago we find overwhelming evidence for the belief in maternal
impressions. More recent {462} literature has but few examples, and
the more the details are studied the less is the evidence of any kind
that the mother's mind influences her unborn child. There is really no
more reason why a child should he marked within its mother's womb than
that it should be marked while nursing at the breast if something
should happen to the mother at that time. This latter effect strikes
one at once as absurd; the former, as we shall see, is exactly of the
same nature.

Many of the older stories of maternal impressions are reported on no
better grounds than the vomiting of snakes and the like, even live
mice, which used to be found in old-time medical literature. It is
true that there was usually no such morbidity about the stories of
maternal impressions, but men wanted to find some explanation for the
problem of the occurrence of deformities and markings and the maternal
impression idea seemed satisfactory and inviting by its very mystery.
The belief that animals could live for some time in human stomachs is
now relegated to the limbo of old-time credulous traditions. Maternal
impressions are on the same path and in twenty-five years they will be
as great curiosities in serious medical literature as the gastric
fauna of two generations ago. Under these circumstances prospective
mothers who are anxious over possibilities and who have dreads of all
kinds about their unborn children should be reassured and informed as
to the scientific status of this important question.


Mother and Child Distinct Beings.--There is no direct connection
between the mother and her unborn babe. No nerves run in the cord and
none pass from the uterine tissues to the placenta. It is easy to
understand the influence of mind on body under ordinary circumstances,
at least the mystery has a rational explanation. The central nervous
system rules the nutrition of the body. To cut off the nerve supply
has as serious an effect as to cut off the blood supply. Owing to the
existence of a chain of neurons, that is, a succession of nervous
elements, instead of one continuous nerve fiber from center to
periphery, it is possible for one of the neurons of the chain to be so
disturbed that the conducting apparatus is interrupted and impulses do
not flow. Hence, if a strong impression is produced on the mind with
regard to a particular part of the body the neurons leading to it may
be so disturbed that trophic nerve impulses do not flow down, the
blood supply of the part may be disturbed through the vaso-motor
system and consequent changes may take place.


_Absence of Circulatory Connection_.--Since no nerves pass, as we have
said, from mother to babe, disturbances acting on the mother's mind
can at most only influence the blood supply to the baby. Most people
think that there is a direct blood supply from mother to child and
that the mother's blood literally flows in the baby's veins. This is
not true. The baby's blood is an entirely independent structure,
originating in the child's own body, and always maintaining a distinct
and quite different composition from that of the mother. The baby's
blood has a higher specific gravity, and it has, in normal condition,
nearly double as many red corpuscles to the cubic millimeter as the
mother's blood. If the blood supply is disturbed by mental influences,
then it is not the baby's blood nor its circulation that is disturbed,
but only the circulation through the maternal part of the placenta
where an exchange of gases and nutrient elements between mother's and
baby's blood takes place. It is {463} impossible to conceive that
during this passage through a membrane of nutrient elements, soluble
proteids, gases, etc., mental influences should also pass over.


Supposed Examples of Maternal Impression.--The stories that are told
would lead us to believe that somehow definite changes in the mother
are reproduced in the babe. One case, which in a circle of friends
that I knew very well made many a convert to the idea of maternal
impressions, was that of a young woman at whom, during an early stage
of her first pregnancy, her husband playfully threw a tiny frog. He
did not know that she had a mortal dread of frogs. She was seriously
frightened and put up her hand to ward off the animal, and as the
clammy thing struck her palm she felt a shiver go through her. When
her baby was born a curious growth that had some pigment in it and
that, by a stretch of the imagination, might be considered to resemble
a frog was in the baby's hand--the same hand, by the way, as that
which the mother used to ward off the animal. The lack of any nervous
connection and of any direct blood connection between mother and child
makes the story simply absurd as an illustration of maternal
impression.

In recent years such stories have come from more and more distant
parts of the country. Kansas was the principal source of them until a
generation of great editors arose there. Texas was then their favorite
location, but Texas has in recent years become so progressive and so
closely connected with the rest of the world that, in spite of its
size, it does not produce so many of these wonders. A generation ago
the announcement of the birth of six children at once in Austria, or
somewhere else in Central Europe, would usually be followed by a
report from Texas announcing seven at a birth. Maternal impression
stories grew luxuriantly for the benefit of the news-gatherer in dull
seasons. A standing type of them is that of the farmer cutting hay on
his farm who puts his fingers too far into the hay cutter and has them
taken off. His wife binds up the bleeding stump. She is pregnant at
the time. When her baby is born--usually two or three months
later--just the same fingers are missing on the same hand of the
child. Now the mechanism by which such maternal impression could be
transferred to the child is incomprehensible. There is no connection
between the two, and the old metaphysical axiom (_actio in distans
repugnat_) that all action between bodies at a distance from one
another, that is without some connecting link between them, is absurd,
holds as good in modern times as it did in the Middle Ages. Surely a
tendency-to-amputation is not carried over from mother's blood to
baby's blood through the membrane in the placenta just as are the
gases for respiration and the nutrient elements for food. If it is, we
have a greater mystery than ever to solve.


Period of Occurrence.--The infant in the uterus is fully formed before
the tenth week of pregnancy and at a time when women are usually
almost unconscious of the fact that they are pregnant. Such
impressional changes as we have referred to, if produced after this,
must be in the nature of backward growth or an inversion of trophic
influences or a great perversion of embryonic life. They have nothing
to do with the formation of the child, since that is completed. They
are as much accidents as if the child should fall after it was born.
We know how fetal limbs are amputated through the formation of
amniotic bands, but that maternal impressions should influence the
formation of these bands is of itself ridiculously absurd. That it
should {464} influence them in a directive and selective way so that
certain limbs may be amputated at a certain point reaches a climax of
absurdity. A distinguished physician of our generation once said that
one might as well hope to absorb a pencil case in one's vest pocket by
medicine as to try to bring about absorption of fully formed
connective tissue by drugs. We cannot think of any mental influence
bringing about such absorption, yet to credit maternal impressions
with the production of fetal amputations not only supposes the
directive formation of connective tissue within the uterus, quite
beyond the domain of the influence of the mother's nervous system, but
also assumes the direction of the anomalous action of that connective
tissue in its mutilating procedures in a very exact and definite way.

Some curious things have been explained on the score of maternal
impressions and it is this very exaggeration that is perhaps the best
proof of how coincidence, imitation, and other factors play a role
that has exaggerated the idea of maternal impressions into a causative
factor. A typical illustration is the case cited years ago, half in
joke, perhaps, half in earnest, by a distinguished professor of
obstetrics. It occurred in the days when the elder Sothern was playing
Lord Dundreary to crowded houses and when Dundrearyisms were the
current witticisms and Dundreary ties and Dundreary clothes and
Dundreary whiskers were all the rage. A young woman who was recently
married became much taken with the actor and went to see him over and
over again, secured an introduction to him, and showed the liveliest
interest in him and the performance. Their acquaintance, however,
remained merely that of chance friends. Some months after it began,
not more than five or six at the most, a boy was born to her.
According to the story this boy, when he began to walk some years
later, developed that little skip in his gait which proved so taking
to those who crowded the theaters to see Sothern as Lord Dundreary.

By this time the play had lost something of its vogue and most people
did not recognize the curious halt in the gait, but it was very clear
to the mother and her friends. It was set down as due to a maternal
mental impression. Mental transfer seems ludicrous in this case. It is
much more likely that the mother was hysterical, and, wishing in a
morbid way to attract attention to herself and her child, taught the
boy the little skip, or perhaps some curious little skip once taken by
the child attracted the mother's attention because of her memory of
Sothern, and her surprise at the act impressed the peculiar action
upon the boy's mind, who proceeded to attract further attention by
repeating it. It is cases like this with their _reductio ad absurdum_
of the whole process that have quite discredited the belief in
maternal impressions.


Some Figures and Coincidences.--The occurrence of mothers' marks in
connection with various external incidents of pregnancy are only
coincidences. Most young mothers dread lest something should happen to
their children. About once in a thousand times an infant is marked in
some way. Nine hundred mothers rejoice over the fact that their baby
is not marked in spite of the fact that they feared it might be,
ninety-nine of them never gave the matter any thought and one of them
finds to her sorrow that her foreboding has come true. Occasionally a
mother who has not dreaded such a result finds that her offspring is
marked. Then she recalls all the happenings of her pregnancy and picks
out something to which she thinks she may attribute the accident.
{465} There must be some reason for it and she finds it. Sometimes she
begins by saying that it must be because she was frightened at such a
time, or fell down at such a place, or saw such a thing, and then a
week later she tells the story with circumstantial additions which
make it very clear to her friends that she knows exactly the reason
and that she had thought about it before and feared it might be so,
though the whole matter was hazy until it had been talked over a
number of times.

Coincidences have been the most serious detriment in drawing
scientific conclusions in every department of medicine. Most of our
diseases are self-limited and any medicine that was given being
followed by recovery seemed to be the cause of that recovery and the
more strictly self-limited a disease the greater the number of
remedies. When stories of maternal impressions are analyzed it is
found that a great many mothers have had forebodings as to their
children being marked and their dreads have not come true. A few have
feared and have realized their worst fears. Many women whose children
are marked can recall no event in the course of their pregnancy which
could have marked their child and they ask the doctor what he thinks
must have been the reason. But unintelligent mothers can always find
some cause by searching out unpleasant details of their experience
during pregnancy.


Intrauterine Nutrition and Nursing.--To explain the occurrence of a
frog-like appearance or a mousey patch on a baby as due to its mother
having been frightened by one of these little animals while nursing
would be the height of absurdity. But it is no more absurd than the
supposition that mental impressions in the late months of pregnancy
can have the effects that are popularly ascribed to them. If a mother
suffers from severe fright, or even if she has a fit of intense anger
or other profound mental disturbance, her milk may disagree with her
infant. Every physician has seen nursing infants made sick by the
change in the milk superinduced by strong mental emotions in the
mother. This, however, could have nothing to do with the production of
a special lasting physical mark on the outside of the body.


Maternal Solicitude and Superstition.--The wonderful stories that are
told are nearly all in the older literature and are much more
reasonably explained on the score of coincidence than on that of any
possible direct connection of cause and effect. Mothers, then, may be
reassured and made to understand that the better their own health, the
less they worry about their condition, the more likely is their
pregnancy to terminate favorably with a perfectly healthy offspring.
This is the source of so much concern in the little world of
child-bearing that it is worth while taking it seriously and making
mothers understand that the old notions in this matter are but
superstitions. Superstitions are not always nor exclusively religious,
they are survivals from a previous state of knowledge, the reasons for
which are now known to be false. Maternal impression, that is, the
belief in the power of the mother's mind over the unborn child, is a
superstition that we must now dismiss.


Favorable Maternal Influences.--Every now and then a sensational
newspaper has an article on how mothers will tend to make their
children physically handsomer by gazing at beautiful works of art,
beautiful scenes in nature, and seeing only handsome (one feels like
inserting well-dressed in the category, also) people during pregnancy.
The reading of good books {466} containing moral lessons of the
highest quality are supposed to have something of the same influence
on the child's character. There is no doubt at all that the more
carefully and simply and beautifully and healthily the mother lives,
and the more her mind possesses itself in peace and happiness, the
better will be her own nutrition and consequently that of her
offspring, and, all things considered, this will contribute to the
perfection of the infant's body and so give the best instrument for
the expression of its soul. That these supposed favorable influences
have any more direct power than this over the state of the infant that
is to be is doubtful. It is worth trying for, but if the indefinite
influence for good emphasizes, as it apparently does in many minds,
the presumed direct and definite influence for evil, then it is not
worth dwelling on.


Etiology of Deformities.--But if these curious deformities and
markings are not due to maternal impressions, what, then, is their
cause? To the question for many of the minor marks and slight
deformities--naevi vascular and pigmentary, extra fingers, slight
overgrowths, special peculiarities of bone and soft tissues--no
satisfactory answer can be given. We must simply say that as yet we do
not know. It is a good thing to say we do not know. Long ago Roger
Bacon declared that the principal reason why man did not advance in
knowledge more in spite of the amount of their work was that they were
afraid to say "I do not know," and accepted inadequate reasons and
insufficient authority in order to avoid this humiliating expression.
On the other hand, there are many deformities and markings, the
reasons for which have been found, and the more important they are the
more we know about them, as a rule. Besides, with the advance of our
knowledge of embryology we are getting to know more and more about
these difficult problems and many things that were mysteries before
are now clear. In addition to observation we have experiment and this
is making observation more thoroughly scientific.

The more we know of the intricacies of the development of animals and
human beings, the greater is our surprise that deformities do not
occur even more commonly than they do. All the openings of the human
as of the animal body gradually close in with the production of the
finished form. The slightest interference with growth in the
neighborhood of these openings, which involve nearly all of the front
of the body, leaves various deformities. Nature has surrounded the
developing embryo with fluid so that it is saved from jars of all
kinds and from contact with other tissues that would disturb growth.
Cell is laid on cell as brick is laid on brick in the building of a
house, and the predetermined plan in the immense majority of cases is
followed without accident to the minutest detail. That more mishaps do
not occur, considering the delicacy of the process and the perfection
of the finished structure, is hard to understand.

There are many factors likely to intrude in every pregnancy that may
lead to the production of unfortunate results. Literally millions of
cells are growing with apparent freedom from constraint in many
portions of the fetus, yet all are directed with definite purpose
corresponding to other cells and are destined to meet in due course of
time. Each one of them or at least each group seems to be independent
in its growth. Each growing cell doubles by dividing every few hours,
yet all are co-ordinated to a definite end. We admire the men who
begin at the two ends of a tunnel far distant from one another and
work without any communication except through the engineer's plans
{467} made long before, and yet make two bores that can be depended on
to meet with but a few inches of divergence. The bridges of tissue
that are built across the openings of the body jut out to meet one
another in this way and in more than ninety-nine out of every one
hundred cases there is not the slightest divergence. Many things may
occur to disturb conditions--not connected with mental influences, but
with distinctly physical factors--missteps, trips, jars on stairs or
getting off and on cars, on the sidewalk, etc. These, and not the
mythical factors that make up so-called maternal impressions, are the
causes of deformities and mothers' marks.


{468}

SECTION XII


_GENITO-URINARY DISEASES_


CHAPTER I

PROSTATISM


It may seem impossible to include prostatic hypertrophy, or the train
of symptoms connected with it, among those affections likely to be
benefited by mental treatment. The history of this affection, however,
and especially of its treatment in recent years since it has come to
be the subject of special study, has furnished many examples of the
value of suggestion in the relief of many of its symptoms. Many forms
of treatment have been exploited for a time, attracting attention
because of the cures attributed to them, and have then been relegated
to the limbo of unsuccessful remedial measures. A striking example of
the place of suggestion came with the development of organo-therapy
some fifteen years ago. The succession of events illustrated well how
much persuasion and a favorable attitude of mind might mean even in so
purely physical an affection as interference with urination by
enlargement of the prostate.

It was at a time when thyroid medication for myxedema having proved
successful the medical journals were full of reports of other
successful phases of organo-therapy. The spleen and the bone marrow
were being used in the anemias, the ductless glands in various
nutritional diseases and even extract of heart for heart disease. Just
on what general principle it was assumed by some German investigator
that possibly extract of prostate from animals might be of benefit in
the treatment of prostatic hypertrophy is hard to understand. The
German physician, however, gave an order to the butcher to send him
prostates and as furnished they were administered to the patients. A
number of patients began at once to improve on the treatment. They
were able to empty their bladders much better than before, the
residual urine was decreased, the tendency to fermentation was
diminished and, above all, the patients' general symptoms were much
improved.

The success was so marked that the German investigator published his
cases and, with the public mind interested in organotherapy, they
attracted wide-spread attention. He was asked how to obtain the
material and only then did he take the trouble to investigate just
what the butcher had been sending him. The description furnished the
butcher by the doctor was that he wanted an organ lying below and
somewhat in front of the bladder of the bull. It was found on careful
inquiry that the abattoir attendants following these directions had
supplied not prostates but seminal vesicles. As soon as this was found
out some of the therapeutic suggestions failed. A number of cases,
{469} however, continued to improve. German medical journals made fun
of the whole proceeding and most people will consider the ridicule
deserved.

Shortly before this time, however, we had had a very similar
experience with another pair of organs. In spite of the fact that
whatever we know about Graves' disease would seem to indicate that
that affection is due to an increased thyroid secretion in the system,
at the time of the organo-therapeutic fads, thyroid extract was
reported as having been used successfully in the treatment of this
affection. The name signed to the report was that of a trustworthy
English clinical observer. A few practitioners of medicine got similar
results, but most of them failed entirely to get his successes and
some of them were sure that their patients were rather harmed than
helped by the new medication. An investigation of just what material
was being employed in the English cases showed that the butcher was
supplying thymus and not thyroid glands. Suggestion did the rest, for
thymus has proved to be quite ineffective, and the treatment was
entirely expectant but acted on a favorable state of mind. Anyone who
has had much experience with Graves' disease knows how amenable to
suggestion the patients are. It would seem evident from the foregoing
story of organo-therapy for prostatic hypertrophy that sufferers from
prostatism are probably as prone to suggestion as patients with
Graves' disease. This is all the more surprising as the two affections
are so different in their etiology. Graves' disease being undoubtedly
a ductless gland disease, while prostatism is due entirely to
mechanical obstruction.

We have abundant additional evidence of the role of psychotherapy in
prostatism. Some years ago a well-known American surgeon suggested
that removal of the testicles would reduce the enlarged prostates. And
much improvement was seen after castration in those who previously
suffered from prostatism. The subject was carefully studied.
Experiments were made on animals and the results seemed to prove that
castration in them constantly produced prostatic atrophy. The fallacy
probably came from the fact that at the time so little was known about
the prostate in comparative anatomy and, above all, with regard to the
prostate in dogs, that it was impossible to come to any sure
conclusion as to reduction in weight and size after removal of the
testicles. A number of prostatic cases were treated by different
surgeons and with excellent results. Then after a time the number of
supposed successes dwindled or proved to be failures and now no one
does the operation. The only explanation that is at all satisfactory
in these cases, is that the rest in the hospital, the favorable
suggestion of reported cures and of an experimental demonstration on
animals led many patients, some of them even physicians, to secure a
better control over their bladders.

It took a good deal of persuasion as a rule to bring men, even men
well beyond seventy, to consent to the sacrifice of their testicles,
but once they did, the sacrifice brought a favorable suggestion to
work and so it was not long before they were able to make their
bladder act much more efficiently against the obstacles presented to
its contraction. Some could be persuaded more easily to sacrifice a
single testicle, but in these cases the mental influence was less and
the reported cures fewer. After a time the operation of vasectomy was
suggested as a substitute for the removal of the testicles. For a time
even this in the hands of certain operators gave excellent results.
Almost any other operation in the genito-urinary tract performed with
the definite persuasion {470} on the part of the patient that he would
be better after it would probably have acted just as favorably. The
whole story of these series of incidents in the surgery of the last
decade of the nineteenth century ought to be a clear demonstration of
how valuable for therapeutic purposes is mental influence oven in
prostatism, and how much we should try to secure its favorable
effects.


Unfavorable Suggestion.--Since enlargement of the prostate has become
a familiar subject of discussion and men know and hear much about it
every now and then, one has to reassure a man but little beyond fifty
that he is not suffering from this affection. Just as soon as a man
begins to urinate frequently during the day and to have to got up once
at night he begins to wonder how soon he will be likely to suffer from
further symptoms of enlarged prostate. If he is of the nervous kind
his worrying will soon give him additional symptoms that will confirm
his suspicions. Probably one of the most familiar of phenomena, even
to the non-medical man, is the ease with which worry and excitement
causes frequent urination. Probably no system of organs in the body is
so likely to be disturbed by the mind as the urinary system with the
exception, of course, of the allied tract, the genital system, but the
two are so one in union and sympathy that they cannot be separated in
practice. The prostate is rather a genital than a urinary organ.


_Urinary Worries_.--When a man begins to worry about the possibility
of bother from enlarged prostate and recalls that frequent urination
is one of the symptoms of it, it will not be long before this symptom
develops. Occasionally his first wakings to urinate at night or in the
early morning are only due to passing conditions, either he drank
freely shortly before bedtime or perhaps he did not drink enough. In
the one case the bladder is rather full; in the other a concentrated
urine, especially with the patient lying on his back, makes itself
felt over the sensitive area at the base of the bladder, waking him
up. The rest of the symptoms may develop as a consequence of
solicitude over a few such incidents.

Practically all men who reach sixty have some tendency to more
frequent urination than before. Their bladder does not hold as much
fluid with comfort and they are likely to have to get up in the early
morning. This does not necessarily mean any enlargement of the
prostate nor any pathological change. The physiological change that
takes place seems to be rather conservative than otherwise. Old
muscles are less capable of extension and thorough reaction than they
were earlier in life and in order that the bladder may not be
over-distended nature makes it more sensitive than before.


_Emptying the Bladder_.--In the study of these cases individual
peculiarities in the emptying of the bladder must be remembered. There
are some men who cannot urinate if anyone is near them, and who even
have to step into a closed toilet if they are to succeed in emptying
their bladders when others are in the room. Some who find no
difficulty in the presence of others in open urinals find it difficult
or impossible to urinate when it is expected of them. Under worry and
excitement urination may become urgent or imperative, but on the other
hand some men find it very difficult to empty their bladders under an
emotional strain. Now that much more is written publicly with regard
to symptoms from enlarged prostate and much more is heard of the
affection, many old men got worried and lose some of the power that
they had over their bladder before, not so much because of their
enlarged prostate as from the {471} psychic loss of control over their
bladder. The viscus consists of a series of muscles, the fibres of
which must be rather nicely coordinated and controlled in order to
secure that complete contraction necessary for thorough emptying. A
certain amount of residual urine occurs occasionally at least in many
other persons besides those who have prostatic obstruction.


_The Question of Operation_.--In recent years there has been a
tendency to suggest operation even on comparatively small prostates
when symptoms referable to them are noted. Operations on the prostate
have become much more easy and successful, and there has been the same
sort of feeling about them among surgeons as there was when operations
for affections, real or supposed, of the ovaries came into general
vogue twenty years ago. I have seen patients in whom an operation for
the removal of the prostate had been suggested, though the only
symptoms were somewhat increased frequency of urination during the day
and the necessity for rising two or three times at night. Such a
suggestion, by calling the patient's attention strongly to his
condition, emphasizes the irritability of the vesical tissues and is
almost sure to bring about a considerable increase in the symptoms.
The first principle of any treatment of irritability of the bladder
should be the setting of the patient's mind as free as possible from
solicitude. Any over-attention is sure to lead to reflexes and often
to what seems to be even imperative urination, though with a little
care and discipline much can be done for the relief of such symptoms.

The necessity for operation must be judged entirely from the symptoms
of the individual patient and not from any hard and fast rule with
regard to the size of the prostate. Prostates are eminently individual
organs, at least as individual as the human nose, and their projection
into the rectum is dependent on the relations of other tissues in the
neighborhood as well as on mere size. Men have been known to live with
comparatively few or no symptoms for many years, though at autopsy
they proved to have what would ordinarily be considered a
pathologically enlarged prostate.

Operations upon the prostate are valuable and indeed often afford the
only avenue of relief from an intolerable condition. The results are
not so encouraging in all cases, however, as to make recourse to
operation advisable until a thorough trial of palliative measures has
been made. It is surprising how often the confident suggestion of
assured relief when accompanied by the same amount of rest in bed and
the special care that is required for an operation, brings about a
disappearance of symptoms that seemed inevitably to demand surgical
intervention. There may be much residual urine, there may even be, as
a consequence of this, some fermentation with cystitis, and yet a
course of rather simple remedial measures may serve to bring about a
period of prolonged freedom from vesical symptoms. If these patients,
however, have heard much of the trials and sufferings of a catheter
life, the solicitude aroused with regard to their condition is
sufficient of itself to disturb their urination to a marked degree.
Unfavorable suggestion is particularly serious in its effects in these
cases, while favorable suggestion frequently repeated will enable the
patient very often to regain bladder control when the developments
present might seem to put that almost out of the question.


Position Suggestions.--An important suggestion for treatment in
prostatism with residual urine seems to be to teach the patient to
urinate lying down, {472} especially with the hips somewhat elevated.
This seems to be the element that proved capable of making many
different operations, castration, the removal of one testicle,
vasectomy, and other suggestions appear curative. My own experience is
too limited to make my opinion of much weight; but I have seen certain
patients greatly relieved of prostatic symptoms and their residual
urine much diminished by the advice to urinate leaning well out of
bed, lying prone with the head lower than the body. A small stool is
brought to the side of the bed, a pillow placed on it and the patient
leans over face down on this with the shoulders considerably lower
than the pelvis. This allows gravity to assist rather than hamper the
emptying of the bladder and after men have become a little used to it
they are quite satisfied to take the trouble. Personally I feel sure
that more generally applied this would put off the necessity for using
a catheter a good deal and even save some cases from operation that
now seem to need it. The principle is exactly the same as that by
which patients suffering from bronchiectasis avail themselves of the
help of gravity and get rid of the nocturnal accumulation of material
in their dilated bronchi. They can thus be saved much trouble and
exhausting effort.

So much, as we have said, is written in recent years with regard to
prostatic symptoms that a body of unfavorable suggestion has been
created. This must be neutralized as far as possible by calling the
attention of patients who have initial symptoms of vesical disturbance
to the ease with which mental influences act upon the urinary
functions. Solicitude and anxiety will add to symptoms and may even
bring about their continuance when the original, local and passing
condition which has caused them has ceased. Very often if the
patient's mind can be properly disposed a marked relief of symptoms
will follow, especially if, at the same time, remedial measures of
other kinds are employed to lessen the irritation that is being set
up. While prostatism seems to be due to such purely mechanical
difficulties that mental influences can mean very little, the history
of the therapeutics of the condition for the last twenty years shows
us clearly that if strong mental influences are aroused they bring so
much relief that many patients consider themselves cured. This
psychotherapy will not do away with the necessity for operation in
many cases, but it will cure many of the sufferers from milder
symptoms and will in not a few cases bring such relief as will prepare
the patients to undergo operation, if it should be necessary, with
more assurance of favorable results.



CHAPTER II

SEXUAL NEUROSES


Anything that disturbs the sexual sphere in either sex, no matter how
trivial it may be, becomes a source of worry and depression quite
beyond its real importance. It is not unusual for men and women to
become so worried over some trifling affection of their sexual organs
that they become convinced that serious pathological conditions are
developing and that there is little hope of anything like a complete
cure. This is particularly true of young patients, but holds also for
those of older years. Slight discomforts are exaggerated into nagging
aches and pains which produce extreme depression of spirits.

{473}

It is important, then, for the physician to recognize this and to
treat the patient's mind by reassurance while conducting whatever
other therapeutics may be required. There is danger always in these
cases of either making too little or too much of the affection. If too
much is made of it, an unfavorable influence is produced in the
patient's mind and the discouragement leads to so much inhibition or
even actual physical disturbance that the affection will not improve.
If too little is made of it, patients get discouraged and are prone to
think that the physician does not understand their cases. Then they go
to the advertising specialist in men's diseases who works upon their
fears and makes them feel much worse than before, though in the end he
may lift the cloud of anxiety from their minds and pretend to have
cured them. He always leaves them, however, with the impression that
something serious has been the matter, and this acts as a nightmare
and a source of dread in after time.

In men the unfavorable suggestions occur particularly as a consequence
of affections of the external organs. In women the same suggestions
are likely to make themselves felt with regard to the internal genital
organs. We all recognize the exaggeration of feeling and even physical
reaction that takes place with regard to slight sexual ailments in the
male, because it is easy to recognize just exactly what pathological
conditions are present and how trivial they may be and yet produce
serious depression and all kinds of symptoms, reflexly referred to
many other organs. There is a tendency to listen to the complaints
from women more seriously because the actual pathological condition
cannot be determined and there is always the fear that some serious
affection may be at work. It must not be forgotten, however, that the
complaints of pains and aches, the disturbance of sleep, of digestion
and of the intestinal function, the mental and physical lassitude and
the over-reaction to irritation which occur in both sexes as a
consequence of sexual affections may be due entirely to mental
solicitude and not to any real pathological change.


Trivial Afflictions--Varicocele.--It is curious what a little thing
will sometimes set off the explosion of a train of sexual symptoms.
Every physician has probably had some young man come to him with the
look and the tone that there was something the matter that he knew was
serious and would affect all his after life. The patient then goes on
to say that he wants to know all and is brave enough to face it, and,
though he has lost sleep for two or three nights and is not looking
well for the present moment because his health has been disturbed by
the loss of sleep, still he has the strength to know the worst and it
is to be told him and he will bravely battle on in spite of the
suffering that must come. Or he will submit to a serious operation if
it is necessary for his relief. With a prelude like this, the
inexperienced physician might expect strangulated hernia or some
preliminary symptoms of brain tumor, but what he usually finds is a
varicocele, and a small one at that. By chance the patient has
discovered it and slept none the following night, went round in an
agony of dread next day meaning to go to a physician, but too fearful
to be told the worst, losing another night's sleep and then finally
coming to a friend to be told all the ill that is in store for him.

There is no need for alarm in these cases; they merely illustrate the
role of the mind disturbing the body. Nearly one-fourth of the male
world carries its {474} varicocele around with it and never bothers
about it. A few sensitive individuals are annoyed by a sense of weight
and a feeling of distention from congestion in connection with it. In
a few, because of special pathological conditions or congenital
defects, the varicocele becomes so large that it has to be supported
by a special bandage. In people who ride horseback, in athletes, and
those who indulge in severe exercise, this sort of a bandage may be
necessary or at least may make the wearer more comfortable even in
slighter forms of the affection. Severe cases may be much relieved by
it.

On first discovery of his varicocele nearly every young man, because
of concentration of attention on it, is so much annoyed that he thinks
he must wear a bandage. After a time, however, he often finds that the
bandage itself is a source of more annoyance than the varicocele, and
then he learns to forget it and its feelings--and that is all about
it.

I have dwelt on this succession of events that takes place so often
with regard to varicocele, because it is typical of the effect that an
affection of the sexual organs has upon the mind. It exerts an
unfavorable influence entirely disproportionate to the physical cause
that is at work. If, as sometimes happens, a young man hesitates to
confide in some one capable of undeceiving him with regard to the
supposed significance of his affection, he may work himself into a
decided nervous condition and lose much weight before he discovers his
mistake. This physical running down confirms his exaggerated notion of
the significance of the affection. He is sure that it constitutes the
reason why he is losing weight and declining in health and he rather
congratulates himself on the fact that he discovered the cause so
shortly before the serious effects began.

If under these conditions he places himself in the hands of any of the
men who advertise themselves as curing "men's diseases," or as
relieving the "awful" symptoms that are likely to follow varicocele,
instead of being reassured he will be told that he has come just in
time and that while his cure will require a long time and will cost a
great deal of money, yet it can surely be effected. In nothing can men
or women be more easily imposed upon than with regard to affections
involving their sex organs. They lose their power of judgment and
their control over their feelings and so plunge sometimes into
profound depression. Every year we have a number of suicides among
young men, the most important element in whose depression is due to
unrelieved occupation of mind with the thought that they are suffering
from some incurable sexual disease which will unsex them, and that
even death is to be preferred to the alternative of being recognized
generally--as they are sure they will be--as sexual defectives.

As a rule, these young men are suffering from only some slight ailment
that could be easily cured if they were frank about their state of
mind and described their symptoms to a reputable physician. Oftener
than not their supposed ailment is something so common as to be of no
significance, so far as any serious results may possibly be
anticipated, and their only real ailment is the mental condition which
has developed because of concentration of mind on this one phase of
organic life and the consequent inevitable exaggeration of symptoms
and feelings. It is sometimes not easy to disabuse them of their
unfortunate notions, but there is probably no set of cases in medicine
where psychotherapeutics means more than it does with regard to the
curious {475} neurotic and psychic conditions which develop in those
who are suffering from any sexual ailment, real or imaginary.


Long Prepuce.--Much has been said in recent years about the influence
of a long prepuce in the male in producing various reflexes the
effects of which may be seen in serious disturbance of even distant
organs. The kidneys are sometimes said to be thus reflexly affected,
and occasionally the digestion and the bowels--even, sometimes, mental
processes are said to be influenced unfavorably by the diffusion of
reflexes from the irritation consequent upon this sensitive structure
being too long. A whole system of nosology exists in some minds due to
an over-long prepuce. There are, of course, cases in which
circumcision should be performed. There is a larger number of others,
however, in which the redundant prepuce is neither adherent nor
constricted and is only slightly longer than it should be.
Occasionally something arouses the attention of the possessor of the
redundant tissue and he gets the idea that it is the source of reflex
irritation even for distant parts of his organism. It is an
interesting study in suggestion to see how symptoms develop in various
organs as a consequence of the cultivation of this thought. Urination
becomes frequent, the patient even wakes at night to urinate and the
urine, as in many neuroses, becomes more abundant and of lower
specific gravity--the typical nervous urine of the hysterical, and
there may be much worry and emotional disturbance.

These symptoms, however, are not effects of the long prepuce, but are
results of the neurotic influence of concentration of mind on it. It
will often be advisable, in young men particularly, to have
circumcision performed, but in most cases this is unnecessary, and if
the patient can be made to understand how the symptoms have developed
he will learn a precious lesson in not interfering with his functions
by over-attention to them. Of course, there are many surgeons who will
continue to hold, as they seem to now, that nature was quite at fault
in the production of this organ and that it should be removed in
nearly every human being. The majority of men, however, have lived
their lives quite well and happily without such intervention and there
are certain inconveniences attached to the condition which remains
after operation that may in their way be quite as bothersome as the
symptoms due to the long foreskin.


Psychic Impotence.--An important sexual neurosis, at least in the eyes
of sufferers from it, is what physicians have come to know as psychic
impotence. Young married men, because of over-anxiety with regard to
themselves for a number of reasons, but without any physical factor to
disturb them, find it impossible to complete the sexual act. Naturally
this creates a serious disturbance of mind. The patient will either
hurry to a physician at some place on his wedding tour, or his wedding
tour will be shortened and he will return to consult a friend. He
presents a lively picture of despair. He has not been sleeping, his
appetite is disturbed, he feels lassitude and weakness, and if he has
a lively imagination he is inclined to think that the fatal
termination of some serious nervous disease of which he has heard, and
which is accompanied by the symptom of sexual impotence, is impending
over him. His condition is quite pitiable, though largely imaginary.


_Reassurance_.--The treatment of the condition is not so difficult as
it might seem if the patient has a reasonable confidence in his
physician. If he {476} goes to an advertising "specialist," as
occasionally happens, because he concludes that the ordinary physician
cannot know all the details of these intricately complex nervous
diseases, he is sure to suffer severely in general health before cure
is obtained. His morbid ideas will be fostered because he is ready to
pay any amount of money in order to stop the progress of the presumed
serious disease. An investigation of these "specialists" in New York,
made a few years ago by a committee of the New York County Medical
Society, showed to what an extent the terrors of these unfortunate
patients are exploited for monetary reasons.

A physician of even a little experience in these matters, however,
recognizes at once the entirely neurotic character of the case and by
reassurance soon enables the young man to dispel many of his worst
terrors. His general health can be regulated, his constipation, which
so frequently exists, is relieved, and he can be told, what is very
true, that the excitement consequent upon the preparations for his
wedding and the exhaustion due to the overwork so frequently necessary
in order to enable him to take the time off for his wedding journey,
have made him so nervously irritable that the ordinary mechanism of
the sexual act, which is extremely delicate and requires nice
co-ordination for proper function, has been disturbed. Just as soon as
this fatigue and the over-excitement of mind consequent upon the
unfortunate experience are mitigated his potency will return. This
assurance can be given almost at once.

His fears, however, will delay his recovery. His dread of incapacity
will become an obsession. Probably the most effective means of
treating this is to forbid him to attempt the sexual act for a
definite length of time, say two or three weeks. This must be
impressed upon him. There is a good reason for insisting that he shall
not irritate his already excited sexual system by such attempts.
Usually at the end of a week or ten days he will come back with a
smiling look of confidence in himself and his physician, to confess
that he has violated the injunction, but that he was not disappointed
as before.


_Subconscious Obsession_.--In most of these cases the young men have
been victims of sex habits of some kind or of drug addictions, and
they have heard that occasionally individuals who have had such
experiences may suffer from sexual impotence later in life. This is a
strong suggestion to them and in some cases becomes a haunting
obsession, and produces the unfavorable effect upon the organism. It
is necessary to remove this obsession before a cure can be effected.
The patient's confidence must be obtained and the physician's
personality and persuasive powers used to change his point of view.
Occasionally I have seen cases in which the patients themselves seem
to be scarcely aware of this strong suggestion or obsession at work in
them. It seemed to be more or less subconscious. An idea with regard
to the evil effects of the old habit had been implanted and remained
in their minds, occasionally making itself felt but more often
apparently lying dormant. In these cases it is important that the
physician should make this underlying factor clear to the patient. In
some of these cases hypnosis is necessary. Usually the hypnoidal
condition, with suggestions in the waking state, is all that is
necessary and ordinary suggestions will often effect the purpose
completely.


Organic Impotence.--Certain forms of sexual impotence are really
preliminary signs of serious organic nervous disease. Sometimes it is
the first {477} symptom of paresis or of locomotor ataxia. Oftener it
is a very early symptom of syphilitic spinal myelitis. In practically
all of these cases, however, there is a history of syphilis and the
presence of this should always be a warning not to think of functional
or psychic impotence until the possible influence of the syphilis
itself or of some of the parasyphilitic diseases is thoroughly
excluded. Unfortunately, not a few people who have had syphilis are
nervous and anxious about themselves and by their very anticipation of
possible developments may auto-suggest themselves into a state in
which these symptoms will develop. It is cases of neurasthenia that
develop after secondary syphilis in persons who have been studying
syphilis and its possible effects, which present the most difficult
problems in diagnosis that come to the nerve specialist. Many
simulated symptoms are unconsciously developed and this makes
differential diagnosis extremely hard. As a rule, the psychic
impotence is merely functional and patients need reassurance more than
anything else.


Nocturnal Emissions.--One of the sexual neuroses that gives rise to a
high degree of solicitude centers around the question of involuntary
seminal emissions. Young men who are living normal healthy lives and
who are in robust health with no indulgence of sexuality are likely to
experience more or less regular involuntary emissions. If for any
reason they become nervous or anxious about their sexual functions,
especially at times when they are under much mental strain, these
phenomena of emptying the seminal vesicles may occur rather
frequently. If they have been reading some of the literature, or
hearing some of the exaggerated notions that are often expressed with
regard to the evil effects that may come from this, they are likely to
suffer much mental anxiety over it. Occasionally they lose sleep,
frequently they feel so wearied and worried the day after the
occurrence as to be disturbed at their work, sometimes they are sure
they are so tired that they are unable to fulfill their ordinary
duties, and I suppose every physician has known young men who were
even sure that the loss of the seminal fluid was seriously interfering
with health, hampering many physical functions and bringing them to an
untimely grave. They had no appetite and in consequence of not eating
enough they were constipated and then a whole round of physical
troubles, headache, lassitude, over-fatigue, to which they are almost
sure to add loss or disturbance of memory, began to annoy them.

In those cases it is not the physical effect of any loss of seminal
fluid that is the disturbing factor of their health, but their worry
over the losses. Just as soon as their minds can be taken off the
subject, the supposed physical effects begin to disappear. So long as
the solicitude continues the emissions themselves increase in number
and the condition is made worse. These patients must be taught that in
every normal healthy man in whom there is no regular occasion for the
emptying of the seminal vesicles, nature provides for an evacuation
about every ten days or two weeks. In some it is more frequent than
this. In those who are much indoors and in whom oxidation processes
are low this emptying takes place more frequently. In those who lead a
sedentary life with the consumption of much proteid food the same
thing seems to be true. Any anxiety about it is sure to cause frequent
repetition of the evacuation processes. Over-solicitude about the
bladder will have just the same effect. If the patient will take his
mind off the subject, will eat normally, will get out in the air more
than before, tiring himself thoroughly {478} if he is young and
vigorous, and will not allow the sexual side of his being to be
excited by stories or pictures, plays or voluntary thoughts, his
affliction will soon disappear.


_Prophylaxis_.--Certain directions are helpful and by occupying the
patient's mind will overcome certain physical factors that underlie
the affection. It is important that the bladder should not be allowed
to be full, above all, not to be over-distended at night. Some care
should be exercised in not taking too much to drink shortly before
going to bed and the bladder should be faithfully emptied before
retiring. The weight of a large amount of urine in the bladder
pressing down upon the seminal vesicles situated below and behind it
causes them to contract rather easily. This is particularly true if
the patient sleeps on his back and occasionally in certain
over-irritable patients for a time at least an arrangement may have to
be made by means of small pillows that will prevent him from sleeping
on his back. On the other hand, it must not be forgotten that too
great abstinence from fluid will cause the urine to be more
concentrated and this will irritate the bladder and either wake the
patient up at night, which of itself is undesirable, or else will
cause congestion in the prostatic region which will irritate the
seminal vesicles to the point of evacuation. While five or six glasses
of water a day should be taken besides the ordinary fluid taken at
meals, the only regulation necessary is of the amount of fluid taken
in the evening after the last meal, that is, if more than three hours
intervene before retiring for the night.

Besides the physical conditions in the bladder, an accumulation of
fecal material in the rectum may cause irritation of the seminal
vesicles. It is important, moreover, to remember that thoroughly free
movements of the bowels, by preventing to a great extent the
reabsorption of material from the intestines which may prove irritant
when excreted through the kidneys and when present in the bladder, is
of itself an excellent therapeutic measure in cases of irritability of
the genital organs. The setting of the patient's mind to thinking
about his rectum, his bowels, and his bladder instead of his genital
tract is an excellent psychotherapeutic measure that will soon bear
fruit.

The consumption of various foods, condiments and drinks enters into
the underlying condition which produces frequent emissions. We have
already suggested that the use of a large amount of proteid materials,
especially in people who live a sedentary life, often predisposes to
this condition. An abundance of the carbohydrates, however, by
supplying more heat than is necessary may have a like effect. Certain
spices seem to predispose to irritability of the sexual system. Red
pepper has always seemed to those who saw much of these cases to be
particularly at fault. Mustard, curries, peppers generally, however,
and even other spices seem to have a corresponding effect. As a rule,
young folks suffering from this disturbance or from the tendency to
eroticism in other ways should be warned about this irritation of
spices. In neurotic individuals tea and especially coffee has the same
effect. Probably this is only an indirect influence of tea upon the
nerve centers, making them more irritable, but coffee, by raising the
blood pressure, seems to have a direct unfavorable effect.

All alcoholic drinks are contraindicated in these cases and must be
forbidden. Certain of them seem to be more harmful than others.
According to French tradition warm wine or mulled ale as it is used in
England is {479} especially likely to excite sexuality. Warm alcoholic
drinks of any kind are absorbed more rapidly than are cool drinks,
which is the main reason in modern times for having these liquids
cooled so that they will not be absorbed too rapidly and disturb the
equilibrium. Champagne also has, by tradition, a special effect,
sometimes said to be due to the increased hyperemia of the stomach
induced by the carbonic acid gas and the consequent more rapid
absorption.

The prohibition of spices and alcoholic drinks has a good effect in
itself. It acts constantly as a suggestion to the necessity for care
and guard over one's self. Besides the exercise of self-denial
necessary to keep away from the use of such substances, especially
under present social conditions, is of itself a good training that
strengthens the will against certain tendencies to indulgence in
sexual thoughts which predispose to the frequent emptying of the
seminal vesicles.


_Erotic Dreams_.--Very often these nocturnal seminal emissions are
associated with erotic dreams. Patients are inclined to attribute the
occurrence of these dreams to some fault of their own or to consider
that they are at least in some way responsible for them. This thought
often becomes a source of serious worry, making their condition worse.
A study of this question has convinced me that in most cases there is
practically no responsibility in the matter. Pressure on the seminal
vesicles by an over-full bladder, or a distended rectum, leads to the
production of nervous stimuli around which the erotic dream-ideas
gather. A straightforward explanation of this will relieve many
patients' minds, and keep them from bothering about the subject in
such a way as to make their genital tract even more sensitive than it
is because of their concentration of attention on it.


Sexual Mental Troubles.--In our generation sex occupies a great deal
of attention. Sexual tendencies are emphasized by suggestive reading
of all kinds and by forced attention to sex matters. Most of the
successful novels deal with the so-called sex problem, our plays are
to a great extent sex problem plays and our newspapers are full of sex
crimes and sexual divagations of many kinds. This acts as a strong
incitement to sexuality and represents exactly the opposite of what
nature intended in the matter. As a consequence, all the tendencies to
over-solicitude with regard to sexual affections and all that
instability of mind and over-reaction to all forms of irritation that
comes in the midst of sexual excitation are noted. This seriously
disturbs the minds of many patients and makes their health as well as
their morals worse than they should be. The neurotic conditions seen
in those who occupy their leisure with erotic subjects are fostered by
this unfortunate over-attention to sexual matters. For general
prophylaxis the physician needs to throw all the weight of his
influence toward the correction of unfortunate tendencies in our
present-day life and healthier subjects of thought should be
encouraged.

We often hear it said in our time that the great fact of life is sex.
Indeed, this has been insisted on _ad nauseam_ in recent years. There
is no doubt that without the sex element the race would not continue
under the present dispensation. If sexual feelings did not mean so
much to the generality of men and women it is doubtful whether
marriage would be the success that it is, though so much is said
nowadays about its failure. The analogy with all the beings lower in
the scale than man shows how imperative and prominent {480} in life
this instinct is and how much it signifies. Those who insist so much,
however, on sex as the one great fact of life seem to forget that
there are many other natural functions of quite as much importance to
the individual at least, if not to the race. Without eating neither
the individual nor the race could go on. Neither would the race go on
without eliminating waste products. If there is one thing that our
consideration of the problems of psychotherapy has made clear it is
that whenever any of these animal facts of life is made much of and
occupies attention to the exclusion of higher ideas, there is sure to
be trouble. It matters not how apparently automatic and completely
spontaneous a function may be, if exaggerated attention is given to
it, it is sure to be disturbed in its functions and cause serious
troubles in the organism.

There is no need further to illustrate this with regard to such
physiological necessities as feeding and excretion. At present the
world is much occupied with sex problems because, unfortunately, its
attention has been focused on this subject. Physicians, particularly
if they are paying attention to nervous patients, are likely to know
many individuals who have food problems, diet problems, digestion
problems, bowel problems, and many others of similar nature because
they have been focusing their attention on these functions of their
being.

The most distinguished psychiatrist of our generation, certainly the
man whose works have done most to open up new vistas for us in mental
diseases and who has added not only new knowledge but new
possibilities of development, visited this country not long since and
said, "Oh! here in America you are sex mad." He added, "I knew that we
were madly following sex problems in Europe, but I thought that in
this country, with so many other things to occupy the minds of men and
women, you were not bothered so much with sex problems." What he said
represents the impression of nearly every thoughtful foreigner who is
surprised to find that wealth and luxury have brought to us this same
degenerate interest in things sexual that occupies the so-called upper
classes and their imitators in Europe.

Livy, the Roman historian, said long ago, "Whenever women become
ashamed of the things they should not be ashamed of, it will not be
long before they will begin not to be ashamed of the things they
should be ashamed of." Whenever in history men and women have occupied
themselves, not with the rearing of families, but with the suppression
of families to as great an extent as possible, sex problems have
always become emphasized. The woman who is a mother, and especially
many times a mother, usually has no trouble at all about sex problems
and no tendency to have "affinities." With her there is usually no
question of sex as the central factor of life nor of any other of the
curious nonsense that has been talked about this matter as the result
of giving sex a place of importance that it does not deserve. Until
there is a reform in this matter we can look for many "neurotic,
erotic and tommy-rotic" tendencies, as they have been called, due to
over-attention to one set of organs. Any organic system in the body
would be disturbed by such attention, but the sexual system is
particularly susceptible to suggestion.

The state of affairs thus emphasized is the result of interfering with
an animal instinct. It will make itself felt properly and secure the
due exercises of function if allowed to pursue the even tenor of its
way under reasonable {481} control, but if it is fostered, thought
about, discussed, excited in various ways, pampered by indulgence and
perversion, it runs away with nature. The gourmet who constantly
thinks about food, plans new modes of exciting the appetite, studies
savors and odors in order to satisfy a palate that has been
artificially stimulated, gets a certain animal enjoyment out of his
food that other people do not; but he usually overeats, loses his
appetite, and with it any real satisfaction in eating, and suffers
from indigestion as a consequence of indulgence, so that the suffering
much more than compensates for any slight additional pleasure that he
has enjoyed. Besides, man is an essentially intellectual being, and
occupation with the things of sense, that will manage themselves very
well if let alone, takes up just so much of the precious time that
should be devoted to other things to attain that satisfaction that
makes life well worth living. Sexuality cultivated with the degree of
attention that certain people devote to feeding, becomes a pest, ruins
intellectual effort, hurts initiative, leads to the most serious
disappointments in life and is the most fruitful cause of despondency
and suicide that we have besides being the origin of many social evils
that still further complicate life.

One great modern nation has debauched its literature to such an extent
that probably the major portion of its books treat of sex and sex
problems. Practically all of its esthetic expression has been
seriously hurt by the same fault. Its painting, its sculpture, its
dramatics, its art of all kinds, have all gone the same road. The
result is seen in the lowered moral fiber of its people. A recent
census report showed that the nation has reduced some 20,000 in
numbers and that this was only the beginning of the race suicide. They
have been thinking, talking, writing, painting, chiseling, acting sex
problems, but in the only phase of life in which sex really counts it
has been so pushed into the background or perverted that there it is
failing utterly to accomplish its one legitimate purpose. The younger
generation as they grow up are given the idea that they are missing
the most wonderful thing in life unless they have memorable sex
experiences. These experiences must be varied in order to satisfy the
artificial appetite that has been created. As a consequence, family
life and the real meaning of love and the affection of man for woman
rooted in the depths of their nature is spoiled by mere animal passion
and its passing expression.

Nature's own attitude with regard to over-attention to sex matters
must not be forgotten. The purely sexual organs have been pushed into
the background to as great an extent as possible and are intimately
associated in both sexes with one of the two ugly excretory functions,
urination, and placed in close relationship with the structures which
subtend the other--defecation. Evidently nature intended that they
should be the subject of as little attention as possible.
Unfortunately, the paying of attention to them to any great extent
lessens somewhat of the disgust naturally aroused by the excretory
functions with which they are associated. Nature has provided as far
as possible for deterrence from over-interest. One might expect that
cleanliness and the cultivation of the feelings of refinement would
serve as auxiliaries in the repression of sex indulgence. The lessons
of history are that usually the great bathing nations have been most
sexually divagant. Among the Greeks and the Romans the ugliest sex
habits and proclivities found a place--among peoples who devoted
themselves to the cleanliness of the body. The classes {482} who bathe
most are often those with the strongest tendency to sexuality.
Refinement instead of lessening the tendency to sexual indulgence
rather increases it.

Education and the development of intellectuality, far from being a
barrier to sexual divagations, seem to predispose to the exaggeration
of the significance of sex in life, unless the individual has a
well-balanced character or has been thoroughly grounded in ethical
principles. The ugly stories of Greek love at a time when the Greeks
were at the climax of culture, as well as what we know about the
relations of the freedmen to their masters among the Romans during the
classical period, is all confirmed by the revelations of corresponding
tendencies in recent generations among the intellectual classes even
at the universities. Development of mind apparently does not
neutralize to any extent these sexual tendencies. Evidently the rule
of life for health's sake must be to push sexuality as much into the
background of the mind as nature has put the sex organs in the human
body. Reason does not protect knowledge but increases suggestion. Only
absorbing occupation of mind with other subjects that will bring about
neglect of these functions, as of all other physiological functions,
leaving them to nature, serves to keep them in their proper place and
condition.



CHAPTER III

SEXUAL HABITS


As was emphasized in the preceding chapter, sexual symptoms are
usually the subject of so much worry and disturbance of mind and
become the center of so much unfavorable suggestion, that the only way
to ameliorate the conditions which develop is by securing relaxation
of the attention and diversion of mind. Mental influence is much more
important than any other remedies that we have at our command in these
cases, not only for their relief but for their ultimate cure.

A state of depression of mind similar to that which develops in
patients frightened by seminal emissions is often seen in those who
have for some time indulged in the habit of self-abuse. Rather
frequently a physician, especially if he is known to be interested in
nervous diseases, has to listen to the story of a patient who is sure
that his health is completely undermined and that his future is the
darkest possible, because of this habit in younger days. Usually the
patient is a young man who has been reading some of the literature of
the advertising "specialists" who distribute reading matter which
pictures appalling and almost irretrievable effects from such sexual
habits. The consequence is that the patient is in highly nervous
condition, has lost his appetite, is not sleeping well, is avoiding
society, because he fears that some one may recognize his condition
and its cause, and he is really in a pitiable state. Such patients are
usually sure that little can be done for them. Sometimes they have
already been through the hands of several "specialists," particularly
of the mail-order variety, and the literature provided for them and
the letters written to them have all helped to make them worse and
much more solicitous about themselves.

{483}

Unfortunately some of the exaggerated notions with regard to the
effect of these habits that are so widely diffused by the exploiters
of the young have been adopted by moralists with the idea that they
can thus deter youth from certain practices and scare the victims of
such habits out of them. It is extremely doubtful, however, whether
self abuse of itself, unless practiced in very early years or indulged
in to a degree that is possible only in those of unbalanced mind, ever
works anything like the serious harm that is claimed. Certainly
physicians who are most familiar with its results are not ready to
confirm the opinions usually advanced as to the awful harmfulness of
the practice. Personally, I have had a number of patients confess to
me that they had indulged in the habit to some extent for twenty years
and longer and yet had never suffered anything more than passing
physical discomfort. It is unfortunate, then, that the exaggerations
of the quack should by receiving the approval of the well-intentioned
moralists, be emphasized so as to add to the neurotic disturbance of
mind which makes these patients so miserable and for a time may
seriously interfere with their health. Occasionally even suicides are
reported in which the underlying motive seems to have been the dread
on the part of a young man that a sexual habit has so undermined his
health that cure is impossible and that physical and mental
deterioration to a marked degree is inevitable. The opinions of
conservative physicians tend to show that there is no good reason for
thinking that in normal healthy persons such habits ever have the
serious effects thus set forth.

Patients can be assured that whatever evil effects follow the practice
will not remain after it has been given up. There are no serious
enduring sequelae, with one or two exceptions in very special cases,
that perhaps should be noticed. Most men of considerable experience in
the matter are now decidedly of the opinion that self-abuse does not
produce any more serious consequences than the same amount of ordinary
sexual intercourse. It is possible for sexual intercourse indulged in
excessively, as it sometimes is in early marital life, to produce the
same feelings of exhaustion, lack of control over the vasomotor system
and disturbance of the gastro-intestinal tract which are noted in
self-abuse. In both cases the symptoms promptly disappear upon proper
regulation of life. This is a very different opinion from that which
used to be expressed in this matter and it is given only after due
deliberation and consultation of many authorities both in writing and
orally. Its expression, far from taking away one of the best deterrent
motives against the practice, rather forces an appeal to the manliness
of the individual. The motive of fear never accomplishes much, while a
frank statement of the real condition may be greatly helpful.

While the habit of self-abuse as indulged in by the ordinary
individual practically never has the awful consequences that have been
sometimes pictured as resulting from it even long after its cessation,
there is no doubt that it is productive of many physical symptoms
during the time of its indulgence. There is almost sure to be a
discouraging lassitude and a tendency to exhaustion after even
comparatively small efforts. While this is true for ordinary muscular
efforts it is also true for other bodily functions that involve
muscular activity. In recent years we have learned that of the stomach
functions the motor is more important than the chemical. In the bowels
the motor function is extremely important. There are likely to be
disturbances, then, in the gastro-intestinal tract as a consequence of
the muscular condition that {484} develops in those patients. Probably
more important even than the physical, however, are the psychic
results of the habit. The patient feels discouraged and cast down at
his inability to conquer himself and is likely to avoid such exercise
and diversion of mind as would make normal healthy function possible.


Mental Disturbances.--It is the custom to say that mental
deterioration almost surely follows the habit. Those familiar with
mental cases often see self-abuse practiced with serious results by
young folks whose mentality is deteriorated. In these cases the
practice was indulged in with great frequency and with direct physical
consequences, such as loss of sleep, of appetite and the like. It is
not the habit, however, that has caused the mental deterioration. The
young patients are going crazy, but not because of self-abuse. Their
habit of self-abuse had originated and become exaggerated because they
were already mentally unbalanced. Their extreme indulgence in it is
especially due to their lack of control over themselves, because they
are not possessed of strong will power with regard to any thing. A
vicious circle is formed and the insane young man gradually deepens
his insanity by hurting his physical condition through over-indulgence
in the habit and all this further lessens his self-control; but were
it not for the original mental weakness the habit would not have been
indulged in to so great an extent.


Effect on Prostate.--There is one phase of the ill effects of
self-abuse that it is well to recall as having the confirmation of men
of large experience and conservative views. There is a definite
impression among specialists in genito-urinary diseases that
enlargement of the prostate in some cases is due to the frequently
repeated irritation and the prolongation of that irritation of the
prostate during the practice of self-abuse. When such men as Bangs and
Keyes are agreed on a subject of this kind, then even though in a
certain number of cases the changes in the prostate leading to its
enlargement are evidently inflammatory, it is well to consider that
the functional over-activity of the gland superinduced by the practice
may lead at least to an enlargement of the glandular elements with the
consequent interference with urination which so frequently comes in
old age.


Physical Factors.--Besides mental elements that predispose to the
formation of sexual habits there are physical factors that are
important in these cases. They must be particularly looked for and
treated carefully if found, or there can be little hope of relief for
the conditions. The most prominent of these is the existence of a long
foreskin, especially if its opening is small, thus leading to the
retention of urine, the deposition of urinary salts with the formation
of preputial concretions or so-called calculi. These are intensely
irritant, cause frequent itching and thus predispose to these sexual
habits. Even where the preputial opening is free and allows egress of
urine without residue, the accumulation of smegma often causes
considerable irritation and if the most scrupulous cleanliness with
cleansing at least once a day is not maintained, irritative conditions
arise, especially in hot weather, that may give occasions for sex
habits.

Under these conditions the habit is sometimes seen in extremely early
years. The youngest case I ever saw occurred in a child not quite
nineteen months old whose mother said that for several months she had
noticed certain curious actions that she could scarcely understand
until finally the truth dawned on her. Then she was morbidly sensitive
about it, sure that the habit was due {485} to a fault of her own and
it was some time before she consulted a physician. This was her fourth
child and, strange as it may seem, it was only at the conception of
this child that she first knew what sexual pleasure was. She feared
that her feeling had been in some way sinful and that as a consequence
of her sin this curious habit had developed in such early years in her
baby boy. As is usually the case in these instances, I found that the
prepuce was very tight indeed, having scarcely more than a pinhole
opening in it. During urination this ballooned and there remained in
the pouch-like process at the end of the penis a certain amount of
residual urine after every urination. From this urinary salts had been
precipitated and had formed scaly concretions which remained in the
preputial pouch and were extremely irritant. As a consequence of this
irritation the baby had been very itchy and it was in the endeavor to
relieve the itching by the natural process of scratching that the
pleasure of the sensations aroused had been discovered and the sexual
habit had been formed.

Not infrequently in young men a condition resembling this to some
degree at least is found and then, of course, the question of its
removal must be taken up at once. It is surprising how often in youths
in their late teens concretions are seen. The constant irritation
makes it practically impossible for the patient to keep his hands from
the parts, and so circumcision is absolutely necessary. Not
infrequently when the preputial condition is not nearly so bad this
operation may also be at least advisable if not necessary. The matter
of cleanliness must be attended to, preferably after getting up in the
morning and not before going to bed at night, for the reaction after
cold water may cause congestion of the organ. After a time the
frequent use of cold water seems to make the parts much less reactive
to irritation of any kind.


Physical Effects.--The super-excitation of nerves consequent upon the
more or less general erethism that is induced, lessens resistive
vitality. Victims of the habit are more liable to colds, to various
infectious diseases, and are subject to fatigue and lassitude, with
incapacity to work to their full power. They lose control over their
vasomotor system to some extent as a result of this systemic erethism.
They blush easily, they perspire easily, there is a tendency in many
of them to flash as if of heat and cold, they become pale under
excitement or anger more than formerly, they are likely to suffer from
cold hands and feet, and the surface of the body is inclined to be
cold and as a consequence patients are tremulous. This represents a
waste of nervous energy and as a consequence sleep may be disturbed
and digestion interfered with.

It is important, therefore, to consider these cases as really needing
medical care. For their treatment the most important consideration is
prophylaxis, not alone of the habit itself, but of each of the acts.
Prophylaxis of the habit is an ethical question that we can scarcely
do justice to here. Prophylaxis of the acts requires consideration of
the physical and moral factors that predispose to their commission.
While the habit may have secured such deep control that the patient
almost despairs of relief from it, when care is taken to remove
physical and moral predispositions the conquest of the habit becomes
comparatively easy. Over and over again I have seen cases that have
lasted for years in which the patients were surprised at the ease with
which they were able {486} to drop the habit just as soon as they took
the measures necessary to prevent predisposing conditions.


Breaking the Habit.--Once physical factors predisposing to it are
removed, the habit is not so hard to break as it would seem to be from
the suggestions to that effect made in sensational literature. It is
neither so deleterious in its physical effects nor so deteriorating as
regards character as is usually stated. Anyone with a reasonable
amount of firmness can break it off if he really resolves to. Over and
over again I have seen patients quite surprised at the ease with which
they were able to avoid the practice for weeks once they made up their
minds in the matter. Indeed this is one of the unfortunate features in
completely conquering the habit. It is comparatively so easy to break
it off when the mind is made up that there comes the feeling that now
it must be absolutely facile to keep away from it. This is, however,
never true. Relapses are extremely easy. If the patient allows himself
to read vicious books, or suggestive literature of any kind, or
permits himself an indulgence in the reading of several columns of the
account of a sex murder trial, or goes to see a sex problem play with
its suggestions, or exposes himself to sexually exciting conditions of
any kind, he will be almost sure to lapse into the old habit.

Relapses are almost inevitable. But it is easier to break the habit
the second time than it was the first and it becomes increasingly easy
if the patient keeps up the effort of regulating his life so as to
avoid the occasions of the habit. Relapses are quite as sure to occur
as with regard to alcoholism if occasions for the taking of liquor are
not sedulously avoided. The patient always seems to need a
confidant--someone to whom he can go for help and who assures him of
the ability that he has to overcome himself if he only will. The
practice of confession in the Roman Catholic Church makes it
comparatively easy for serious people of that faith to overcome the
habit. The physician must be taken into confidence in the same way and
for a time, at least once a week, the patient may have to be perfectly
frank with regard to his condition in order to have the help afforded
by such confidences. The physician can often, particularly at the
beginning, make the physical conditions such as to help in the
breaking of the habit. Bromides taken to the extent of a dram or more
a day are almost a specific for superirritability of the nervous
system, and if taken for two or three weeks the patient will usually
have little or no difficulty in overcoming the habit. They are not of
much avail after this time unless the patient's character has been
aroused to determined helpfulness in the matter.

In obstinate cases it may be necessary to have a patient come every
day, or at least every second day, for some time and give an account
of how he has succeeded in resisting his habit in the interval. At
least he must be asked to report whenever there is a lapse. It is
surprising how much the anticipation of having to tell someone else of
a drop back into the habit means in helping the patient eventually to
overcome it. Very slight motives serve to cause relapses, but almost
any external personal aid, if pursued with confidence, will avail
effectually to break it. I talk from an experience of many cases and
know how much can be accomplished even though patients insist that
they have tried all the resources of their will power and of prayer
without avail. They have really not tried, they have not willed in
reality; sometimes they {487} have reached a point where they cannot
will without the moral support of another personality. This can be
readily supplied to them by a firm, sympathetic physician whom they
respect. It will take time to overcome the tendency to relapse
whenever the will is relapsed, but the habit itself can be broken
without much difficulty in a few days.

Certain times are particularly dangerous for relapses into the habit.
These are just before going to sleep at night and before getting out
of bed in the morning. At these times the mind must be occupied or
else the patient will almost surely find his habit recurring. Often
the habit of reading in bed, properly supported by pillows and with
abundant light at an angle that makes reading easy, seems to be good
for these patients, because they may read until their eyelids get
heavy, then pull the chain of their light to extinguish it and turn
over to sleep. In the morning prompt rising after waking is important.
Bed clothes that are too heavy and too great warmth of clothing
predispose to sexual excitation and must be avoided. The room should
be cool rather than warm and the mattress rather hard.

The more tired the patient is the less liability will there be to
difficulty in these matters. But air is even more important than
exercise in giving the tiredness which superinduces deep sleep. A
lessening of the normal amount of oxygen seems to relax the inhibitory
power of the higher centers over the sexual centers in the cord.
People who are drowned, those who are hanged, and those whose supply
of oxygen is shut off by the inhalation of the heavier gases are
likely to have involuntary seminal emissions. These are probably
consequent upon the shutting off of the air.

The important element in the treatment is to make the patient feel
that, if he really wants to, he can conquer in this matter. The old
motives of fear, and especially fear of physical consequences, were
quite unworthy, and inasmuch as they had any effect rather produced a
deterioration of character than a strengthening of it. The patient
must understand that if he is a man he can overcome it. Religious
motives will help much. I do not know that I have ever seen a case
where religious motives were not the most important element in the
cure, but that may be due to the conditions in which I have been
placed. I have seen a number of these cases in men and women because
clergymen have sent them to me in order that they might be helped in
the work of reform, and while there are many relapses and some had
apparently given up the effort in despair of their power to overcome
themselves, nine out of every ten of those who have seriously faced
the problem have succeeded in overcoming themselves, and as a result
have a better knowledge of their own characters and more respect for
themselves. They are better men in every way than if their improvement
had come about through selfish fear of physical consequences.


After Cure.--After the habit of self-abuse has been conquered the
seminal vesicles will have a tendency to evacuate themselves rather
more frequently than before and as a consequence they will nag at
certain sexual nerve endings. They are used to having their contents
emptied and distention is followed by rather ready evacuation. During
the course of this evacuation sexual thoughts are awakened in dreams
and this may lead to dream states in which there seem to be lapses
into the old habit. This constitutes a serious difficulty in getting
rid of the habit entirely in young and vigorous men. They may even
become disheartened by it. It should be explained to them that they
must let {488} contrary habits form gradually and permit nature to
accommodate herself to the new state of affairs. The bromides are a
useful adjunct for body and mind.


_Supposed After-effects_.--At times a patient suffering from some
exhausting or serious disease, consumption, heart disease or the
various forms of Bright's disease, will be discouraged by remembrance
of the fact that in earlier years he allowed himself for some time to
fall into the habit of self-abuse. If he has read, and very few men
have not, some of the literature issued by the advertising
"specialists" and has heard the unfortunately exaggerated ideas
commonly entertained with regard to the influence on health of this
habit, he will become more or less disheartened by the idea that he
thus undermined his constitution and that one reason why he is not
able to react better against his affection is that he seriously
diminished his resistive vitality. This idea must, of course, be
overcome or it will act as a constant source of unfavorable
suggestion, lessening appetite, tending to disturb sleep, banishing
peace of mind to some extent and thus inhibiting the patient from
releasing such stores of vital energy for his recovery as would surely
be in his power under favorable conditions.


Female Habits.--The habit is more rare in women than in men, but when
it occurs is a little harder to break. In men it usually develops in
youth, but oftenest in women who are past thirty-five and unmarried.
In these cases it is much harder for the patient to regain
self-control, because the class of women patients who acquire such a
habit have less character, as a rule, than the men who fall into the
same condition. In all sex matters, once passion is aroused or habit
formed, the woman is likely to lose control of herself more than is
the man. Even in women, however, it is not only possible, but under
favorable circumstances, quite easy to secure a break in the habit,
though relapses are more frequent than in men. Certain occupations
seem particularly to favor the development of the habit. These are
mainly sedentary occupations that can be followed without the
necessity for such attention as to prevent the mind from wandering off
into thoughts that may prove provocative of sexual sensation.
Dressmakers seem particularly likely to suffer from the affection, and
those who run sewing-machines are predisposed by the movements
involved in their occupation to the development or, at least, to the
persistence of the habit.

For women even more than men religion and the motives it supplies are
the most efficient factors for the ultimate cure of the habit. In
general, the greater difficulty of overcoming it in them is due in no
small degree to the fact that they live indoors much more than men,
often have sedentary occupations, and are more frequently alone. These
afford opportunities for introspection and for the harboring of
thoughts that lead to relapses into the habit. Besides, women are more
prone to read novels and stories relating to sex problems and the
details of sex murder trials and the like which constitute
ever-recurring sources of mental erethism. If their habits can be
modified, especially if they can be made to realize the necessity for
being out in the air as much as possible, and for keeping their
windows open at night, as well as for thorough cleanliness--for every
gynecologist notes the necessity for this and how frequently it
happens that neglect of it leads to irritability of the external
organs that is of itself a serious factor--then it would be no more
difficult for women to overcome the habit and get beyond the relapses
than it is for men. {489} Sometimes we have to overcome a morbid dread
of touching themselves even for cleansing purposes which allows the
accumulation of irritant material and predisposes to relapse.


Sexual Perversion.--Sexual perversions are sometimes considered as
different from sexual neuroses, but such they really are. They are
oftener due to habit than to anything deeper. Much has been said about
the unfortunate natural inclination of some people to indulge in
sexual perversion, but such talk partakes of the nature of similar
remarks with regard to habits of other kinds. The alcohol habit, for
instance, is formed by many men as the result of their environment and
a weakness of character, with lack of resolution to support themselves
in self-denial when they are tempted to drink. In recent years it has
been only too often the custom to excuse or to justify many of these
cases. There are a few persons in whom, owing to weakness of
character, alcoholism is more or less inevitable if occasions for
indulgence occur. And in the same way there has been much maudlin
sentimentality wasted on sexual perverts, as if most of these men
could not avoid the actions that the rest of humanity abominates.
There are, perhaps, a few individuals who because of a failure on the
part of nature to define sex in them properly--as if she had not quite
made up her mind which sex they should belong to--are more to be
pitied than held to account for their delinquencies in this matter.
Compared to the whole number of sexual perverts, however, these are
very few. Under the protection of the pity awakened for these, a large
number of others find quasi-justification for their acts.

Anyone who knows much about these patients realizes that their story
is, as a rule, very different from what it would be if they were
inevitably impelled to the commission of the acts in question. Many of
them had the greatest abhorrence for it at the beginning, were
attracted to it out of curiosity and morbid sexualism, because they
had allowed themselves to think and read and dream about sex matters
overmuch. They are usually idle people who do not take life seriously
and who have an inordinate curiosity about sex subjects. At the
beginning the commission of the perverted sexual act was associated
with an intensely deterrent rather than an attractive feeling, but
gradually this was overcome and a contrary habit has been formed. It
is difficult to break this habit and to get away from the morbid
sexual ideas that have been allowed to develop and grow strong in
connection with it.

This opinion is somewhat different from that held by many men who are
recognized as authorities on this subject and who find many excuses in
the nature of their patients for these perversions. If it is recalled,
however, that whenever wealth has brought luxury to a people and
luxury has brought over-refinement, such sex perversions have been
particularly noted, it will be realized that not nature, but the ways
of men are responsible for their development. Whenever men pay much
attention to their bodies, exercise for the sake of their muscles,
bathe not for cleanliness but for luxury, sex perversions become
common in history. The story of Greek love is well known.
Corresponding conditions developed at Rome under similar
circumstances. According to good authorities, the English universities
became tainted with it a generation ago. Our athletic clubs in this
country have rightly or wrongly fallen under suspicion in this matter,
though the tendency to exaggeration with regard to such things, and
popular credulity in such matters must be recalled. {490} Some
confirmatory evidence undoubtedly there was. Sexual perversions then
would seem to be due in most cases to definite conditions and our
knowledge suggests readily what should be the prophylaxis.

In the course of some studies with Professor Magnan at L'Asile Ste
Anne in Paris I saw a number of these curious cases of sexual
divagations, exhibitionism, sex perversions and similar conditions.
Some of his cases were clearly curious examples of natural tendency,
at least, to mental hermaphroditism. Occasionally men of normal
development otherwise have a woman's waist and woman's torso above the
waist, and many womanly coquettish ways that point to this curious
mixture of sexes. Occasionally women are lacking in all the sex
characteristics of the upper portion of the body, have no breasts and
have the hirsute characteristics of men on the face and even on the
chest. In such cases one may be tempted to let one's pity override
one's better judgment and feel that resistance to the temptations to
indulge in perverted sexual feelings may be so difficult for these
people as to be almost impossible. Even in such cases, however, under
Magnan's gentle tutelage, under his faithful care and sympathy, men
and women lost most of the tendency to commit unnatural acts and
certainly found it easier to live normal lives than before.

For the majority of these sexual perverts, however, it is as with
regard to drug addictions, alcoholism, and obesity, just a question of
willing not to indulge in certain appetites that serves to help them.
There is no doubt that it is a difficult matter to break a habit that
has become a second nature, and it is almost impossible that it should
be accomplished without a number of relapses. If the patient really
wishes to correct the evil habit, however, this is perfectly possible.

The talk of a third sex with homo-sexual inclinations is quite beside
the mark. Certain of this class have a weakness of intellect and of
will that is at the root of their trouble, but not a few of them pride
themselves on their intellect and will power in most other things and
must not be permitted to deceive themselves as to their weakness and
its significance. It is not nature but self that is at fault and the
disease can be completely eradicated.


{491}

SECTION XIII

_SKIN DISEASES_



CHAPTER I

PSYCHOTHERAPY IN SKIN DISEASES


The place of mental influence in the treatment of skin diseases will
be best realized from the role that we know the mind plays in the
production of various skin manifestations. There is a whole series of
skin affections which depend to a considerable extent on mental
conditions, worries, anxieties, shocks, frights and the like, and a
number of skin affections that have been labeled hysterical which
occur in nervous persons, due to over-attention to self and their
conditions. It has been well said that it is possible to make the feet
warm by thinking about them. Certainly attention to any part of the
skin surface causes a tingling and hyperemia may follow. Blushing is
an illustration of mental influence on the skin, and anything that
would tend to make this endure for some time would give rise to
erythematous conditions. We know the creepy, uncomfortable, hot
feelings that come over us in times of suppressed excitement when we
are waiting for something to happen; and, on the other hand, there is
a pallor and tremor that accompanies fright or fear, which points to
mental influences over the vasomotor system in the skin.


Urticarias.--Certain skin diseases, especially those allied to the
urticaria group, are prone to occur in connection with excitement and
worry. In the chapter on Neurotic Intestinal Affections attention is
called to the fact that many patients who suffer from intestinal
idiosyncrasies and have excessive reactions to special kinds of food,
as cheese, strawberries, or the like, sometimes also suffer from skin
lesions and intestinal disturbance through worry or excitement. While
preparing for examinations or undergoing some physical trial or
suffering from worry or anxiety such persons may have urticaria or
even wheals on the skin. There may be some dietary disturbance to
account for them, but they would not occur, or at least would not be
so serious and annoying, but for the disturbed mental condition. Under
these circumstances dermatographia is a common manifestation. It used
to be considered a symptom of many physical conditions, but will occur
in almost any nervous person during the course of an examination by a
strange physician or when some important medical decision is pending.


Eczema.--Not only these passing conditions of the skin, however, but
more lasting affections have been connected with mental disturbance.
Probably every skin specialist has noted in a number of his cases that
a first attack of eczema came after a period of worry or excitement,
or sometimes followed directly on a fright. When relief from the
condition has been brought about {492} by treatment, relapses occur
during periods of business worry or family anxiety or mental stresses
of one kind or another. Cabinet crises in England are found to be
likely to be followed by the recurrence of eczematous conditions in
older members of the Cabinet or by first attacks in some of those
whose skin has been irritated by some internal condition. Unless
business worries can be removed or family anxieties allayed the cure
of eczema becomes a difficult matter. Men or women who worry about
their eczematous condition apparently prolong it. This is particularly
true if they have little to do and are likely to be much occupied with
themselves and their condition.


Herpes.--Herpetic conditions resemble urticaria in their response to
mental conditions. Herpes preputialis and herpes progenitalis occur
particularly in people who worry over the possibility of some
infection of the genitals. The lesions are likely to be indolent until
the state of mind with regard to them is relieved by reassurance as to
their comparatively innocuous character. Even herpes zoster is prone
to come on after a period of worry and anxiety. It is due to
infection, but the infection becomes more possible after a lowering of
resistive vitality in the nervous system. This is particularly true as
regards herpes facialis. It has been noted again and again that facial
neuralgia is most likely to occur after fright, deep emotion, or
prolonged anxiety. Treatment of these cases will only be successful if
the mental state is set right. This is particularly true with regard
to Bell's palsy. Patients who worry much about it and who fear that it
may have lasting results are likely to prolong its course and to put
off complete cure for a good while.


Vasomotor Disturbance.--There is a series of skin affections connected
directly with the vasomotor system of the skin which are largely under
the influence of emotional or mental factors. These represent
particularly the milder forms of Raynaud's disease and the parallel
forms of Weir Mitchell's disease. In the one case there is a spasm of
the arterioles causing what the French call "dead fingers," and in the
other paralysis of the vasomotor system with venous congestion in the
parts. They are seen particularly in persons of highly nervous
organization and especially after periods of emotional strain or
stress. There is a series of affections related to these,
characterized by numbness, paresthesiae, going to sleep of the fingers
or members, tingling, and even milder forms of itchiness--sometimes
dignified as pruritus--which are largely due to mental factors. Some
physical condition will need to be corrected, but they will only
disappear if the mind is set at rest and if the patient is kept from
occupying his attention much with them. Concentration of attention
will make them chronic.


Scurvy.--Scurvy is not usually thought of as a skin disease, though it
has many local manifestations on the skin and mucous membrane. It is a
deep nutritional disturbance of such nature that it would seem the
mind could have but little influence over it. When scurvy was common,
however, it was often noticed that any change of attitude of mind in
affected persons brought amelioration or deterioration of condition.
Scurvy develops with special virulence during discouragement; it gets
better with the dawn of hope. It has been known to be much improved by
the prospect of a naval engagement when all the sick men wanted to get
into the fighting. The famous case of the Siege of Breda in 1625 is
often quoted. The city was about to capitulate because so many of the
soldiers were suffering from the disease. The Prince of Orange, {493}
however, sent word that a new and powerful remedy had been discovered
that was sure to cure the affection, and that he had secured some of
it and it would not be long before they would all be well. What he
sent was a remedy that had been used with indifferent success for
scurvy when taken in large doses. He could send only enough to give a
few drops to each patient. This small dose was wonder-working in its
effect and proved to have the healing virtue of a gallon of the
liquor. Most of the patients got better and surrender was put off.


Warts.--A striking evidence of the influence of the mind upon the skin
is given by what we know of warts. All sorts of charms have been not
alone suggested for them but found to work in certain cases. Lord
Bacon in his "Natural History" tells the story of the charming away of
warts and exemplifies it by his own experience. When he was about
sixteen a number of warts--at least 100--came out upon his hands. One
of these had been there from childhood. The manner of their cure he
details as follows:

  The English Ambassador's lady, who was a woman far from
  superstition, told me one day she would help me away with my warts;
  whereupon she got a piece of lard with the skin on, and rubbed the
  warts all over with the fat side; and amongst the rest that wart
  which I had from my childhood. Then she nailed the piece of lard,
  with the fat towards the sun, upon a post of her chamber window,
  which was to the south. The success was that within five weeks'
  space all the warts went away, and that wart which I had so long
  endured for company. But at the rest I did not marvel, because they
  came in a short time, and might go away in a short time again; but
  the going away of that which had stayed so long doth yet stick with
  me.

Lucian, the Greek satirist, tells that warts were cured by magic in
his time. Carpenter in his "Human Physiology," page 984, says: "The
charming away of warts by spells of the most vulgar kind belonged to
those cases which are real facts, however they may be explained." Dr.
Hack Tuke in his "Influence of the Mind Upon the Body" says: "In
visiting a county asylum some years ago my attention was directed to
several of the patients who were pestered with warts and I solemnly
charmed them away within a specified period. I had quite forgotten the
circumstance until on revisiting the institution a few months
afterwards I found that my practice had been followed by the desired
effect and that I was regarded as a real benefactor." This feature of
the method of removing warts, setting a date before which they shall
disappear, is noted in most of the successful charms. Dr. Tuke tells
of a case in which a gentleman on shaking hands with a young lady
noticed that she had many warts. He asked her how many she had; she
replied about a dozen, she thought. "Count them, will you," said the
caller; and taking out a piece of paper he solemnly took down her
counting, remarking: "You will not be troubled with your warts after
next Sunday." Now it is fact that by the day named the warts had
disappeared and did not return.


Neurotic Pigmentation.--Pigmentation occurs very commonly as the
result of neurotic conditions. Dr. Champneys, in his article on
"Pigmentation of the Face and Other Parts, Especially in Women," in
St. Bartholomew's Hospital Reports, Volume XV, has illustrated this
very thoroughly. The pigmentations of women during the phases of
genital life, menstruation, pregnancy, the menopause and the fact that
eunuchs are usually fair and fat, while deep pigmentation in the white
race is usually associated with sexual irritability, all make
interesting studies in this subject. From comparative {494} anatomy
and physiology the influence of the nervous system over pigmentation
has been very well illustrated. Brücke in 1851 established the
influence of the nerves on the color of the chameleon and of the frog,
and there have been many confirmations of his work. Pouchet, in 1876,
in the _Journal de l'Anatomie et de Physiologie_ proved that fish
gained the power of changing color by practice and lost it by disuse.
The influence in most cases, animal and human, which produces
pigmentation is exerted by the nervous system through the vascular
supply. The duskiness that sometimes comes with emotion, the pallor
that accompanies strong mental disturbance, as well as the blushing
states, show that the vasomotor system can be influenced in every
part. Pigmentation often seems only a consequence of local continuance
of such disturbance. Many of the feminine patients in whom even deep
discolorations around the eyes occur in connection with menstruation
are typical neurotic individuals. It is worry in combination with the
physical disturbance that produces the pigmentation. There are some
cases on record where emotional states have caused loss of pigment in
the negro or other colored races, or in the hair, as when, in
well-substantiated cases, people's hair has become white in a single
night. In every case of pigmentary disturbance, then, the individual
must be carefully studied and as far as possible all emotional
disturbance must be eliminated. Without this other treatment usually
fails.


Pruritus.--Pruritus in the old is often a bothersome symptom. All
sorts of remedies, internal and external, are recommended for it and
successes are reported with them. Whenever there are many remedies for
a symptom complex, it usually means that the suggestive element in all
of them is large. For pruritus the influence of the patient's mind is
extremely important. Often it will be found that these old patients
are getting out scarcely at all, but are living in close confinement
in their rooms, the air of which is scarcely ever changed. I have
known even the keyholes to be stuffed and arrangements made by which
the cracks between the door and the frame were rendered impervious to
air. In these cases the most important feature of any treatment is to
secure a proper amount of air. Sir Henry Thompson, the great English
surgeon, in his advice how to grow old successfully, written when he
himself was over 80, suggested that the cells of the skin needed an
air bath every day. He advised that men should make all their toilet
arrangements for the day without any garments on. Washing, the
preparation of clothing, shaving, and whatever else was done in the
early morning was to be accomplished after the night clothes were
taken off and before other clothes were put on. He lived to be well
above eighty and was sure that this practice had been of help to him.
Stimulating rubbings, if done gently and without the production of too
much reaction, will always benefit these people.

If old people have no interest, nothing that attracts their attention,
and if they once develop pruritus their mind gets concentrated on
their cutaneous sensations and it will be impossible to relieve them
by any treatment until their minds get occupied with something else.
Anyone who wants to sit in a chair for a few minutes and think about
his cutaneous sensations will soon realize how vividly these can be
brought to mind and how annoying they can become. To sit and think of
a portion of the body is to want to scratch it before long. Scratching
produces a flow of blood to the surface that adds to the itchy
feeling. The only way to get away from it is to get the mind {495}
occupied with something else. Of course, where circulation is weak
because of failing heart or disturbed because of arteriosclerosis,
treatment directed to these conditions should be employed, but the
influence of the mind on blushing and skin feeling must not be
forgotten.

When pruritus develops in the old in connection with phases of
arterial degeneration--its most intractable form--it is important to
remember that diversion of mind is the most important therapeutic
agent that we have. The old have few diversions. They have given up
their ordinary occupations, they are often no longer interested in
reading, friends whom they used to know have died, and they are left a
great deal to themselves. Under these circumstances anything the
matter with them brings about a concentration of attention. This is
even more true if they have been very well in earlier life and have
had practically no experience with sickness.


Hysterical Cutaneous Conditions.--There are certain cracks of the skin
with ulcerative lesions which occur in hysterical patients in the
neighborhood of the knuckles that represent a phase of unfavorable
influence of the mind. When these patients begin to worry or be
anxious they know that these skin lesions will follow. Expectancy
seems to make it certain that the lesions will come and attention adds
to their chronicity. It has been noted that "chapped hands,"
especially when accompanied by deep cracks in cold weather, are made
worse by anxiety or worry. In many neurotic patients it is impossible
to treat such conditions satisfactorily unless the patient's mind can
be put at ease. It is surprising how intractable these conditions can
be, but that is usually because all the physician's attention is
devoted to the skin instead of a considerable portion of it being
given also to the patient's mental and nervous condition.


Artefact Skin Lesions.--Of course artefact skin lesions produced by
the application of carbolic acid or nitric acid or ammonia or some
other chemical irritant, or by rubbing with pumice stone, or with the
thumb as schoolboys make what in my schooldays were called "fox
bites," are skin lesions connected with a special state of mind and so
deserve a mention here. The physician finds them under the most
unexpected circumstances at times and in patients apparently above all
suspicion of their self-infliction. They can only be prevented by
changing the patient's state of mind, though this is scarcely what is
ordinarily thought of in psychotherapy. Where skin lesions are
atypical it is well to bear in mind the possibility of this curious
condition.


The Mind in Dermatotherapy.--I have had old dermatologists assure me
that they felt that the mind influenced materially the course of many
forms of skin disease. Younger dermatologists are prone to be
localists; as they get older the treatment of the patient's general
condition is felt to be more important; after twenty years of
experience they realize the place of psychotherapy in the treatment of
their cases. What is said here is only meant to be suggestive, but
certainly sufficient data are supplied to make it quite sure that the
mind greatly influences skin conditions and must always be treated if
success, especially in chronic cases, is to be secured. I have seen
confidence in a particular physician or remedy do much for even the
most sloughing and obstinate psoriases. Eczema follows the same law.
If psychotherapy can help in the treatment of conditions that are so
often intractable, it must surely not be neglected in other cases.


{496}

SECTION XIV

_DISEASES OF DUCTLESS GLANDS_



CHAPTER I

DIABETES


Diabetes is an affection of metabolism definitely recognized as due to
serious organic changes, though existing in several forms. We are not
as yet absolutely sure whether there may not be quite different
organic diseases in the various forms. Of one thing clinical
experience has given us assurance, that the condition of the patient's
nervous system is extremely important. While certain forms of diabetes
are due to pancreatic changes and others perhaps to changes in the
liver or other abdominal organs, the nervous system itself can affect
the consumption and excretion of sugar within the body. Certain
injuries, especially, as pointed out by animal experiments, irritation
of the floor of the fourth ventricle may produce passing diabetes. The
symptom may also occur in connection with states of the nervous
system. Glycosuria, or the passage of sugar in the urine, may occur
simply as alimentary glycosuria; and while this is usually due to an
excess of sugar in the diet, the glycosuria itself is predisposed to
by neurotic conditions in the patient. Diabetic patients are made
worse by worry of any kind and particularly by solicitude about
themselves and their ailment. Hence, the place that psychotherapy has
in the treatment of the disease.


Unfavorable Suggestion.--In most cases of diabetes, however, probably
the most important factor in the production of symptoms is the serious
disturbance of mind. The patient has an incurable disease and is
frankly told so. For the physician the word "incurable" means only
that his remedies are as yet inefficient in preventing certain
nutritional or metabolic disturbances, and that these will be likely
to continue in spite of all he can do. For the patient "incurable"
means that he has a disease for which the doctor confesses that he can
do nothing--which is not true--and that it is almost surely
progressive, while the many reports of death from diabetes of which he
hears only confirm the impression that he has not long to live and
that most of the time remaining will have to be spent in irksome care
of himself and almost superhuman self-denial.

As a consequence of this train of unfavorable suggestions, the history
of practically every case of the milder form of diabetes in older
people contains a period in which, shortly after the discovery that
they had the disease, they suffered more severely from it than at any
other time. As a rule, the discovery was accidental. The occurrence of
a succession of boils, the development of a {497} carbuncle,
occasionally an intractable eczema or a great itchiness of the skin,
or an irritation of the external urinary organs, the occurrence of
cramps at night, or neuralgia pains, have led to an examination of the
urine and the finding of a considerable quantity of sugar. As a rule,
the patients are at once put on a diet containing little starch and no
sugar, and after a short time most of the bothersome symptoms of the
diabetes have ceased. Their own worry, however, the strictness of the
regimen, the craving for starches, the decrease in weight from the
limitation of diet, have made them profoundly miserable. Their
feelings have been translated into the definite conclusion that the
disease must still be making progress since they feel so miserable,
and they have suffered more from their mental state than from their
diabetes.

This is as true of physicians themselves when they are sufferers from
diabetes as of ordinary patients. Indeed, it seems that physicians
make themselves more profoundly miserable because of their supposed
knowledge of the disease than other people do. I have had the
confidences of more than a dozen physicians who were sufferers from
diabetes, and all of them admitted that they had suffered more from
their scare over the disease and from trying to maintain a sugar-free
diet than from the effects of their ailment. The lowering of nutrition
reacts upon the nervous system, already laboring under the strain of
the persuasion that an incurable disease is present, and the
consequence is a whole series of nervous and often mental symptoms,
especially of the depressive kind, that still further disturbs
digestion, interferes with peristalsis, causes constipation or
alternate constipation and diarrhea, leads to wakefulness at night,
inability to concentrate attention and a constant state of worry. All
this reacts upon the system and further increases the diabetes, that
is, the inability to use sugar properly, and adds to its elimination
through the urine.


Favorable Suggestion.--Just as soon as these patients realize that
people have often had considerable quantities of sugar--two per cent.
or more--in their urine for years without serious consequences and
that most diabetics die, not from the affection itself, but from
intercurrent disease, the reassurance of mind which ensues makes their
nervous system cease to be a factor in the further disturbance of
metabolism and they are able to consume more starch and sugar without
increasing the amount of sugar in their urine. This is not true, of
course, for the severe diabetes that attacks young people. These run a
rather rapid course and usually end in from one to two years in
diabetic coma or some complication connected directly with the
diabetes.


Danger of Over-treatment.--To strive to keep the urine of diabetic
patients free or nearly free from sugar is practically always sure to
produce a serious effect upon general nutrition and to disturb the
patient's mind and nervous system. Very often, however, an attempt of
this kind is made. Doctors who suffer from diabetes are too prone to
watch their urine carefully from day to day and this only emphasizes
their solicitude about themselves, impairs their digestion, and
produces such preoccupation of mind that all their functions are sure
to be disturbed. After a time they learn that their general condition
is a more important question than the amount of sugar in their urine.
If they can maintain their weight with reasonable freedom from the
secondary symptoms of diabetes, then the primary symptom--the amount
of sugar in the urine--may be almost or quite neglected.

{498}

Interval Treatment.--Van Norden has pointed out that if diabetic
patients are occasionally made to observe for a couple of weeks at a
time an absolute diet, these intervals seem to form a new
starting-point for metabolism and enable the patient to increase his
power of utilizing sugar and consequently to diminish his pathological
elimination of it. Patients look forward with interest to these
periods, provided that in the intervals they are allowed a certain
amount of starch; and each one of them seems a landmark on the road to
recovery. There is a strong element of suggestion in this that acts
very favorably and greatly influences the actual power of such
intermissions to help nature recover her lost metabolic faculties.
This is certainly a better method of treatment than the attempt to
keep up an absolute diet which so easily produces the other evil of
nervousness that adds to the diabetes, so that there is question of
choosing between two evils, and the lesser evil includes particularly
the reassurance of the patient.


The Individual in Diabetes.--While diabetes is a question of
glycosuria and usually of hyperglykemia, and the consumption of any
form of cane sugar or of starch convertible into it, will usually
increase the diabetic tendency, not all the forms of starch which may
change into cane sugar have the same effect in all individuals or
undergo the same modifications. Some patients, for instance, stand
milk better than others and may take large quantities of it so that
there is less craving for starchy foods. Most patients can take
potatoes better than bread even when there is the same equivalent of
starch in each. Those who have been accustomed to potatoes from their
early years sometimes stand them well and may be able to take them
almost with impunity. I have noted in several cases that the Irish and
Scotch, accustomed to oatmeal from their early years, seem to be able
to take notable quantities of this food when suffering from diabetes
without having a marked increase of sugar in the urine.

There are forms of sugar that satisfy the craving of patients for
sweets and may be taken in considerable quantities without seriously
disturbing metabolism. Honey is one of these, its sugar occurring in
the form of mannite, and there are other substances related to it that
probably can be employed to advantage. It must not be forgotten that
what seems to be sugar in the urine of certain patients, that is,
grape sugar, has proved on more careful investigation to be one of the
other chemical forms of sugar. We have a number of cases of pentosuria
on record in which patients were excreting penatomic sugar, but had
not glycosuria, though their urine responded to the ordinary tests for
this. It seems well not only to be sure of the diagnosis in these
cases, but to use what we have learned to make patients feel that
their condition though not curable is by no means hopeless. Care must
be exercised to take advantage of every possible individual
peculiarity for reassurance, for the extension of the diet in any
possible way, and for the satisfaction of the cravings which are so
likely to come to these patients. Some of their craving is really due
to the suggestion that they cannot have a particular article of diet.
Whenever any human being knows that he cannot have a thing, the liking
for it grows by suggestion and then it may become an obsession. To be
allowed even small quantities of it is often enough to enable patients
to overcome this and at least put them in a better state of mind.


Physical Condition.--The most important element in the treatment of
{499} the less severe cases of diabetes is exercise in the open air.
Whatever the ultimate solution of the mystery of diabetes may be,
there is no doubt but that the muscles are an important factor in our
disposal of sugar within the body. The material which is burned up in
the muscles during movement is a form of sugar derived directly from
the starch and sugar ingested. When diabetics exercise freely much
more of their sugar is consumed within the body and much less of it
eliminated through the kidneys than when very little or no exercise is
taken. It is interesting to note the difference in the amount of sugar
in the urine when patients are taking abundant exercise and when they
are taking practically none. Even on a much more liberal diet the
percentage of sugar is likely to be less in the exercising patient.
One of the results of the diabetic scare is likely to be almost a
cessation of muscular exercise. This is partly due to the fact that
one of the results of diabetes in many cases is a sense of fatigue in
the muscles on comparatively little exertion. Indeed, this is
sometimes the first symptom that is noted and that calls the attention
of the patient to the fact that there is something seriously wrong
with him.

This occurs when there is a serious disturbance of sugar metabolism so
that the patient who consumes large amounts of starch and sugar is
excreting most of it. Just as soon as the diet is made a little more
rigid and the sugar metabolism improves, then exercise can be taken
and will benefit the patient. This is particularly true of women
suffering from diabetes whose depression on being told that they are
suffering from an incurable disease tempts them to remain within
doors; the frequent tendency to urination further adds to their
disinclination to go out. Under these circumstances they lose their
appetites, do not sleep well, and become highly nervous, thus
increasing their diabetic tendency. If they are required to go out and
take exercise in the open air and rather long riding or walking
periods every day, their general health will at once improve and the
diabetes will become more manageable. I have seen this happen without
exception even in patients well beyond middle age, and I am convinced
that it is the diversion of mind as well as the salutary tiredness and
thorough oxidation consequent upon outdoor exercise that is the best
possible remedial measure for these cases.


Solicitude.--It is important that diabetic patients should not be
bothered by frequent reports upon their urine. Their improvement and
the reduction of the amount of sugar excreted is at best but slow, and
is subject to many variations. While improvements, especially at the
beginning, are sources of great encouragement, the deteriorations that
are likely to be rather more frequent are prone to overweigh the good
effects and eventual discouragement results. It is not from the urine
but from the general condition that the improvement in the diabetic
condition is to be judged. So long as the patient feels strong, gains
in weight (when they do not belong to the obesity type of diabetes),
the diabetes itself is almost sure to be improving, even though there
may be discouraging periods as regards the amount of sugar eliminated.


Dangers of Rigid Diet--There are more dangers in a rigid diet than in
a certain amount of liberty in the consumption of starches and sugars.
The craving for these becomes so strong as to make life intolerable to
many people unless a certain amount of these substances is allowed. It
is rather easy to manage limitation while it is almost impossible to
be sure that {500} patients will practice absolute denial. Besides,
the almost complete absence of starches and sugars, even though their
place is supplied by the fats, always seems to predispose patients to
the development of the acid intoxication which results in the coma
often so serious an incident of diabetes. It is for this reason
particularly that mild diet regulations are clinically more judicious
than the absolute denial which on chemical and physiological grounds
seems to be the scientific ideal. A rather good therapeutic method is
to have the patients maintain a rigid diet for some ten, fifteen or
twenty days and then leave them practically without restrictions for
the rest of the month. Continuous restriction of diet becomes
appalling. Looking forward to a period when they can eat as other
people do relieves the tedium, and makes it much easier to keep the
restrictions. The mental influence of this moderate treatment is very
favorable and encourages the patients in the thought that after all
their disease is not so serious. This is the most important element in
psychotherapy.



CHAPTER II

GRAVES' DISEASE


Graves' disease, sometimes called Basedow's disease, though the Irish
physician has a right to the name by priority, is often called
exophthalmic goitre, because this term is descriptive of the two most
marked symptoms. It must not be forgotten, however, that there are
cases in which there is no exophthalmos and even no goitre, at least
no enlargement of the thyroid gland that can be demonstrated
externally. It is said that in these cases there must be an
enlargement of the thyroid bound down by fascia and concealed by other
structures of the neck so that it does not appear externally. It is
probable, however, that there are cases of true Graves' disease
without enlargement of the thyroid yet with the characteristic tremor,
rapid heart and the mental symptoms of the affection.


Etiology.--The symptoms of the affection often develop after a period
of excitement or worry, or at critical times in life, if sorrow or
misfortune proves a burden. Responsibility sometimes has a like
effect. I have seen a woman patient on several occasions in the last
fifteen years develop marked symptoms of Graves' disease when she was
placed in a position of responsibility involving worry, while in the
intervals when pursuing a simple ordinary life without trouble of mind
no symptoms were present. Occasionally a fright seems to be at least a
predisposing cause for the development of the symptoms. Emotional
strains, mental stresses, play a large part in occasioning Graves'
disease, though the cause of it is probably deeper in some structural
defect. In recent years nearly all the medical attention has become
concentrated on the idea that the disease is primarily due to
hyperthyroidization. More detailed study, however, has shown that
other ductless glands are probably also concerned in the etiology. The
adrenals particularly seem to be associated closely with the thyroid
and Graves' disease may be due to some disturbance of the
co-ordination between these glandular systems. The thymus gland is
usually {501} persistent in these cases and this must represent
something in the affection and at one time the use of thymus substance
for therapeutic purposes seemed to confirm this idea. The parathyroids
have also been called into question and their use in therapeusis seems
to justify this to some extent, though probably we know too little
about them to be able to say anything definite in the matter.

Even though the affection may be due directly to hypersecretion of the
thyroid, it is possible that the mental and nervous state may be
closely concerned in the etiology. Some patients have had an enlarged
thyroid for years, without any symptoms of Graves' disease. Then
during a time of stress and worry or anxiety and responsibility
symptoms of the affection develop. The circulation of the thyroid is
under the control of the cervical sympathetic. It is possible that
this may be affected by states of mind to such an extent as to cause
an increase of the circulation in the thyroid and as a consequence
more of the thyroid secretion may get into the blood stream and
produce its effect. Under these circumstances anything that would
allay the excited mental condition and thus neutralize the unfavorable
effect of the cervical sympathetic would cure or at least relieve
Graves' disease.

The affection is about five times as frequent among women as it is
among men. This has sometimes been attributed to the fact that there
seems to be some more or less direct correlation between the sex
organs in women and the ductless gland systems. It has often been
pointed out that the thyroid is likely to be engorged at the time of
menstruation and, indeed, there are those who have attributed some of
the symptoms of tremulousness, irritability, and tiredness at this
time to over-functioning of the gland. In women who have borne a child
the thyroid is usually somewhat enlarged. Good authorities in
obstetrics have insisted that they could pick out of a group of women
in evening dress, those who had borne children, from the appearance of
their necks. Probably this is an exaggeration, but there is no doubt
that the thyroid is intimately related to the genital functions in
women. It has been said that a direct connection could be traced
between disappointments in love or in sexual matters and the
development of Graves' disease. To put much stress on this would
easily lead to mistaken conclusions, though it represents a principle
that should be recalled in certain cases of the affection. The
frequency with which slighter disturbances of the thyroid occur in
connection with the common genital incidents of female life and their
comparative insignificance for health or strength, should make for the
holding of a not too serious prognosis in the affection.


Symptomatology.--There are four cardinal symptoms of the disease:
rapid heart action, tremor, enlargement of the thyroid, and
exophthalmos. At least two of these are largely dependent on mental
influences. There are certain accompanying symptoms that are of
importance and supposed to be connected directly with the disease,
though oftener they can be traced to the influence of the state of the
patient's mind upon the organism. Emaciation is common. It is due to
the fact that the appetite is likely to be seriously disturbed by
anxiety and solicitude. Anemia develops as a consequence and there may
be slight fever which is sometimes inanition fever. Attacks of
vomiting and diarrhea occur intermittently and sometimes there is
constipation. The disturbance of eating consequent upon the affections
seems largely {502} responsible for these. The disturbance of the
vascular system gives rise to flashes of heat and cold and often to
profuse perspiration. Certain of the symptoms of the menopause can be
compared rather strikingly with those of Graves' disease and have been
attributed to the disturbance of the external secretion of the ovaries
which are now known to act as ductless glands as well as genital
organs.

With the exception of the enlargement of the thyroid and the
exophthalmos, all of the symptoms of Graves' disease are of a kind
that can be produced in states of excitement with nothing more present
than a functional neurotic condition. It is true that the tremor is
characteristic and differs from that of hysterical patients, being
finer and at the rate of a little more than eight to the second. The
rapid heart action, however, and the disturbance of the general
circulation which causes flushing and pruritus and the sense of
nervousness, as if the patients were in a constant state of fright,
are always characteristically neurotic. The changes in disposition,
often in the line of irritability, sometimes with severe mental
depression, seem in many cases to be only a mental reaction to the
patient's solicitude. The weakness of the limbs which sometimes
amounts to a giving away of the legs, is connected with the tremor,
but seems to be neurotic rather than of any more serious character. In
spite of all our study of the affection its place among the neuroses
must still be reserved for it, at least as regards many cases, and its
treatment must be conducted with that idea in mind.


Diagnosis.--The disease is easy to recognize when fully developed. At
the beginning of cases, however, and in certain abortive types of the
affection which the French have called _formes frustes_, the diagnosis
may be difficult. Usually the first symptom is tremor and this of
itself will often serve, especially in association with general
symptoms of nervousness, to make the diagnosis. Tremor with
tachycardia puts the case beyond doubt, as a rule, though of course it
must not be forgotten that hysteria may simulate rather closely this
much of the disease.

The abortive types of the affection are important because they
masquerade as forms of psychoneurosis, hysteria, and the like, though
the patients are not suggestible, have very definite, not variable,
symptoms and get better and worse according to the variations in the
underlying affection. Occasionally they seem to be associated with
certain other forms of neurotic conditions, especially those with
vascular disturbances. There may be tinglings in the ends of the
fingers, occasionally with suffusion, erythromelalgia--Weir Mitchell's
disease--and even a tendency to the white "dead fingers" as the French
call them, of Raynaud's disease. It seems not unlikely that further
study will show that many of these affections involving disturbances
of the vasomotor system are connected in some special way.


Prognosis in Young Patients.--Some of the cases, especially in young
people, are likely to seem quite discouraging and apparently to
justify even a serious operation. I have in mind a young woman seen
some fifteen years ago when she was about seventeen. The prominence of
the eyes, the enlargement of the thyroid, the tremor and the rapid
heart were all marked. The symptoms had been growing worse for over a
year and the outlook was serious. Ten years later I saw her in another
city in perfectly normal health, married and happy and the mother of
two healthy children. The only trace {503} apparently of the
disturbance of the thyroid to be noted in the family was that her
children got their teeth very late, her first child, a boy, not
cutting his first tooth until after he was fifteen months old. In
every other way, however, the boy was perfectly well, rugged and
strong, having passed through his summers without any serious
disturbance and not being a particularly nervous or excitable child.
Such complete relief from symptoms after the condition had been so
grave would ordinarily have seemed quite out of the question. It
emphasizes the fact that for Graves' disease as it occurs among young
growing people, where perhaps the thyroid does not grow in proper
proportion to the rest of the body, but for some reason overgrows, the
prognosis of the case may seem to be much worse than it really is.


Treatment.--The story of the various methods of treatment that have
been reported as successful for Graves' disease serve to show very
well how much the affection must depend upon psychic and neurotic
conditions, for most of them have been positive in action at the
beginning when their suggestive influence was strong, and quite inert
after they had lost their novelty and their power to influence the
mind. Sometimes even slight operations as on the nose, the removal of
polyps, or of a spur on the septum, or an enlarged turbinate, have
been found to bring relief of the symptoms of Graves' disease even in
marked cases. Operations upon the tonsils have had a like effect and
even shortening of the uvula has been reported as curative. A
generation ago applications of iodin to the goiter were reported to
have good effects. In lancing the goiter, sometimes evidently a cyst
was punctured, but sometimes the lance was only followed by a slight
issue of blood, yet the affection was favorably modified. More serious
operations have followed by complete relief of symptoms for a time,
though relapses are not infrequent and occasionally the patient was
not relieved, though apparently all the conditions present were
similar to those of other patients in whom the operation produced
excellent results.

The medical treatment of Graves' disease demonstrates interestingly
the power of suggestion. About fifteen years ago a distinguished
English observer announced that he was getting good results in the
treatment of Graves' disease by the administration of thyroid
substance. At that time our present theories with regard to
hyperthyroidization as the etiology of the affection had not been
formulated, though some vague connection between the thyroid secretion
and the symptoms had been accepted. A number of patients were improved
by taking thyroid. Other observers found, however, that not only were
their patients not improved, but they seemed to be worse as the result
of the thyroid feeding. The English physician therefore was asked to
say exactly how he obtained his material and prepared it for his
patients. Organo-therapy was then new and it was found that the orders
given to the butcher for thyroid had been filled by him according to
the directions by furnishing portions of a large gland situated in the
neck of the calf. This was the thymus, and not the thyroid. Thymus was
then deliberately used for a while and there were some reported good
successes while the treatment was new and strongly suggestive. After a
time it proved to be of no avail.

A number of biological remedies were tried after this. Personally,
after having made some studies of the parathyroids while in Virchow's
laboratory, I resolved to try material from those glands. The first
two patients to whom {504} the material was given, with a careful
explanation of the theory on which it was administered, proceeded to
obtain relief from their symptoms and an intermission in their
disease. Just as soon as I purposely omitted to explain to patients
how much might be expected from this new remedy and failed to make
suggestions founded on the parathyroids, no improvement was noted. In
the first two cases this had been more or less necessary in order to
determine whether the patients could stand the doses suggested, which
began very low and were gradually increased. The material seemed to
have no ill effects, however, and a definite dosage could be used
without the necessity of taking patients into one's confidence.

A number of serums of one kind or another were reported as beneficial
for Graves' disease. It was admitted that they did not benefit all the
cases, but that in certain cases they did much good. Practically all
of these were strikingly more efficient in their discoverers' hands
than when used by anyone else. Thyroids were removed from animals and
after some time serum from these animals, supposed to be of lower
thyroid content, was injected into human beings with the idea of
reducing the hyperthyroidization or perhaps neutralizing it by some
substance present in the serum. One very interesting observation on
most of these cases deserves remark. The animals deprived of their
thyroids, such as goats and sheep, lived on absolutely unhurt by the
operation, and as one experimenter expressly noted, sold for more
money after being kept for a year under observation than they had cost
him before dethyroidization.

Most of our biological remedies for Graves' disease then are strongly
reminiscent of the therapy of the affection in older times. It was
particularly for Graves' disease, or at least for nervous symptoms
closely resembling Graves' disease--those of fright, nervousness,
irritability and tremor--that various more or less terrifying
procedures and particularly deterrent substances were employed in
medicine. These patients, for instance, were cured by the touch of a
hanged criminal, and particularly by the touch of their goiter to the
mark on his neck. It was especially for them that _Usnea_, the moss
gathered from the skull of a criminal who had been hanged, was of
benefit when administered internally. Mummy as a remedial substance
remained in common use until well on into the latter half of the
eighteenth century in England.

In older times a dead snake wrapped around the neck was said to be an
excellent remedy for goiter and especially those cases of goiter that
caused symptoms of fright and nervousness. Evidently anything that
produces a strong effect upon the patient's mind may prove helpful.
Perhaps the suggestion enables the mind to control the cervical
sympathetic and by that means the circulation in the thyroid gland,
thus lessening the amount of blood that flows through and therefore
the amount of secretion that is carried out. There is no doubt but
that the sympathetic is largely under the influence of the emotions
and that through it very important effects may be worked out in
various structures. There seems no other possible explanation for the
uniformly reported success of remedies when their suggestive power is
strong and their failure quite as invariably later even in the same
cases.


_Operations_.--In recent years operations for the removal of portions
of the enlarged thyroid have become popular and some very successful
results have been reported. Those of us who know how easy it is to
influence the minds of {505} patients in Graves' disease favorably
hesitate as yet to pronounce definitely with regard to the indication
for operation except under such conditions of pressure in the neck or
projection of the eyeballs as may lead to serious symptoms. Not all
the operators have been as successful as some who made a specialty of
the affection. I have personal information which shows a number of
unsuccessful cases after operation and the records of conservative
surgeons as published indicate this. Unfortunately, a great many cases
have been reported within a few months as cured; if they were
comparatively without symptoms, surgical intervention is considered to
have been eminently successful. For, be it noted, very few are
entirely without symptoms, even after operation.

Dr. William H. Thompson in his book on "Graves' Disease" points out
that even so good an operator and so thoroughly conservative a surgeon
as Kocher reports cases of Graves' disease as cured, which are still
exhibiting symptoms that would make the medical clinician hesitate to
agree with him and, indeed, rather lead him to expect that under the
stress of worry and excitement there may be redevelopment of the
symptoms. As the number of cases operated upon has increased there has
been a growing feeling that relapses might be expected in certain
cases even after removal of large portions of the thyroid gland. The
fact of the matter is that we do not understand as yet what is the
underlying pathological significance of the symptoms grouped under the
term Graves' disease. When there are severe symptoms, as extreme
exophthalmos, greatly enlarged thyroid pressing upon the important
neck structures, or serious disturbance of nutrition, an operation is
always needed; but as yet we cannot be sure that it will produce even
complete or lasting relief.

Many patients have been greatly benefited by operation, some of them
perhaps permanently, but we need more of the after-history of these
patients covering a long period of time, to be sure that the results
flow entirely from the operation. There was a time when operations
were reported as doing quite as much good for epilepsy as they are now
for Graves' disease. As we have pointed out, a number of operative
procedures that had nothing to do with the underlying basic pathology
of the disease have proved the occasion for considerable improvement
or sometimes what might be called a cure for a prolonged period. We
can be sure, as a rule, that patients will be benefited immediately
after operations. The rest, with care, the strong suggestion, the
aroused feeling of expectancy, the confidence in the surgeon, all this
would do much of itself. It remains to be seen how much more than this
the operation does.


_General Condition_.--The treatment of patients suffering from Graves'
disease consists largely in having them take up some occupation that,
while reasonably absorbing, does not make too great a demand upon
them. Often when they complain most of their symptoms they are below
normal weight and the first indication is to have them brought back to
it. I have seen such cases over and over again almost entirely without
symptoms when they were up to normal weight and with a good many
symptoms when they were below normal. It would be easy to theorize as
to why this is so, but the observation is the most important
consideration for practical purposes, and we are not yet in possession
of enough scientific knowledge with regard to the thyroid or {506} its
possible connection with other organs that have an internal secretion,
to be able to say anything definite about it.

After weight and nutrition the most important indication is sleep. It
is impossible for patients to get along with less than eight or nine
hours of sleep. Most of them are much better if they have nine or ten
every night. Late hours are particularly prejudicial to them. They are
tired if they have been on their feet all day and they should be
encouraged to take more sleep than others. Sleep is one of the most
important considerations for sufferers from the abortive forms of
Graves' disease and they must be encouraged to take it in the quantity
that they need. This can only be decided by their feeling.


_Diversion of Mind_.--Much more than other nervous people these
patients need encouragement and require diversion of mind. They are
prone to be discouraged, rather tired, and easily tempt themselves
into a routine in which there is little recreation and no diversion.
For them more than for most other patients it is necessary to
prescribe that twice every week they shall have some engagement
different from their ordinary routine to which they look forward for
several days. This looking forward to a break in the routine does much
to make life more livable for them and must be encouraged in every
way. As to what the diversion is to be must depend entirely on the
character of the individual. Some find complete diversion of mind in
the theater or even in vaudeville. Others are bored by this after a
while and need other recreations. I have known people who were bored
by the theater find an evening a week spent in helping a poor person
or an afternoon devoted to a visit to a hospital ward or to an ailing
friend an excellent diversion. Some of those who do not care for the
theater like music and are helped by it. As a rule, however, one must
be careful about the indulgence of music for neurotic people since it
seems to exert a serious emotional strain on many of them and as the
phrase goes "takes a good deal out of them." This is particularly true
for younger people who have a passion for music. Older people may be
trusted more in this matter and the attendance on concert and opera,
which is looked upon as a social duty by some, giving them an
opportunity to greet friends and to display their gowns and jewels, is
a harmless diversion of mind.


_Mental Treatment_.--Graves' disease is, then, as we have said,
especially likely to be influenced by the patient's state of mind.
Nothing disturbs patients more than the declaration sometimes made by
physicians that their condition is incurable or that they will have to
doctor for it for many years. This must be avoided because our present
knowledge does not justify any such positive declarations. Most cases
of Graves' disease, while not particularly amenable to treatment by
specific drugs, are very much improved if the patient's general health
is brought up to the best standard and if all sources of worry and
emotion are eliminated, as far as possible. Nothing is more serious
for them, however, than the suggestion that they will not get well.
Probably no one has ever seen a mild case of Graves' disease that did
not improve so much as to be practically well after the lapse of some
time. Recurrences take place, but if all sources of worry and
irritation of the digestive tract and over-tiredness are removed, then
patients will stay free from their symptoms for surprisingly long
periods. Old people do not have these {507} favorable remissions so
much as the young, but under twenty there can be, as a rule, definite
promise of decided improvement and sometimes of results that seem like
complete cure. For patients under thirty there is every reason to
think that if they are in a run-down condition when the disease is
first noted remissions of symptoms can be looked for lasting for long
periods, during which they will be comparatively well.


_Diet Suggestions_.--The changes in diet necessary to bring
improvement in Graves' disease are different for individual patients.
Prof. Mendel, in Berlin, found in his extensive experience that meat
does not seem to be disposed of well by these patients and acts
somewhat as an irritant. He reduces the meat taken and usually allows
it at but one meal. If patients get on well as vegetarians, meat is
gradually eliminated from their diet. On the other hand, there are
patients who seem to develop Graves' disease during a vegetarian diet.
Very often it will be found that there is an intermittent constipation
and diarrhea in these cases, and that the bowels will act much better
if a certain amount of meat is given, and then the symptoms of Graves'
disease remit, as a rule. As in most of the major neuroses, as is
known so well in epilepsy, any irritative condition of the digestive
tract will surely revive neurotic manifestations and make many of the
major neuroses much worse than they were before.


{508}

SECTION XV

_ORGANIC NERVOUS DISEASES_


CHAPTER I

PSYCHOTHERAPY OF ORGANIC NERVOUS DISEASES


Since we know that the basis of many nervous diseases is an
obliteration of certain cells of the brain or of the spinal cord, or
certain tracts of the central nervous system through which impulses
must pass if they are to be effective as motion, sensation or function
in some other form, we realize that we cannot recreate these portions
of highly organized tissue and that therefore organic nervous diseases
are beyond the action of any remedies we now know or may even hope to
discover.

The development of pathology has shown us that once there has been
serious nephritis or cirrhosis of the liver certain portions of the
glands are destroyed and therefore there cannot be any question of
cure. There is no possibility of redintegration of destroyed tissues
when they are of highly organized character, and so the patient will
always be maimed. One might as well talk of causing an amputated
finger to grow again as talk of curing diseases that involve
destruction of specialized cells. When this first dawned on modern
medicine as the result of the careful study of pathology a period of
therapeutic nihilism developed during which physicians trained in the
pathological schools were prone to distrust drugs entirely, or at
least to a very great degree. The effect of this wave of nihilism has
not entirely disappeared in our time, though we have learned that even
where serious damage to an organ has been done by disease we may still
hope to compensate for defect of tissue by stimulation of other organs
and to replace its function by certain physiological remedies or
biological products; and if we can do nothing more, we can at least
alleviate the symptoms which develop as a consequence of the organic
affection.


Nature's Compensation.--Physicians are prone to forget nature's
wonderful powers of compensation. Apparently even some regeneration
may take place in diseased organs of highly organized type if the
patient's general condition is kept up to its highest point of
nutritive efficiency. How far this may go we do not know, but
observations show some marvelous examples of unexpected regeneration.

These counteracting processes can be stimulated sometimes by drugs,
but oftener they can be best brought into play by keeping the patient
in just as good condition of body and favorable condition of mind as
possible for a prolonged period, so that nature accustoms herself to
the defect and her powers of compensation have full play.

{509}

Unfavorable Suggestion.--What is true of organic diseases of all kinds
is especially true of organic nervous diseases, and in spite of the
fact that most of these are essentially incurable, so much can be done
for patients that their condition is made more tolerable and indeed
some of them improved to such an extent that they consider themselves
quite relieved of their organic affection. One of the most serious
burdens that the patient laboring under an organic nervous disease has
to suffer is the consciousness drummed into him by successive
physicians, by his reading, and by every possible means of suggestion,
that his malady is incurable. This makes every symptom as severe in
its effects as it can possibly be. Hope does not buoy up and
discouragement weighs down every effort of the organism to compensate
for the serious defect under which it is laboring. Nothing can be done
for the disease itself, but much can be done for the patient. Many of
the symptoms from which the patient suffers most are really due to his
own discouragement, to that sluggish condition which develops in his
body as a consequence of his lack of hope, to the absence of exercise
and of air and of diversion of mind consequent upon the gloom that
settles over him when he is told that his condition is incurable.


_Adventitious Symptoms_.--If the adventitious symptoms that are always
present in cases of organic nervous disease are eliminated, if the
conditions which develop from the unhygienic condition in which the
patient lives because of his discouragement and retirement are
removed, as a rule he feels so much better that it is hard to persuade
him that some change has not come in his underlying nervous disease
and that a process of cure is not at work. It is because of this that
irregular practitioners so often succeed in apparently doing much more
for these patients than the regular physician. The irregular does not
insist on the incurability of the disease, but, on the contrary, he
promises a cure. He then proceeds to relieve many bothersome symptoms
that are quite extraneous to the underlying disease, but thus makes
the patient ever so much more comfortable than before, gives a
cheerful air to his life for a time, makes him sleep better as a
consequence and it is not surprising that the patient thinks that his
disease has been bettered, if not cured.


Suggestive Prophylaxis.--While we are optimistic just as far as
possible since genuine nervous disease has declared itself, it must
not be forgotten that we can by suggestion and warning often prevent
or delay the development of nervous degenerations. This, too, is
psychotherapy and must be employed wherever it seems advisable.

Post-syphilitic nervous conditions of so many kinds are likely to
develop that it is important to warn the patients who are sufferers
from this disease from taking up the more strenuous forms of
existence. This may seem an exaggerated view of the condition, but it
is amply justified by the results of the opposite rule of life in
almost any physician's experience in city practice. A man who has had
syphilis must be warned of the danger, one may almost say likelihood,
if he takes up any of the professions in which there is much mental
strain and nervous worry, that he will almost surely not live out the
normal span of life without some serious nervous incident. Locomotor
ataxia, and, above all, general paralysis develop, as a rule, in men
who, having had syphilis, have some occupation in life that calls for
considerable mental strenuosity, and involves excitement and worry.
Actors, brokers, soldiers and sailors, speculators of all kinds,
race-track gamblers, these are the classes from {510} which victims of
paresis and locomotor ataxia are particularly recruited. People who
have suffered from syphilis and who live the ordinary unemotional life
of a teacher, or a merchant, or a writer, do not, as a rule, develop
the postsyphilitic and parasyphilitic conditions.

Precocious apoplexy is especially likely to occur in patients who have
had syphilis and who have then spent themselves at very hard work. I
doubt if hard work alone, without some such antecedent condition, ever
produces this result. Of course, it is not alone syphilis, but other
serious conditions which affect the nervous system that ought to be
guarded against in this same way. If there has ever been any affection
of the kidneys, as a complication, for instance, of scarlet fever,
then it has always seemed to me to be the duty of the family physician
to warn such patients that their kidneys are more prone than those who
have not suffered from such an incident to break down under any severe
strain that may be put upon them by worry, especially worry following
a period of strenuous work. In these cases the affection of the
kidneys nearly always makes itself felt in the nervous system, and
especially in the brain, and so this warning has a proper place here.
Where there has been severe cerebro-spinal meningitis this warning
seems also to be needful, though here our records have not been kept
with sufficient care to enable us to speak positively of the necessity
for the warning.


Treatment.--It is important to remember that as physicians we do not
treat disease but patients. We _care_ for patients, that is the real
etymological significance of the Latin _curare_, we do not cure
diseases in the modern sense that has come to be given to that term,
of completely removing the _materies morbi_ and setting the patient on
his feet once more just as well as he was before his illness.


_Relieving Incurable Disease_.--A new cure for locomotor ataxia, for
instance, is announced every now and then, and the evidence for its
beneficial action is the testimony of patients who have been relieved
of many symptoms that they thought connected directly with their
spinal affection. All sorts of remedies have been employed with
announced success. One man builds a particular kind of shoe for them
and has a number of witnesses to his skill in curing them. Another
does some slight operation on their nose or their throat or their
urethra and straightway the patient feels so much better that he talks
confidently about being cured. All the characteristic symptoms of the
affection remain. Their knee-jerks are gone, their pupils do not react
normally, they have some incoordination in their walk, but a number of
other symptoms have disappeared and their walk is probably much
improved because of their confidence and a certain amount of practice
that they have gone through. The new hope born of confident assurance
that they could be relieved gives them an appetite, makes their
digestion better. This lessens the sluggishness of their bowels, gives
them confidence to get out and see their friends, life takes on a new
hope, they sleep better and it is no wonder they talk of having been
helped or even cured.

There is a definite relation between the nervous affection in these
cases and many visceral symptoms. There is no doubt, for instance,
that certain cases of intractable dyspepsia are associated with tabes
and that in nearly the same way obstinate constipation frequently
develops. Notwithstanding the connection of these symptoms with an
incurable condition of the spinal cord {511} that is no reason for
thinking that they cannot be relieved even though no improvement of
the spinal-cord lesions is expected.

Frequently, indeed, gastric dyspepsia is due more to worry over
discomfort somewhere in the stomach region than to any real
disturbance of the digestive functions. It may then be considerably
ameliorated simply by the assurance that the trouble is local and is
localized outside of the stomach itself, though there may be some
sympathetic irritation of the gastric nerve supply. Probably Dr. Head
and those who have studied reflexes so enthusiastically would not
agree with this explanation of the relief of the gastric symptoms in
some of the cases they have described, as due rather to suggestion
than to the local treatment, and, as a matter of fact, we are not
quite sure which factor may be the more important. Counter-irritation
probably plays quite an important role in the relief of discomfort,
but I am sure that the suggestive influence of acute sensory feelings
at the surface produced by counter-irritation serves to divert the
mind from the duller ache or the functional disturbance below.
However, Dr. Head's paragraph should be given in his own words, for it
furnishes a scientific basis for one aspect of these cases.

  Throughout the study of cases of nervous diseases, evidence of the
  relation between pathological condition of certain viscera and
  sensory disturbances in the superficial structures of the body is
  constantly manifested. For instance, a man with caries of the spine
  suffered from a girdle sensation round the area of the eighth dorsal
  segment. At the same time he was greatly troubled by flatulent
  dyspepsia which was untouched by drugs. It was, however, greatly
  relieved by counter-irritation applied to the maximum tender point
  of the eighth dorsal area in the eighth space and mid-axillary line.

_Optimistic Suggestions_.--Our most prominent neurologists have in
recent years insisted on the necessity for encouraging patients and
for not permitting them to brood upon the worst side of what is to be
expected from their ailment. Patients are entirely too prone to read
up about their disease and the worst symptoms of the extreme cases
impress their minds and are constantly recurring as suggestions of
possible ills to come. Prof. Oppenheim in his "Letters to Nervous
Patients" states in a striking way the optimistic view that it always
seems advisable to give a patient in the initial stages of a serious,
incurable or even progressive nervous disease. That letter is worth
quoting:

  I cannot conceal from you the fact, which you have already
  ascertained from other sources, that you show the premonitory
  symptoms of a disease of the spinal cord. This admission is not,
  however, as you fear, synonymous with the sentence "the beginning of
  the end." There is no reason for you to despair. We doctors regard
  and welcome it as a marked advance in our scientific knowledge that
  we are now in a position to diagnose a nervous disease of this kind
  in its first commencement. This is undoubtedly a great gain for the
  patient, as on account of this knowledge a judicious, experienced
  physician may, at least in many cases, by the timely regulation of
  the mode of life and the prescription of certain remedies, arrest
  the progress of the disease or retard its development. This advice
  may, however, and should as a general rule, be given without the
  patient himself being made aware of the diagnosis, for the ideas as
  to the nature of this disease which prevail in lay circles, and
  indeed among many doctors of the old school, arise from the
  knowledge of the disease in its advanced and fully established form,
  since it was only in this completely developed stage that it was
  recognized. Then, indeed, its very noticeable symptoms were obvious
  even to the uninitiated. This picture, sad enough indeed in itself,
  was rendered still gloomier by {512} the misery and despair which
  popular fancy has associated with the conception of locomotor
  ataxia.


_Arteriosclerosis_.--Even with regard to so serious a disease and, of
course, absolutely fatal in its progress as arteriosclerosis, it must
not be forgotten that much can be done for the patients and especially
for the nervous symptoms that develop in connection with the
condition. For the progressive hardening of the arteries on which the
nerve symptoms depend absolutely nothing can be done. A man is as old
as his arteries, and we cannot bring back the years even though the
patient has become prematurely old. For the symptoms so frequently
seen in connection with arteriosclerosis, the paresthesia, the
burnings, the numbness, the pruritus, the pains around joints and the
difficulties in connection with them, even for the intermittent
claudication which develops, much can be done. Above all, the patient
must not be allowed to cherish the notion that his disease is not only
incurable, but that nothing can be done for it. It is inevitable and
progressive, but then according to one definition, life is a
progressive disease and every day brings us nearer death. "Life is a
dangerous thing at best," as an American humorist once said, "and very
few of us get out of it alive."

These patients can be relieved of many physical symptoms, they can be
encouraged, their attention can be diverted from their symptoms, and
it is concentration of mind on them that often makes them intolerable,
while occupation with something, especially if it is interesting, will
often prove an efficient remedy for the discomforts complained of. Old
people who have no interests, who have retired from business, who did
not have the opportunity when young to acquire tastes in art and
literature, above all, those who have no interests in children, no
grandchildren nor close relatives near them, are likely to become
centered on their ills in the midst of their arteriosclerosis, and
this more than the advancing degeneration of arteries itself is at the
root of their symptoms. The ideal old age is that which is passed in
the midst of younger people, with an occasional happy hour during the
day with children in whom one is deeply interested. This is the best
psychotherapeutic factor that we have.

Prof. Oppenheim has given the optimistic side of arteriosclerosis so
suggestively that most patients suffering in this way should have the
opportunity to read it. It occurs in his "Letters to Nervous
Patients":

  An eminent physician for whom I have much esteem has told you that
  your troubles, especially your vertigo, are caused by calcification
  of the arteries. You, sir, heard in this your death sentence, and
  since then the encyclopedia has revealed to you all the sufferings
  and terrors with which you may expect to be overtaken.

  I would, however, explain to you, as the result of the most careful
  examination and the most absolute conviction on my part, that your
  anxiety is unfounded.

  Since you have a certain amount of information and scientific
  knowledge, I may speak to you upon this matter almost as a
  colleague. One is certainly justified, when a man of your age
  complains of vertigo, in suspecting calcification of the arteries to
  be the cause of the trouble, since it constitutes the common senile
  change, and vertigo forms one of its most frequent symptoms.
  But--apart from the fact that in senile calcification of the vessels
  this vertigo is frequently a temporary and not always a serious
  sign--one is by no means justified in assuming that the appearance
  of this symptom in later life is in itself, and without further
  evidence, the sign of such a cause. This is an error which in my
  experience is {513} far too frequently made, to the detriment of the
  patient. It is first of all essential to closely examine and analyze
  the symptom in itself. . . . Two years ago, after having overloaded
  your stomach, you had a real attack of vertigo, which was repeated
  several times during the day, until, by vomiting and diarrhea, the
  contents of your stomach were evacuated. Since that time the fear of
  vertigo has overpowered you. In my experience it is neither new nor
  uncommon to find that a man who has shown his intrepidity and his
  contempt of death on many a battlefield, who is a hero in war, may
  be overcome by some dread of illness, by some anxiety, or even by
  some pain, and may be distressed by it in a way that is in sharp
  contrast to his whole personality. Your remembrance of that vertigo
  is so lively that the mere idea of it suffices to reawaken the
  symptom, or at least an imitation of it which very nearly approaches
  the reality. That this idea is present in your case is quite certain
  from the consideration of your symptoms. You admit that you almost
  never have vertigo at home, but as soon as you leave the house, and
  especially if you find yourself alone in the street far from home,
  the remembrance of the vertigo comes over you, puts you into a state
  of anxiety, and is followed by a sensation of tottering and swaying,
  so that you have to stand still; and at last it has gone so far that
  you no longer venture to go out alone. And so the hero of X sits
  like a timid woman in his arm chair, making life bitter for himself
  and for those around him.

  Even were I to find that signs of arterial calcification were
  present, I should still be satisfied that your vertigo is not due to
  this cause, but that it is a vertigo of recollection and of fear.



CHAPTER II

CEREBRAL APOPLEXY


Cerebral apoplexy is an extremely serious organic disease that seems
surely to be an affection for which psychotherapeutics can mean little
or nothing. When an artery has burst in the brain and blood is either
actually flowing out or has flowed out in damaging quantities into the
delicate brain tissues, seriously injuring and perhaps destroying some
of them forever, no amount of mental assurance will do any good for
the organic lesions that have been produced. All that can be hoped is
that the hemorrhage will not prove fatal and that the powers of nature
will be sufficient to deal with it, and though not able to cure it in
the sense of restoring tissues to former conditions, will compensate
for the lesion in some way and dispose of its products so effectually
that but little interference will result with nerve functions within
the skull.

There is no pretence that by psychotherapy or any appeal to mental
powers anything can be done for the underlying pathological process.
And it may be frankly said that no remedy of any kind, physical or
mental, will avail much, while some of those that have been suggested
are just as likely to do harm as good. Position, with the head
elevated and quiet of mind and body are the only remedial measures
that promise definite help. Excitement greatly increases the danger.
Reassurance does more than anything else to lessen blood pressure and
lessen also the danger of a hemorrhage producing fatal effects. In
nervous, excitable people the first stroke is often fatal.
Occasionally the phlegmatic have three or more ruptures of brain
arteries before death supervenes. Psychotherapy, then, has a definite
role even at the time of the apoplexy.

{514}

The Mind Before and After.--Much can be accomplished for the patient
by proper attention to his state of mind both before and after
cerebral hemorrhage. There are many symptoms which point to the
possible occurrence of the rupture of a cerebral artery, and older
people are likely to know something about these and to dread them so
much that to some extent they may by worrying precipitate the evil
they fear. Many people, having read vaguely about apoplexy, having
seen a case or two of it perhaps, and having heard of others, develop
a dread of its occurrence in themselves that makes them miserable.
Finally, the shock of a cerebral hemorrhage is very great and its
after-effects likely to be very disturbing. It affects the whole
personality and often makes a strong, vigorous, healthy man a decided
hypochondriac. All of these associated mental states may be greatly
benefitted by psychotherapy.

A number of neurotic symptoms are always added to whatever
manifestations of mind and the somatic system may develop as a
consequence of the cerebral apoplexy, and these are treated more
effectually by mental reassurance than in any other way. Besides,
apoplexy confines people to the house who have often been vigorous and
active before, and this confinement with deprivation of exercise and
air and consequent disturbance of appetite and digestive functions,
acts as a serious factor in the production of neurotic symptoms. Tears
and hysterical manifestation are not uncommon, and for these
psychotherapy is the most important remedial measure.

In the period preceding true apoplexy there may be such symptoms as
persistent headache with peculiar sensations in one hand. These
sensations are variously described as creepy feelings or as of "pins
and needles," and occasionally as if the fingers and sometimes the arm
were asleep. The group of symptoms known as paresthesia are rather
common as premonitory symptoms of cerebral apoplexy. When these are
combined with headache patients often become seriously disturbed and
begin to dread the occurrence of apoplexy. While these are premonitory
symptoms of cerebral hemorrhage in those whose arteries are
degenerated, patients must be made to understand that just because the
fingers or hand or arm go to sleep occasionally, even though there may
be complaint of headache, these are not indications of impending
apoplexy unless other objective symptoms are present. Subjective
symptoms alone can never mean much as regards organic disease. It is
particularly neurotic individuals who are likely to exaggerate the
significance of their subjective sensations, who are also prone to be
so solicitous about apoplexy that they work themselves into a state of
fear with regard to it. Even children have their hands go to sleep
rather frequently, and at all ages if the arms or legs are placed in
certain positions or under certain conditions of pressure, they are
likely to develop that numbness which ends in the prickly "pins and
needles" feeling that is spoken of as "going to sleep."


Diagnosing Arterial Sclerosis.--Unless, then, some of the arteries at
the periphery of the body show signs of such degeneration as to
indicate advanced arteriosclerosis, any subjective symptoms, no matter
how bothersome, must not be allowed to depress the patient. Usually
they mean nothing at all, and would pass quite unnoticed but for the
patients' nervousness about themselves. If the temporal arteries are
not prominent and visibly thickened and tortuous, and this may be seen
at a glance, the patient may be assured almost without more ado. If
his radial arteries on careful observation show no signs {515} of
degeneration, then it is extremely doubtful if there is sufficient
arterial change in the brain to justify a fear of arterial rupture. In
examining the radial artery it must not be forgotten that the pulse of
nervous people, especially such as have exerted considerable mental
control over themselves in order to come and see a physician about
what they think is a serious condition, is likely to be of high
tension. When the artery is rolled under the finger, then it may seem
that there is some thickening in its walls, though it is only
heightened blood pressure from emotion that causes the feeling. This
high blood pressure may, of course, of itself be an indication of
danger whenever there is heart or kidney disease, but it often occurs
as a passing event in nervous patients whose vasomotor control is so
capricious that arterial tension and blood pressure may change at very
short intervals as the result of excitement.

It may not be easy to obliterate the pulse in the usual way in many of
these cases and as a consequence the illusion of a thickened artery
may remain even when the vessel is quite normal. The important rule is
to ascertain whether the artery is tortuous. Whenever there is
thickening of the arterial wall the artery is lengthened as well as
thickened. If the artery is not lengthened the degenerative changes in
it are so slight, as a rule, as to be negligible. Indeed, the very
beginning of arteriosclerosis may thus be diagnosed. When this cannot
be found, patients may be completely reassured that their suggestive
symptoms have no significance as regards any possibility of cerebral
hemorrhage from the ordinary causes of advancing years and arterial
degeneration.


_Differentiation_.--Occasionally such paresthesiae as have been
described especially when associated with headache, point to an
intracranial growth, or to a developing syphilitic brain lesion, and
these must be carefully eliminated, but they constitute quite separate
problems which always present other accompanying symptoms that make
diagnosis possible once a suspicion as to the nature of the lesion is
aroused. Above all, these occur in much younger patients than are, as
a rule, the subjects of cerebral apoplexy.


Symptoms.--_Dreads--Dizziness_.--There are other symptoms of which
people have heard as preliminary signs of brain hemorrhage which
occasionally disturb them to a great degree and set up a set of dreads
that may be difficult to banish. Probably the one that is spoken
oftenest of is dizziness. There is no doubt that under certain
circumstances this may be a symptom of impending cerebral hemorrhage,
especially if it is accompanied by headache and by objective signs in
the arteries, but dizziness by itself is not enough to justify any
anxiety in even elderly people. If, when a man stoops over and then
straightens up rapidly everything becomes black before him and he must
immediately take hold of something to keep himself from falling, it is
probable that a pathological condition of his cerebral arteries is
present. This interferes with brain circulation and may have seriously
impaired the elasticity of the arteries which is so necessary to
overcome the rapid variations of the influence of gravity on the blood
current when there are sudden changes of position. Fits of dizziness
that come on immediately on rising in the morning, or that attack the
patient when he sits up suddenly in bed may have the same serious
significance. None of these signs are significant, however, unless
there are, as we have said, objective signs in the arteries.

{516}

But dizziness may come from many other causes besides degeneration of
arteries. A very common cause of it is the presence of gas in the
stomach which interferes with the heart action mechanically and so
disturbs the circulation. The column of blood to the head is more
easily affected than the rest of the circulation because it must be
pumped up directly against gravity when we are in a standing position,
and so any, even a slight, interference with the heart action is felt
at once in this portion of the body. Besides, the brain is extremely
sensitive to changes of circulation and even a slight disturbance of
the blood supply to it may cause dizziness. There occurs also
undoubtedly a feeling of dizziness that is entirely subjective. The
patient for some reason loses confidence in himself and has a feeling
of dismay, as if he could not support himself. Such a patient may
complain that when he comes down stairs, at the first step or two,
particularly of a high stairs, he has the dread that he may pitch
forward. Such people have never actually fallen, but they have to
grasp the railing and they have a dread of some accident of this kind.
This is, however, rather a form of akrophobia than a true dizziness.
Prof. Oppenheim has dwelt on vertigo as a dread (see preceding
chapter).


_Vertigo_.--Besides, there are pathological conditions that cause
dizziness yet have no connection at all with the dizziness that is a
premonitory symptom of apoplexy. Menière's disease, for instance, even
in its milder forms, causes at times a vertigo that is extremely
annoying and that frequently gives rise to the fear that a serious
brain lesion is either actually occurring or is impending. I have seen
even comparatively young patients suffer so much from this dread that
life became miserable to them and they were unable to do their work
properly. A few words of explanation and reassurance literally work
wonders for such patients. In one case the young woman assured me over
and over again that my explanation meant a new lease of life for her.
She still has occasional dizziness, but now she knows that it is due
to her accompanying ear trouble and it does not worry her.


_Motor Symptoms and Over-solicitude_.--Besides dizziness, there are
other symptoms of which patients complain and which may indicate that
an apoplexy is impending or may mean only that a patient is occupying
himself too much with himself and his symptoms. Not infrequently when
there is degeneration of arteries in the brain there will be slight
weaknesses of the limbs or awkwardness in the use of them.
Occasionally women will complain of the fact that they do not button
dresses as they used to. Sometimes men will complain that they do not
button their collar or their suspenders at the back with facility, or
that they are awkward and grow fatigued easily in such strained
positions.

These symptoms may be indicative of some disturbance in the motor
areas of the brain, but it must not be forgotten that all of these may
be simulated by nervousness, especially if the person knows the
meaning that is attached by doctors to these symptoms. In this matter
particularly a little knowledge is a dangerous thing. We are only just
getting a generation of trained nurses to the age when they are likely
to suffer from dread of apoplexy and some of them are over-anxious
patients because of their knowledge without the balance of complete
practical experience with the meaning of such symptoms. Doctors
themselves are prone to be disturbed by such thinking more than {517}
almost anyone else. The delusion of thinking apoplexy is not at all
uncommon in elderly physicians. In men it is important to insist that
objective symptoms are the only details of real value and that
subjective feelings are utterly illusory. If this cannot be brought
home to them they make themselves extremely miserable and may even
help to precipitate through worry the fatal complications they dread.


Prophylaxis.--There is no doubt but that heredity plays an important
rôle in apoplexy. In certain families most of the members terminate
existence by rupture of an artery in the brain, sometimes at
comparatively early ages. Apparently the resistive vitality of their
arteries is only sufficient to enable them to maintain themselves for
a limited length of time against blood pressure. They are destined to
have arterial degeneration that will predispose to arterial rupture
sometime before they are sixty. Father, grandfather and
great-grandfather had their apoplexies from fifty-five to sixty-five
and the son must realize that he probably will go the same way. Even
the delay of a year or two is important. Anything that will save the
wear and tear of existence may bring about such a delay and it is not
by drugs, nor even by dietetic precautions, so much as by attention to
the patient's state of mind that this decided benefit can be best
secured.


_Over-indulgence_.--People with such an unfortunate heritage should be
made to understand reasonably early in life that they must save
themselves from as much arterial wear and tear as possible. There are
certain occupations involving intense emotion and excitement that are
barred to them if they want to live out their lives, even to the
extent usual in the family. There are three causes that weaken
arterial walls. When the question of causation of aneurism is
discussed it is usually said that it is especially the devotees of
three pagan deities--Venus, Bacchus and Vulcan--who suffer from this
form of arterial trouble. Just this same class suffer particularly
from the tendency to early arterial rupture in the brain. Under the
head of devotees of Vulcan, the hard workers, must now also be placed
the advocates and exemplifiers of the strenuous life, who are
perpetually doing, though often it is hard to see what they
accomplish; the money-getters, who are really overworking as much as
the forced laborers of olden time. People with an apoplectic heredity
should not take up such professions as that of the actor, the broker,
the speculator of any kind, the lawyer absorbed by the strain of trial
work, perhaps not even that of the surgeon. Physicians generally are
not long lived because of the irregularity of their hours of eating
and sleeping and the responsibility of their professional life.

Many men will not be guided by such considerations and insist on
living their lives in their own way in spite of the possibility of the
family inheritance shortening their career in the late fifties. More
than one has said that he would prefer to have the life of the salmon
rather than that of the turtle. The strenuous life alone appeals to
them.

  "Better fifty years of Europe than a cycle of Cathay."

This would be an admirable response if what these men accomplished
during their lives amounted to anything. Most of these who run out
their existences in the midst of excitement, however, only do harm by
adding to the swarm of speculators in life, or accomplish very little
because of the intense {518} excitement under which they labor. It is
the quiet lives, doing a few things and doing them well, outside of
the strenuous current of the bustle of existence, that accomplish most
for mankind. The others may attract attention for the moment, but they
soon pass out, often having done rather harm than good.


_Life-direction_.--It is perfectly possible for the physician to make
this clear to a young man with a dangerous heredity and perhaps change
the current of life so as to make it effective in simplicity and
serious patient work. The young man will usually be quite impatient to
think that anything thirty years ahead should be expected to influence
his decision as to how or what he shall do with life, yet this motive
added to others may help to get at least some of this and the next
generation from wasting their lives in an over-strenuous existence
that at most merely accumulates money, often accumulates it only in
order to lose it, with consequent disappointment and worry, and
frequently leaves no real accomplishment but only the problem of the
disposal of accumulated wealth for future generations. Where large
wealth is left to the succeeding generation there is usually little
use to give any advice with regard to the possibility of early
apoplexy, because excitements of other kinds than those of business,
of the heart rather than the mind, are likely to wear out existence
even before the time when the family life of arteries ordinarily,
though precociously, runs itself out.

Certain people have what is called the _apoplectic habitus_, that is,
they are short in stature, rather stout, with short necks and florid
complexions. It seems not unlikely that the mechanical arrangement
within their bodies by which the distance from their heart to their
brain is so much shorter than in ordinary persons is responsible for
the tradition so generally accepted that there is a definite tendency
in such people for apoplexy to occur at a comparatively early age.
Such people should be warned gently but firmly of the danger that they
incur if they subject themselves to a life of excitement or emotional
stress or permit themselves to get into circumstances in which they
will worry much. It may seem as though a warning of this kind would
precipitate the worry of mind that it is meant to ameliorate, but in
present-day publicity such people are likely to have heard of the
meaning of their particular constitution of body and consequently
worry about it, but usually after it is too late to do any good. In
this matter, as in heart disease, the warning must come before there
are any symptoms, or else must not be used at all.


_Certain Abuses_.--In most of these cases definite warnings with
regard to habits of life and indulgence in stimulants and narcotics
should be given. Both Prof. Von Leyden and Prof. Mendel of Berlin
insist that for patients in whom there is any likelihood of the
development of early apoplexy indulgence in alcoholic liquors is
almost sure to be serious, but in addition to this generally accepted
warning, both of them also insist that smoking has a tendency to
produce serious, premature degeneration of arteries, especially in
people who already have tendencies in that direction. Overeating and
high living in general without moderate exercise causes a plethora of
the circulation that must be avoided. On the other hand, violent
exercise, running especially to catch trains or cars, haste in the
ascent of stairs or hills, heavy lifting, straining at stool, and the
like, are particularly prone to have serious consequences for such
people. This warning is all the more needed because many a short,
{519} stout man acquires the idea that gymnastic work and various
exercises indoors may help him to reduce his weight and restore the
activity of his earlier years. This is practically always a delusion
and indoor gymnastic work is always of dubious value.

What these people need is not more muscle and the wearing off of fat
but more air and the burning of it off by increased oxidation. Such
patients must be taught to lead tranquil lives without any of the
excitement and strenuosity that, after all, accomplishes so little.
The sacrifice when first suggested, appears too great a one to make,
but after a few years patients instead of feeling that it was a
sacrifice at all pronounce it to be a blessing in disguise and are
proportionately grateful to their physician. Life for many of these
people may be prolonged not for a few years of hustle-bustle, but for
many years of good work in quiet and peace, without hurting others by
competition, but helping many because there is time in their
considerate lives to see something of the sorrow and suffering around
them and to relieve it.


_Change of Occupation_.--In the matter of prophylaxis it is
particularly important to insist on the fact that when men have worked
at hard manual labor when they are young and then, about middle life,
have turned to intense intellectual labor, such as the management and
administration of important affairs, they are a little more liable
than are the general average of humanity to have an apoplectic seizure
at sixty or a little later. Apparently inurement to a particular kind
of labor when young makes for the capacity to stand it longer than
would otherwise be the case. In this matter, however, the most
important factor is heredity. Men who come from long-lived families
are likely to live long--indeed far beyond the ordinary term of human
life. Even in them, however, certain of these directions are helpful
in securing the full measure of life.


After the Stroke.--After a stroke of apoplexy when it becomes clear
that nature is about to reassert her control over the circulation in
the brain and dispose of the remains of the old hemorrhage,
psychotherapeutics is more important than anything else that we have
for the treatment of these patients. As a rule, they have been active,
vigorous men who are stricken and who suffer more from doing nothing
and waiting to get better than from any pain they have to undergo.
They know that another stroke may come at any time. It is no wonder
that introspection plays its part, that every feeling that they have
becomes exaggerated in significance, that their appetite fails them,
that their bowels become sluggish, that they do not sleep, or that
after having fallen asleep they wake up and then for hours lie awake
thinking.


_Lack of Air and Exercise_.--As they usually have no exercise of any
kind, do not get out into the air, and have very little diversion of
mind, it is easy to understand that neurotic or hysterical symptoms
develop, that they lose all confidence of recovery and make themselves
even worse than they are by dwelling on their condition. The only way
that this group of symptoms can be treated is by favorable suggestion,
by encouragement, by mental reassurance and by occupation of mind.

I have always felt that the condition of affairs which developed in a
family immediately after the occurrence of an apoplexy usually makes a
very unfavorable environment for the treatment of these cases. It is
practically impossible for those who come to visit the patient or for
the members of the {520} family for some time to wear anything but the
resigned air that indicates that they fear the worst.


_Sympathetic Care_.--After the stroke at once when survival is assured
comes the question of the management of the patient. A devoted
daughter seems to be able to do more for an apoplectic father than
anyone else. Somehow her youth appeals to him sympathetically, and he
has not that feeling of sadness mixed with a little envy that comes so
readily to all men when they find themselves slipping out of life
while their contemporaries and friends and relatives are left behind.
It is as if the idea of his daughter being young and strong, even
though he has lost vitality, docs not touch him poignantly because he
has always expected that she should have health and strength after he
was gone. On the other hand, a daughter is not always a good nurse for
a mother. Just why, is hard to say. A hired nurse must take, as a
rule, the place close to the mother which, in the case of the father,
so naturally falls to the daughter. These ideas may be founded on too
few cases to generalize very much about, but I have discussed them
with many physicians, including some women physicians, and they agree
with them, in general principle at least.


_Trained Attendance_.--As a rule, then, the first thing that has to be
done for a patient who has had apoplexy and who is beginning to
recover, is to have trained attendants near him who talk
professionally to him and reassure him and do not make him feel
constantly the possibility of an approaching end. If his improvement
has begun his family must not be allowed to bother him, his affairs
should not be talked over and, as far as possible, some occupation of
mind should be secured for him. He needs new interests at once. These
must be gradually awakened and he must be made to feel as early as
possible that though he may be more helpless than before and most of
his ordinary occupation in life may be cut off, there are still many
interests in life which he may thoroughly enjoy. I shall never forget
hearing Thomas Dunn English, the dear old poet to whom in his earlier
years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the
University of Pennsylvania that he used to think that all the good
things of life were somehow contained in its first eighty years, but
that now since he had past his eightieth birthday (he was at the time
in his eighty-third year) he was beginning to agree with Bismarck, who
declared under similar circumstances that he had found many interests
in the second eighty years of life. At the time English was quite
blind, was almost completely deaf, had been seriously ill for several
months, and had suffered a rather severe stroke some years before; and
yet he made the best speech at the dinner that evening and had the
youngest heart of us all--joyous, uplifting, encouraging, optimistic.


_Outlook_.--Men who have been great workers are prone to think that a
stroke of apoplexy means the end of all serious work. Of course, it
means nothing of the kind for the majority of patients. Many men find
not only enjoyment in life after their recovery from even a serious
stroke, but also possibilities of accomplishment sometimes better than
they had done before. It has even been known that men who had been
occupying themselves with things scarcely worth while, with the mere
accumulation of money without any purpose, were awakened to a sense of
their responsibilities to life and to their fellowmen by a stroke and
planned in the after years institutions or aids to {521} existing
institutions that did much to make life more livable for others.
Nothing makes a man face life in a better mood to do really effective
service for mankind than the prospect of possibly soon having to go
out of life.


_Encouraging Examples_.--On the other hand, many men have been able in
spite even of a severe stroke to go on after a time with the work they
had been at before and, though feeling its effects, accomplish the
best achievements of their lives. A typical example is the case of
Pasteur, the great French bacteriologist, to whom we owe most of our
modern preventive medicine and to whom Lord Lister frankly attributes
the germ idea of the antiseptic theory. When little past fifty,
Pasteur after years of hard work and worry suffered from a severe
stroke of apoplexy followed by several of slighter character. It
seemed absolutely the end of his labors. For more than a year he was
able to do nothing. For all his after life he was seriously lame as a
consequence of his stroke. In spite of this, which would seem to
preclude the possibility of great intellectual work, Pasteur's most
important discoveries were developed after this time and he continued
for over twenty years to be the leader of biological science. Had he
died at the age of fifty or given up his work we would scarcely know
him for the great scientist that he afterwards proved.

It is worth while to be able to tell the stories of such lives as
examples to patients who are dispirited and downhearted after a
stroke. Of course, men must be prevented from doing hard work or from
worrying during the time immediately following the hemorrhage of the
brain, and, indeed, for some months. Work and worry, though worry much
more than work, might easily hasten a recurrence of the seizure. It
has always seemed to me, however, that it is impossible to keep the
human mind utterly unoccupied. Men must think about something during
their waking hours, and if they have not some interests close at heart
they worry about themselves. Of the two things, worry is much harder
on the tissues, raises blood pressure more, disturbs the circulation
of the brain to a greater degree than does work. Anything that a man
will interest himself in, then, should be allowed to him, provided, of
course, that he is kept from getting into the state of mind which
precipitated the rupture of the artery in his brain. It is a change of
mental occupation above all that is needed and this is secured by
deliberate attempts to interest his mind in various ways and keep him
from dwelling on himself and his ills. This injunction cannot be
repeated too often.


_Change of Mental Interest_.--I have already insisted in the chapter
on Diversion of Mind that so far as we know at the present time
different portions of the brain are occupied with different subjects
in which we may interest ourselves. When a man by business worries,
occupation with financial affairs, or with political troubles, has
apparently worn out one portion of his brain, he may still use other
portions to decided advantage. Hence the necessity for finding new
interests for the apoplectic after their attack. The best interests
for them are those associated in some way with their fellows, because
these are accompanied by feelings of consolation, of encouragement, of
desire to live and do good to others. These do more to take men out of
their moodiness, their morbid introspection, and their
self-centeredness, than anything else. With the help of a good nurse,
herself of broad interests, this must become the main purpose of the
physician's treatment.

{522}

_Misplaced Sympathy_.--After the first few days, when the shock is
over, a strong, healthy man who has been suddenly taken down with
apoplexy, then rendered helpless as a consequence of the lesion in his
brain, rather resents the sympathy and, above all, the frequent
expression of the feelings of his friends towards him. Time is needed
for him to recover, there is no way of hastening it, he is already
impatient at the delay and words of sympathy do him very little good
and often add to his impatience. He is to be taken absolutely with
professional calm, made to understand that time is the most important
element in his cure, provided he will not worry and will have patience
to wait and to help as far as he can. I nearly always feel that it is
better for these patients to be away from home as soon as they can be
moved with safety. This enables them to avoid without much difficulty
what they are apt to consider the intrusive and obtrusive sympathy of
friends. Especially is this true of business friends, themselves in
good health, who come to offer their condolences.

Their hysterical condition is largely influenced by the fact that they
are indoors and have so little diversion of mind. Just as soon as
possible they must get out of doors. Over and over again I have found
that patients did not care to expose themselves to the inquisitive
gaze of neighbors and preferred to stay in the house, though the
outing would be of much benefit to them. Hence the necessity for
getting them away from home, among people whom they can observe
without attracting too much attention themselves and, above all,
without being the subjects of such obtrusive pity as will disturb
them. None of us likes to be pitied and least of all the strong,
vigorous man who often has had nothing the matter with him all his
life and is now suddenly stricken. It requires years of experience to
enable one to take sympathy properly and without resenting it.


_Outings and Human Interests_.--When patients care for carriage riding
I have found that the city park is an excellent place for patients
suffering from the effects of apoplexy, who require outdoor air and
diversion of mind, yet without exercise or much exertion. The children
in the park, if they play around, serve as a better diversion of mind
than almost anything else for elderly people thus stricken, for they
seem to renew their youth at the sight of the little ones.
Grandchildren make the best possible consolers even when they seem to
probe deep into old wounds by asking questions and by talking about
death. The talk of death from young lips has not the same disturbing
effect as from older people. The games of children interest the old
once more, and if there is occasional music and the chance to see the
passing throng of carriages and motor cars and the pleasure boats and
all the rest there is refreshment and reinvigoration in it all that
soon brings back to the patient deep, satisfactory, even dreamless
uninterrupted sleep at night, and appetite and strength. At first
there will usually be some objection to being thus treated as an
invalid, but only a few days of experience are needed to convert even
the most morbid to the idea that this outing will do them good. As a
rule, friends must be warned not to spoil the effect of it by fearing
lest the patient should be lonely and so go to the park to entertain
him. If the drive, the lake and the children, as well as the
passers-by, do not suffice to give the patient sufficient diversion of
mind, the visits of friends will not have any favorable effect. As a
rule, it is better for them to see the {523} patient at home and even
that not too often unless they are of his immediate family.

Where people are able to go away and, above all, where they can have
some pleasant companionship, a seaside resort is an ideal place for
those recovering from apoplexy. The long ride in a wheel-chair on the
boardwalk at least several hours in the morning and afternoon soon
acts marvelously. There is constant diversion of mind at any season of
the year, for there are lots of people to be seen in all sorts of
costumes and the shops and the shows and the passing throng all have
their interests. Then the sea air is bracing and tempts to
sleepfulness and just as soon as sleep improves courage comes back. I
have known patients so hysterical that they were crying every day and
that seemed to have given up all hope, improve so much in two weeks at
Atlantic City that it seemed little short of marvelous. What is
needed, however, is not a stay of a few weeks but of several months.


Prognosis of Strokes.--While, of course, any single stroke may be
fatal and no one can tell anything about the prognosis of a rupture of
a brain artery, there are many favorable things that can be said to
patients, and they are so prone to think of all the unfavorable things
that this better side should be presented to them at once. The
physician is tempted to present the worst side of the case lest it
should be thought that he did not realize how serious the condition
was. All the seriousness of it may be impressed upon friends, but the
patient must be told all the possibilities of good. I have always felt
that the tonic quality of hope was worth more in preventing further
damage and in encouraging the beginning of repair than any drug that
we have. If patients have been unconscious, just as soon as
unconsciousness disappears, they should be told that very probably
this is the beginning of recovery and that the great majority of
people who have a stroke recover. The more rapidly the symptoms
disappear the better is the ultimate prognosis. Many a man who has had
a stroke has done years of good work afterwards and very few men who
recover fail to accomplish something that is of supreme satisfaction
to them. They have a new outlook on life as a consequence of the near
vision of death.

Those who have had one stroke usually die in a subsequent one, though,
of course, some intermittent disease such as pneumonia or some organic
complication may anticipate the second stroke. Those who have had two
strokes and survive are often much worried by the old tradition that a
third stroke is always fatal. I am reasonably sure that many old men
have not survived their third stroke when they felt its premonitory
symptoms and knew just what was coming from their previous experience,
because they had given up hope on account of this old tradition.
Ignorant people or those of the lower classes who have not heard this
axiom often survive their third stroke and I have seen a man who had
suffered from seven apoplectic seizures.


Complications.--Occasionally a patient, especially if of the educated
classes, may be much worried by the fact that while one side is
distinctly lamed after his stroke, yet there is also a pronounced
weakness on the other side of the body. This sometimes gives rise to
the rather appalling thought that there was perhaps a simultaneous
rupture on both sides of the brain. It needs to be explained to such
patients that this slight weakness, sometimes quite distinct, however,
on the side opposite that which is most affected is extremely {524}
common. Ordinarily the rupture of an artery on one side of the brain
causes a paralysis on the other side of the body. This paralysis or
loss of control over muscular action is due to disturbance of the
motor tracts of nerves through which muscular action is controlled and
directed by the brain, and these normally cross to the other side on
the way to the periphery. In nearly everyone the tracts remain
uncrossed to some slight extent. In some so much of the pyramidal
tract remains uncrossed that there may be decided weakness on the same
side as the lesion in the brain.



CHAPTER III

LOCOMOTOR ATAXIA


How much can be done for organic nervous disease by attention to the
individual patient and by favorable suggestion is illustrated in
locomotor ataxia. This is, of course, an absolutely incurable disease.
We know definitely that certain tracts of nerves in the spinal cord
are entirely obliterated and their functions can never be restored.
Occasionally the disease gives rise to severe localized pains called
crises, for which even our strongest anodyne remedies are of little
avail. As a rule, the patient grows more and more helpless and though
he may live for twenty or thirty years after the beginning of the
disease, and usually dies from some intercurrent affection rather than
from any direct effect of his disease, the condition is burdensome and
the outlook is most unfavorable and depressing. It is for locomotor
ataxia, however, that the irregular practitioners have succeeded,
apparently, in working wonders. Some of them, indeed, have made quite
a reputation for the cure of the disease. This was not because they
did the impossible and cured genuine cases, but because individual
patients can, in many cases, be so much improved by attention to
particular symptoms, and so much can be done to make life more livable
for them, that it is no wonder that so many of them are ready to
proclaim that they have been cured, though only certain symptoms, are
bettered and their underlying disease remains in essence unchanged.

One thing that constantly happens in the progress of locomotor ataxia
is a yielding of joint capsules and attachments so that there is more
motion permitted in joints than is possible in the normal individual.
As a consequence of this relaxation of tissues around the hip joint
the leg may be stretched up along the trunk when the patient is lying
down, the foot being placed over the shoulder almost as a gun is
placed at carry-arms. Patients often walk with a distinct "back knee"
because of the yielding of the tissues around the knee-joint. The
ankle nearly always yields and a specially severe form of flat foot
develops. This causes muscles to act at a disadvantage and produces
great fatigue and even a painful muscular condition when the patient
stands much on the feet. This form of flat foot is hopeless so far as
cure is concerned, but it can be greatly relieved by the wearing of
flat-foot braces or even, to a greater degree, by the wearing of
specially fitted shoes. This does not seem much to do for a patient
suffering from the serious organic nervous disease of locomotor
ataxia, and yet a lot of patients for whom properly fitting shoes
{525} were made, thought themselves so much improved and relieved by
this simple measure that they allowed themselves to be persuaded that
their locomotor ataxia was cured. In some cases, where the brunt of
the disease was borne by the feet, this relief really did so much to
afford the patients freedom from most symptoms of their affection that
they thought themselves on the road to recovery.


Value of Favorable Suggestion.--If once the idea of the awful
hopelessness of their cases is removed from locomotor ataxia patients
they will suggest their own betterment so powerfully that they easily
persuade themselves that their affection is considerably improved. It
is evident, then, that the regular physician must take advantage of
this wonderful power for the relief of human suffering and depression
that proves so helpful to the irregular. We cannot cure the tabes of
the spinal cord. We cannot re-create the nerve tracts that have been
obliterated. We realize that there is no use trying to do so any more
than there would be in trying to make an amputated finger grow to its
full size again. We can treat the patient, however. We can remove many
symptoms that sometimes bother him more than those necessarily
connected with his spinal affection. We can relieve annoyances of all
kinds that add to his misery and as a consequence we can give him
hope, keep him from brooding about himself and thus perform the proper
function of a physician. We shall not forget that we can only rarely
cure, but we can almost always relieve pain and we can always help the
patient in some way. The ataxic patient needs consolation, and this
can be given without in any way deceiving him. The loss of sight seems
an irreparable ill to those who see, yet the blind are quite happy,
are much more cheerful than many seeing people, and have learned to
stand their affliction not only with equanimity but really without
much depression. In the olden times, before proper care was taken of
the blind, they had little occupation, they had nothing to do with
their hands, the future was blank and they suffered severely from
depression. As a rule, they did not go out enough and their bodily
health suffered and the disturbance of their functions still further
heightened their depression. All of this happens now with the ataxic
patient. A host of symptoms not at all necessarily connected with his
spinal affection develop and prove sources of annoyance. Many of them
can be removed entirely, all of them can be ameliorated. If, while
doing this, we succeed in impressing a discouraged patient's mind with
our power to benefit in spite of an underlying incurable disease, we
have another triumph of psychotherapy.


Removing Unfavorable Suggestions.--The general experience with those
suffering from locomotor ataxia has been that the depression
consequent upon the announcement that they have the disease and the
stigma that is supposed to attach to it in our day leads them to a
great extent to avoid going out into the air. This adds woefully to
their depressed condition. Take a healthy man, let him stay inside a
great part of the time without any exercise, seeing no new faces,
without any interests in life, and at the end of three months he will
have a set of neurotic symptoms on a basis of depression that will
make him supremely miserable. This will be true even though he has not
the threat of an incurable disease hanging over his head. He must be
made to realize that every neglect of any law of health in his
condition is even more serious in its effect upon him than it would be
were he in good health. Above {526} all, it must be made clear to him
that while his neglect of hygiene may perhaps not shorten his life, it
will greatly add to the mental suffering, much more unbearable in its
way than the physical suffering which he will have to endure during
the progress of his disease.


Treating Accessory Symptoms.--Nearly every ataxic patient who is not
directly and almost constantly under the care of a physician, is a
sufferer from two conditions that are so constantly present that they
are sometimes thought to be consequences of the primary affection.
These are loss of appetite with consequent loss of weight and
constipation. Almost without exception neither of these symptoms or
syndromes are at all connected with the locomotor ataxia. They are the
result of the unhygienic life that the patient is living and of the
depressed state of his mind and lack of diversion. They are mutually
connected, for a man who does not eat enough will not have regular
movements of his bowels, and constipation reacts to produce further
depression. A vicious circle in pathogeny is formed and the patient is
likely to get into a very debilitated and depressed condition. Both of
these troublesome symptoms may be corrected to the manifest
improvement of the patient by proper advice and ordinary care for his
well being.

Appetite is largely a function, as the mathematicians say of something
that depends on something else, not of exercise, as is often thought,
but of fresh air. In the tuberculosis sanatoria patients with fever
are not permitted to take exercise, yet if they are out in the air
most of the day and if their rooms are well aired at night, they can
eat heartily and digest their food well. Of course, appetite is
largely a psychic matter and the thoroughly discouraged man will have
no care for food in spite of abundance of air. A little persuasion,
however, of the necessity for making the best of a bad job will
usually arouse even a locomotor ataxia patient in the early stages of
his disease to the necessity for eating a reasonable amount. If he has
suffered from gastric crises and fears that eating normally may
precipitate these, he must be persuaded that this is not the case,
that the presence of food, or its amount, or quality, has nothing to
do with the initiation of these painful attacks so far as we know, and
that even though at the beginning of his affection before his
locomotor ataxia was recognized, his gastralgia may have been declared
by his physicians, as is so often the case, to be connected with some
form of gastritis or indigestion, that idea may now be given up and he
may eat plentifully with confidence that it will not increase his
pains. On the contrary, limitation of food seems to have a distinctly
unfavorable effect in increasing the number and severity of these
attacks.

The same thing must be made clear to him as to intestinal and rectal
crises. It seems likely that tendencies to constipation by irritating
peripheral nerve endings may have some effect in bringing about the
explosion in sensory nerves which have been called intestinal or
rectal crises. In general, however, these are dependent on spinal and
not peripheral conditions, and no thought of any connection must be
allowed to disturb the consumption of a proper amount and variety of
food. It seems clear that when patients are much run down, have lost
considerable in weight and are in a generally depressed condition,
their nervous system is much more irritable than it would otherwise be
and they are likely to suffer more frequently from crises of various
kinds. Once a patient is made to understand that his general {527}
nutrition may affect not only the course but the occurrence of
symptoms in the disease, as a rule it is not difficult to get him to
eat enough and to do so with the definite feeling that it is going to
do him good. Even though it should be necessary to use tonics, and
often they will have to be prescribed, it is clear that this treatment
of the patient's general condition is the physician's first duty,
though it does not and cannot affect the specific disease.


Neurotic Complications.--There can, of course, be no doubt that the
crises of locomotor ataxia represents extremely poignant attacks of
pain. But on the other hand, anyone who has seen many of them is prone
to think that not a few of them are really attacks of pain resembling
those which occasionally develop in hysterical subjects. The pain of a
gastric neurosis may, indeed, so simulate the gastric crises of
locomotor ataxia as to make what is only a case of hysteria seem
beyond doubt one of locomotor ataxic. Locomotor ataxia patients are
prone to think much about themselves and to fear the recurrence of
these painful crises once they have had experience with them. As a
consequence they sometimes suffer from what are pseudo-crises, that
is, from neurotic painful conditions which simulate genuine crises
mainly in the amount of reaction they produce in the patient. True
tabetic crises yield more readily to ordinary anodyne drugs than do
these pseudo-crises. Nearly always the true crises are associated with
and exaggerated by neurotic symptoms due to the depression of the
patient, the yielding to his feelings, the conclusion that his pain is
inevitable and is going to be worse each time, while successive crises
are, as a matter of fact, often milder until they disappear for good,
and this element in the case must always be borne in mind. Much can be
done for the relief by psychotherapy, that is, by making the patient
see the realities of his condition, suggesting to him that succeeding
crises are less painful and that if his general condition is as good
as it should be he becomes better able to stand the pain of his crises
and the shock of them is not so disturbing to his system.


Mental Attitude.--Prof. Oppenheim, in one of his "Letters to Nervous
Patients," advising a patient suffering from an incurable organic
nervous disease, evidently locomotor ataxia, though that is not
explicitly stated, outlines emphatically the favorable side of that
disease. This is absolutely needed. Ever so many unfavorable
suggestions with regard to his affection find their way to the
patient. The very fact that it is pronounced absolutely incurable is
disheartening. Prof. Oppenheim's words, then, may be a precious help
and to have them repeated from time to time renews the suggestion:

  Now, however, we neurologists know that that disease frequently runs
  a very mild course, that a man showing certain early symptoms of
  such a disease may for ten to twenty-five years and even longer
  retain his capacity for work and enjoyment. This for a man of thirty
  to forty years is almost tantamount to the expectation of a whole
  normal lifetime. But on the other hand, what danger to the peace of
  mind, what destruction of happiness in life may be caused if the
  knowledge that such a disease has begun to develop is imparted to
  the patient without being combined with the consoling information as
  to the nature and course of the benign forms of this trouble! In
  unceasing anxiety and fear, in daily expectancy of some fresh
  symptoms, of some increase or aggravation of his troubles, does the
  poor man waste his life; and I have frequently found that this
  wretched apprehension and excitement cause a nervousness and mental
  depression which in their effects are much more momentous than is
  the commencing spinal disease.

  From this miserable condition I desire to protect you, and I would
  ask you to {528} take this advice deeply to heart: do not bear
  yourself as one who is condemned; as one who, affected by a
  progressive, incurable disease, will soon fall a victim to
  paralysis. On the strength of my own experience I give you the
  assurance that your condition of health will not necessarily in ten
  years' time be essentially different from what it is at present. But
  I would also strenuously exhort you to observe all the precautionary
  rules laid down for you, to avoid all unaccustomed strain or
  indulgence such as can only be undertaken with impunity by a man in
  full vigor and absolute soundness of health. I would advise you also
  to be thoroughly examined once a year by an experienced physician.
  But apart from these restrictions, you should as far as possible
  feel yourself and bear yourself like a healthy man, remaining
  attached to your work, and not withdrawing yourself from the
  pleasures of social intercourse.


Relearning Muscular Movements.--Perhaps the most interesting evidence
of how much may be done for organic nervous disease in spite of the
fact that the underlying lesion is absolutely incurable, may be
obtained from what is accomplished by Frenkel's method of treating
locomotor ataxia. As is well known, by reteaching the movements
necessary for walking, ataxic patients regain control of the movements
of their limbs to a marked extent. As a consequence, bed-ridden
patients are enabled to walk once more even though they may have to
carry a cane and be supported, and patients who have had to use two
canes get along with only one, or may even eventually be able to walk
without any artificial support.

Just how the improvement is brought about we are not quite sure. It
seems probable that the eyes become trained to replace the muscle
sense to a noteworthy degree, but there is in addition apparently a
re-education of the muscle-sense. Perhaps there is also a transfer of
the function of certain degenerated nerves to other tracts than those
in which muscle impulses originally traveled. The improvement in
muscular control originally obtained is a striking illustration of how
much nature is able to compensate for even organic lesions and is a
lesson in the necessity for never ceasing to try to do something even
when the case seems hopeless. Certainly locomotor ataxic patients
would seem the least likely to be benefited by training in movement
and yet this movement therapy for tabes has had some wonderful
results.

The story of how this mode of treatment came into existence is
interesting and instructive as an illustration of how happy chance in
our time, as so often with regard to drugs in the past, came to assist
the rational development of therapeutics. A German professor wished to
demonstrate to his class the varying inco-ordination of a series of
tabetic patients. Some of them had their main inco-ordination in the
legs, others in their hands. He went over the cases in his wards so as
to arrange the demonstration for the next day. He told each patient
that he would ask him to perform a particular set of movements before
the class which would illustrate strikingly a particular phase of
muscular inco-ordination. His patients were interested in the
announced demonstrations and during the afternoon they went over the
movements that they were expected to perform. They practiced them as
assiduously as their condition permitted for the exhibition. As a
consequence the most striking features of their inco-ordination
disappeared. After having practiced the movement for a certain length
of time they could do it ever so much better than before. The special
feature of the professor's demonstration was spoiled, but a great
contribution to our knowledge of nature's compensatory powers {529}
was made and fortunately the hint of its significance for treatment
was taken and developed.


Effect of Favorable Suggestion.--How much can be accomplished for the
relief of the general symptoms of locomotor ataxia and for the placing
of patients in an attitude of mind that makes most of their symptoms
of vanishing importance, can be judged from some recent experiences
with a new cure for the disease. This consisted only of some rather
conventional treatment of the urethra by applications and dilatation,
yet patients were relieved so much of the symptoms of locomotor
ataxia, or at least persuaded themselves that they were, that both in
this country and in Europe the discoverer of the new "cure" soon had
scores of patients. The active therapeutic agent undoubtedly was the
fact that patients who had been told that their disease was incurable
and who had settled down in a state of discouragement and apathy in
which their power over their muscles, their general health and their
strength and vitality were at the lowest ebb, and their tendencies to
discomfort emphasized and made poignant by the supposed hopelessness
of their situation, became aroused to new vitality by the promise of
cure and then, under the repeated suggestion of a treatment said to be
sure to cure them and that had cured others, became so much better,
that is, released so much latent energy, that they felt better, ate
better, walked better, got out more and had their general health
improved, and all to such a degree that their disease seemed cured.

Another interesting illustration of what would seem to be the power of
suggestion over the symptoms of tabes occurs in a recent article in
the Archivos Españoles de Neurologia Psyqiuatria y Fisioterapia of
Madrid   [Footnote 39] on the improvement of tabes dorsalis by
antidiphtheritic serum. It is quite impossible that the serum should
affect favorably any of the underlying lesions of the disease any more
than that these should be ameliorated by the wearing of shoes of
special character or operations on the urethra. The patient in this
case, however, was distinctly improved in many ways _after_ the
antidiphtheritic serum was injected. There were some interesting
sensory manifestations, pains in the arms and legs after the
injection, but these were removed by santonin or methylene blue. Both
of these drugs are eminently suggestive in their action, so that one
would be prone to think the pains rather neurotic than actual. After a
dozen injections had been given, the patient's sensations improved,
his power to pick up small things was better, and the sense of walking
on carpet had disappeared to a marked extent and he was able to walk
much better than before and without support. Probably any attention
given to him to the same degree would have produced like results.

  [Footnote 39: Tomo 1 No. 7, July, 1910.]

We have had previous examples of this kind in the history of the
treatment of locomotor ataxia. Certain drugs when given in the past
with the definite promise of cure and pursued for a good while with
frequently repeated favorable suggestions, have often seemed to
benefit patients, though subsequent experience has shown their total
lack of value to modify the disease. Nitrate of silver was one of
these in the old days and many locomotor ataxia patients acquired an
argyria as a consequence of the amount of silver absorbed and
deposited in the skin. Arsenic was another and some of the aluminum
{530} compounds were also used. When we recall the suspension
treatment and its reported good effects--and failure, the
over-extension treatment with the same history and many others in the
past, the real place of the mental in the therapeutics of tabies is
revealed. Once this is practically realized, we find that we have
ready to hand and easy to use, the one really efficient factor in all
these treatments--that is, the influence on the patient's mind. It is
for the physician to devise thoroughly professional ways and means of
using that in each particular case so that his patients may be
benefited as much as possible. Certainly it would be foolish for us to
leave to the irregular practitioner the use of this extremely valuable
remedial measure, when we may do so much good with it, for the relief
of symptoms at least.



CHAPTER IV

PARESIS


Paresis would seem to be one of the affections so inevitable in its
course, so positively helpless as regards any medication, and so
hopeless in its absolutely sure termination in idiocy and death, that
nothing can possibly be done for it through the patient's mind, yet it
is probably one of the diseases for which most can be accomplished by
psychotherapy. Mental treatment for it naturally divides itself into
three periods: that of prophylaxis, that of the early stage and that
of the severer stage with remissions. Prophylaxis is much more
important than is usually thought. It is very generally known at
present that paresis is usually a parasyphilitic disease, that is, an
affection not due directly to syphilis, but which develops by
preference and perhaps exclusively in a soil prepared for it by an
attack of syphilis. As a consequence of the diffusion of this
knowledge men who have suffered from syphilis sometimes become
supremely fatalistic as regards the development of locomotor ataxia or
paresis in their cases. Worry is a prominent feature in the causation
of paresis, and it is, therefore, extremely important to neutralize
this.

I have had university graduates tell me their histories and ask
whether I thought they had suffered from syphilis, and when I replied
affirmatively have seen a look of despair come into their faces. One
of them, a graduate of a large eastern university, said, after hearing
my opinion, though it was given with every assurance that my
experience with Fournier in Paris taught me the absolute curability of
the disease, "Well, there are three men of my class who have already
developed paresis, and I suppose I will go the same way." With a
persuasion like this haunting him night and day, exhausting nervous
energy and making his central nervous system less and less resistive,
it would be almost a miracle if paresis did not develop. It is
particularly in those who have had nervously exhaustive
occupations--brokers, speculators, actors, and the like--that paresis
does develop. The strain upon their nervous systems seem to be so
great that the syphilitic virus still remaining in their system has a
peculiarly degenerative effect upon nervous tissue. A man may be in
the least worrisome of occupations, however, and if he is constantly
brooding over the possibility of the coming of the hideous specter of
paresis, {531} he puts himself in the condition most likely to
encourage the development of the pathological changes that underlie
the disease.


Prophylaxis.--As a rule patients who have had syphilis and who dread
the development of paresis should be warned with regard to their
occupations in life. After a patient has had tuberculosis which
developed in particular surroundings, if it is at all possible, we no
longer permit him to go back into the surroundings in which his
disease developed. We are coming, more and more, to apply the
principles of preventive medicine and this is as important in paresis
as in anything else. Even though there may be many monetary or
economic reasons in favor of certain occupations, the danger may
overweigh these. Those who have had syphilis should be warned of the
risk they run if they continue in occupations that require much mental
excitement or the strain of anxiety and the speculative factor of
uncertainty with the inevitable occurrence of disappointments. It is
unjustifiable to permit a patient whose central nervous system is
subjected to the deteriorating influence of the virus of syphilis,
still in his body even after ten years, to submit to the nerve-racking
irritation of occupations which require all the vigor of a healthy,
undisturbed organism to survive their wear and tear.


_Sources of Worry_.--One of the symptoms which neurotic patients are
sure must be a preliminary sign of paresis is a disturbance of memory.
Patients have heard that paresis causes memory disturbances and
fearing the development of the disease, they disturb themselves very
much by finding real or supposed defects of memory. Most of them have
had only a very vague idea of the sort of memory they possess and
cannot tell whether it is worse than before, but finding a certain
difficulty in recalling things they conclude that it is deteriorating.
Occasionally their supposed defect of memory is founded on nothing
more serious than the fact that they are paying so much attention to
themselves, that they cannot concentrate their attention enough on
what they wish to remember so as really to impress it on their
memories. It is curious how persistent some patients are in making
themselves believe they have serious lacunae in their memory when
there are only certain conventional disturbances of it. The paretic
has defects of memory, but he is, as a rule, quite unconscious of
them. He has to have them pointed out to him. Patients who are
supremely conscious of their supposed defects, by that very fact show
their possession of good intellectual faculties.

Tremor is another symptom that may develop in the midst of the
solicitude of those who dread paresis. The power to hold the limbs in
a given position is due to a very nice balancing of flexor and
extensor muscles. There are many people, especially those a little
awkward in the use of their muscles, who lack this power to some
extent. To stand without swaying is rather a difficult task in one who
is nervous or anxious about himself. Patients who are worrying about
paresis and its possible development will almost surely disturb their
power over their muscles and cause at least a slight tremor or
swaying.

In other words, in all of these cases a series of dreads, or mental
obsessions which interfere with various functions which may cause
tremor, or some stuttering, or at least some apparent difficulties of
speech and which will surely revive any old-time difficulties of this
kind, may develop in nervous persons and must not be allowed to pass
as signs of developing paresis. The {532} diagnostic tests, of course,
consist in the knee-jerks, the pupillary reactions, the difference in
disposition, the delusions of grandeur, and, in general, the
characteristic symptoms of a physical degeneration running parallel
with a mental deterioration.


_Prophylactic Reassurance_.--The first point in psychotherapy, then,
is to give just as much reassurance as can be given. Probably not one
out of a thousand of those who have suffered from syphilis afterwards
develops paresis. Nearly always there is something in the history
besides syphilis that seems to be an essential etiological factor. A
great many of the people who develop this disease have some hereditary
taint of mental incapacity at least, if not of actual insanity. Very
often there is a personal or family history that indicates some mental
unevenness or at least some lack of intellectual vigor. When people
are sanely intellectual and have no unfortunate hereditary tendencies
they can be almost completely assured as to the possibility of the
development of paresis, provided they take reasonable care of
themselves.


_Alcohol_.--It is still an unsettled question whether alcoholism has
anything to do, even in a subsidiary capacity, with the etiology of
paresis. Probably it helps to predispose nerve tissues to degeneration
by lowering their resistive vitality to the direct pathogenic action
of the virus of syphilis. It seems clear, besides, that men who have
acquired syphilis sometimes take to over-indulgence in alcohol, at
least to a greater degree than would otherwise be the case, because of
the discouraging dread that develops as a result of their worry over
this constitutional taint. A warning in this matter of indulgence in
intoxicants is important because there are many nerve specialists who
insist that alcoholism is probably one of the prime factors in
paresis.


Unconclusive Diagnosis.--When the first symptoms of paresis have
developed so that the physician is almost certain that the disease is
present--the cumulative experience of recent mistakes on the part of
the most careful experts seems to show that he can never be entirely
certain--then it is important not to announce the worst to the
patient, but to let him learn the reality of his condition gradually,
so that all the awfulness of it does not overwhelm him. What have
seemed typical cases of paresis, so diagnosed by excellent
authorities, have occasionally proved to be something else, or, at
least, to be wayward and very irregular forms of that disease with a
long course and marked remissions. There are forms of paranoia in the
middle-aged which sometimes exhibit symptoms so strongly simulant of
paresis as to deceive even the expert. There are forms of nervous
weakness--neurasthenia--some of which are really cases of mental
exhaustion or incapacity--the modern psychasthenia--which often lead
even experienced physicians to think of and sometimes to diagnose
paresis. There are cases of dementia praecox that only time can
differentiate.


Prognosis.--_Seeing the Worst_.--There is a tendency in most
physicians to see the worst side of the story rather than the better.
This is not because of any desire to be a harbinger of evil tidings,
nor, as is sometimes said, to show the patient, should he get better,
from what a depth of affliction he has been rescued, but it is rather
due to the very natural tendency existing in most of us to look on the
worst side of things. Besides, we have found by experience that if
patients are to be aroused to the necessity of care for themselves
they must be scared a little, and so we have formed the habit, not of
consciously {533} and deliberately telling the worst, but of stating
the unfavorable possibilities of a group of symptoms, in order that a
patient may take due precautions and that he may realize, if the worst
does happen, that we were not ignorant of it. If he gets better he is
correspondingly grateful for this. If the unfavorable happens and we
had not warned him, he is more or less justifiably resentful.


_Consoling Hesitancy of Final Judgment_.--Patients suspected of
suffering from paresis can then without any violation of truth be
reassured that their cases may not be incurable until the epileptiform
incidents of the disease bring on that happy obscuration of mentality,
that either takes away all the terror of the disease or lessens so
much its awful significance that the patient is spared the worst.
There are cases of reported cures in the literature even after what
seemed to be characteristic epileptiform attacks had occurred.

We cannot be sure, in any case, of the future course of an affection
exhibiting symptoms resembling paresis. The patient can always be
given the advantage of this doubt then and the awful word incurable or
even the diagnosis paresis need not be mentioned to him. It is
perfectly possible, as a rule, to take other means to prevent
unfortunate incidents from tendencies to violence or serious loss from
foolishness, without overwhelming the patient with an absolutely
unfavorable prognosis, and the diagnosis of paresis, involving as it
does, now that so much more is popularly known of the disease than
before, the dread of inevitable idiocy. In this way much of the
depression that constitutes so large a part of the really sane period
of the early stage of paresis and which inevitably hastens the course
of the disease may be avoided. On the other hand, failure to announce
absolutely the diagnosis of paresis until there can be no particle of
doubt, can do no harm and will do good to the patients themselves, as
well as save their anxious friends from the trial of having to think
of the awful possibilities of the disease. A single sensible member of
the family may be selected as the confidant and the situation saved.


Rôle of Psychotherapy.--While it is important that someone closely
connected with the patient should know the doctor's suspicions, he
should be bound to absolute secrecy as regards the patient himself and
especially as regards women friends and relatives. The attitude of
mind assumed by women relatives, and especially those nearest and
dearest, is sure to be communicated to the patient, if not directly at
least indirectly and inadvertently, and makes for anything but relief
from the depression that is sure to be his if he has any gleam of
understanding of his condition. Indeed, so much of pain and suffering
is needlessly inflicted on relatives of paretic patients in the early
stages of the disease by a premature announcement of the diagnosis
that it is especially important to insist on care in this matter. The
family will usually clamor to know just what is the matter, but it is
the physician's duty to care for his patient and save the sufferings
of the patient's family, regardless of their unwitting insistence.
Once the disease has developed and the patient's mind becomes affected
it may be thought that psychotherapy is no longer of value. As a
matter of fact, these patients as a rule become more childlike and are
much more affected by suggestion than in their normal states. All this
is worthy of careful attention on the part of the physician who feels
that it is his duty to treat patients and not merely their disease.

The psychic care of the patient is the most important element in any
{534} scheme of therapeutics during the longer remissions of paresis,
which are sometimes so complete that it is difficult to understand
that the patient, who is now as sensible as he ever was, only a few
months before was doing the most foolish things under the influence of
his delusions of grandeur and probably within a few months will be
quite as insane as before and perhaps hopelessly demented. The brevity
of these remissions in most cases seems to depend directly on how much
the patient is persuaded that his disease will return without fail and
run its inevitable course. It is well worth while to lengthen these
remissions by setting the patient's mind just as much at rest as
possible. Instead of the attitude which is so often assumed of
absolute assurance on the part of the physician that the old condition
will inevitably return, it is advisable always to give the opinion
that the previous mental derangement was paranoiac rather than
paretic, or was perhaps only a passing syphilitic condition and that
the ultimate outlook is not as hopeless as might be thought. This
opinion is thoroughly justified by certain surprising results in a
number of recently reported cases. Some patients whose symptoms have
been diagnosed as paresis by excellent diagnosticians, have, after a
time, experienced a cessation of their symptoms which looked very much
like a remission occurring in the midst of the inevitably progressive
paretic degeneration and then to the surprise of their physicians have
not exhibited any further symptoms of the affection. Syphilis of the
nervous system sometimes simulates paresis to such an extent as to
deceive the most expert, and proper antisyphilitic treatment will
sometimes produce results that are little short of marvelous. It is
beyond all question, then, for the good of the patient suspected of
paresis that his physician should give him the benefit of every doubt.



CHAPTER V

EPILEPSY AND PSEUDO-EPILEPSY


EPILEPSY


With regard to the major neuroses generally, very much more
therapeutic benefit can be secured than in any other way that we know
by reassuring the patient's mind, by careful regulation of his life
and by such modifications of his occupation as will take him out of a
strenuous existence, so likely to be harmful to a nervous system
laboring under these serious handicaps. In recent years we have come
to realize that epilepsy, for instance, is more favorably influenced
by a simple outdoor life in the country without worries and cares,
with carefully regulated exercise in the open air and special
attention to the digestive tract, than by any formal remedial measures
or drug treatment. The fewer the emotional storms the less likelihood
of repetitions of attacks of epilepsy. No medicine is so effective in
prolonging the intervals between attacks as this placing of the
patient in favorable conditions of mind and body. Our experience with
the colony system has emphasized the fact that drug treatment is quite
a subsidiary factor in this general care for the patient. The most
important element in this treatment is the effect on the {535}
patient's mind and the consequent gain in poise and in resistive
vitality against emotional explosions which are so often the immediate
occasion of attacks. This lessens their number and it is well known
that frequent repetition is likely to be associated with that
deterioration of the physical nature and mental condition which is
most to be dreaded.


Mental Influences.--When living a quiet placid life without worry
about himself or his concerns, the number of the epileptic attacks
goes down in a noteworthy degree and the intervals between them become
longer and longer. After years of quiet country living epileptics who
had two or three attacks a week have scarcely more than one a month,
if, indeed, that often, and their general condition is greatly
improved. We have had many remedies for the affection, only a few of
which have proved to be really therapeutic. The remainder have had
their effect through the mental influence that went with them, the
assurance of relief and the confidence that it aroused.

First attacks of epilepsy are not infrequently the result of an
immediately preceding fright or sudden emotion of some kind or other.
Gowers tells the story of a sentinel posted near a graveyard who was
very much disturbed by his proximity to the dead and who, during the
night, saw a white goat run past him, jump over a low wall and
disappear. He was sure it was a ghost. He had his first attack of
epilepsy shortly after. Children not infrequently have their first
attack after a scare from a dog or a rough-looking stranger who has
come near them. After the affection has established itself attacks of
epilepsy follow vehement mental disturbances of any kind. Sometimes
after a long interval of freedom from attacks a sudden strong emotion
is followed by a fit and then the epileptic habit is reestablished. In
order to be as free as possible from the affection patients must be
protected from emotional storms.


Power of Suggestion.---A strong proof of the favorable influence of
suggestion upon epilepsy was given when operations for epilepsy became
common about twenty years ago. A number of patients were operated on
by trephining, even though almost nothing else was done except to open
the dura and examine the brain, for often no definite pathological
condition to justify surgical intervention was found. But these
patients did not suffer from attacks of epilepsy for months and
sometimes years afterwards. Many surgeons reported these cases as
cured, as they apparently were when discharged from the hospitals, for
no attacks had recurred; but physicians had to treat them later when
their epilepsy redeveloped. The surgical procedure, as indeed might
have been expected from the findings, had given only temporary
betterment. The real therapeutic factor at work had probably been not
any definite change within the skull, but the suggestive influence of
the operation, the period of rest with favorable suggestion constantly
renewed, and the confidence of recovery inspired during convalescence.
Even in cases where adhesions were found between the dura and
calvarium and these were broken up, the relief afforded was usually
but temporary. The succession of events, the relief afforded and
subsequent relapse, probably represented the same influence of
suggestion as in the preceding cases with perhaps a slight physical
betterment in addition.

An important factor in the psychotherapeutics of epilepsy is to
relieve the patient as far as possible from the haunting dread of
insanity, which, especially if he has read much of the disease, is so
likely to hang over him as {536} a pall because of the absolutely bad
prognosis which often occupies so prominent a place in older
text-books and articles on epilepsy. There is no doubt that in a great
many cases epilepsy is a progressive degenerative disease and that a
state of lowered mentality will eventually develop. There are many
cases, however, in which epilepsy is only a series of incidents which
does not seem to affect the intellectual life and which is quite
compatible not only with prolonged existence, but with mental
achievements of a high order and, above all, with a personality that
may be commanding in its power over others. This knowledge, which
unfortunately is not usually given in text-books because they are
studies in the pathology rather than in the psychology of epilepsy, is
extremely important for the epileptic. This view is of special
significance for those sufferers from the disease who are well
educated and in whom mentality means so much.


The Individual in Epilepsy.--In epilepsy, indeed, the individual
counts much more than his ailment, and even in severe cases of
epilepsy there are individuals to whom the recurring convulsions are
only annoying occurrences of life, somewhat dangerous because of the
risks encountered during unconsciousness, but without any ulterior
significance for degeneration of character or intellectual power. As a
matter of fact, there are many men in history who were epileptics and
who yet succeeded in great work of many kinds, even purely
intellectual, unhampered by this condition, and some of them have
proved to be leaders in achievement. In his paper read before the
National Association for the Study of Epilepsy and the Care and
Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew
Woods discussed what certain famous epileptics had accomplished in
spite of epilepsy. He takes three typical examples--Julius Caesar,
Mohammed and Lord Byron--the founders, respectively, of an empire, a
religion and a school of poetry--with regard to whom there is
convincing evidence that they were epileptics. A fourth name, that of
Napoleon, might easily have been added. Greater accomplishments than
these epileptics made in their various departments are not to be found
in the history of the race.

Many other names of epileptics distinguished for achievement might
well have been added to the list. The argument that would be founded
on their lives is not that epileptics are necessarily or even usually
of high intelligence, but that some of them, at least, retain in spite
of the major neurosis, or even serious brain disorder, whichever it
may be, all their intellectual qualities undisturbed. Lombroso,
arguing from the other standpoint, has pointed out that there is a
close relation between genius and insanity, and he sets down epilepsy
as one of the forms of insanity (mental un-health) often associated
with extraordinary mental qualities. A study of this subject is
extremely reassuring to the epileptic who is prone to think from
traditions with regard to the disease that his fate is almost sure to
be a gradual lapse into imbecility. No epileptic is likely to be at
all worried over the suggestion that epilepsy and genius are allied,
for since he has the one he is quite willing that the other shall
follow.


Treatment.--Reassurance is especially important when patients develop
epilepsy in adult life. There is an unfortunate social stigma attached
to the disease which adds to the unfavorable suggestions that are
likely to run with it. This probably cannot be overcome, for it is a
heritage, not alone of many {537} generations, but of many centuries.
Our better knowledge of epilepsy, however, should gradually take the
disease out of the sphere of suspected mystery in which it has been
popularly placed and set it among the diseases to which human nature
is liable, but which is surely as physical in its character as any
other. If a favorable attitude of mind on the patient's part can be
secured there is less necessity for many of the disturbing drugs that
are used and there seems to be no doubt that even in producing the
effect of these, such as it is, suggestion of a favorable character
plays a large role. Over and over again in the history of the
affection we have had remedies introduced which have seemed to be
quite efficient in producing longer intervals between attacks, making
the patient less nervous and putting him in better physical health.
After a time, however, these have proved to be quite useless, or at
most of but very slight value. It was suggestion that gave them their
apparent value, and this suggestion must be used without the drugs
whenever possible.

The bromides have done good in the treatment of epilepsy, but they are
the only drugs that maintain the reputation they first had. All the
others accomplished whatever benefit they conferred on the patient,
and some of them for a time seemed to excellent authorities of large
experience to give marvelous results, through their influence over the
patient's mind. Nothing can produce more confidence in the physician
who is using suggestion for epilepsy than this fact. Even the
bromides, unless used carefully, easily do more harm than good and
they have often worked mischief. Favorable suggestion cannot do harm.
At the present time those of largest experience in the treatment of
epileptics, the directors of farm colonies, as Dr. Shanahan of Craig
Colony, insist that diet, hygiene, especially hydrotherapy, are of
much more importance than drugs, but that the patient's attitude of
mind towards himself and his malady and the future of it is even more
important. He must have occupation of mind so as not to worry about
himself. He must have recreation so as to relieve the gloom so likely
to come in the disease. He must have outdoor air and proper exercise,
which these patients are so prone to neglect.

Those who have studied the subject most in recent years agree that the
great majority of cases of epilepsy are not primarily due to acquired
causes, but to some congenital defect, so that there is an inherent
instability of the nervous system. This makes the patient liable to
explosions of nerve force, figuratively represented as boilings over
of nervous energy, when not properly inhibited. Once such a paroxysm
occurs it is likely to happen again, and very often it brings on
gradual degeneration of the nervous system and of mentality. In many
cases, however, this degeneration can be delayed or even completely
kept off by putting the patient under favorable conditions. These
patients need, above all, to realize that they cannot live the
strenuous life nor even the ordinary busy life of most people. They
are as cripples compelled to limit the sphere of their activities. If
they will but take this to heart, however, and not attempt too busy
occupations, they may live quite happy lives for many years, and if
mentally content and without worrying anxieties they will have so few
attacks as to incur only to a slight degree the dangers inevitably
associated with fits of unconsciousness. To get the epileptic's mind
into a condition of satisfaction with his condition must be the main
portion of the treatment.


{538}

PSEUDO-EPILEPSY


There is a large and important field of psychotherapeutics in a class
of cases so closely related to epilepsy that it is often extremely
difficult to make the differential diagnosis between the two varieties
of seizure. Fifteen years ago, while I was at the Salpêtrière, there
was much discussion of a variety of attack called hystero-epilepsy, in
which the patients' symptoms were such that it was difficult if not
practically impossible to decide whether the case was true epilepsy or
merely hysteria. Personally I do not think there is any third,
intermediate variety deserving a separate term. The attacks are either
hysterical, or, to use a less objectionable name, neurotic, or they
are genuinely epileptic, that is, due to some as yet not well-defined
change in the brain, and therefore not likely ever to be completely
relieved. To decide whether a given case is neurotic or epileptic,
however, is sometimes quite out of the question until long and careful
study of it has been made. It is true that such signs as full loss of
consciousness, biting of the tongue, the so-called epileptic cry,
involuntary urination, dangerous falls and the like in the midst of an
attack, have often been declared to be signs of true epilepsy, but
there are cases in which one or other of these signs has been present,
yet the subsequent course of the affection has shown them to be
functional and not organic in origin.


Neurotic Simulation of Epilepsy.--Nearly every physician who has
reasonably large experience with neurotic patients has seen cases in
which there were recurrent attacks of loss of consciousness that came
on sometimes at most inopportune moments, that rendered the patient
quite incapable of caring for himself for the moment, yet lacked many
of the signs of true epilepsy. Teachers sometimes complain of a
complete lapse of memory that begins without warning and then recurs
at intervals, making their work very difficult. Preachers sometimes
bring the story of having lost the thread of their discourse and
forgetting absolutely what they were talking about, there being a
complete blank for some seconds at least. Occasionally such lapses are
associated with falls that resemble fainting spells and seem to be
accompanied by complete loss of consciousness. Usually after them
there is a distinct tired feeling and an inclination to sleep, though,
as a rule, there is a more marked tendency to want to get away from
observation. Some of the cases are much more severe than those
described and the conclusion that they are true epilepsy seems
inevitable, yet they recover so completely that this conclusion is
negatived.

Occasionally such attacks occur only when the patient has been
strenuously exerting mind or body for a much longer period than usual.
In teachers it is likely to occur toward the end of the year or in the
midst of the hard work about examination time. In students this same
period is likely to be a favorite starting point for the attacks and
they recur oftener at this time than at others. Very often there is a
story of some digestive disturbance in connection with the attacks. At
times it seems possible to trace them to some interference with the
cerebral circulation through a distended stomach pressing upward
through the diaphragm and interfering with the heart action. In such
cases stomach resonance will sometimes be found as high as the fifth
rib {539} and the apex beat may be pushed out to the nipple line or
beyond it. This may be true though there are no signs of valvular
lesions and no symptoms or physical signs of dilatation or hypertrophy
of the heart.


_The Suggestive Element_.--Analysis shows the real course of the
trouble in these cases. The sufferer is usually following a sedentary
occupation, not getting much exercise or diversion and prone to
introspection. Many symptoms of themselves of no importance have been
emphasized by concentration of attention on them. Especially is this
true of any heart irregularity. The patient has dreaded for some time
lest the feeling of pressure in the precordia and of discomfort in the
heart might not sometime interfere with him in the midst of his
teaching or preaching duties. Some day when he is feeling much worse
than usual, in the midst of his work, there comes over him the feeling
that now his intellect is going to stop action because there is
something the matter with him. The sudden concentration of his
attention on this with the fear of the consequences and the
uncomfortable feeling that he will not be able to go on with his flow
of ideas, cuts off the thread of what he is thinking about and puts
but one single object before him--this possibility of failure of
mental action. Usually the first attack is only such an interruption
as is thus indicated. The fear of subsequent attacks, the worry over
what has happened, the dread that some serious mental affection or
nervous disease is at work emphasizes introspection and subsequent
attacks are even more likely to be serious, and especially to last
longer than the first.

The more the cases are studied the more the conclusion comes that in
many of these instances it is nothing more than auto-suggestion that
is responsible for the mental lapse. It is true that some physical
condition may be the occasion, though the mental state is the active
immediate cause. Suddenly concentrated attention on the dread of
mental interruption inhibits mental action and what was dreaded
follows almost necessarily. It is a sort of auto-hypnotism in which
the patient's train of thought is interrupted by a momentary or longer
hypnotic state the causes of which can be traced. Even when there is a
real organic lesion of the heart, the lapses of memory and even of
reasoning power that occasionally occur, have often seemed to me to be
due rather to the patient's dread than to any real physical condition.
I cannot think that there is a sufficient interruption of the cerebral
circulation, even though only for a moment, to cause such a lapse. It
is a question of nerve interferences rather than of blood supply. If
the blood were diverted, even though only for a moment, or if there
was a stoppage, the consequences would be more serious and more
lasting than they are.

What evidently happens is some disturbance of neurotic connections
within the brain brought on by sudden dread or emotion. The will has
lost control or has seriously disturbed the conducting apparatus. The
best proof that this is what happens and that it is not the result of
organic change is found in the fact that when the physical occasion,
that is, the digestive disturbance or the heart palpitation which is
the initial factor in these states, is relieved, the attacks do not
take place. Patients in whom they have occurred even for years cease
to have them. This improvement does not begin, however, until their
solicitude over their condition has been lessened by a confident
declaration to them that they are suffering from merely functional and
local reflex conditions apart from the brain itself. Usually it needs
to be made clear {540} to them, too, that their anxiety in the matter
means much more for the continuance of the attacks than any physical
condition.

Almost invariably patients somewhat resent this suggestion. Their
response to this explanation of their ailment usually is that the
attacks come on them when they are not particularly expecting them and
that there is first some physical symptom which might readily be taken
for a sort of aura to a genuine epileptic attack and then the attack
itself comes on. It is this preceding symptom, pain or discomfort, or
whatever else it may be, that provokes the suggestive element and
brings about the state of quasi-hypnosis, which is the main part of
their attack.


Neurotic Syncopal Attacks.--Some of the cases of pseudo-epilepsy are
very mild, though if the word epilepsy has been mentioned there
naturally arises a feeling of dread in patient and friends with
consequent unfavorable suggestion. A type not infrequently seen has
for its main symptom a period, usually of but short duration, in which
there is an intense tired feeling so that even the eyelids droop and
require effort to lift them. During such attacks the respirations may
slow down to fifteen or below, though usually the pulse is inclined to
be rapid. The feeling of fatigue is almost entirely subjective, in the
sense that, if patients are required to do something, they are able to
accomplish it by a little urging, though a moment before they were
sure that they could not. Such attacks are invariably functional, have
no organic basis and do not deserve the name of epilepsy. If called
hysterics this will cause the patient, who is often a woman, to rouse
herself and so gradually overcome them. They are really a loss of
confidence in one's power to do things and a passing astasia-abasia.
The use of the word hysterics may cause the patient to lose the
sympathy of her friends, though she may need it; for often there is an
underlying pathological condition not in the nervous but in the
somatic system. Sometimes the patients are anemic, sometimes they have
an abortive form of Graves' disease, and sometimes they are low in
nutrition.

These conditions give the indication for treatment. What is needed is,
of course, improvement of the general condition, but, above all, a
restoration of the patient's confidence in herself. Once it is made
clear to her that the attacks are largely subjective, that is, are due
to a feeling of prostration because of the fear that she is unable to
do something, then the intervals between the attacks will gradually
grow longer. It is important that long hours of sleep should be
advised with plenty of fresh air, and that whatever disturbances of
the digestive system are present should be carefully treated.


Pseudo-Epilepsy and the Menopause.--A number of these cases of
pseudo-epilepsy occur at the menopause. They seem particularly likely
to occur in women who have not much to occupy themselves with.
Childless women who have no cares and enjoy every luxury sometimes
seem to have these pseudo-epileptic attacks as equivalents for the
flushings of the ordinary menopause. During "a rush of blood to the
head" they lose control of themselves. Occasionally mothers who have
two or three daughters and who get their menopause late in life, that
is, well after fifty, are especially likely to suffer in the same way.
The solicitude of those near them seems to eliminate some of their
power of inhibition and makes them think overmuch of themselves. If
then they keep much at home, as women at this time are prone to do,
have few {541} diversions of mind, little fresh air and exercise,
there is an accumulation of unused nervous energy which dissipates
itself in explosive attacks very like epilepsy. It is with regard to
these that the term hystero-epilepsy almost seems justified. Just as
soon as occupation and diversion of mind and relaxation of the
solicitude of friends for them is secured they begin to get better.

The differential diagnosis of these cases is made from the absence of
certain of the pathognomic signs of true epilepsy. The tongue is not
bitten, involuntary urination does not take place, and when the
patient falls she does not hurt herself as a rule, though occasionally
the fall may result in accidental abrasions or bruises, but these are
quite trivial. If stress is laid upon the fact before these patients
that they do not present any or all of the symptoms of epilepsy, some
of them are likely to occur a little later. Slight abrasions on the
tongue will be noted and the sputum will become a little bloody. Even
very cleanly women will sometimes wet themselves. It is not a
deliberate attempt at deception, but their curious psycho-neurotic
condition causes suggestion to act upon them. Their attacks are really
auto-hypnotic and during these the remarks made by the physician occur
as suggestions and then are accomplished. If the suggestions in this
matter have been carelessly made by previous physicians the attacks
will so closely simulate true epilepsy that it will often be almost
impossible to differentiate them with assurance.

In the preliminary diagnosis of these cases, as well as of all other
cases of pseudo-epilepsy, we must, as far as possible, avoid the use
of the word epilepsy, even of hystero-epilepsy. The unfavorable
suggestion attached to such terms will have the worst possible effect.
There is no need to fear that the patient will be any less taken care
of, if the disease is called by some other name, for instance,
neurotic paroxysms or nervous attacks.


Cure by Suggestion.--Such patients are often cured by remedial
measures of one kind or another that are administered with the
confident declaration that they will get well. A number of cases of
epilepsy which were really of this character have been reported cured
by Eddyism. A number also have been very favorably influenced by
osteopathic treatment. Needless to say, the reports of such cured
cases have not been diminished in significance by the publicity
bureaus of these various cults. Mental healing has relieved a number
more. Usually this relief has been afforded these cases after they had
tried regular physicians who had treated them in the ordinary way with
bromides, without doing anything more than causing them to miss a few
attacks for a temporary period of relief, if even that, giving them
bromism and further increasing their solicitude about themselves by
unconsciously emphasizing their ideas as to how serious epilepsy can
be. The cures of these cases are not due to the various treatments to
which the patients proclaim their debt of gratitude, but to the
confident assurance given them that their condition is not serious,
and will be cured. After analysis of their attacks has shown them to
be neurotic and not genuinely epileptic, the regular medical
practitioner can readily do as much and even more; for psychotherapy
has much more to do in affording relief in these cases than any other
form of treatment. It must be applied with confidence and the results
are often most favorable.


{542}


CHAPTER VI

PARALYSIS AGITANS


This is a chronic affection of the nervous system having for its most
characteristic symptom a tremor, but with marked muscular rigidity and
weakness. It is much more common in men than in women, in almost the
reverse proportion of Graves' disease. It is usually a disease of the
old, but may occur in early middle life and has been known to develop
even early in the twenties. In the old days when malaria was a common
diagnosis for many different conditions, paralysis agitans apparently
followed malaria so often that there was thought to be some connection
between the two diseases. The more we have learned of malaria the less
likely this seems to be. Continuous exposure to cold for long periods
and to dampness during the daily occupation for years, or repeated
severe wettings, have been considered as causative elements. None of
these physical factors, however, has been as directly connected with
the occurrence of the affection as various emotional conditions, and
the thought is suggested that even in cases of severe exposure the
worry and fright and solicitude incident to the fear in an elderly
person that this exposure will have serious consequences, is an
important etiological element.


Psychic Factors.--_Fright_.--Practically all the authorities agree
that mental conditions are prominent factors in the production of the
disease. Serious business cares and worries and anxieties have often
long preceded its development. Fright is mentioned by nearly all those
who write on the subject as at least an occasion for the development
of paralysis agitans if not a cause. One of my own most interesting
cases occurred in the sheriff of a county of the Southwest who had
earned for himself the deep enmity of an Indian by arresting him. Not
long afterwards one Sunday morning when the sheriff quite unarmed came
round a corner he found the Indian just in front of him wildly drunk
and armed with a rifle. At once the rifle went to the Indian's
shoulder, but he did not want to kill his man without having his
revenge by torturing him, so he did not pull the trigger, but
announced to him in vigorous though broken English that he had him now
and was going to kill him. The sheriff tried to parley and for a
moment the Indian permitted him to do so, apparently in order to
prolong the agony. They were not more than two yards apart at the
beginning, and the sheriff took his only chance and jumped and knocked
the gun up. It went off just as he did so, the bullet singeing his
hair. He succeeded in arresting the Indian and throwing him into jail,
but the next day a tremor developed in the arm which had grasped the
rifle. This spread and finally became typical of paralysis agitans. He
was a man only slightly past fifty and there had been no preliminary
symptoms.


Mental Control of Symptoms.--Many similar cases following fright or
vehement emotion have been reported, so that it is easy to understand
the feeling that the affection has a large psychic element in it,
though evidently from its persistency and its continued development,
there is some underlying pathological condition. The tremor may be
controlled in voluntary {543} movements, while emotion exaggerates it.
There is no doubt, however, that concentration of will and the
definite effort to control the symptoms enables the patient to rid
himself of them to a great degree for a time at least. It has been
noted frequently that when a consultant physician is called the
patient will be better for the day of the consultation than he had
been for months before. The visits of particular friends will often
arouse a sufferer to such efforts as greatly lessen his rigidity,
decrease his tremor and make him capable of getting around better than
before. The state of mental depression that commonly develops in these
cases exaggerates the symptoms, adds neurotic and even physical
conditions that develop from lack of exercise and air, and makes the
patient's general state much worse than it would otherwise be.


Pathology.--Our scanty but growing knowledge of the pathology of
paralysis agitans makes it clear that the disease is, in typical
cases, probably due to an overgrowth of connective tissue, the
neuroglia cells, in the central nervous system. Just what causes this
overgrowth of connective tissue is not clear. It is an exaggeration of
a normal senile process. Apparently one of the processes of age in man
is a decadence of the vitality of important higher tissues with a
corresponding increase of vitality in the lower or connective tissues.
When Flourens declared at a meeting of the French Academy of Sciences
that such an overgrowth of connective tissue was natural with
advancing years, he added that this probably accounted for the
slowness with which older men come to conclusions. The old members of
the Academy did not accept this new-fangled doctrine with equanimity.
They were inclined to think that their conservatism and deliberateness
were due to greater poise of intellect.

There seems to be no doubt that at least a comparative overgrowth of
connective tissue is characteristic of the brain in advancing years.
In some people this occurs to a greater extent and is more precocious
than in others. Just what causes are responsible for individual
differences we do not know. Paralysis agitans is seen often in those
who have worked hard most of their lives, but, on the other hand, may
occur in those who have lived sedentary lives, and in people of all
occupations. Over-indulgence in alcohol, though this is often thought
to predispose to the disappearance of the parenchyma of organs and to
the overgrowth of connective tissue, does not seem to have any place
in the etiology of this affection. Its occurrence is a part of that
mystery by which the equilibrium of different kinds of cells in the
body is maintained or diminished. In a mild way paralysis agitans
represents such a change in the central nervous system.


Mental Influences.--With an overgrowth of connective tissue as the
pathology of the disease there would seem to be no question of any
relief of its symptoms or any benefit to be derived from
psychotherapy. Anyone who has much to do with cases of paralysis
agitans, however, knows that they are extremely susceptible to mental
influences. Whenever there is anything that interests them, any
business that they feel they must do, any special event that they look
forward to, they will for days at a time be so much improved in
general symptoms as to be greatly encouraged themselves and make their
friends feel hopeful with regard to them. When they give in to their
condition, however, and make no special effort at self-control and
stimulation their symptoms increase very much. Their rigidity
particularly increases, their {544} tremor becomes more marked and
various inconveniences associated with these two cardinal symptoms are
emphasized.


Methods of Treatment.--_The Vibrating Chair_.--It is interesting to
recall some of the forms of treatment which have been reported as
beneficial in paralysis agitans, because they illustrate how much the
influence of the patient's mind has over his bodily condition and how
much the interest aroused in any new and particularly in any unusual
form of treatment has in mitigating symptoms and how often it seems to
bring about remissions in the progress of the disease. Twenty years
ago Charcot suggested the use of a mechanically vibrating arm-chair.
He had noticed that patients who travelled by rail seemed to have
their symptoms improved for the time at least by the shaking up in the
train. This treatment undoubtedly made patients much less rigid and
much less tremulous. The improvement lasted sometimes for hours and
sometimes for days. It was tried rather extensively and everywhere
with reported good results, when first tried at least. After a time it
was found that it failed to have the desired effect. Apparently
whatever therapeutic value it had was due to the interest aroused in
the patient's mind and the consequent effort that was made to control
his muscles.


_The Suspension Treatment_.--When the method of treatment by
suspension became popular for cases of locomotor ataxia, the idea came
to try the same thing for paralysis agitans. Accordingly suspension
apparatuses of many kinds were used with reported good results.
Patients were suspended by the neck for some minutes and some of them
got used to the treatment and could stand it for a prolonged period.
The effect was always a distinct mitigation of symptoms. The rigidity
particularly became much less marked, but the tremor also was lessened
and besides certain secondary symptoms were bettered. Constipation was
improved, partly because patients were more cheerful, ate more
heartily and, above all, were willing to make some effort in order to
get out regularly into the air. There was a variety in life, different
from the solitary sitting at home into which these patients so often
drift. Sleep was better at night and the subjective sensations of heat
and cold were lessened. Patients were encouraged to think of
improvement and used all their available nervous energy. In the same
way when overstretching of the spinal cord by forcibly bending of the
body at the hips was tried with reported success in tabes it was also
applied to paralysis agitans with similar improvement of symptoms.
Both methods of treatment have gone out for both these affections and
evidently their observed therapeutic efficiency at first was entirely
due to their effect upon the mind.


_Psychic Elements and Other Remedies_.--When organo-therapeutics
became the fad paralysis agitans was treated also by this method. Some
cases were treated with reported good results by thyroid. Later when
the parathyroids attracted attention they were administered with
reported good success in even very severe cases. I think that there is
a report of some cases of paralysis agitans being improved by
injections of diphtheria serum. In other words, anything that was
given to a patient with the promise that he would be better after it
and that produced a definite effect upon his mind was likely to do him
temporary good. If the remedy had some special theory behind it, if
there was a story of some new scientific significance for the material
employed or the method of giving it, then this improvement was sure to
take place. {545} In the drug treatment of the disease the same
principles applied. Earlier, when nitrate of silver was the main
recourse for organic nervous diseases, cases were reported improved by
its administration. When the alterative properties of arsenic became a
therapeutic fad this produced good effects. Atropin had for some time
a reputation of relieving patient's symptoms. After a time all of them
ceased to be used to any extent.


_The Frenkel Method_.--In recent years the application of the Frenkel
directed movement method, modified somewhat from its application in
tabes, has attracted attention in the therapeutics of paralysis
agitans. It is interesting to note how often a mode of treatment that
has been applied successfully to one of these diseases has also proved
successful with the other. The two diseases are, of course, very
different in etiology and pathology; but have one thing in common. The
control over muscles has been lost to some degree in both cases in the
progress of the disease, and a special effort of attention is required
on the part of the patient in order to regulate movement. Anything
that will arouse the patient to make this special effort will relieve
the symptoms for a while and in tabes may bring about a lasting
improvement, because the habit becomes easier after a time, though
apparently this does not occur in paralysis agitans, except perhaps in
the younger patients. It might very well be expected, then, that
Frenkel's method in many cases would do good in paralysis agitans and
it has proved to be another adjunct in the treatment of the affection.
It must be used with great care not to exhaust the patient, but this
is true also in tabes. The real source of its therapeutic quality
seems to be the patient's interest in it and if this cannot be aroused
it usually fails to do good. The success of these various mechanical
methods makes it easy to understand why these patients often improve
for a time under osteopathic treatment.


_Psychotherapy_.--It is clear, then, that the most important aid for
these cases is the arousing of mental interest in some form of
treatment that promises to be of benefit to them. New forms of
treatment cannot always be invented and mental occupation must be
secured by interest in other things. Patients suffering from paralysis
agitans are prone to allow themselves to give up efforts to do things
in which their interest would be aroused. They must be encouraged to
do many things. Carriage riding, automobiling, train excursions,
because of the effort required to resist vibration, are all helpful.
They must not be allowed to drift into vacuous habits in which they
make no effort for themselves. They can thus be made much more
comfortable and most of their symptoms can be relieved to a marked
degree. This requires constant attention and ever-renewed efforts to
arouse the patient's mind and to have him make such efforts as will
overcome rigidity and control the tremor to some extent; but with care
an amelioration of the condition can always be brought about and can
be maintained, at least to the extent of making the patient much more
comfortable than would otherwise be the case.


{546}


CHAPTER VII

HEADACHE


In spite of the improvement in the general health of the community,
due to more hygienic living, more healthy food and better ventilation,
headache, instead of decreasing, has increased to a great degree. Any
number of headache cures are advertised in the daily papers, in the
street cars, on the signboards, even in medical journals, and besides
these nearly every druggist has his own special preparation for
headache, so it would seem as though literally many millions of doses
of these headache cures must be taken every week. It would seem as
though there must be some special unhygienic factor at work to produce
headaches at a time when all other pathological conditions are being
reduced in number and severity.

A study of the patients who are especially affected by headache seems
to furnish evidence as to the special factor that has led to the
increase of the affection. It occurs much more frequently in women
than in men. It is complained of particularly by those who have less
regular occupation, and the notable increase has come with the
opportunity for leisure on the part of large numbers of the community
due to the growth of wealth.

A feeling of discomfort in the head to which much attention is paid
will become such a painful condition as to deserve the name of ache,
if it develops in those who have no serious occupation in life and no
interests that demand peremptory attention. With the noise of many
children around them in the olden times women suffered comparatively
little from headaches. Most of our grandmothers scarcely knew what it
was to have a headache. Now most business men are likely to say the
same thing. Very rarely do they suffer from headache. When they do,
there is some specific reason and when this is removed the headache
disappears. There are many women of leisure who have regular headaches
for which they must have some remedy at hand or the pain becomes
intolerable, but there are few women strenuously occupied with
business affairs or with interests in which their attention is
absorbed who find themselves under any such necessity.

It is evident that certain conditions predispose to headache. The
principal of these is having sufficient time to advert to certain
uncomfortable feelings in or around the head. Few people who stop to
think of what their head feelings are but will find there is some
unusual sensation somewhere in or outside the head which if dwelt upon
becomes emphasized into an ache. If the mind can be diverted it
disappears. If there has been some injury of the head or some
pathological conditions set up by congestion or anemia, the feelings
may become emphasized and occupy the center of attention, and even
after the injury has disappeared or the pathological condition been
ameliorated some sensations remain which with advertence produce achy
feelings of discomfort. This is the history of a great deal of the
increase of headache in our time. There are, of course, real headaches
due to definite pathological conditions, but the great majority of
headaches complained of {547} are the result of over-attention to
certain sensations, some of them normal, some of them only slightly
abnormal, which are emphasized by concentration of attention on them
until they become a torment.

Two main classes of headaches come to the physician for treatment. One
class is seen in patients who suffer from real and even acute pain
that cannot be distracted by diversion of mind, that is usually worse
when they try to sleep, as toothache is, and is evidently due to
definite physical disturbance. In the second class are the many queer
feelings about the head called headaches, though the patient suffers
rather from annoyance than from pain. It is said that the Chinese in
olden times put criminals to a lingering death by fastening them in
such a way that a drop of water fell every minute on their heads. It
was impossible to avoid the falling drop, and its constant recurrence
became an awful torture. Any feeling that engrosses consciousness will
be followed by the same sense of torment. The constant exercise of
function of any nerve without rest is of itself physically disturbing
to a serious degree. This must be realized with regard to many forms
of headache which, though trivial in origin, are the source of bitter
complaint.


Attention Headaches.--Professor Oppenheim, in his "Letters to Nervous
Patients," has a paragraph with regard to headache that is worth
recalling for the benefit of patients who suffer from low-grade
headaches. Doubtless these were at the beginning real aches due to
some local condition. They are now due merely to exaggeration of more
or less normal feelings within the head which have come into the realm
of the conscious because of the attention attracted to them when the
intracranial affection was first noted. Professor Oppenheim says:

  Your headache also I ascribe to this source. Originally it may have
  been a real headache, the result of your nervous shock. There is no
  one who has not at some time had a transient feeling of pain in the
  head or in some other part of the body, quite apart from those
  caused by injuries or painful diseases. Out of a thousand various
  kinds of causes I will mention only an extremely common one: the
  pains which result from straining muscles or nerves. Every sudden
  awkward movement may in this way cause pain in different parts of
  the body, but very specially so in nervous persons, in whom the
  mechanical excitability of the nerves--that is, their sensitiveness
  to pressure and strain--is usually exaggerated. As a rule, however,
  this pain is quite transient. But here again the law of which I have
  been already speaking comes into force: under the stimulating
  influence of introspection the tiny, perishable seed-grain of pain
  grows into the firm, strong, enduring tree of neuralgia or
  psychalgia.

The first condition for the successful treatment of headache, then,
must include the recognition of the possibility of some rather simple
pathological condition being exaggerated by over-attention to a
disturbing affection, or of some affection, now past, having produced
a suggestion that, in a mind given to introspection, continues to have
influence even to the inveteration of sensations for which there is no
longer a physical cause.

These patients insist that their medical status is that of real pain.
Hysterical patients describe a sensation as if a nail were being
driven into the forehead--the so-called clavus hystericus. In nervous
people the sense of pressure increases from one of mere discomfort to
a positive pain, as a consequence of attention to it. In most cases of
headache, however, what is most needed is a distraction of the
attention from the ailment. Over and over {548} again I have found
that when all remedies failed the deliberate search for an occupation
of mind that would interest the patient during many hours of the day
was the only thing that promised relief and in many cases the relief
afforded was so complete that patients were effusive in their
gratitude.


_Power of Distraction_.--The proof that these so-called headaches are
really not aches is found in the comparative ease with which many of
them may be suppressed. Almost any interesting occupation will make
the sufferer forget them entirely and they will not return immediately
after the occupation ceases, but usually only when the patient is
alone and attention is once more directed to this symptom. These queer
feelings about the head that are often raised to the dignity of
headaches by attention and auto-suggestion may be distracted away
completely. That they are not pain is shown by the fact that the
ordinary remedies which ease pain so promptly often fail to relieve
these or soon cease to have any effect on them.


_Lack of Distractions_.--The apartment hotel system has multiplied the
victims of headaches. When a woman has nothing in the world to do
except get her clothes fitted and attend to what she calls her "social
duties," it is no wonder that her head bothers her. Blood is
constantly going to the brain and interchange of nutritive elements is
taking place, yet there is no real function of cells and no
consumption of material, or at least function is so slight that
consumption of material must be trivial. There is no reason why these
women should get up in the morning. Their breakfast is brought to
their rooms, and some of them do not get around until eleven o'clock.
Women used to have a morning occupation in going out to market or else
in planning the household day with housekeepers, but of course there
is no more of that. In olden times, too, many of them had religious
practices. Now women are likely to be unemployed until the afternoon,
which must be occupied at most with so-called social duties that may
be done if one wishes to do them, but that may be put off for many
reasons and there are constantly recurring reasons for not making any
special exertion. Also, the rooms these women live in must be kept at
a high temperature because the poorer the air that we breathe the
higher must be its temperature for comfort, while stimulating fresh
air may be quite low in temperature and yet produce only a brisk
reaction instead of chilly feelings.

Children used to be the best possible remedy for these non-occupation
headaches, but either there are no children any more or there are but
one or two and these are largely cared for by _bonnes_ at home and by
various schools once they have reached the age of three. The old idea
that children should not leave home until six put upon the mother the
burden of their early education, but since the coming of the
kindergarten she is relieved of responsibility of this and the mother
of one or two children might now almost as well be childless as far as
any serious occupation from care of her children is concerned.

If patients are told all this bluntly there will be a vigorous protest
from most of them, for to them their pains are very real. It must not
be forgotten that a pain in the mind is often worse than in the body.
Some of these women save themselves from having their unused mental
faculties disturb them from very lack of something to do, by becoming
interested in charities, in clubs, in social movements of various
kinds, in art and in literature. It is {549} not to these that I
refer. On the contrary, if women have nothing else to do I would
insist that they find some cause or movement in which they may become
deeply interested. Their interest will save them from self-annoyance,
though it may not exactly add to the gayety of nations in its effect
upon other people. As a physician, however, I am only interested for
the moment in the good of particular patients.


Source of Pain.--I would not be understood as saying that all
headaches are not real aches nor pains in the most literal sense of
the word, for some of them are agonizing tortures. With regard to all
headaches, however, even the most genuine variety, there are certain
considerations that are of value from the standpoint of
psychotherapeutics. The most important of these is assurance as to the
source or location of the pain. Most people think that it is the brain
itself that is suffering pain and not a little of their suffering is
due to the fact that they dread the effect of such pain upon the
cerebral tissues and its possible consequences upon their mental
state. These people will be much relieved to be told at once that the
brain tissue itself is not sensitive, that when exposed it may be
touched with impunity without causing any pain. It is the structures
surrounding the brain that are sensitive. As a rule the lesion that
causes pain is not progressive and all dreads with regard to serious
after effects may be put aside.


Pressure Headaches.--It is important to insist on the fact that, as a
rule, headaches and pains in the head are not due to the brain, but to
extraneous structures within the skull. It is true that brain tumors,
gliomatous and cystic and, above all, the overgrowth of the pituitary
body in acromegaly give rise to agonizing pains. The cause of these
headaches is undoubtedly pressure. It is not the pressure upon the
brain tissue itself, however, that is the underlying cause of the
pain, but pressure upon the sensitive structures connected with the
brain. The same thing is true with regard to congestive headaches.
Pain is produced not because vascular congestion presses on sensitive
brain tissues, for we have no reason to think that any such exist, but
because the congested brain exerts pressure upon sensitive filaments
in its integuments. Neuralgia may be unbearable and yet it is borne
with more equanimity, and less dread of results, because it is felt to
be in a comparatively unimportant structure. One of the most serious
elements in severe headache is the fear of lasting results in the
brain tissues, that may lead to disturbance of mentality or to injury
affecting mental processes. Patients find their pain much more
bearable as soon as they are assured that headaches do not lead to
mental disturbances and that, as a rule, even the growth of a tumor
does not disturb mentality.

In the relation of the brain to the intellectual faculties that are so
closely associated with it, we must remember that direct connection
between the two has not been demonstrated and that the relations of
the brain and the mind are almost as mysterious as they ever were.
There are some who still think that the frontal convolutions are
especially concerned in carrying out mental operations. All that we
know about them in pathology, however, is that they are the silent
convolutions. When a lesion occurs in other portions of the brain we
see the effect of it practically always without delay, in some way,
either in the sensory or motor functions of the body. Large lesions in
the frontal region, however, often give no sign. Large tumors have
been found {550} pushing frontal convolutions from their ordinary
positions without any noticeable effect upon the individual.


Hard Study and Headache.--It is worth while to impart this knowledge
to patients who suffer from headaches, because it at once improves
their outlook on life. I have known hard students--men who had spent
twenty or thirty years in work at a special subject--live in constant
dread that sometime their minds would give way because they frequently
suffered from headaches, or at least from some uncomfortable
sensations in their heads, which they feared as a portent of ultimate
mental breakdown. The assurance that such a thing is utterly unlikely
and quite apart from the physician's ordinary experience, not only
relieved their anxiety and made their headaches more bearable, but in
a dozen of cases in my note-books the headache has gradually
disappeared as certain habits of life were corrected and modified, as
their habits of eating were varied, as bodily functions were
controlled and as diversions of mind were introduced into lives that
had before been too unvaried for healthy functions.

I do not think that I have ever seen a case, and I have been closely
in touch with hard students for over twenty years, where I felt that
the cause of a headache was mental overwork. I have known men who at
the age of seventy or over have taken but four or five hours of sleep
and who have worked at their favorite subjects for the better part of
half a century. They never complained of headaches. Of course, there
are others whose physical and mental power is less and who cannot be
expected to stand a strain that for large-minded men is only the
normal exercise of function. It has not been the mental work that they
were doing, however, that was the source of whatever central nervous
disturbance was to be found in lesser minds, but worry and anxiety and
dread over what they were doing, anxiety as to what they were going to
do that constituted the real pathological agents at work.


_Local Conditions_.--A striking case that impresses patients much more
than the physician's declaration and is more likely to be remembered
and is therefore of psychotherapeutic value, is that of Von Bülow, the
German musician. He suffered for many years from excruciating
headaches. They were so severe as almost to drive him crazy. His only
relief was morphine and he and his friends lived in the midst of no
little dread that sometime or other either the pain or the process
which caused it would bring about a deterioration of mentality. After
his death an autopsy was made. It was found to be a small nerve fiber
pinched by a scar in the dura as a consequence of an injury received
when Von Bülow was very young. Many other stories of this kind have
been told.

It must not be forgotten that in many cases the pain is not within the
skull itself or at least its cause is not and other sources should be
carefully looked for. The connection of the eyes with headache has
been so well worked out, owing to the initiative of S. Weir Mitchell,
that nothing more need be said of it. One feature perhaps deserves to
be mentioned. While strain of accommodation is a frequent source of
headache and is at once looked for by ophthalmologists, there seems no
doubt that some headaches, much fewer than accommodation cephalalgias,
are due to muscle difficulties, that is, a lack of balance among the
external muscles of the eye, whose full pathological significance has
perhaps not yet been worked out. Headaches are {551} frequently due to
sinus troubles, especially to disturbances in the frontal sinus and to
intranasal difficulties. These must be eliminated before the patient
can be helped. Sometimes these nasal and sinus difficulties are signs
of a deeper constitutional disturbance, due to lack of fresh air and
exercise and are relieved promptly by the establishment of hygienic
habits.


Congestion Headaches.--Some headaches require changes of habit and
persuasion of the necessity for arranging the day's work so as to give
proper intervals for relaxation. Much experience with persons whose
absorption in their work causes them to miss a meal or delay taking it
for seven or eight hours from the last time of eating has shown me
that this disturbance of the routine of vegetative life is
particularly likely to be followed by headache. This headache is not a
mere dull ache and is much more than a sense of discomfort; it is
often an excruciatingly painful condition that usually does not come
on until toward the end of the day and then may seriously disturb
sleep. An interesting thing about this class of headaches is that
nearly always they are increased by lying down. Often only a faint
preliminary symptom of it is apparent when the patients go to bed,
though they may be wakened after two or three hours of disturbed
slumber by a headache that prevents further sleep, and pass the
remainder of the night in painful wakefulness.

Usually it becomes impossible to continue lying down. The head must be
raised and much relief is afforded by sitting up. The headache does
not disappear at once but it will gradually pass away and sleep may be
resumed after a half an hour of sitting up, though the sleeper will
have to be in a sitting posture. Older people get up and sit in an
arm-chair. I have found that placing a chair with a rather long back
beneath the mattress, the mattress slanting along the chair back at an
angle of about forty-five degrees and then an arrangement of three or
four pillows above that, will enable these patients to get to sleep
better than anything else. The ordinary remedies for headache afford
some relief, but even very large doses of the coal-tar products will
not relieve the pain entirely unless some arrangement is made for
keeping the head quite high and immovable.

The headache is evidently due to congestion. The reason for it is
perhaps the failure of the blood to be recalled from the brain to do
its usual physiological work at the digestive tract, with a consequent
distention of arterioles in the brain so that a little later they do
not react to prevent congestion. Usually with the headache there is
some digestive disturbance, a feeling of unrest, flatulency with
perhaps acid eructations. Accordingly the headache is often attributed
to digestive disturbance. But both would rather seem to be effects of
the same cause--the failure to supply the digestive apparatus with the
proper amount of material to work on at the time when it expects it,
while the mental absorption naturally attracts blood to the head. We
know from delicate experiments made in physiological laboratories that
at times of mental work there is an appreciably larger amount of blood
in the head. A proof of the connection between the lack of a meal and
the headache seems to be the fact that with most people even a glass
of milk and a cracker, taken at the time when the meal is normally
eaten, is sufficient to prevent the otherwise inevitable headache.

Whenever some such simple explanation as this for a headache is found
and the patient made to realize its truth on his own observation, the
{552} significance of the headache at once dwindles and it becomes
much easier to bear it. Before the very real pains of it were
emphasized by the dread of the consequences that would result from it.
If it was really a brain ache patients would find it hard to
understand how under its influence even serious changes might not take
place in the brain. This is only a rational suggestion, but it is
mental healing of the best kind.

Many of the aches which are spoken of as headaches are really forms of
tenderness associated with the integuments of the skull. Certain of
the muscles particularly are likely to suffer from achy feelings which
are spoken of as headaches. This is true of certain feelings of
discomfort in the frontal region and also of those that occur on the
occipital region. External applications of many kinds relieve
headaches in these regions, particularly in the frontal region. It is
easy to understand that such applications do not affect the contents
of the skull.


Some Occipital Aches.--Occasionally I have found that people who
complained of a sense of weight at the back of the head, with some
muscular tenderness, were sleeping on pillows that were too high. They
were over-exerting these muscles and this gave a sense of fatigue,
which when much attention was paid to it, became such an ache or at
least discomfort as is often found in the occupation neuroses. I have
seen schemata according to which headache complained of at the top of
the head meant digestive disturbance, headache in the anterior portion
of the head was referred to the eyes or the brain, and headache at the
back of the head spinal exhaustion or severe neurasthenia, but these
are at most very uncertain and I do not think that the tabulation of
cases justifies any such diagram of absolute causes and effect.
Usually there is some local condition that calls particular attention
to a special part of the head and then the attention being
concentrated complaint is made of that part.


Local Head Discomfort.--Usually a headache, accompanied by a localized
sense of pressure or weight or constriction, occurs in highly neurotic
people or those inclined to think much of themselves and whose
attention becomes concentrated on some part. At all times we have
sensations streaming up to our consciousness from every portion of the
body and anyone who wants to think about them, or a particular set of
them, can make them sources of considerable discomfort by
concentration of attention. Sometimes there are special conditions
that predispose to these localized sensory disturbances. I have known
tight hats to produce such effects. It is sometimes surprising how
tightly hats are worn. Nervous people are prone to overdo everything,
and they overdo the pulling down of their hats. At times the wearing
of a heavy hat will be the root of the trouble. I have known nervous
men accustomed to wearing high hats all their lives who began to
complain of headache when they were in the midst of busy worries and
troubles of late life, find considerable relief by abandoning their
high hats.


Toxic Headaches.--There are headaches that are due to the taking of
stimulants, as is well known from common experience. The mistake is
often made, however, of thinking that only alcoholic stimulation will
cause a severe headache. Tea and coffee headaches may be quite as
severe. Whenever people complain much of headache it is important to
revise their dietary as to the consumption of tea and coffee. Of
course, the headaches following {553} alcoholic stimulation are
usually recognized as such, though occasionally a man accustomed to
taking much alcohol without any such after effects is surprised in the
midst of the worry incident to business stresses to find that he is
having headaches. These are due to the combination of stimulants and
congestion consequent upon an excess of alcohol with the increased
brain work that is demanded, or even with the same amount of brain
work from a tired brain. Gradually stopping the alcohol will do more
to relieve these headaches than anything else. To advise the sudden
stoppage of regular quantities of spirits that have been taken for
some time, will sometimes produce an anemic headache and defeat the
purpose of the advice.

When for some other reason tea or coffee or alcoholic stimulants are
suddenly omitted after they have been taken to excess for some time,
patients' complain of a headache. Some of this is probably imaginary,
or at least is due to the idea that their craving for the stimulant,
whatever it may be, must have a local manifestation, and the head
sensation is exaggerated as a consequence. Tea and coffee cravings may
here give more trouble than the longing for alcohol. Sometimes there
may be a real disturbance of the circulation from the lack of the
heart stimulant to which the system is accustomed and therefore an
uncomfortable feeling in the head from brain anemia. This can be
overcome by not cutting off the stimulant, whatever it may be, all at
once, but by bringing about its gradual cessation. These patients,
however, are very prone, even with the best of good will in the
matter, to deceive themselves and find an excuse for not having their
favorite tipple, be it tea or coffee or alcohol, taken from them, so
that they readily create symptoms by auto-suggestion.


Direct Mental Treatment.--For both congestive and anemic headaches
mental treatment is important. For those suffering from the congestive
kind the physicians's business is not so much the cure of any one
attack of headache (for this can be accomplished by various now rather
familiar anodyne drugs as a rule), but the discovery and removal of
the cause for the recurring attacks. These will be found in some habit
of the patient which must be corrected. Drugs are seldom needed for
the underlying condition which occasions the headache, for when it is
due to such organic affections as brain tumors or other intracranial
lesions, drugs can accomplish very little. In less serious conditions
benefit may be obtained by having the patient change his attitude
towards certain important details of his life, such as eating,
sleeping, attention to business or to study and the like, so as to
prevent the mistakes of daily habit that predispose to headache.

With regard to anemic headaches, especially those which occur in
persons who are very much run down in weight, the most important
element of treatment is to bring about an increase in weight. This can
be accomplished much better through the mind than in any other way.
Appetite is a function of the will, and patients should have an
increase of diet dictated to them and then be persuaded to follow
that. I have seen many a headache disappear among teachers, and
religious workers particularly simply as the result of this measure.

As regards headaches for which no definite cause can be found mental
treatment is the only efficient remedy. Practically nothing but a
change of mental attitude towards the affection and its underlying
causes, whether these {554} be neurotic or psychic, will bring about
relief, and each patient is a problem quite distinct from any other.

There is no pretense that this use of mental healing for headache is
new or even modern. Many stories show that in olden times headaches
were often relieved by this means, and that suggestion was looked upon
as an important element in the treatment for their relief. In the
chapter on Great Physicians in Psychotherapy the quotation from Plato
with regard to Socrates curing the headache of his young friend
Charmides illustrates this very well.

In the old stories of Greek medicine there are a number of references
to headaches cured by suggestion or at least by mental influence. Miss
Hamilton, in her book on "Incubation," [Footnote 40] tells the story
of Agestratos and his headaches and how they were cured at Epidaurus.
Agestratos had a combination of headache and insomnia, the description
of the ailments having a strangely modern air. Just as soon as he came
to the Temple at Epidaurus he fell asleep and had a dream. The God of
Medicine, AEsculapius, whose cult was practiced assiduously at
Epidaurus, came to him in his sleep and promised him the cure of his
headache and at the same time taught him wrestling and advised its
practice. When day came he departed cured, and continued to practice
wrestling. Not long after he competed at the Nemean Games and was
victor in the racing. The suggestion that his headache would get
better had come to him and at the same time he had been given a
suggestion that provided him with occupation of mind and body. Many of
the people who suffer from persistent headaches need this advice more
than anything else. Probably every physician has had the experience of
headaches being cured by some interesting exercise, especially if
taken in the open air. The important factor is the change of mental
attitude, though changes in exercise, diet, amount of sleep and the
like are helpful auxiliaries.

  [Footnote 40: London, 1906.]


{555}


SECTION XVI

_NEUROSES_


CHAPTER I

NERVOUS WEAKNESS (NEURASTHENIA)


Neurasthenia, from the Greek roots, _neur_, meaning nerve, and
_sthenos_, strength, joined by the negative particle _a_, turning
strength into weakness, means nothing more than nervous weakness. To
tell a patient that he or she is nervously weak, or is suffering from
nervous weakness is usually not satisfactory, but it may be absolutely
true and may represent the limit of our knowledge with regard to the
particular case. To tell them that they are sufferers from
neurasthenia is satisfying as a rule, because then they have a nice,
long, and imposing word with which to talk to their friends about
their ailment. To discuss with friends one's own nervous weakness is
just a little absurd; to talk over neurasthenia and its symptoms,
however, adds importance to those symptoms and makes them seem
manifestations of some interesting underlying condition.

The discussion of symptoms always does harm, but the internal
complacency with its constant auto-suggestion of the underlying
nervous disease is still more harmful. Neurasthenia seems to most
people to signify a new and serious disease of the nervous system
which has developed as the result of our high-pressure civilization
and the modern strenuous life, and, therefore, has a special interest
and an exaggerated importance. All of this makes for an unfavorable
attitude of mind towards the affection and encourages the
intensification of symptoms by attention to them. The opposite state
of mind in which symptoms would be given their proper value by the
term nervous weakness would act as a constant source of favorable
suggestion. I believe that if the word neurasthenia must be used, it
should be translated for the patient and the absolutely functional
character of the affection insisted on in order to neutralize its
suggestive influence.

Probably the most serious objection to the use of the word
neurasthenia comes from the number of organic affections having vague
nervous symptoms, including especially tiredness, a certain incapacity
to do what was readily done before with tired feelings and a general
feeling of unfitness, that have come to be grouped under this head. In
this it resembles the word rheumatism rather strikingly. The
diagnostic general principles seem to be: tired feelings equal
neurasthenia; achy feelings (especially if worse on rainy days) equal
rheumatism. So whenever either word is used, patients are apt to think
of cases they have known which were labeled by one of these two terms,
{556} rheumatism or neurasthenia and ended by developing some serious
condition. The unfavorable suggestion consequent upon this has made
many patients miserable and has prevented them from using their
nervous energy to relieve their condition.

The use of the word neurasthenia has another decided disadvantage in
that the facile recourse to it often keeps the physician from
examining his patient sufficiently to detect an underlying
pathological condition. The term can be made to cover so much that it
has done great harm in this way. I feel, therefore, that in the
discussion of what can be done for patients suffering from nervous
weakness we should first of all describe and set aside a number of
forms of disease that have sometimes masqueraded as "neurasthenia" and
that have given the affection stronger unfavorable suggestiveness. Sir
William Gowers, whom no one would suspect of either minimizing the
significance of the word or of the affections that have come to be
grouped under it, nor of wishing to attract attention by differing
from others, has in one of his recent smaller medical works
[Footnote 41] emphasized both of these unfortunate connotations of the
word. Because his expressions as applied to other medical terms that
are too general in their significance, will help physicians to get at
the real meaning of them I venture to quote his opinion at some
length:

  [Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy
  and Other Lectures," Philadelphia, 1904.]

  The history of the word "neurasthenia" is noteworthy. ... I have to
  confess to the authorship of two words. One, "myotatic," was always
  a puny infant, and I doubt whether it still maintains an independent
  existence. The other, "knee-jerk," instantly attained universal use,
  and indeed, I think has seemed to most persons to have sprung
  spontaneously from the thing itself, without suggestion--perhaps the
  greatest compliment a word can pay its author. But the general use
  at once achieved by "neurasthenia" was in spite of a strong
  objection to it which was felt by many. The Royal College of
  Physicians of London could not include it in their "Nomenclature of
  Disease," and yet it is now one of the most common of medical words
  in every language. It would be instructive in more than one way to
  have a careful study of the forces which have influenced its career,
  but that I cannot attempt. We must, I think, admit that not only is
  it a satisfying word to those who suffer, but it has a certain
  convenience which has also compelled many to employ it who at first
  objected. If I may be pardoned for a partial paradox, its
  convenience is not the less real because this rests on features that
  are illusory. Remember that the word is a name which should have
  little meaning, even to those who use it. You may employ it to
  collect the symptoms of the case under a general designation, but do
  not let it cover them as a cloak.


Neurasthenia and Melancholia.--A serious mistake of diagnosis, though
it is often not a mistake of knowledge but of medical judgment, is the
confusion, apparent or real, of neurasthenia with melancholia. The
word melancholia has come to have a definite serious significance, as
it should, in the minds of many persons and as a consequence
physicians sometimes hesitate to use it, and employ instead the
all-embracing term neurasthenia, or neurasthenic depression. It is
popularly well known that melancholies are likely to commit suicide if
their condition is serious, while neurasthenia is not at all connected
with the idea of suicide. As a consequence, patients are often not
guarded as they otherwise would be and so we have suicides every {557}
month of so-called neurasthenics who were really sufferers from
melancholia. This sad state of affairs reflects in two ways to the
detriment of medicine. First, it leaves melancholies without due
protection. Second, it leads many of the neurotic patients whose
ailments have been labeled neurasthenia and who read the stories of
these supposed neurasthenics, to think that they, too, are tending
toward suicide and so they are less capable of reacting against their
neurotic condition and in general are much worse for the unfortunate
dread of some such fatal termination.


Neurasthenia Simulation by Organic Disease.--Neurasthenia is
especially a dangerous term since, like other words of this kind with
wide connotation, many quite disconnected diseases may in early stages
simulate it and give rise to the thought that there is only a
functional nervous disease present, when the symptoms are really a
manifestation of an underlying organic disease, heightened somewhat by
a nervous organization or by worry on the patient's part. So-called
neurasthenia in the old must always be looked upon with suspicion.
Neurasthenia in the young may be a purely functional nervous disease,
though it is probable that in most cases the nervous system is
congenitally defective, or at least is unable to perform the functions
which have been assumed by the patient. If a nervous organization has
stood the strain of the trials of early and middle life, which are
usually severe enough to try out individuals from the physical side,
if they are in moderate circumstances, or from the mental side if they
are wealthy, it will not, as a rule, be overborne by the burdens put
upon it by age unless some organic disease has come to seriously
disturb it.


_Neurasthenia and Arteriosclerosis_.--There are many serious
conditions that masquerade as neurasthenia. Perhaps the most important
is precocious arteriosclerosis. That a man is as old as his arteries
is now recognized as an absolutely sure maxim of internal medicine. In
many people the arteries wear out before their time and in all there
is an inevitable wearing out in the course of years. With the
beginning of degeneration of the arteries there are likely to be many
symptoms that closely resemble neurasthenia. In the elderly these are
nearly always symptoms of defective circulation because of lack of
elasticity in the arteries and their failure to accommodate themselves
to the variations of pressure in the circulation as the consequence of
changes of position, variations in the barometer, heat and cold, and
the like.

In these cases a study of the blood pressure will give the
differential diagnosis when the actual thickening of the arteries
cannot be felt, but it must not be forgotten that nervous excitement
may greatly heighten blood pressure on occasions so that a number of
observations have to be made.


_Neurasthenia and Bright' s Disease_.--Other general diseases almost
inevitably produce nervous symptoms. It is curious how often a severe
exacerbation of Bright's disease, which has been in existence for some
time but has given no specific indication, is preceded by a series of
neurotic symptoms thought to be due to nothing more than neurasthenia.
Men of thirty-five to forty-five, the favorite time for the occurrence
of the severe forms of Bright's disease, begin to complain of
tiredness, especially on waking in the morning, of inordinate fatigue
in the evening, of some stomach symptoms and occasionally a tendency
to diarrhea. All of these are ascribed to a neurasthenic condition.
Early in these cases an examination of the urine should be made {558}
as a routine practice, because if there is nothing in it the patient
will be just that much more reassured, while if it contains any
pathological elements he need know no more about it than his physician
deems proper, yet the real nature of the case and its indications will
be appreciated. Without this a physician will often find himself
suddenly confronted by serious symptoms in a patient when nothing of
the kind was anticipated because the condition was thought to be
entirely functional.

Occasionally the symptoms of Bright's disease seem to develop
suddenly, as it were a storm in the organism out of a clear sky. As a
matter of fact, however, there have been for some time before more or
less indefinite symptoms pointing to some serious process at work,
which if valued at their proper worth might have led to a much earlier
diagnosis of the impending nephritis. Such patients are labeled as
neurasthenics for months and at times even years before the serious
conditions develop which make the recognition of their ailment
comparatively easy. One case of this kind has come under my
observation that is interesting in its lessons. A medical student had
during the first year of his course exhibited every now and then what
seemed to be neurotic symptoms. He was inclined to complain of
headache for what seemed very slight reasons, and of pains and aches
whenever there was a change in the weather and especially a fall in
the barometer. He often had stomach symptoms and was anxious about his
heart; in general he was looked upon as one of the nervous,
complaining kind. During the course of a lesson in clinical pathology
in his fourth year, he was asked to furnish a sample of urine which it
was supposed would be normal, for comparison with an abnormal sample
that was being investigated in the laboratory. To the surprise of the
professor and to his own consternation, his urine was loaded with
albumin. Up to that time there had been absolutely no objective
symptoms and only the vague indefinite subjective symptoms mentioned.
The next day his feet swelled. Even this for a time was considered to
be rather an index of the neurotic tendency in him to react to very
slight causes. It was hoped that the albuminuria was functional, as
the examination was made in the full tide of digestion, and that it
would pass off. Subsequent examinations, however, showed not only
albumin but also casts. There was a slight intermission of symptoms
and then an exacerbation. Within a month after the chance examination
of his urine and its unexpected result he had a convulsion. Two weeks
later, altogether six weeks after the albumin was first discovered, he
died in nephritic coma.

Such cases are not so rare as they are thought, though they are seldom
so fulminant. There is a story told of a professor at one of our
American medical schools who, some twenty years ago, took a sample of
his own urine in order to demonstrate the normal characteristics of
healthy urine, and to his utter surprise he found albumin and casts in
it. Within six months he was dead from Bright's disease.


_Nervous Diarrhea and Organic Disease_.--Other internal conditions may
be called neurotic when they are really due to definite pathological
entities. For instance, in three cases I have seen what had been
pronounced by several physicians to be chronic diarrhea of nervous
origin, proved to be due to quite other and serious pathological
conditions of internal organs. In one of them a chronic diarrhea of
several years' standing finally culminated in death in {559} early
middle age from nephritis. After the event, there seemed to be no
doubt but that the diarrhea, which no ordinary means of treatment had
succeeded in benefiting more than temporarily, was really due to the
effort of the intestinal mucosa to supplement the defective work of
the kidneys. In this case apparently one of the strongest evidences
that the affection was of nervous origin was the fact that whenever
the patient was away from home, eating rather plentifully of a varied
diet, his intestinal condition was better than when he was eating much
more simple and unvaried food at home. The change of scene and
surroundings proved a tonic to his kidneys and perhaps also to his
skin, thus saving his intestines some of the extra work they had
assumed.


_Neurasthenia and Diabetes_.--Another serious disease that may in its
earlier stages be mistaken for neurasthenia is diabetes. There is no
doubt that some patients have been passing sugar for a long time
before any sure symptom can be noted in their general health, or,
indeed, before there is anything to call attention to the possibility
of glycosuria. In many of these cases, however, there is a feeling of
muscular tiredness and a sense of inadequacy for occupations which
were before easy, that may be attributed to neurasthenia. When this
muscle tiredness changes to crampy feelings that should be enough to
lead to an examination of the urine.

Undoubtedly one of the reasons why neurasthenia is sometimes called
the American disease and is thought to be more frequent among us than
it is in Europe is this confusion with the beginnings of serious
organic disease because of failure to examine patients carefully in
order to detect underlying organic conditions. In recent years this
neglect has become rarer and the consequence has been a reduction in
the numbers of so-called neurasthenia cases. Our morbidity statistics
of twenty years ago, for instance, seemed to show that we had only
half as much diabetes to the population as they had in Europe. One of
the reasons for this was undoubtedly the ease with which the diagnosis
of neurasthenia might be made at the beginning of diabetes, and that
the terminal stages of the affection were often masked by the
development of the tuberculosis so frequent in diabetic conditions or
of albuminuria with symptoms pointing to Bright's disease. Even at the
present time it would be quite possible to reduce the number of
neurasthenia cases by more careful attention to diagnosis.


Simulated Neurasthenia Due to Over-attention.--While there is danger
of confusing neurasthenia on the one hand with more serious disease
there is a distinct liability on the other hand to exaggerate the
significance of certain minor symptoms by employing the word when it
is only over-attention of mind to certain portions of the body that
constitutes the disease in its literal sense. If something has
particularly attracted a patient's attention to some part of his
anatomy and if his attention is concentrated on it and allowed to
dwell long on it, his feelings may be so exaggerated as to tempt him
to think that they are connected with some definite pathological
condition and he may even translate them into serious portents of
organic disease. If a patient once begins to waste nervous energy on
himself because of solicitude with regard to these symptoms then it
will not be long before feelings of tiredness, incapacity for work, at
times insomnia and certain disturbances of memory are likely to be
noted. Then the neurasthenic picture seems to be {560} complete. This
is the process so picturesquely called "short-circuiting" by which
nervous energy exhausts itself upon the individual himself instead of
in the accomplishment of external work. Many of the worse cases of
so-called neurasthenia have their origin in this process. It is true
that this set of events is much more likely to occur among people of
lowered nervous vitality, but under certain conditions it may develop
in those who are otherwise in good health up to the moment when the
attention happened to be particularly called to certain feelings. The
physician can start these patients off anew after improving their
physical condition, if he can only bring them to see how much their
concentration of mind upon themselves is the cause of their symptoms.

It has been well said, though to some it will doubtless seem an
exaggeration, that we human beings are a regular boiler factory of
sensations which, fortunately for our sanity, mental and physical, we
have learned to neglect to a great extent. Wherever our clothing
touches us, wherever the air touches us, wherever shoes or belts
constrict us, there are definite sensations. These continue, but
attract no attention unless they exceed a certain limit to which we
are accustomed. Habit in this matter is very different in different
individuals. After men and women have grown used to tight shoes or
tight corsets these no longer produce disturbance. The chance visitor
in a boiler factory or loom room of a cotton mill thinks he could not
live in such din. But after a time people get so used to the din that
silence and quiet may even become oppressive to them. City dwellers
from the slums, especially children, find the peace of the country
disturbing when they are first taken for vacations.

Over-attention to sensations, often scarcely abnormal, is indeed the
real source of many of the symptoms that can so readily be exaggerated
into pathological portents when attention is directed to them. Every
portion of our body is connected with the central nervous system.
Every square inch of surface touched either by clothing or the
movement of the air producers a sensation at every moment of our
waking life. Ordinarily we pay no attention at all to these
sensations. We can recognize their presence by turning our attention
for the moment to any portion of the body and recognizing at once that
there are sensations coming from it, though the moment before we did
not notice them. If we think of the point of our big toe on the right
foot we find, though we were totally unaware of it a moment before,
that a certain pressure is being exerted in it. If we continue to
think of it queer feelings develop in it. We may get a sense of
numbness that proceeds up along the tendons that lead to it. We can
follow them up to the insertion of the muscles in the shin. If we
dwell on the subject we have curious prickly sensations and numb
feelings, all of which were there and were neglected a minute before
but now are acutely felt.

This same thing is true of all the manifold sensations that come
streaming into the brain. We learn almost to enjoy them though we are
paying no attention to them. To be without them would mean very often
a fright lest there should be something the matter. Usually we think
of the outside of our body as the main source of sensation. It must
not be forgotten, however, that our viscera have also certain
sensitive nerves and while these are not as closely distributed as
those on the surface they are there and their presence is often a
source of pleasure or at least of satisfaction, but may be the source
{561} of poignant discomfort. We are constantly disregarding ordinary
messages from these, too. Something may easily call our attention to
these sensations, however, and then we may translate them into
pathological terms though they are really only physiological.
Ordinarily man may put a couple of pounds of food and drink into his
stomach and not feel it at all. If anything particularly calls
attention to our stomachs, however, and we dwell on it, then this
weighty feeling may seem to indicate serious indigestion because of
the discomfort that is produced. This is what nervously weak persons,
the so-called neurasthenics, are constantly doing. It is this habit
that by suggestion and training they must be taught to break.

There is a tendency to the substitution of one neurotic symptom for
another whenever by psychotherapy and mental discipline one condition
is overcome. Often the substitution is of something just as bad or
even worse. I have known cases where people when properly persuaded
gave over paying too much attention to their stomachs and then
proceeded to pay too much attention to their sleep with the result
that insomnia developed. On the other hand, I have known patients to
get over insomnia and then develop a series of complaints of queer
feelings in their head which they usually spoke of as headache, though
when asked to describe them carefully they confessed that they were at
most a sense of pressure or of unusual feeling in some part of the
head.

These curious substitutions take place particularly if for any reason
special attention is called to another part of the body, either by
accident or by some therapeutic manipulation or remedial measure. I
have known a patient who complained of headache and was advised to
take up exercise in the open air, do much stooping and lifting while
cleaning snow from the sidewalk, develop a tired condition in the
lumbar muscles and straightway this was thought to be rheumatic.
Liniment was employed and the counter-irritation which developed
attracted the patient's attention to that portion of the body for a
week. The headache was no longer complained of, but lumbago was
considered to have developed. I have known a person who suffered from
headache develop what seemed to be a retention of urine for which
unfortunately the doctor thought it necessary to use a catheter and
after this there was no complaint of the headache, but the patient
became almost unable to hold any amount of urine in her bladder and
could not go out for social or other duties because of the fear of
imperative urination.



CHAPTER II

CHOREA


This twitching affection, so familiar that it need not be described
particularly, is sometimes classed as a pure neurosis, sometimes as a
nervous disease with perhaps some organic basis and sometimes is
placed among the ailments related to rheumatism and attributed to some
pathological condition of the circulation.


Etiology.--Two elements must be considered in the problem of the
etiology {562} of the disease--the predisposition and the direct
occasion. The affection occurs particularly in nervous children who
are made to occupy their intellects too much while their muscular
systems are kept quiet for long hours. Often a preceding running down
in weight is noticed, though sometimes the child only fails to
increase in weight as it should in proportion to its growth. It occurs
quite frequently among chlorotic girls just before or about the time
of puberty. Anemia generally seems to predispose to it, but the
affection may occur among children who seem to be in excellent
physical health, though usually a distinct nervous heredity is found.


_Immediate Causation_.--Fright is one of the most frequent immediate
causes or occasions of the development of chorea. Mental worry of any
kind may have the same effect. Scolding has produced it; a sudden
grief has seemed to be the occasion; a slight injury, and still more,
a severe injury, or a surgical operation, even a slight one, may be
the forerunner of it.


Pathology.--No definite lesions have been found to which the disease
can be attributed, though a careful search has been made for them.
Endocarditis is an extremely common accompaniment. It is probably
present in three-fourths of the cases that have come to autopsy. Osler
found it in sixty-two out of seventy-three cases in the literature.
The association of the affection with rheumatism is insisted on by the
French and English particularly, and certainly in a considerable
number of cases there is a history of preceding or coincident
rheumatism, that is, an acute rheumatic arthritis. Often these attacks
are concealed under such names as "growing pains" or "colds in the
joints" but it is not hard to elicit a history of a red and swollen
joint with some fever. In children mild cases may occur of genuine
acute rheumatism with the involvement of but a single joint and that
not severely. These mild forms are often found in the history of cases
of chorea.

It seems likely that the heart affection is often responsible for the
symptoms and it is probably through the endocarditis that whatever
connection there is between chorea and rheumatism exists.

All the elements in the disease point to the influence of the mind
over it. The predisposition is caused by over-use of the mind at a
time when many claims are being made on the nervous system because of
the growth of muscles. There must, as a rule, be a pathological basis,
natural or acquired, that is, something that tends to produce a defect
in the circulation, but even without this certain children suffer from
the affection. If the patient is an object of solicitude or of
curiosity at home or at school, the symptoms rapidly become worse. At
any time the consciousness of observation makes them worse. The
symptoms do not occur during sleep, or at times when the patient's
mind is much occupied with some absorbing interest. They lessen just
to the degree that the patient's own attention is not called to them
or the consciousness not allowed to be concentrated on them. Chorea
often occurs in bright, intelligent children and always seems worse in
them.


Treatment.--The story of the therapeutics of chorea in recent years
strongly confirms the idea of the place of mental influence in the
cure of the disease. We have had a whole series of remedies,
introduced with a promise of cure by distinguished authorities, used
for a time with apparent success by many physicians, and then
gradually falling into innocuous desuetude. It was recognized that any
remedy would have to be used over a rather {563} prolonged period, at
least from five to ten weeks. It was appreciated, also, that the
patient must be kept quiet, both in mind and body, emotional
disturbances especially being avoided, that all physical functions
have to be set right and that the nutrition particularly must be
corrected if in anything it is abnormal. Where all this is done
patients recover without any remedy quite as promptly in most cases as
with any of the supposed specifics. Expectant treatment, supplemented
by symptomatic treatment, has proved in many institutions to give
excellent results without the necessity of troubling the patients with
more or less dubious drugs. It was important that the patient should
be given certain medicine and impressed with the idea that this
medicine was expected to do them good, a suggestion automatically
emphasized at every dose, but it is probable that few men of
considerable clinical experience now hold the notion that we have any
genuinely curative remedy for chorea, though we have certain tonic,
alterative remedies which, in conjunction with the setting of the mind
at rest, help to put the patient in a condition where the affection is
gradually overcome.

The most important object in the treatment of chorea must be its
prevention or its early recognition, and its immediate treatment; then
there is little likelihood of relapses and, above all, the condition
does not last long. Children who have had an attack of acute articular
rheumatism or who have suffered from growing pains or any other of the
rheumatic simulants of childhood should be watched carefully during
their growing period and at certain critical times in early life. They
should be especially regarded immediately after being sent to school.
The first sign of involuntary twitchings should be taken to mean that
the children are overborne and a period of rest from anxiety and study
and over-exercise should be afforded them. Of course, all this
watchful care must be exercised without attracting the little
patient's attention, or the very purpose of the care will be defeated
and the mind disturbed.

Rest does not mean that patients should be kept absolutely in bed even
after chorea has frankly developed, but that there should be hygienic
rest. Long hours of sleep, interesting occupations without much
exercise, a period of lying down in the afternoon, but, above all,
such occupation of mind with simple pleasant things as keeps their
attention from themselves. Visitors should not be allowed to see them;
above all, they should not be conscious objects of over-solicitous
care on the part of father and mother or the relief of symptoms will
be delayed and the condition will be made worse. As a rule, children
do not worry about themselves nor their physical ailments, but they
can be made to do so by seeing the over-anxiety of others. A good
nurse of sympathetic nature with power to interest the child, is
better than its mother for a constant companion, though family life,
the playing with brothers and sisters and the regular routine of home
is the best possible mental solace and occupation. Grandmothers are
useful adjuvants in the treatment late in the affection. At the
beginning their over-solicitude nearly always does harm.


Habit Following Chorea.--In certain nervous children after the chorea
itself has subsided there remains a habit of twitching that often is
almost more intractable than the chorea itself. This is particularly
likely to be manifest in children who have an unfortunate nervous
heredity or in those whose {564} nervous systems have been impaired by
preceding infections disease as anterior polio-myelitis, syphilis or
one of the forms of meningitis. Occasionally it is seen in children
without nervous heredity, but they are usually children surrounded by
solicitous relatives, made the centre of pathological interest and
constantly fussed about. The habit is not surprising and would remind
the observant physician of the whoop that by habit sometimes clings to
children in any cough that they may have for months after they have
had whooping cough. Often it will be found that these children are
capricious eaters, that they take tea and coffee, that their diet
instead of being the simple nutritious food that they should have
consists of many things that their mothers obtain to tempt their
appetites and that the children can really have anything they crave
for and get it much oftener than is good for them. To continue any
form of presumedly specific treatment in these cases does no good. If
arsenic is used over long periods, or any of the salicylates because
of the supposed connection of chorea and an underlying rheumatic
diathesis they will certainly do harm. The patients' diet can be
regulated, nerve stimulants of all kinds must be denied them, and
their appetites must be brought into order by the proper care of a
nurse who will not yield too readily to their caprices, and then the
solicitous environment must be changed. These cases represent a good
many of the so-called prolonged choreas and are really habits or tics
due to concentration of mind and a certain hysterical tendency to
continue to attract attention which may be noted.



CHAPTER III

TICS


Without any good reason in the etymology or the history of the word,
the term "tics" has now been generally accepted to signify certain
involuntary movements, frequently recurrent, of which, by habit,
certain persons usually of diminished nervous control, become the
victims. For the psychotherapeutist, however, they have an interest
quite beyond that which they have for the ordinary student of nervous
diseases. They represent the possibility of the formation of habits in
the nervous system, originally quite under the control of the will,
but which eventually become tyrannously powerful and quite beyond
management by the individual. They deserve to be studied with
particular care because it is probable that they represent objectively
what occurs also on the sensory side of the system, but which not
being manifest externally, is spoken of as entirely subjective. If
nerve explosions of motor character can, through habit, get beyond the
control of the patient, it is not unlikely that sensations, primarily
of little significance, may, in persons of low nervous control, become
by habit so likely to be repeated as to make the patient miserable.
Hence the study of tics as here presented.

As a result of the studies of Gilles de la Tourette, we realize that
there is an essential distinction between involuntary movements of
various kinds, and that spasms and tics must be separated from one
another. Tics consist of various movements of the voluntary muscles.
Probably the most familiar {565} is that of winking. Everybody winks
both eyes a number of times a minute quite unconsciously, though the
unconscious movement accomplishes the definite and necessary purpose
of keeping the conjunctiva free from irritant particles. When this
same movement is done more frequently than is necessary, or is limited
more to one eye than to the other, or is repeated exaggeratedly in
both eyes, then it is a tic. There are many other facial tics. Most of
them represent movements of the lips or of the nose or of the skin of
the forehead and all of them are identical with movements that are
occasionally performed quite voluntarily. There are movements of the
lips as in sucking, or smacking sounds may be made, or such movements
of the features as are associated with sensations of taste or smell.
Sometimes changes of facial expression may be tics and without any
reason there may be recurring expressions of emotion, of joy, or
grief, or fright, or even pain. Sometimes the tics affect structures
that are internal, as various motions of the larynx accompanied by the
production of grunting or sighing sounds or sometimes even of
particular words. In children the tendency is prone to manifest itself
in the utterance of forbidden words, usually vulgar, sometimes
indecent.

Besides these facial and throat tics any of the voluntary muscles of
the body may be affected. There may be the gestures that accompany
certain mental states, or there may be twisting or turning movements
as if the patient were in an awkward position and wanted to get out of
it, or as if the clothes were hampering movement and there was an
effort to relieve some discomfort. The head may be lifted and lowered,
or may be twisted from one side to the other and, indeed, various
nodding tics are extremely common. Almost any ordinary movement may,
in nervous people, come to be repeated so frequently as to be a tic.

Practically all of the convulsive or quasi-convulsive movements
associated with respiration are likely to become the subject of tics.
Yawning, for instance, involuntary to some degree, usually a reflex
with a physical cause, but so readily the subject of imitation, may
become so frequent as to be repeated a couple of times a minute and
this repetition kept up for many days. Sneezing may also become a tic,
though it is usually a definite reflex due to palpable physical
causes. Hiccoughs may easily become the subject of a tic. The
occurrence of a persistent hiccough is in popular medicine a sign of
unfavorable prognosis in serious diseases, especially such as involve
the abdominal region. In connection with neurotic affections of the
abdomen, however, hiccoughs are not uncommon and are of no serious
significance.


Varieties of Tics.--There are many more tics than are ordinarily
supposed. Indeed, there are few of us who escape them entirely. Nearly
all the curious phrases that people interlard so frequently into their
conversation, usually quite unconscious of them, or of the ridiculous
significance they often have, must be placed under the tics. Some men
cannot say a dozen words without interpolating "don't you know."
Others use some such expression as "in that way." I once knew a
distinguished professor of elocution who by actual count used this
phrase forty times in an hour. Some say "hum" or "hem" every sentence
or so. Whenever there is a bit of obscurity in their thought these
voluntary but unconscious expressions are sure to pop out. No one who
has had much experience in public speaking ever succeeds in keeping
entirely out of such bad habits. It is curious how phrases will insist
on repeating {566} themselves. One year one set of words, or a pet
phrase, or mode of expression, creeps unconsciously here and there
into an address. Then either because the speaker has been reading
dictated copy, or because some good friend has the courage to tell him
of it, he finds out the bad habit and suppresses it.

Word formulas senselessly repeated are only one of many forms of tics
that public speakers are prone to indulge in. Gesture which begins as
an artificial adornment of speech, very appropriate in itself, after a
while may settle down into certain forms that not only often lack
elegance but that are really disturbing to an audience. Of these
gestures and movements men are often quite unconscious. They have
become habitual and in the absorption of mind with the thought and the
words, they are reproduced quite involuntarily though they are all
originally voluntary movements. Nearly every public speaker needs a
mentor to correct him of such faults. It is rather difficult to break
some of these habits and it requires no little concentration of effort
and attention to be successful in eradicating them. It can be done,
however, provided the habit is not too inveterate, and this is the
best evidence that tics of other kinds can also be eradicated if the
patient really takes the matter in hand and is not of a weakened will.


_Teachers' Habits_.--Indeed it is almost impossible for public
speakers and teachers not to acquire certain habits irritating to
their auditors at first but amusing as they grow used to them, and
students particularly learn to look kindly at the ridiculous side of
many of them. I remember an old professor of literature who used to
lecture at some length on each of the important contributors to
English prose and poetry. We soon observed that whenever he came to
their deaths he took out his handkerchief and blew his nose. This was
as inevitable and as invariable a rule as the laws of the Medes and
the Persians. It was, as it were, his tribute of sympathetic
condolence with humanity for the loss of a brilliant contributor to
English literature.

Occasionally the effort to break up these habits will seriously
interfere with modes of thought and habits of expression, for the time
being at least. A professor at a certain university had a habit every
now and then of plucking at a button on his coat. His students could
tell when his hand was going to find this object of its occupation and
knew from experience that he would twist it a certain number of times.
He was not what would ordinarily be called a nervous person. One day
he happened to take off his coat shortly before a lecture and one of
the students surreptitiously removed the button. At the end of the
first few minutes of his lecture his hand went up to find the button
as usual but failed. For the moment there was a hesitancy in his
speech; then he tried again. A little later his hand went up
unconsciously and was disappointed; then he stammered and lost the
thread of his discourse. The last half hour of that lecture was
seriously impaired because of the absence of that button.


_Tricks of Speech_.--There are many other curious tricks of speech
that are really tics. Women often indulge in them and sometimes even
pretty women spoil their appearance by bad habits. All of us know the
pretty woman who talks very fast, but who every now and then projects
her tongue a little beyond her teeth. Occasionally there is a tendency
to wrinkle the nose or the forehead. Most of us have seen the woman
who sets her face into a definite smile of a particular kind whenever
her company manners are in {567} use, though there is a vacancy behind
the smile that is rather disturbing. Some people have habitual
movements of the fingers that are really tics, and even positions
assumed on sitting down that are very ungraceful, or that are very
noticeable, sometimes partake of this character.


_Fussiness_.--A very common form of tic that is quite difficult to
control is that tendency to be doing something with some of their
muscles which characterizes many men. They must handle a pencil or a
knife, or they must swing on their chair or tilt back on it, or keep
one of their limbs swinging over the other, or twirl their moustaches
or stroke their beards, or rumple their hair, and they cannot find it
quite possible to sit still. The difference between men and women in
this regard is remarkable. Women are conceded to be much more nervous
than men, but men are ever so much more fidgety than women. The author
of "The Life of a Prig" in his book "The Platitudes of a Pessimist"
has some striking paragraphs with regard to this subject. He says:

  To look nearer home, the British bar affords splendid examples of
  nervous fidget. Observe barristers pleading a cause. How they
  torture a piece of red-tape, how they twirl their eye-glasses or
  spectacles, and how they hitch at their garments, as if they
  momentarily expected them to desert their finely proportioned
  figures. But worse than the Queen's Counsellors, and even worse than
  the domestic peripatetic, is the villain who is abandoned to a
  performance vulgarly known as "the devil's tattoo"--drumming with
  the fingers.


_Writers' Tics_.--Writers, and above all writers for the daily press
and such as have to do their writing in a rush and therefore get
nervous and anxious about it, are especially prone to develop tics,
though others who write leisurely may do so. Some of these are curious
and others are only expressions of nervousness common to all people.
Many of them chew their nails, some of them bite at their fingers
round the nails and make them sore, many of them chew the ends of
their pens and find it practically impossible to keep a pen with a
long handle to it. Some of them run their hands through their hair
until it is in a greatly rumpled condition, some of them pluck at
their eyebrows. I have one patient who when he is going through a
particular nervous strain plucks out the middle portion of his right
eyebrow so that he has a distinct bald spot at this point.

The tradition in newspaper offices is that these curious expressions
of the tendency of the body to occupy itself with something while the
mind is occupied are more or less inevitable in nervous people. They
continue for many, many years. They are only habits, however, that it
would have been rather easy to break in the beginning, though they
become extremely difficult to modify after they have once secured a
firm hold. Occasionally I have fastened a piece of adhesive plaster
over a much battered eyebrow, but that made it difficult for the man
to go on with his work. His hand would go up involuntarily time after
time and while plucking at his eyebrow would not disturb in the
slightest his train of thought, just as soon as his fingers touched
the unusual object a serious distraction occurred and work was not
only slower, but much more difficult.


_In Games_.--The tendency to the formation of curious habits of
associated movements can be seen very well in most games where skill
is combined {568} to a certain degree with chance. It is most
noticeable, perhaps, in bowling. Few men are able to restrain
themselves from making some special movement just as the ball strikes
the pin. This is sometimes a motion of the head, oftener it is a jerk
of the trunk, sometimes it is an associated movement of the arms,
occasionally it is a kick or a stamp. In billiards the same movements
are noticeable if a man is much interested in making a difficult shot.
Usually there is some movement of the body or of the hands or of the
head that would indicate his desire to move the ball in a particular
direction. Women who play these games do not usually have these
associated movements to such a marked degree and this may be due
either to their better restraint to movement in general, for as we
have said men do not acquire the habit of self-restraint in small
matters of deportment as women do, or to the fact that such associated
movements might disarrange their clothes. Perhaps, also, they are not
as much interested in the games as a rule as are the men. Of course,
similar associated movements may be seen in outdoor sports that
require skill yet have an element of chance in them. For it is, as it
were, to overcome this that the additional movement is made.


_Children's Tics_.--Some tics consist of some very curious habits.
Occasionally children hear some obscene or vulgar expression and
repeat it. The repetition of it produces such a look of shock to
propriety on the part of some of the other little ones who happen to
be present that they repeat it in the spirit of bravado and then
continue to utter it until it becomes a habit that is hard for them to
break. After all, the use of blasphemy later on in life is really a
tic, a habit of uttering words no longer expressive of any particular
feeling, as a rule, unless in exceptional circumstances but just the
result of a tendency for the speech organs to repeat certain words.
They tell a good story of the Rev. Sydney Smith who, wishing to break
an acquaintance of the habit of indulging in expletives, interlarded
his speech with "fire tongs and sugar tongs" every ten words or so and
when his auditor protested that that added nothing to the significance
of what he said the Rev. Sidney suggested that that was also true of
various blasphemous expressions that his acquaintance was accustomed
to use.

At the Salpêtrière they tell the story of a little boy who had the
habit of saying the French word which the corporal in Victor Hugo's
"Les Miserables" made use of when anyone told him that it was because
Wellington was a greater general than Napoleon that the French Emperor
was defeated at Waterloo. Nothing seemed to be able to break the boy
of the habit of interjecting this word into conversations sometimes in
which he had no part and sometimes toward which he was expected to
take only a respectful and childlike attitude of silence. He was sent
to the Salpêtrière. The ordinary remedies had failed entirely. One day
he was allowed to go outside of the hospital, or rather stole out of
the gate and played marbles with some street gamins in front of it.
During the game he used the word in question and they proceeded to
give him a good thrashing. It is Charcot who tells that this broke him
effectually of the habit.

One of the childish customs that sometimes disturbs parents very much
because it seems to be such an unaccountable lapse into barbarism,
though it is really nothing more than a tic in the strict sense of the
word, is the habit that some children acquire of removing portions of
hardened material {569} from their nose and then putting it into their
month. Refined parents are apt to be so seriously disturbed by this
that they fear for the child's mentality. Really the habit is not
nearly so rare as is usually thought by some grown-ups who have
forgotten about their own and others' childhood. In country places the
habit is very common. It is not alone the dull children who do it but
some very bright ones. Indeed, the tendency to the habit is so common
that one wonders whether there is not something in nature that tempts
to it. Parents who are fearful lest their children may be seriously
hurt in health by the awfully insanitary habit may be reassured that
after all a certain amount of the drainage of the nose is normally
carried off through the posterior nares to the stomach and that no
danger to health seems ever to have resulted from the practice. As a
rule, the habit can be broken rather easily by a little judicious care
and insistence, though I know of cases where relapses occurred and the
habit continued surreptitiously.


_Motor Tics_.--Motor tics frequently develop as a consequence of some
injury to a nerve or some intense overuse of it. Winking habits follow
an herpetic involvement of the superior branch of the fifth nerve.
Bell's palsy is sometimes followed in the face by a tendency to
twitching on the unaffected side that makes the patient quite
uncomfortable. Herpes zoster is sometimes followed by a catching of
the breath, probably due to a little spasm in the muscles supplied by
the nerve thus affected. Some of the yawning tics have this origin.
Any neuritis may in the course of its betterment be followed by this
curious tendency to explosion along the nerve that has been affected,
as if the pathological process had more seriously interfered with
inhibition than with the actual function of the nerve. Examples of
over-exertion followed by twitchings are not rare. A scrubwoman who
has seen better days and now has to carry a heavy bucket and use her
right hand much with the brush may develop a twitching of the right
arm. A janitor's wife who sweeps much may have a tendency to
twitchings of the fingers as a consequence of the unusual exertion of
holding the broom. Twitchings in the limbs of men who work at a foot
lathe or other machine requiring foot power are not unusual though
they are more often seen in the leg on which the workman habitually
stands than in the other one and it seems to be oftener a strain on
muscles than actual over-exercise that precedes the development of
these tics.


Heredity.--Heredity plays as large a role in tics as it does in
stuttering and other functional nervous disturbances. Occasionally the
direct inheritance of some habit will be found, though there is nearly
always more than a suspicion that a trick of speech or of act, which
constitutes the tic, was learned by imitation rather than transferred
directly. Besides, it is a case of a similarly constituted nervous
system reacting in the same way to a similar environment, rather than
any definite tendency existing by heredity in the nervous system. It
is surprising what close observers children are and how easily they
learn to imitate any habitual action of father or mother or, for that
matter, of nurses or those who are close to them.


Mental Treatment.--The most important element in the psychotherapy of
tics is their prophylaxis. They run in families, not by any inevitable
hereditary influence, but as a consequence partly of imitation and of
corresponding tendencies resulting from certain weaknesses in the
family. Wherever they are known to be likely to occur, parents should
be warned of the {570} possibility and the first symptom of any motor
habit should be considered the beginning of a tic. As we have said,
they are likely to begin in muscles that have been overstrained for
any reason, especially when patients are run down. They are often seen
after herpes and certain facial neuralgias.

There is probably no tic, no matter how long or how serious, that can
not be eradicated, or greatly modified, if the patient will take the
trouble and if the treatment is conducted so as gradually to get rid
of it. Peculiar movements cannot be done away with at once. They can
be lessened in intensity and in frequency and then gradually the
patient will be encouraged by their becoming less noticeable than
before to make renewed efforts. The habit must be gradually undone and
this will take as long as it did to form it originally. The exercise
of contrary muscular movements carefully carried out, and of gentle
repression with definite times of exercise during the day, gradually
increasing the length of the intervals of repression, in the end
proves successful. Only a determined struggle will effect a cure. It
depends on the patient's will. Like a drug addiction, or a tendency to
overeat, or a craving for alcohol, it must be gradually overcome and
then care must be exercised to prevent relapses; for when the
condition is somewhat better, to relax vigilance and give up effort
will allow the old condition to reassert itself with startling
rapidity. People suffering from severe tics will often give up.
Without the patient's hearty co-operation cure is impossible. With
good will its gradual diminution gives the patient a confidence in
self and an uplift in character that is extremely valuable, not only
for physical but for mental conditions.



CHAPTER IV

STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC.


The difficulty of speech called stuttering has usually been considered
rather as an unfortunate lack of control over the organs of
articulation, somewhat corresponding to muscular awkwardness of any
other kind, than as a pathological condition deserving the physician's
attention. If anything was done for it formally, the first effort of
the parents or the teacher was to correct the supposed bad habits and
this failing the affection was relegated to someone who claimed to
produce wonderful results by some special method. Perhaps, even
oftener, stuttering was considered one of those affections,
fortunately decreasing in number, that the child may be expected to
outgrow. Often there was noted an hereditary element which was
supposed to indicate incurability.

Stuttering deserves special treatment in a work on psychotherapy
because it illustrates very strikingly one phase at least of mental
influence over bodily function. While in the study of the etiology of
the disease much has been made of anatomical features, nerves and
muscles and anatomical anomalies of the speech organs and the
respiratory tract, the sufferers from stuttering are certainly quite
up to the average both in the physiology and anatomy of these regions.
They are of all ranks and conditions of life, of all sizes and build,
and it is evident that the trouble is not physical, but mental. They
{571} pay too much attention to their speech and to the co-ordination
of the many muscles engaged in speech production and the consequence
is that they impair their power to use these organs. Practically all
the cures recommended contain some element which distracts the
attention from the speech to something else and so permits the
function of the speech organs to proceed undisturbed.

A number of conditions develop in nervous individuals that resemble
stuttering. There are disturbances of swallowing, disturbances of
walking (astasia abasia), neurotic disturbances of writing, and of
other uses of the hands and of the legs.


State of Mind.--It is perfectly clear to anyone who has closely
observed the ways of stutterers that the state of mind is extremely
important in these cases and indeed probably constitutes the
underlying factor in the speech disturbance. Stuttering and all speech
defects are much worse when the patient is laboring under excitement.
This is so amusingly true that the impotence of a stutterer to say a
word when he wants very much to say it is a commonplace in the cheap
drama and never fails to raise a laugh. In ordinary conversation with
friends the stutterer may have little difficulty. As soon, however, as
he begins to talk with those with whom he is unfamiliar his speech
defect becomes noticeable. When the others present are entire
strangers and, above all, strangers whom he wishes to impress
favorably, then his stuttering becomes pronounced. The mental element
is the most important factor. Just as soon as consciousness of the
task supervenes his power of co-ordination fails and stuttering
begins.


Stuttering in Complex Activities.--There are many actions that become
habitual and people are thus saved from the necessity of constantly
performing them under the control of the will and the consciousness.
Walking is a typical illustration of this and is seldom disturbed by
consciousness, but there may be a stuttering in the gait of sensitive
persons if they become overconscious when passing people who are
watching them. Talking is even a more striking example of elaborate
co-ordination without conscious effort. We have to bring into play
more than a score of muscles whose movements are nicely and accurately
co-ordinated, or else the effort at articulate speech is a failure. We
have to change the positions of most of these muscles many times every
minute, yet we do it without a thought of how it is done and most of
us accomplish it with ease and perfection.


_Stuttering Walk_.--Stuttering, after all, comes most naturally under
the head of dreads in the classification of the psychoses. Stuttering
is not a physical difficulty so much as a nervous apprehension, and
there may be a stuttering in any co-ordination as in speech. I have a
patient under observation who, if people are looking at her, finds so
much difficulty in walking because of a trembling that comes over her
that she fears she may not be able to keep from falling. Boys at
school whistle a certain air that requires a little halt in the gait
to keep time with it, as their schoolgirl friends go by, and it is
impossible for these not to drop into the peculiar gait indicated by
the time of the tune.


_Stuttering Writing_.--There are many men who become so nervous about
writing their signatures that they cannot sign while anyone is
present. There are others whose penmanship becomes very irregular, or
at least exhibits many signs of nervousness, whenever they think
someone is watching them. Most of {572} the difficulties seen in
speech may, indeed, be exhibited in writing. The same difficulty in
beginning, the same elision of letters under stress of excitement, may
occur.

Writer's cramp is, after all, much more of the nature of a stuttering
in writing than a real cramp. Over-action, added motions, and,
finally, incomplete power to act as desired are seen in both cases. It
might be expected that this would not affect so simple and familiar a
set of motions as those required for a personal signature, but it
does, as many cases illustrate. A typical example was the treasurer of
a large trust company who had to sign a number of bonds, some thirty
thousand. At the rate of 200 an hour, over three a minute, as he did
the first day with others making it easy for him, it looked as though
he could complete the task, huge as it was, in a month. At the end of
a week, however, the rate had fallen to 120 an hour and, toward the
end of the second week, one a minute on the average was all that could
be accomplished. At the end of the month his signature, while
retaining certain of its original characteristics, had become very
different from what it was at the beginning and signing had become an
extremely difficult matter. He had to take a rest from business for
several weeks after accomplishing this apparently mechanical
procedure.


Emotional Ataxia.--Dr. S. Weir Mitchell in his article on "Motor
Ataxia from Emotion" in the May number (1910) of _The Journal of
Nervous and Mental Disease_, discusses some cases in which inability
to write even a signature came as a consequence of nervousness and
emotional disturbance.

In one of Dr. Mitchell's patients, other manifestations of ataxia
occurred as the result of the consciousness that people were watching
the patient. At times he is compelled to leave a dinner table, since
with strangers it is almost impossible for him to eat. If there are
two or three at the table with him, however, and especially if he is
worried about himself, he may become almost helpless, requiring both
hands to get a cup of coffee or a glass of water to his mouth. A
patient of mine with like symptoms has described to me equivalents of
various kinds to his own difficulties in his sisters. One of them
cannot play the piano before strangers, though an excellent musician.
The other cannot crochet with any success if any but intimate friends
are present. How much of this family trait is due to suggestion or
psychic contagion would be hard to say. The state that comes over
amateur actors and which makes them forget their lines, stammer in
their speech, walk awkwardly, and trip easily, are really
manifestations of this same incapacity to control even familiar sets
of actions when there is great self-consciousness and over-attention.


Mental Influence.--The correction of these conditions comes through
soothing the mind of the patient and getting him or her not to be so
self-conscious as to disturb action by thought about it. It is easy to
say this and extremely difficult to do it. In certain nervous
organizations it is quite impossible to overcome the tendency to this
ataxia or inco-ordination of voluntary movements. Much can be
accomplished, however, by proper training and discipline in all cases,
and, while the patient can never be completely cured, great
improvement may be brought about by patient habituation under
favorable circumstances. In Dr. Mitchell's cases the taking of a glass
of whiskey or of wine sometimes stimulated the patient so that
co-ordination became possible where it was impossible before. In
nearly all cases of writer's cramp {573} and writing difficulties the
power to write is restored for a time by such stimulation. Strong
coffee will sometimes serve the purpose as well as alcohol. It is easy
to understand, however, how dangerous is the resort to such
stimulation.


_Practice in Self-Control_.--The excitement and nervousness incident
to appearance before an audience which make thought and speech so
difficult and action so awkward and so exaggerated gradually disappear
as the individual becomes habituated to appearing in public. In most
people there is never a complete loss of self-consciousness with
entire freedom from nervousness, but the conditions are much improved
so that there is no noticeable interference with ordinary actions and
speech. Whenever there is some reason for additional excitement,
however, as when a new play is being put on, or when some special
audience is being entertained, there is a reappearance of many of the
old symptoms due to a self-consciousness.


Stuttering in the Young.--The prognosis of stuttering when it develops
at a certain period is much better than at others. The stuttering of
the very young can usually be overcome by a little careful training,
if it is taken early and treated patiently by a competent teacher. Not
infrequently a certain amount of stuttering develops at puberty when
the voice changes, partly due to the inability of muscles and nerves
to co-ordinate so easily as before upon the rapidly-enlarging vocal
chords and larynx, and partly to that greatly increased
self-consciousness amounting almost to painful bashfulness which
develops in boys about this time. Breathing exercises and especially
slow expiration is an excellent thing in these cases and distracts
their attention from themselves and their speech.

The chest has usually developed rather rapidly at this time and the
muscles have to some extent lost control over it, and it will be found
on careful observation that the breathing is particularly superficial,
that the descent of the diaphragm is quite limited and that the use of
this important muscle of respiration requires practice in order that
it may be controlled properly.


In Women.--Perhaps the most interesting thing about stuttering is that
it is ever so much rarer in women than it is in men. Something less
than one-fourth as many women suffer from it as men and this is true
for all periods of life. Women are usually more bashful and
self-conscious than men, but this rarely goes to the extent of
disturbing their speech faculties. Ungallant observers have suggested
that the sex quality of ready speech is too profoundly seated in
nature to be disturbed by mere bashfulness, but there seems to be no
doubt that the breathing of women has much to do with the difference
between them and men in the matter of speech defects.

When stuttering occurs in women the defect is much less tractable and
is usually dependent on a more serious disturbance of the psyche or of
the central nervous system. The prognosis of cases of stuttering in
women is not so good as in men, but remarkable cures are sometimes
effected by mental treatment of the self-consciousness which causes
the speech defect.


Correction of Respiratory Defects.--This last point, the correction of
all pathological conditions in the respiratory tract, is especially
important. Many stutterers are for one reason or another mouth
breathers. If they are mouth breathers because they have adenoids,
these must be removed. This must {574} be done early in life,
certainly not later than the third or fourth year, or else there will
come a serious deformation of the chest and that chicken-breastedness,
which is not undesirable in itself, but which hampers to some extent
the action of the diaphragm because that muscle cannot act as well in
the deformed as in the natural chest. Not all who are chicken-breasted
have any defect of speech, nor any tendency to stutter, but when there
is a natural tendency to a lack of inco-ordination because of
sub-normal nervous ability the presence of such a deformity makes the
prospect of cure much less favorable than would otherwise be the case.
If the mouth-breathing is due to stoppage of the nostrils, this must
be relieved.


Realization of Allied Conditions.--A helpful suggestion for stutterers
is found in the recognition of the fact that there are so many
conditions allied to stuttering and so many people afflicted with
them. Under the heading Neurotic Esophageal Stricture stuttering in
swallowing is treated of. In the chapters on urinary symptoms
stuttering in urination is discussed. Any set of muscles requiring
careful co-ordination may thus be disturbed. The stutterer is apt to
look upon his affliction as a very special individual annoyance. When
he learns that in practically every set of muscles requiring nice
adjustment for function like difficulties may occur, that in every
action requiring careful co-ordination of muscles there may be a
similar disturbance, and yet that in most of them careful mental
discipline, especially training in self-control, proves a source of
relief, he takes new courage to face the struggle necessary to
overcome the self-consciousness which is the root of most of these
troubles.

A striking form of inability to co-ordinate muscles so as to enable
them to perform their ordinary function is aphonia, or mutism,
sometimes spoken of as hysterical mutism. After some sudden emotion or
fright or accident a neurotic person proves to be quite unable to
talk. He cannot utter a sound. In Prof. Raymond's clinic at the
Salpêtrière I once saw the classical case described by Charcot and
presented at his clinics several times. It was a man whose wife had
run away from him and been taken back three times. Each time on her
disappearance he had an attack of aphonia, inability to utter a sound
of any kind. It lasted for from several weeks to a few days. The cases
are much commoner in women. After a disappointment in love or a scare
the patients become unable to speak. Sometimes they can whisper but
cannot phonate. The affection is entirely functional or neurotic, and
if the patient's mind is properly predisposed speech returns without
difficulty or delay. A little massage of the muscles of the throat or
of the tongue by means of a tongue depressor or the use of Politzer's
bag in the nose with the assurance that after proper swallowing
movements the ability to speak will return, have proved successful.
Occasionally hypnotism is recommended for these cases, but many of
them are too highly neurotic to be readily susceptible to hypnotism
and, besides, suggestion in the waking state proves just as effective.

After several days of speechlessness it seems little short of
marvelous to make a patient talk readily after a little massage of the
throat. It is all dependent, however, upon confident assurance and the
suggestion to talk. The physician himself must possess absolute
confidence in his power to bring this about, for the slightest sign of
doubt or hesitation will make it impossible {575} to influence the
patient and will completely destroy his psychotherapeutic efficiency.


_Neurotic Esophageal Stricture_.--A rare but interesting form of
neurosis, which should be studied in connection with stuttering
because of the light shed on both by their relations to each other, is
that seen in the sufferers from so-called neurotic esophageal
stricture. These patients are unable to swallow solids except after
determined deliberate effort and occasionally the discomfort caused by
this effort leads them to eat much less than is sufficient for their
nutrition. The physician is sometimes tempted to overcome the
spasmodic closure or partial closure of the esophagus by bougies and
dilators, and these the patients learn to pass by themselves. I have
never known any of these cases to be benefited more than temporarily
by this treatment and I have seen two that were made distinctly worse.
Forcible dilatation by concentrating attention on the affected parts
hampers the proper flow of nervous impulses and the ordinary reaction
to these which should occur.

To appreciate how closely related to stuttering this spasmodic closure
of the esophagus is, it is necessary to see these patients swallow
when they do not know that they are under observation. For when they
are on exhibition for the physician, when their condition is
intensified by the excitement of the occasion and by the definite
purpose to make the doctor appreciate how serious is their case, they
swallow with more difficulty. Nearly always they have more difficulty
in eating in public than with friends, and it is only with those with
whom the patient is on a footing of perfect familiarity that the best
swallowing power is obtained.

In sufferers from esophageal stricture of the neurotic type the
muscles by an unfortunate perversion of nerve force contract in front
of the bolus instead of behind it. This contraction may be so complete
as to prevent even the swallowing of liquids. Usually, however,
liquids can be swallowed without much difficulty. Such patients, then,
if they become much run down in weight, must be fed on milk and eggs
and ice cream and the gruels and soups until they gain in weight.
While they are much under weight their condition is distinctly worse
and their power of co-ordination much less. It is, however, not hard
to make them gain in weight. This gain in weight acts as a strong
suggestion which persuades them that they are getting better and this
of itself soon helps them to control their muscles. Local treatment
does harm rather than good. Ice in small pieces swallowed shortly
before a meal seems in some patients to have the effect of making the
muscles less prone to follow the inco-ordinate nervous action and thus
renders swallowing much easier. In some, and especially in nervous
people, warm liquids have the same effect, while ice produces further
irritation. Acids nearly always increase the spasmodic condition.
Sucking a piece of hard candy for some time before a meal, especially
if it is not too sweet nor flavored with acid, helps some people.

Nearly all of them when carefully questioned prove to have special
foods that are more difficult of deglutition than others. Not
infrequently these idiosyncrasies for food are found to follow ideas
with regard to their digestibility. If the patient is hurrying for any
reason and suddenly becomes conscious that he is not masticating
sufficiently, swallowing at once becomes much more difficult.

{576}

The main element in the treatment, however, must be as far as possible
to get the patient's mind off his condition. The more attention he
gives to it the worse it will be. No treatment that we have will cure
it any more than stuttering can be cured, though a deliberate effort
to form a habit for the control of the swallowing muscles will often
do much to lessen the discomfort and the inability to swallow.

It is important in all these cases to be sure that there has been no
incident in childhood which might have caused the production of scar
tissue in the esophagus with a consequent stricture. Sometimes it is
many years before this manifests itself and, as in the case of the
urethra, even ten to twenty years may pass before serious trouble
comes. When the first symptoms are noticed, the actual stricture may
be so slight as scarcely to be possible of diagnosis by the bougie.
Occasionally the first symptom of a cancer of the esophagus is an
inability to swallow, and cancers of the esophagus have been known to
occur in quite young people, especially young men. I remember seeing a
case at autopsy in Vienna where the first symptom had been the
difficulty of swallowing and the man, at the recommendation of
friends, swallowed a glass of beer with some black peppers in it and
these stuck in his esophagus and produced death. Such cases are
exceptional but must not be forgotten. Neurotic esophageal stricture
is entirely benignant and its prognosis altogether favorable.


Treatment.--The treatment of stuttering presents the best example that
we have of the influence of the mind over neurotic difficulties of any
and every kind. Many forms of treatment have been announced as
successful, most frequently in the hands of men who have themselves
been stutterers and who have helped themselves by them. This would
seem to make it clear beyond all doubt that discoveries in direct
therapeutics had been found. As a matter of fact, however, when a
review of all the methods is made, they are seen to be so different
from one another and founded on such essentially diverse principles
that the only common connecting link to be found is in the occupation
of mind with something else besides speech which all these methods
recommend. We have had successful cures announced by surgery, by
discipline, by making speech more difficult by obstacles of various
kinds, by special positions of the tongue--up against the palate or
down against the floor of the mouth--by associated movements, by
rhythmic speech, by special control of the muscles of respiration, and
of many other structures much less related to speech. The interesting
phase of all this is the uniform success claimed by different
specialists using many different methods.

From the beginning of history cures have been suggested. That idea,
still held among the non-medical, that the sufferer from a difficulty
of speech is tongue-tied and needs to have the frenum cut, is as old
as the history of medicine. Galen suggested cauterization of the
tongue. Aetius, the first prominent Christian physician of whom we
have any record, divided the frenum of the tongue. So did Paul of
AEgina. Of course, in the Renaissance, when the old medical classics
were revived, this became a favorite method of treatment. Hildanus is
sure that it accomplishes great things. This idea has never been
entirely given up, and recurs from time to time in the practice of
those who do not reason much, but who look for some ready explanation
and, above all, some direct method of treatment. Much more {577}
serious surgical intervention has been suggested from time to time,
however. Velpeau advised division of the extensor muscles of the
tongue. Of course a number of surgeons have quite properly insisted on
the removal of the tonsils, uvula, polyps in the nose and other
obstructions of respiration.


_Singing in Treatment_.--A number of the stuttering cures employ
singing as a method of training in forthright utterance. Few people
stutter when they sing. Most people can be given confidence in
themselves and their power to talk right on by being shown that as
soon as they try to follow a set of notes there is little or no
difficulty in utterance. The teaching of singing, then, is of distinct
value in many cases. Taking advantage of this a number of those who
correct stuttering endeavor to introduce a certain rhythm into speech.
So long as the rhythm can be maintained stuttering does not occur. As
Kussmaul has pointed out the rhythmus acts as an efficient
will-regulator, so that nerve impulses go down regularly and are not
interrupted by consciousness and by the sudden starts and stoppages
due to fear and tremor and mental uneasiness. Undoubtedly the lesson
of this method of teaching is extremely important as an index of how
stuttering may be relieved.


_Regulation of Respiration_.--A number of systems to correct
stuttering depend on the regulation of breathing. It has been shown
over and over again, and notably by Prof. Gutzman of Berlin,
[Footnote 42] that one of the most important differences between
stutterers and those who talk naturally is that the normal individual
talks during expiration as may be seen in Fig. 23, while the stutterer
begins at the end of inspiration or at least where normally on the
respiratory curve expiration is just about to begin, but instead of
permitting his diaphragm to go up as in ordinary expiration, the
stutterer makes it sink lower and lower in a forced inspiration.

    [Footnote 42: See my translation of one of his clinical
    lectures In _The International Clinic_ for July, 1899.]

  [Illustration: Fig. 23.--Normal Diaphragm Curve in Normal Breathing.
  Expiration as we Talk Normally.]


  [Illustration: Fig. 24.--Curve in Diaphragm Before and During Talking
  by a Stutterer.]


_Attention to Something Besides Speech_.--The attention must be
centered on something besides speech itself. This is the important
element in any method of treating stuttering. If it is allowed to
occupy itself with that {578} nothing will save the individual from
getting tangled in the efforts that he makes to co-ordinate the
complex movements necessary, though if he would only allow them to
proceed automatically, as do the rest of mankind, there would be no
difficulty at all. Washington Irving, so ready with the pen, could not
utter two successive sentences at a banquet without having to sit
down, with expression absolutely inhibited from excitement.
Expression, thought, utterance--all may be inhibited by overconscious
attention, which may also disturb all other complex activities.

The most interesting methods of treatment for stuttering are those
which involve the use of various hindrances to speech and which would
seem to be least likely to make it possible for a person already
laboring under speech difficulties to talk with more ease. The secret
is, of course, that the added impediments so distract the attention of
the patient that he is unconscious of the co-ordination necessary for
speech and so accomplishes it without difficulty. It is because of
over-attention to himself that the disturbance occurs. These methods
developed very early in history. We all know the tradition of
Demosthenes overcoming his impediment by placing pebbles in his mouth.
One of the most earnest advocates of a similar method, who had himself
suffered very seriously from stuttering was the Rev. Charles Kingsley,
one of the most distinguished of English literary men. He cured
himself, or at least greatly relieved his symptoms, by keeping a cork
fast between his back teeth.

There have been many other curious suggestions for the cure of
stuttering. What was known as the American method had great vogue in
the early part of the nineteenth century. It was probably invented by
Yeats of New York, though it came to be known as the Leigh method.
Yeats, himself a physician, seemed to fear that he might fall into
professional disrepute if he advertised the method in any way, so he
had his daughter's governess, a Mrs. Leigh, open an institute for the
cure of stuttering in which this method was practiced and it proved to
be very successful. The entire secret of it was to have the patient
raise the tip of the tongue to the palate and hold it there while
speaking.

Another mode of treatment that attracted considerable attention
consisted mainly of just exactly the opposite maneuver, that is,
keeping the tongue as far as possible firmly placed on the floor of
the mouth during speech. It is evident that neither of these
suggestions does anything more than occupy the patient's attention
with an additional activity, so that his speech function may be
allowed to proceed automatically of itself, as it will if not
disturbed by attention to it and by conscious attempts to regulate the
various activities of it. Instruments were invented to help the
patients to secure various positions of the tongue. Itard, for
instance, during the second decade of the nineteenth century invented
a golden or ivory fork to be placed beneath the tongue, so as to
support it.

After the various methods of managing the tongue, the most popular
curative maneuver has been that of regulating the breathing. During
the nineteenth century there were at least a dozen different methods,
all of which had a number of reported successes, of treating
stuttering by means of breathing exercises.

Very simple methods of diverting the attention from speech are quite
{579} sufficient in many cases to bring improvement. For instance, the
insertion of extra letters that are themselves easy to say between
words or preceding consonants that are hard to utter has been a
favorite method among the specialists in stuttering. Johann Müller, as
I said, suggested an e. Others have suggested an n. Occasionally
stutterers themselves form the habit of using an m or a to and find
that it aids their facility in uttering difficult sounds over which
they would otherwise halt and stutter. A combination of these methods,
as, for instance, an e between all words and the placing of an easy n
before the most difficult sounds, has been repeatedly revived as an
infallible method of treatment.

All this serves to show that in patients whose functions are being
interfered with by over-attention diversion of mind must be the main
remedy. If this can be secured, the function they are disturbing will
be allowed to proceed unhampered. What will prove effective for one
patient will fail with another, however. After the patient gets used
to a particular form of diversion another must be tried. Simple
methods are sometimes sufficient to secure good results. The one thing
is not to be discouraged and to proceed from one effort to another,
satisfied even if relief is obtained for a while, for after relapse
another method of treatment may always be tried.


_Suggestion for Stuttering_.--There are many systems to train people
out of the spasmodic inco-ordination that constitutes stuttering. All
of these systems have their successes, but, as is well known, all of
them have their failures. When the patient has confidence in the
teacher and his method there is practically always quite a remarkable
improvement, at the beginning. This improvement is more noticeable
during the first month than at any other time. Not infrequently after
this there is a tendency for patients to drop back into old habits,
apparently discouraged, as a consequence of loss of confidence. It is
the mental element that means more than anything else. It is the old,
old story that we have to repeat with regard to every chronic ailment.


_Distraction of Mind_.--Each inventor is sure that his method is the
best and his "cured cases" support his claim. Others who try his
method, however, never succeed as well as he does and those who are
interested invent methods of their own. I have on my desk, as I write,
six different, infallible--to their authors--methods of treating
stuttering. I am sure that none of them succeed absolutely, that is,
none of them will cure every case and most of them will not succeed
beyond a moderate degree, except where the enthusiasm and the
confidence of the inventor or an immediate disciple of his is behind
them to make them efficient. There are all sorts of elements in these
cures, but most of them depend on their power to distract the patient
from his over-attention to himself and what he is doing when he talks,
so as to permit without hindrance the automatic movements which are so
necessary for the complex function we call speech. Those who have
spent most time in treating stutterers confess that the effect
produced upon the patient's mind is an extremely important part of the
treatment and that, if this cannot be secured, failure is almost
certain. If the patient has no confidence that he can be cured and by
this particular method, failure is inevitable from the very beginning
and just as soon as a patient loses confidence improvement ceases.


{580}


CHAPTER V

TREMORS


Two types of tremors come to us for treatment: those that are quite
involuntary and occur when muscles are at rest, and those that are
associated with voluntary movements. The most common type of
involuntary tremor is that seen in paralysis agitans to which a
special chapter is devoted. After this, though coming for treatment
much less frequently, is senile tremor which may, however, also be
increased by voluntary movement. The tremors associated with voluntary
movements are spoken of as intentional tremors. They may occur as the
result of organic disease of the nervous system and the most
characteristic type is that seen in multiple sclerosis. They are more
frequent, however, with functional diseases of the nervous system and
with emotional disturbances of various kinds. They are especially
frequent as the result of dreads. Usually the idea of tremor is
associated only with the head and the hands. Tremors may occur in
other parts of the body, however, and tremors of the legs are
particularly important. A familiar type is the tremor and unsteadiness
of the legs which occur as a consequence of the dread of heights when
a person unused to such situation attempts to walk across a narrow
path a great distance above the ground.


Senile Tremor.--The most common of the involuntary tremors is that
associated with old age. It develops in practically all very old
people, but it comes to some who are comparatively young. Its
occurrence at the age of fifty-five usually gives the sufferer a
severe shock which is emphasized by the attitude of mind of friends
toward the affection. They seem to be always sure that it is the index
of rapidly advancing age and that it is practically a signal of
approaching dissolution. As a matter of fact, when unassociated with
gross pathological lesions, the senile tremor has no such
significance. When associated with definite lesions it is the
prognosis of the special condition and not any supposed significance
of this particular symptom of tremor that expresses the genuine
outlook in the case. Many people who live to a very old age develop
tremor before they are threescore. Most of those who live to be eighty
or more have some tremor that develops about or just after the age of
seventy.


_Significance_.--Senile tremor is supposed to be due to, and in most
cases probably is the result of, an overgrowth of connective tissue in
the central nervous system which disturbs the ordinary conduction of
nerve impulses, rendering them wavering and uncertain. This seems to
indicate that it will not be long before the advancement of this
sclerotic process will make serious inroads on the vigor of the
individual. As a matter of repeated observation, however, the ordinary
involuntary tremor of old people may last twenty years.


_Reassurance_.--The main principle in the treatment of tremors of the
old is to make the patients realize that the symptom has no such bad
prognosis as is usually attributed to it. Of course, they will find
this out for themselves after a few years, but what they need is
assurance at the beginning lest during the period of depression
consequent upon the conclusion that the end is not far {581} off,
which seems to be forced on them by their fears and the foolish
sympathy of friends, their resistive vitality should be so lowered as
to permit the invasion of some serious disease. In spite of
apprehensions on the part of themselves and friends, tremor is rather
a good sign than a bad one. It indicates the formation of connective
tissue in the central nervous system, but this is always a slow
process and is usually quite benign. As a matter of fact, most
sclerotic processes are so chronic as to be compensatory in their
action for many other degenerations. Those in whom tremor develops
early often seem to be better protected against rupture of cerebral
arteries, as if the growth of connective tissue was a conservative
process here also. Information of this kind helps patients not to
borrow trouble because of their condition.


Intention Tremors.--The tremors that occur in association with
voluntary movements are often very troublesome and may be difficult to
manage. The worst cases are entirely functional. They are typical
neuroses and often develop as a consequence of some serious crisis
through which the nervous system has passed. In older people they
sometimes pass over into paralysis agitans or a close simulant of that
affection. The incident of the Texas sheriff and the Indian related in
the chapter on Paralysis Agitans illustrates how these tremors may be
induced.


_Tremors from Fright_.--Frequently the tremors have no direct
connection with any action, though they may be the result of fright. A
little girl bitten by a dog and much shocked may, for some time
afterwards, be quite unable to stand when she sees a dog on the
street, so disturbing is the tremor that comes over her. Tremors of
the same kind have been connected with horses after the patient had
been run down in the street, and, in one case that I saw even when the
patient was only thrown out of a carriage during a runaway.
Occasionally fright by a burglar may cause a distinct tremulousness
that supervenes whenever the patient thereafter is wakened suddenly at
night.


Influence of Dread.--Tremors of all kinds can be made worse by the
dread of them. In the chapter on Dreads we discuss the disturbance of
function by dreads and especially the tendency to exaggeration of
pathological conditions of any kind when the patient's mind becomes
concentrated on it. Steadiness in any position is due to a nice
balancing of extensor and flexor muscles requiring the sending down of
a continuous stream of impulses. The equilibrium is attained and
maintained in spite of the fact that, as a rule, the flexor muscles
are stronger than the extensors and better situated to exert their
mechanical force. If anything happens to disturb this balance even to
a slight degree, the mind becomes attracted to it and there is a
corresponding result as in stuttering, or other complex function when
surveillance is too great. It is important to remember this at the
beginning of all cases of tremor, for the patient nearly always
exaggerates his tremor by attention to it and can be made so much
better by reassurance and diversion of mind that he is much encouraged
and his general health usually improves, making him feel, even though
his affection is organic, that he is being cured.

Tremors may occur in connection with almost any set of actions
requiring special co-ordination of muscles, but they are especially
likely to occur when a feeling of dread disturbs the control over
muscles. A typical example of this is noted in shaving. There are many
men who cannot shave without trembling so as to cut themselves. The
feeling that they have a sharp instrument in their {582} hand with
which they may cut themselves sets up the tremor. There are others who
cannot shave because they dread that while using the instrument over
the important organs of the neck, and especially the blood vessels,
they may be tempted to cut their throats. This is, of course, purely a
dread and not a tremor. Some men find both the dread and the tremor
much worse at times when they are tired and worried, and can shave
very well at other times. Some men can shave very well when they are
not under observation, but if anyone is looking at them they tremble
and cut themselves. The safety razor usually does away with these
troubles, large or small, but if it should happen that by particularly
inexpert use they cut themselves even with a safety razor, especially
in the throat region, the old dread and tremor reassert themselves and
shaving becomes almost as difficult as before.


Self-consciousness.--Almost any position or action in which a man
feels himself under observation may cause one of these tremors. As a
consequence this particular set of actions may become the source of so
much discomfort as to produce an intense sense of fatigue. It may,
indeed, become quite impossible of accomplishment. Some teachers
cannot do demonstrating work on a blackboard before a large unfamiliar
class, at least not without serious efforts to control themselves,
though they may be facile demonstrators before a small class. I have
known men, however, who practically could not do blackboard work at
all because of nervousness. Their writing went all askew and very
often their thoughts would not follow one another in such order as to
make demonstrations possible. Sometimes they were good talkers, so
long as they did not turn their backs to the class and feel the eyes
of all on them. The same thing is true of such religious services as
Mass in the Catholic Church, where some of the clergymen have this
feeling. I know of priests who have not said Mass publicly for years
and others who can only say it in a small chapel before a few people
because of the intense discomfort of the fatigue caused by this state
of mind.


_Stage Fright_.--It is not alone the hands and the arms that tremors
are likely to affect, for they may also occur in the legs. A typical
and familiar case is the tremor that occurs upon the first appearance
before large audiences of orators or actors or clergymen. Owing to
excitement, they are unable to make flexor and extensor muscles
exactly balance each other and the consequence is a tremulous movement
that may be complicated by some swaying. Some people never lose this
in spite of long experience in public appearance. Young people may
have it upon being introduced to persons of whom they think a great
deal. This passes off with years, as a rule, but in some it persists,
and any excitement causes tremor of the legs and swaying movements.
The effort to control this is often severe and causes intense fatigue.

Any set of movements requiring even slight co-ordination of muscles
may be the subject of disturbance by a tremor. Since the writing of
the book on Pastoral Medicine, a text-book of medical information
meant to be of assistance to clergymen,  [Footnote 43] I have had some
rather interesting tremors associated with the performance of clerical
duties brought to my attention. One of these is a trembling of the
legs which makes standing at a high altar almost impossible. Another
troublesome tremor is that associated with the giving of communion.
{583} Most priests find no difficulty in the performance of the rite.
Some of them are much worried and anxious about it, however, and
develop a slight tremor. Others become so nervous in performing the
ceremony that they cannot succeed in placing the Host on the tongue of
the communicant without certain false movements. These may cause them
to touch the lips or the cheeks of the recipient and after this has
happened a few times the giving of communion becomes practically
impossible for them. Occasionally the men thus affected have no other
nervous symptoms and often they are very intelligent, strong-minded
men.

  [Footnote 43: O'Malley and Walsh, "Pastoral Medicine." Longmans, 1906.]


The General Health.--Tremor patients always complain more of this
symptom when they are in a run-down condition. One of them is a
wealthy merchant who, when he can be persuaded to take a vacation,
comes back with nearly all the manifestations of his tremor latent or,
at least, well under control. Another is a broker who at the end of a
long winter of excitement and worry is at his worst, but who after a
vacation in the North Woods is quite well again. Slight symptoms of
this kind are not unusual in teachers, especially women, though I have
seen them also in men, and are much more complained of at the end of
the year when the individuals are in poorer general condition than at
any other time. The symptom itself is annoying because of the notice
that it attracts, but their dread that it may have some serious
significance, indicating the development of a progressive lesion of
the central nervous system, constitutes the worst part of their
ailment. When the intentional tremor is intermittent and occurs only
at times of excitement, or when the patients are under observation,
they can be reassured that it is merely neurotic and that no ulterior
development is to be anticipated.


Treatment.--The treatment of these conditions consists first in
bringing the patient's health up to its normal condition as far as
that is possible. Many of the sufferers from tremors are under weight.
Whenever they are, a definite, determined effort must be made to bring
them up to it. This must be done even though they insist that they
have never been heavier and that to be rather underweight is a family
trait. In many cases it will be found that this family trait, instead
of being due to some inevitable hereditary tendency, is only the
result of family habits in the matter of eating. Many of these people
do not eat substantial breakfasts. Their tremor, too, is likely to be
worse in the early morning than at any other time during the day,
unless, of course, they have become overtired during the day, when the
tremor will reassert itself with vigor. Most of them are much less
disturbed in the afternoon than before. The drug treatment of the
affection consists mainly in the use of nux vomica, but, not in the
small doses of five or ten drops so often employed, but, according to
the size of the individual, beginning with fifteen or twenty minims,
thirty or forty drops, and gradually increased to physiological
tolerance, when the dose should be set somewhat below that.


_Mental Control_.--The main treatment must consist, however, in
enabling the patient to secure psychic control over himself and his
muscles. This is not an easy matter. Most of them are quite
discouraged, but their attitude of mind must be changed and the real
significance of their affection made clear to them. As a rule, they
have either heard or read or been told by a physician that their
intentional tremor is significant of a serious pathological lesion of
the central nervous system. Some of them have heard of multiple
sclerosis {584} and are much disturbed. They must be reassured and it
must be made clear to them that their disease is really due to
over-consciousness and consequent lack of control. A good deal of
reassurance can be given by telling them of patients who suffer from
ailments not unlike theirs, showing how multiform the affection is. A
man who has trouble with his signature may be told about the man who
finds it difficult to drink when under observation, then, as a rule,
he will better realize the neurotic character of his affection. With
hysterical women this method must be used with care or the story of
another patient will act as a suggestion and the physician will
subsequently be treated to an exhibition of the symptoms which he has
described.


_Self-Discipline_.--Persistent quiet discipline is the one thing that
eventually does any good. When patients are first told of this and are
persuaded to attempt it, they make such a determined effort to
overcome the affection that they make themselves more conscious of it
than before with the result that their tremor and spasmodic movements
are emphasized. It is the old story of the man trying to stand so
straight that he falls backwards. It must be made clear to them that
discipline, to be of any value, must be carried out as much as
possible without consciousness of it and with all available artificial
aids. The man who has trouble with his signature may be shown that he
can overcome much of the tendency to tremor and spasm of the forearm
muscles that are at the root of his difficulty by sitting at a higher
chair, so that his arm swings free of the table and so that, in
Gowers' phrase, if a pen were attached to his elbow it would write the
same thing as the pen in his hand. The man who trembles as he drinks
may be taught for a time to raise a cup to his lips while resting his
elbow on the table and bringing his head well down. Nearly always
methods of performing particular actions that require less effort can
be found, until the habit of over-consciousness and loss of control is
overcome.


_Hypnotism and Waking Suggestion_.--Occasionally hypnotism is
effective in these cases, but there is likely to be a relapse unless
there is some discipline before and after its use. Suggestion in the
waking state is often very effective. Patients need to be talked to
and even though intelligent they need to be reminded at regular
intervals for some time that their ailment is merely functional and
not organic. Nearly always it will be found that they trace its
beginning to some pathological event: occasionally there has been a
severe accident, but sometimes only a slight accident seems to them a
sufficient explanation. Sometimes it follows an attack of pneumonia,
oftener still typhoid fever. In these cases the patients become
convinced that this is one of the marks left after the accident or
disease and so it is rather hard to persuade them that they can be
cured. All such impressions, which act as auto-suggestions for the
continuance of their tremor and lack of control, must be combated,
otherwise there is very little hope of improvement. The preceding
disease is not the direct cause, though the weakness consequent upon
it may predispose to the tremor. Overhaste in attempting to resume
their occupations before their strength has returned is often the real
cause. It is the patient's mind more than his body that needs to be
set in order, but this will not be possible unless the physical
condition is normal and thorough reassurance can be given.


{585}

DISORDERS OF THE PSYCHE


SECTION XVII

_PSYCHO-NEUROSES_


CHAPTER I

PSYCHO-NEUROSES (HYSTERIA)


As the derivation of the name indicates, psycho-neuroses are
functional nervous affections dependent on states of mind. They are
not necessarily originated by the mind, though they may be. Their
spontaneous occurrence as pure psychic phenomena, however, is rather
rare. There is practically always some slight physical cause. This may
be severe, for all diseases have neurotic accompaniments that disturb
the nerves involved and exaggerate the original symptoms. In most
cases the patient has no serious interest to divert his or her mind
from this occupation with self, and as a consequence the particular
feeling fills up the whole of consciousness, and as it is painful to
begin with, the pain, following Cajal's law of avalanche, may become
almost intolerable.

It is of primary importance to remember, however, that there is
practically always a physical basis for these curiously interesting
affections which are so difficult to treat and which have so often
proved the despair of physicians. While the attitude of mind must be
changed, the physical state itself must be corrected. These two things
must be secured at the same time, however, for attention to the
physical state without correction of mental attitude will usually only
emphasize the condition by calling further attention to the symptoms.
This is especially true of local treatment. The mind must, above all,
be treated and diversion of attention secured. Psycho-neuroses may
occur in connection with sensory or motor nerves. The patient may
either complain of intense pain in some part of the body for which
there is but a very slight basis, or may be unable to move certain
muscles, or there may be a combination of sensory and motor symptoms
with complaint of pain on movement. The painful conditions are most
important because they prove a source of worry and anxiety to the
patient's friends, as well as often of such annoyance at unsuitable
hours as deprives those near them of rest to a degree that may
undermine health.

{586}


FORMS OF NEUROTIC SIMULATION


Every possible painful condition is simulated by these psycho-neurotic
conditions. They occur probably with more frequency in the abdomen
than elsewhere; they may be thought to be colicky in nature and, as a
rule, some accumulation of gas will be found. This gas is sometimes
swallowed air and sometimes gaseous products that have been diffused
apparently from the blood in the intestinal walls. This always
produces discomfort but nothing like the discomfort that the patient
complains of. The condition if treated by carminatives will nearly
always be emphasized rather than relieved. Local treatment by heat
will help oftener, but may exacerbate it. When chronic constipation is
present, calomel in divided doses is suggestive as well as medicinal.

There may be gastric crises that recall those of tabes, and there may
be vesical and rectal crises of a similar nature. I have seen a
patient complain of every symptom of stone in the kidney. At the
beginning the pains were vague, but after she had been to several
physicians and had been asked certain questions intended to elicit
pathognomonic signs of stone these questions were answered in the
affirmative. Her attacks became strikingly like renal colic. After a
consultation, at which two physicians and a surgeon were present, she
was operated upon for stone in the left kidney. No trace of it was
found. But after this she was well nearly a year. Then she had another
crisis of pain in the early morning hours, a time when her painful
condition always came on, apparently because it attracted more
attention and caused more disturbance at this time, and now all the
symptoms pointed to the right kidney. She was treated on the principle
that it was a neurosis, was made to gain some fifteen pounds in
weight, has since then had no attacks, has not passed any stones, and
there seems no doubt but that the whole case was merely neurotic.
During her attacks instead of having suppression of urine, she had a
free flow of urine and no blood. It is not unlikely that the physical
basis of the attacks was that condition of the kidney which allows
urine to flow through very freely during neurotic conditions and which
somehow got into the sphere of her consciousness and being
over-attended to became extremely painful.


Secretory Neuroses.--Lying between the pain and motor neuroses and
dependent on psychic elements to some extent at least, there is a
series of neuroses that have as their principal symptoms an increase
or decrease of secretion. Occasionally, of course, they are
complicated by motor neuroses, especially in connection with the
viscera. There are various stomach affections, represented by an
increase or decrease in stomach secretion, and accompanied by pain,
discomfort, and decrease or increase of peristalsis. There are biliary
neuroses accompanied by increase or inhibition of biliary secretions.
There are gastric neuroses associated with vomiting, often very
intractable, in which there seems to be sometimes a hypersecretion of
gastric juice and sometimes a lessened secretion. All of these occur,
as is said, spontaneously, but there will usually be found a history
of some exhaustive work or worry during the weeks or months just
before. Apparently nervous control is lost and then the secretory
neurosis manifests itself sometimes in conjunction with painful or
motor affections.


Neurotic Vomiting.--Persistent vomiting occurs in these cases but is
not {587} so serious as it seems and patients do not lose weight, as
might be expected. There is sometimes even a probability that some of
the food ingested finds its way through the pylorus and is used for
nutrition, though the vomiting may come on not long after ingestion.
Practically always nature asserts herself and stops the vomiting when
serious conditions seem about to develop. The solicitude of relatives
may be calmed by this assurance, and just as soon, as a rule, as they
show less anxiety about the patient, the first symptoms of improvement
will be noted. The fasting girls exploited in the newspapers, in
connection with these neurotic conditions are often frauds and
investigation has shown on a number of occasions that they were
obtaining food surreptitiously. It must not be forgotten, however,
that, even though these cases have been discredited, we have a number
of cases on record of men and women who have taken absolutely nothing
nutritious and only water for from ten to forty or even fifty days.
Until at least ten days have passed in one of these gastric neuroses,
then, there is no need for urgent solicitude, and this of itself, when
properly explained, makes an excellent favorable suggestion for these
patients, and, above all, for their friends.


Simulant Appendicitis.--Some of these abdominal psycho-neuroses may
simulate serious pathological conditions that, in recent years, have
come to be looked upon as surgical. I have seen a number of cases,
especially in women who have been constipated for some time, in which
there was considerable discomfort in the right lower abdominal segment
and occasionally surgeons thought that an operation should be
performed. Usually in these cases there is no localized tenderness and
no mass of any kind to be felt in this region. Sometimes tenderness is
complained of, though when the patient's attention is diverted even
deep pressure may be made without their wincing. Whenever there is no
history of an acute attack, no temperature and no increase in pulse
rate, unless there are very definitely localized symptoms, the
question of operation is always to be answered in the negative.
Disturbances of the pulse may mean little. The history must guide. I
have seen these cases operated on, improved for a while, but relapse
afterwards just as soon as there was a resumption of their
constipation. As a rule, when the appendix has been removed, either
because its function has something to do with the inhibition of
putrefactive processes in the lower bowel, or because as the result of
the operation and consequent adhesions, the colon was not so active in
its peristalsis, the constipation seemed to be worse than before,
unless special care was exercised. If there is relapse after an
operation the patients' attacks are almost sure to be more frequent
than before and their discomfort likely to be more pronounced.

Lest it be thought that such cases are mainly confined to women or
that the most striking cases occur only in women, I may say that the
most interesting case of this kind I ever saw was in a young, vigorous
German soldier. He was admitted to Koenig's clinic in Berlin with a
story of abdominal tenderness and pain, the tenderness being located
in the right iliac region. There seemed even to be some distention of
the abdomen after a time and the development of greatly increased
diffuse tenderness. The pulse was considerably disturbed, but there
was only a slight rise in temperature, and for a time it was thought
that this might be a case of appendicitis without fever. A surprising
feature of the case was the presence in the right iliac region of
{588} a scar which, on careful investigation, proved to be double.
Apparently the patient had been opened twice before in this region.
His history was carefully investigated. He had had a fall from a horse
about two years before and afterwards had considerable abdominal
discomfort. He was quite sure that something serious had happened
within his abdominal cavity as the result of the fall and his
attention was concentrated on his right iliac region. At the time of
the accident his symptoms were considered to be a psycho-neurosis or
perhaps an exaggeration of symptoms with malingering tendencies.

Shortly after his term of service expired, however, some acute
symptoms developed and there was swelling, or at least tympanitic
distention of the abdomen with disturbance of the pulse, and he was
operated on in the hospital and his appendix removed. There proved to
be nothing the matter with it and no pathological condition was found
within his abdomen. He seemed to recover completely. After six months
he was admitted to another hospital with the same symptoms. He seemed
to have the habit of swallowing air which found its way beyond his
pylorus, or else gas leaked from the blood vessels in the walls of his
intestines, producing a symptom-complex not unlike the tympanitic
distention consequent upon general peritonitis. Once more this was
taken to mean very probably a ruptured appendix and another operation
was done. This operator went through the old scar, but to his surprise
found no appendix and found everything within the abdomen normal. The
third time the patient came to Koenig's clinic and, owing to his
military record, his hospital experience was available and a third
operation was not done. Instead, according to the story current at the
time, the patient was tattooed with the legend "no appendix here." The
case is interesting as an example of the extent to which an abdominal
psycho-neurosis may simulate a ruptured appendix.


Pseudo Biliary Colic.--A similar state of affairs to that with regard
to the appendix has developed in all that concerns the gall bladder
and the biliary tract generally. Any complaint of discomfort in the
right upper quadrant of the abdomen, if persisted in, is almost sure
sooner or later to be diagnosed as due to a calculus. Now that
operations for gallstones are more common than they used to be, it is
probable that almost as many gall bladders are found without
pathological conditions as appendices without justifiably operative
lesions. In treating individuals who have a history of recurrent
symptoms of intestinal reaction to various foods complicated by
urticaria, it is important to remember that there may probably be
lesions corresponding to those in the skin in portions of the
intestinal tract which may functionally involve either the appendix or
the biliary passages. Some of these cases are extremely difficult to
handle because often there is pain, definite tenderness and some fever
with the attacks, and very localized symptoms. The history, however,
will be helpful. Operation will not relieve the patient from liability
to recurrence. There are, however, other cases where the discomfort is
much more vague, where there is no tenderness, no disturbance after
jolting rides and where there has never been any severe pain. These
should not be set down as biliary calculi without further
developments. The possibility of a stone being present should not be
hinted to the patient until some definite pathognomonic sign is
discovered.


Other Simulated Conditions.--There are many painful conditions of the
{589} head that are psycho-neurotic. Many forms of headache are due to
sensations of pressure or tension or constriction, usually in the
external integuments of the skull, which are dwelt on and then become
painful achy conditions. This is particularly true of so-called
headaches in the back of the head. As we emphasize in the chapter on
Headache, probably most of the headaches of patients who have not much
to occupy themselves with, are due rather to queer feelings in the
head emphasized by the concentration of attention on them than to real
pains. Earache may occur in the same way. Nearly always when one has
been out in the wind, there is likely to be an uncomfortable sensation
in the ear. By attention to it this may readily be exaggerated into an
earache. Occasionally the physical basis of an ache in the region of
the ear seems to be an unconscious performance of Valsalva's
experiment while blowing the nose when catarrhal conditions are
present.

All sorts of painful conditions of the arms and legs may develop in
the same way. Unusual tiredness, or some special exertion of the
muscles, may produce a sense of fatigue readily exaggerated by
attention to it, into severe pain. This condition is not a voluntary
simulation, but is due to lack of diversion and a certain inborn
tendency in these people to pay attention to anything that is the
matter with them. Very seldom does the physical condition need much
treatment, though nearly always something can be done for it with
advantage, but the mental state needs alteration and, above all, the
patient needs to be diverted from over-concentration of mind.


Motor Neuroses.--As has been said, beside painful conditions, various
forms of motor trouble may develop. These usually consist of inability
to move certain groups of muscles. They have sometimes been spoken of
as hysterical palsies or paralyses. The word hysterical, by its
derivation connected with the Greek word for womb, apparently
indicates that these conditions are limited to women. It is well known
now that they are extremely common among men and especially among
young men and have absolutely nothing to do with the genital system.
As with painful psycho-neurotic conditions, there is practically
always a physical basis. This sometimes requires careful questioning
to locate exactly. There is some injury of the muscles of a particular
region, or some over-use of them, or some employment of them under bad
mechanical conditions with over-fatigue, and then attention to this
leads to incapacity to use the muscles or inability to co-ordinate
them properly.

Neurotic palsies, to use a term that carries much less unfavorable
suggestion with it than the word paralysis or the word hysterical, may
occur in any limb or group of muscles. They may occur in the legs with
the production of complete paraplegia. One well-known form,
astasia-abasia, inability to stand or to walk, affects the muscles of
the trunk as well as of the lower limbs. These conditions often remain
for long periods in spite of treatment, frequently recur, are often
called by all sorts of names and continue to be a source of annoyance
to the patient, until a definite successful effort is made to change
the patient's mental state to one of less attention to the particular
part.

There is, it seems to me, an unfortunate tendency to think that our
observations upon these cases are comparatively recent. Sir Benjamin
Brodie, nearly a century ago, insisted that at least four-fifths of
the female patients among the higher classes of society supposed to
suffer from diseased joints were really sufferers from neurotic
conditions, or, as they called them then, {590} hysteria. Sir James
Paget, in his Clinical Lectures and Essays, thinks that Brodie has
exaggerated the proportion, for in his own practice, though, of
course, he includes his hospital cases and the poor as well as the
rich, he found less than one-fifth suffering from neurotic joints. The
hip and the knee, which are the most frequent seats of genuine
pathological conditions, are also most frequently the subject of
neuroses. Next in order, but much more rarely, the metatarsal and
metacarpal joints are affected and then the elbow and shoulder. In Sir
James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a
number of cases which show how clearly psycho-neurotic affections were
recognized in his time. He tells the story of a young man who had been
overworking for examinations and who "after a three-hours'
mathematical cram, fainted and when he rallied set up a very close
mimicry of paraplegia which lasted many weeks." He insists that "such
mimicry is found not only or chiefly in the silly selfish girls among
whom it is commonly supposed that hysteria is rife, but even among the
wise and accomplished, both men and women."


DIFFERENTIAL DIAGNOSIS


For the differential diagnosis of psycho-neuroses from definite
organic conditions, the most important element is the patient's
previous history and a knowledge of the condition of the nervous
system. Where this is known the diagnosis is comparatively easy, but
when the patient is seen for the first time it may often be extremely
difficult. It is, above all, important not to jump to conclusions, for
every nervous specialist knows of cases in which the diagnosis was
considered to be surely a neurosis, yet a fatal termination showed
that a serious organic condition was at work. It must not be forgotten
either that neurotic patients may develop serious organic disease in
the midst of their neurotic symptoms and care must be taken not to
miss the significance of special symptoms. When the patient is not
well known, the presence of certain stigmata, as they have been
called, enable the physician to recognize the probability that a
neurotic condition is present. Patients who are subject to neuroses
are likely to have certain areas of the skin surface and of the
palpable mucous membranes more or less sensitive than normal. There
are likely to be spots of hyperesthesia or hypesthesia or even
complete anesthesia somewhere on the skin. These should be carefully
looked for and in serious cases an examination of the whole skin
surface should be made. Not infrequently anesthesia or a decided lack
of sensitiveness to irritation will be found in the throat or in the
nose. Occasionally the conjunctiva is much less sensitive than usual.

These used to be called hysterical stigmata. The word hysteria carries
an innuendo of imaginativeness or occasionally of affection of the
sexual organs that is unfortunate. It would be better, therefore, not
to use the term in any way. The presence of these areas of
hyperesthesia, hypesthesia and anesthesia indicates that association
fibers are abnormally connected in the brain for the moment at least,
and that as a consequence there is over-attention to certain portions
of the body with lack of ordinary attention to others. This will
account very readily for the occurrence of painful conditions in
certain cases and palsies in others. When over-attention is paid,
there may be a {591} hyperesthesia corresponding to that seen in the
skin in any organ of the body. When, for any reason, there is a
disturbance in a particular part, there may be a lack of motility due
to nervous influences, just as there is a lack of sensation. In all of
these cases the one essential element is to correct the nervous state
through the mind as far as possible. Experience has shown that this
can be done in nearly all cases. It must be the principal effort of
the physician.



TREATMENT


Strong Mental Impression.--In the treatment of these affections two
periods are to be considered, one during, the other after the attacks.
During the attack a strong impression must be made upon the patient's
mind so as to divert the concentrated attention. We have well
authenticated stories of the various expedients resorted to by
physicians who were confident of their diagnosis in order to secure
such a strong mental impression. I once knew an old physician who was
summoned to a childless wife whose adoring husband was in manifest
agonies of solicitude over her and whose mother and mother-in-law had
been caring for her for days with all anxiety, walk into the room of
the patient, take one of her hands in his, slap her on the cheek, tell
her to get up and walk and she would have no more of that supposed
inability to walk which had caused the family so much anxiety. He
succeeded. It can be imagined what would have happened had he not
succeeded. We know of cases where an alarm of fire or a burglar scare
or some sudden emotion has produced a like result. We cannot prescribe
these things, however, and at the most, after one or two successes in
a particular patient, they would fail.

The only thing that we can do as a routine practice is to relieve by
direct treatment the slight physical condition that is usually present
and then try and influence the patient's mind. If a thorough
examination is made in the course of which the physician is able to
show the patient that he understands the condition and that he can
demonstrate for himself and them that there is nothing serious the
matter with important organs, he can make them feel that their pain or
disability is entirely due to concentration of attention on a
particular nerve or set of nerves. With many patients this will
succeed, not at once, but after two or three seances of positive
suggestion, even in the waking state. If the patients are bothering
their relatives very much it may be necessary to give some opium as an
adjuvant. As a rule, the needle had better not be used, but a
suppository given. This is not nearly so attractive to the patient's
mind as the use of the needle and is not likely to be called for so
often. Every physician has had the experience that after giving opium
two or three times, either per rectum or hypodermically, almost
anything can be given, provided the patient is persuaded that the drug
is being given again. A reasonably large dose may be used the first
time, but certainly after the second or third time a much smaller dose
will produce the same effect and often a simple gluten suppository,
provided it looks like the other, will work just as well as an opium
suppository.


After Treatment.--The after treatment of these cases is directed
mainly to such alterations of the mental attitude and physical
condition as shall prevent {592} recurrences. The general condition of
the patient must be improved in every case where there is indication
for this. Many of these patients are under weight for their height.
They must put on weight. Weir Mitchell's success with the "rest cure"
consisted to a great extent in his power to cause these patients to
put on weight. This supplies reserve energy, but, above all, replaces
discouragement by hope and buoyancy. Gain in weight can be
accomplished mainly by two methods. First, by seeing that the patient
gets an abundance of air and, secondly, by dictating how much shall be
eaten. In this matter details are important and it may be necessary to
suggest the actual diet for each meal. This must be liberal and must
consist of simple but particularly nutritious materials. Patients'
dislikes need not be taken into much account, their likes are often
helpful. When there is insistence on lack of appetite and decided
objection to chewing, eggs and milk should be given in increasing
quantities, until five or six eggs and some twelve glasses of milk are
taken every day. Besides this, a good portion of meat should be eaten
at one meal with some vegetables. By firm insistence, day after day,
it will not be hard to get patients whose appetites are seriously
inhibited to take this amount of food. To secure this, a good, firm,
sensible nurse is invaluable. Appetite, as we have emphasized in the
chapter on Appetite, is largely a matter of will, and anything that is
eaten, provided it stays down, will do good unless there is organic
disease.

A certain amount of exercise is important in these cases, but not
nearly so important as an abundance of fresh air. Patients must not be
allowed to overtire themselves. Riding in an open carriage or on the
top of a bus, especially where there are distracting scenes and many
human interests, is particularly beneficial. Automobiling is often
likely to be more tiresome than is good for these patients when they
are run down, though it is one of the best of therapeutic measures for
those who are physically capable, that is, up to weight, even though
they may complain of feeling weak.


_Diversion of Mind_.--It is in these cases particularly that diversion
of mind is of prime importance. Many of these patients have either no
serious interest or at most certain interests with which they may
occupy themselves if they wish, but that are not engrossing and
attention to which may be put off whenever they care to. Duties that
are inevitable and that call for the occupation of so much time that
the patient has little opportunity to think of herself are often the
salvation of these patients. As I mention in the chapters on
Occupation and Diversion of Mind, I have seen a number of cases and I
am sure that every physician of reasonable large experience has seen
similar cases, where women, particularly, who in the midst of
prosperity have been constantly suffering from some form of
psycho-neurosis, great or small, have, after some sudden turn of
fortune, been completely relieved from their nervous symptoms by
having to devote themselves seriously to some occupation for a
livelihood.

Occupation, particularly with children, with the weak and the ailing,
with the poor and those who are unable to help themselves, is
specially likely to be helpful to such patients when they are women.
Such interests affect them deeply and by the sympathy they arouse
through contact with real physical suffering, they prevent
over-attention to themselves. I have seen the care of a cancer
patient, and especially of a relative affected by cancer, do more for
{593} a psycho-neurotic sufferer than all that doctors had been able
to accomplish in years. It is often difficult to find occupation and
diversion of mind for these patients, but this is the therapeutic
problem the physician must solve if he is going to secure relief from
present conditions and prophylaxis against further attacks.


Oldtime Cures.--Many of the remedies for obscure abdominal conditions
show how well the real character of the affection was duly recognized
and appreciated in the past. It is in these cases particularly that
the pillulae micarumpanis, the bread pills, of the olden times, were
so commonly used with good effect. We have quoted examples in other
chapters. Many of the drugs that are employed with reported success
for these affections have a strong suggestive element in them.
Valerian probably is a good tonic and yet there is no doubt that the
suggestive quality of its nauseating smell and the almost inevitable
eructations that occur after to emphasize it, are helpful in curing
certain internal psycho-neuroses. Another drug that has been much used
in the same way is asafetida, whose disgusting taste and odor have
been excellent auxiliaries. Fresh pills of quinine and red pepper
uncoated and therefore producing definite effects on the taste before
swallowing and on the mucous membrane of the stomach after swallowing,
often prove the best remedy for persistent vomiting or for enduring
nausea. A drop of nux vomica, taken every half hour with the definite
warning that the patient must by no means take more, and that the
bottle must be carefully protected lest anyone else should be
poisoned, is often very efficient. These remedies have a slight
physiological action and a large psychic action, but that exactly
corresponds with the etiology of the affection for whose treatment
they are employed.


Dominant Ideas.--During the attack it is often possible to find either
from the patient or from friends that there is some dominant idea
which is bringing about the mental short-circuiting that leads to the
concentration of attention. From the oldest times it has been
recognized that in young women a disappointment in love may prove to
be the occasion for a psycho-neurotic or, as they used to call it,
hysterical attack. This is, however, not a specific cause. It is the
disappointment much more than the sex element in the case, as a rule,
that produces the unfavorable effect. It was easy to conclude that the
sex factor was extremely important in older times when women's sphere
of activity was largely limited to the home, and marriage was the one
legitimate object of their ambition. Now that we have had more
experience with the business woman, we know that serious
disappointments of any kind have a tendency to initiate
psycho-neurotic conditions in susceptible and especially suggestive
individuals. A failure to secure promotion in a store, or to secure
some position that is eagerly sought for, a loss of money in business,
etc., especially when they have been preceded by weeks or months of
solicitude and worry over the event that now happens, may lead to the
development of a psycho-neurosis.

This is particularly notable with regard to educational interests of
various kinds. Young women readily overdo application to study, or,
rather, anxiety over it, and as a result get into a state of mind in
which a failure to pass an examination, or to secure promotion, or
even the failure to win a prize, may give rise to a highly nervous
condition in which tears and laughter come unbidden and in {594} which
further developments may bring on a typical psycho-neurotic attack.
All sorts of pains and aches and motor incapacities may occur in these
states. The supreme occupation with the single idea present in their
minds at all times, waking and sleeping, while they try to study, or
when they read or even when they are supposed to be diverting
themselves, finally precipitates a nervous explosion along nerves that
have been irritated for some reason, though the pathological condition
present may be quite insufficient of itself to explain the affection
that ensues. These are the popular nervous breakdowns, not difficult
to treat once their real character is diagnosed.

Sorrows of various kinds may produce a like effect. Worry or anxiety
about the serious illness of a near relative, especially an inevitably
fatal illness, such as cancer or tuberculosis or the disturbing mental
affections, may have a similar result, but usually not in those who
are occupied with the actual care of the patients. The mental states
constitute the psychic elements underlying the neurotic condition that
develops.

Almost needless to say, successful treatment must include a faithful
attempt to lessen the significance of the mental state that is so
important in the case. Usually the mere obtaining of the patient's
confidence is enough to lessen greatly the irritation produced by the
mental condition. A sorrow shared is halved. It is, above all,
secretive individuals who become depressed over their sorrows. While
the patient who insists on constantly sharing them with everyone
becomes a nuisance, it is always a little dangerous not to have a
confidant to whom worries and anxieties are entrusted. If they are
kept to one's self they are nearly always exaggerated--they are seen
out of proper perspective and have a much more depressing influence.
Calm, judicious reasoning with the patient over the significance of
the condition as presented, is often of great help.

Often these ideas, so potent for mental and bodily disturbance, are
almost entirely unconscious or exist in the patient's subconsciousness
and are recalled only under such special conditions as remove the
bonds of the patient's occupation with himself or herself at the
present time and allow memories to come back without interference.
There are many curious stories of such cases. A child is frightened or
very much disturbed by having a cat kill a favorite bird. The cat
becomes a deterrent object. Gradually this deterrence grows. As a
consequence, there may develop one of those intense dreads of cats
which makes life miserable if near that animal. There may even be
physical effects produced by the continued presence of a cat in the
same room. Often in these cases the beginning of this mental attitude,
or at least its occasion in the incident of the killing of the bird is
forgotten, or at least not consciously referred to as an etiological
element in the dread.

Patients have been known to develop states of mind which made them
object to certain figures or names because of earlier associations
with them that were unpleasant. There is the story of a man who would
never take a car with an odd number though this was sometimes a source
of annoyance and delay and who could not explain to himself or his
physician how this objection had developed, until his memory was
searched and it was found that, years before, he had witnessed the
death of a child under the wheels of a car with an odd number. He had
completely lost the sense of the direct influence of this, but it
existed in subconscious memory and proved the source of much {595}
annoyance to him, for if with a friend he were not able to avoid
taking an odd numbered car he would feel quite miserable during the
ride. Frights of various kinds may produce this same effect. I have in
my notes the case of a man who is unable to sleep at night without a
light in his room, because of a fright. Once while asleep in the dark,
he awoke conscious that someone was in the room and sat up and
demanded who was there. The answer was a revolver shot and a bullet,
passing not far away from him, pierced the head of the bed. As he sank
back the burglar leaped from the window and escaped. He realized that
this was the cause of his fear of the dark, but lesser incidents might
easily become subconscious yet continue their influence.


Psycho-Analysis.--In recent years Freud has suggested that in many
puzzling cases of psycho-neurosis, where, so far as is known, there
seems to be no dominant idea bringing about the concentration of
attention, careful analysis of the patients' memories will bring out
the fact that there is a subconscious idea as the underlying
substratum of these affections. Freud has developed what is called the
process of psycho-analysis in order to bring out these ideas which are
sometimes exerting their influence unconsciously to the patient. The
subconscious is one of the fads of the hour, so that Freud's
announcement attracted much attention. Psycho-analysis, however, is
not advanced so confidently even by its inventor as a positively
curative measure, as it was at the beginning. It has been found that
after the dominant idea in the subconsciousness has been found and
neutralized with a consequent amelioration of the psycho-neurotic
symptoms, there may be a relapse, when another dominant idea will have
to be found, and that there seems to be the possibility, in some cases
at least, of an almost endless succession of such ideas to account for
further and further relapses.

Undoubtedly psycho-analysis has its place in psychotherapy and is of
great value in certain cases. There is no doubt, however, in my mind
that in most of these cases reported as cured after psycho-analytic
methods had been employed, what really happened is that the patient's
mind became diverted to another idea--that of marvelous cure through
mind searching which relieved the previous concentration of mind
underlying the psycho-neurosis. These are the cases that used to be
cured by hypnotism. Before hypnotism was developed they were cured by
mesmerism. Before mesmerism they were cured by magnets or by the
Leyden jar, and during the past century they have been cured by
electrical methods or by osteopathy or by Eddyism. Many of the cures
were effected by stroking and touches, the use of Perkins' tractors,
or Greatrakes' methods, or anything else that attracted attention very
strongly. They were given a new idea which occupied them very much and
so saved them from that preoccupation with themselves and their
feelings and whatever slight ailment might be present that was the
physical occasion for psycho-neurotic symptoms. This happened with
psycho-analysis. When it was absolutely new and the operator had great
confidence in it, this confidence was imparted to the patients, with
the consequent cure or decided amelioration of their psycho-neurosis,
just as that used to be brought about by our previous method of
treating such cases by some strong suggestion.

As I emphasize in the chapter on Dreams, the examination of the dreams
in order to get a hint of the dominant idea, is particularly
interesting, because it represents a return to the oldest methods of
suggestion of which we have record. {596} The fact that sexual ideas
seem to represent a great many of the dominant ideas in these cases is
of interest for a similar reason. It represents the tendency
constantly recurring to refer most nervous ailments, as indeed most
other ailments, to something pathological in the sexual or genital
sphere. The old idea embodied in the word hysterical exemplifies this
very well. The "vapors" or "tantrums" or fits which were supposed to
be due, to some extent at least, to suppressed sexuality by medical
writers of three or four generations ago, have come back to us under
another form and with other terms. Psycho-analysis gives occasion for
instruction in so far as it helps the patient to get rid of old
persuasions and exploded ideas as to disease and diet and the various
functions of the body and the mind that have often almost
unconsciously been acquired and secured a dominance. It is surprising
how often it will be found that people are taking too much or too
little water at meals, too many or too few vegetables, too much or too
little of salt or of other condiments as the result of habits and
notions acquired when they were young and under influences that they
may now forget. In the same way habits of life with regard to bathing,
clothing and the like may be the source of unfavorable conditions in
mind and body that need only to be discovered to be corrected. Their
correction will often bring about the relief of symptomatic conditions
that have proved quite obstinate to treatment. We have emphasized this
in the chapters on the Individual Patient and the necessity for
acquiring just as much knowledge as possible about both his
occupations and his mental attitude in order to be able successfully
to treat chronic disease.


{597}

SECTION XVIII

_DISORDERS OF MIND_


CHAPTER I

MENTAL INCAPACITY (PSYCHASTHENIA)


In recent years we have come to realize that many of the so-called
nervous diseases, or if they do not deserve the serious name of
disease, nervous symptom-complexes, are really due to a deficiency of
vital energy. Some people have a store of energy that enables them to
accomplish many different things successfully. Some become exhausted
from a few trivial occupations. What is noteworthy in the cases to be
discussed in this chapter is that they show always certain symptoms of
mental tiredness or, at least, of lack of capacity for affairs.
Patients complain, for instance, that they cannot make up their minds
so as to reach decisions because they doubt so much whether the
decision they come to will be right or wrong. Others dread the outcome
of any and every act and feel that something is hanging over them.
Slight sources of irritation become so exaggerated by thinking about
them and dwelling on their possibilities that they may even disturb
sleep and appetite and, as a consequence, the general health. Fears
come over patients lest various things should happen and they dread
microbes, or infections, or dirt in general, or the approach of
insanity, and all to such a degree as to incapacitate them for their
ordinary occupations.

Many of these patients become quite incapable of willing effectively.
They not only lose initiative, the power to undertake new enterprises,
but they find it difficult to make up their minds as to details of the
ordinary affairs of life. As we have stated elsewhere in Professor
Grasset's expressive formula, these patients say that they cannot do
things, their friends say "they will not," and the physician, taking
the middle course, which, as usual in human affairs, has much more of
truth than either of the extremes, says "they cannot will."

For these states Janet of Paris suggested the word psychasthenia. It
is formed on the model of the word neurasthenia and unless it is used
with discretion will have all the objections that attach to that other
term. Above all, it shares the tendency pointed out by Sir William
Gowers with regard to neurasthenia of being "too satisfying. Men are
apt to rest on it as they would not on its English equivalent.
Physicians, if they do not actually think that they have found the
malady from which the patient is suffering, have an influence exerted
on them of which they are often unconscious, which lessens the
tendency to go farther in the search for the whole mental state." Much
more can be said in defence of psychasthenia, however, than of
neurasthenia, for the substitution for it of the translation of the
Greek words of {598} which it is composed--"mind weakness" would be
alarming. While it is important, then, to realize that the term may
easily be made too general and prove, as such words as rheumatism has
done in our time and malaria did in the past, a cloak for ignorance
and an excuse for incomplete investigation for diagnostic purposes, it
represents a satisfactory answer to the patient's question as to what
is the matter without committing the physician to such definitely
detailed opinions as to the patient's condition as would surely prove
unfavorably suggestive.


Psychasthenia, Natural and Acquired.--There are two forms of the
mental incapacity that underlies many of the curious symptom-complexes
that have been studied under the term psychasthenia. One is natural,
that is, inherent in the special character of the individual, and the
other acquired through disease or exhausting labor, worry, or anxiety.
Some people are born without sufficient mental energy to do the work
they attempt to accomplish. This is true, also, in the physical order.
It is often pitiable to see young men who have not the physical
strength necessary for athletic exercises, or the dexterity required
for them, faithfully trying to accomplish by effort what others do
with ease. When there is some natural defect in the way they will
usually fail, no matter how much they strive. Just in the same way
some persons are not able to accomplish certain more serious purposes
requiring special mental ability or power which they attempt. Their
brothers, their friends, their schoolmates, may have the ability, and
they cannot understand why they should not have it, but the fact
remains that they are not possessed of it and if they try to make up
for this defect by overwork they simply break down.


Differential Diagnosis.--Each of the two forms of mental incapacity,
congenital and acquired, must be carefully differentiated and treated
from a special standpoint. With regard to congenital lack of mental
control, all that the doctor can do is to counsel against the
assumption of duties and responsibilities that are too heavy for the
patient. Some people have not enough nervous energy to run a business
with many details, and some even find it difficult to try to do things
involving much less responsibility. There is no use for a man five
feet in height, weighing one hundred pounds, to try to be a stevedore.
There is no use for men of delicate muscular build to try to make
their living at heavy manual labor; they simply wear themselves out in
a very short time. This inadaptability is recognized at once. Just the
same thing is true with regard to many nervous systems, but the
recognition is not so easy or immediate. Some cannot stand the strain
of intricate business details or the burden of responsibility in
important transactions. They must be taught to be satisfied, then,
with quiet simple lives without what is for them, excessive
responsibility and without strenuous business worries. A country life
with regular hours, plenty of open air and as little responsibility as
possible, is the ideal for them.

The most difficult problem in this matter is the question of
diagnosis. As a rule, the history is the most helpful for this. The
patient tells of having found difficulty all his life whenever
anything of special significance was placed on his shoulders. He is
one of those who were born tired and remain so all their lives. It has
been the custom to blame these people; they are rather to be pitied.
If they are born in circumstances that allow of their {599} living
quietly in the country, they accomplish a certain amount of work quite
successfully and live happy, contented lives. If they are born in the
city where the hurry and bustle around them and the insistence of
friends that they must take up responsibilities becomes poignant, they
get discouraged and even despondent. It is from this class of patients
that the "ne'er-do-wells" of modern life are recruited. They form the
under-stratum of trampdom, the scions of good families with the
wanderlust, the willing but incapable. Certain of them become vicious
and criminal, either because they do not want to work or because their
mentality is perverted in some way. Such patients cannot be treated
with any hope of their becoming successful exemplars of the strenuous
life, but they may be directed into the less exacting occupations of
country life and so live quiet, useful and happy lives. For the
congenital class we can do little except to prevent them from trying
to do things that are beyond their mental capacity and helping them to
see just what their limitations are.


_Mental Exhaustion_.--Many disturbances of mental energy are acquired.
These may be either functional or organic. For the organic variety we
cannot do much, since it is dependent on changes in organs that are
permanent. We can, however, usually predispose the patient's mind to
the recognition of the fact that he should no longer try to devote
himself to occupations that constitute a special drain on his nervous
energy. The man, for instance, who is already suffering from
arterio-sclerosis must be warned that worry and work will surely
hasten the process and that his nervous symptoms cannot be cured, but
must be palliated. He must be advised to lessen his mental strain and
to take up something which, while occupying his mind, does not make
insistent calls on his vitality. In this matter it must be remembered
that when a man over fifty develops nervous symptoms, as a rule there
is no question of functional trouble but of organic change and usually
heart or arteries or kidneys are at fault.

In recent years we have come to realize that typhoid fever often makes
serious inroads upon a patient's vitality which can only be retrieved
by care, not alone for some months but, if possible, even for some
years, not to put an overstrain on the vital energy. Certain other
diseases produce an even more lasting effect. A sufferer from
well-developed tuberculosis will probably never be able to go back to
the strenuous city life. If he attempts to do so, not only is there
danger of a recurrence of his tuberculosis, but there may even be a
development of neurotic symptoms. Syphilis is another disease that
leaves patients in a condition in which it is dangerous for them to
assume the serious responsibilities of an exacting occupation and
especially anything that involves excitement and worry. Syphilitic
patients should be warned of the danger of pursuing vocations that
make such demands upon them. It is the actor, the broker, the
speculator, and the strenuous business man generally, who is likely to
suffer from parasyphilitic conditions, tabes, paresis and the like,
much more than those who follow occupations that make less demands on
them.


Functional Mental Incapacity.--In a large number of cases the
incapacity to do things because of lack of mental energy is due to
functional disturbances of the nervous system. These are the most
important for the psycho-therapeutist because much can be accomplished
for them. Nearly always the patient can be benefited by advice and
suggestion, and very often some {600} unfavorable factor at work,
using up his mental energy to no purpose, will be discovered. In order
to do good, however, careful study of the individual patient is the
most important element. The most frequent functional disturbance of
the nervous system, leading to exhaustion of mental energy, is
over-attention to one's self and to one's occupations. Men can do many
complicated things quite naturally and easily, but when they carefully
watch themselves doing them, accomplishment is not so ready and the
task is double. They tire much easier, for, as a rule, what they are
doing could be accomplished automatically and they are using up energy
attending to it. This is probably one of the commonest causes for the
rather frequent development of that state called nervous exhaustion in
our time. People watch themselves too closely and by so doing they not
only use up energy unnecessarily in the surveillance, but also they
hamper their powers to do things and so consume additional energy in
overcoming this inhibition.

Morbidly introspective people watch almost ceaselessly everything they
do. They not only watch themselves work and worry about it, but they
watch themselves play and grow solicitous that it will do them good;
they watch themselves divert themselves to see if it is giving them
real recreation and so spoil the diversion; they watch themselves eat
and disturb their appetite, and watch themselves digest and hamper
digestion; they even try at least to watch themselves sleep and so
interfere with sleep. Many of the cases of insomnia are really due to
this over-attention. They fear they will not sleep, they worry about
it, they keep themselves awake hoping that they will sleep, and in the
more serious cases even during sleep itself they are so solicitous
that their dreams become very vivid and a form of unconscious
cerebration goes on with surveillance of themselves. They do not rest
even in sleep. They wake feeling not rested, they get up with a
consciousness that they are beginning a long day without being
properly refreshed and they exhaust enough energy to complete a good
part of the day's work in wondering whether they will be able to go on
with their occupation for the day, whatever it may be.


_Inhibitory Surveillance_.--People become afraid that they cannot or
that they may not do things well and set a guard over themselves. This
is illustrated very well in the doubts about accomplishment because of
which they keep going back to see what they have done and how it was
done, though usually it was accomplished quite well without any
conscious attention. Dreads form another phase of this attitude of
mind. For those who are affected with them they make a thing hard to
do before it is begun, and harder to accomplish after it has been
entered upon because of the suggestion that it may lead to some
serious results, or they even inhibit their activities to a marked
extent by their solicitude with regard to them. They worry about
things before the event and thus consume energy uselessly. Worry has
been defined as anxious solicitude about what we have to do next week
at the same time that we occupy ourselves with what we are doing now
and have to do in the next hour or two. The solicitude about next week
is quite useless, as a rule, until the time comes, and it merely
disturbs what we are doing now, making it harder to do and making
errors in it almost inevitable, and so preparing ourselves for
discouragement because of mistakes that have been made and still
further adding to the difficulty of accomplishment.

{601}

_Inhibition of Automatism_.--These introspective people disturb
themselves by over-attention to things that need no attention, that
are accomplished automatically, and that are not done nearly so well
if they are attended to. Not only is it true that it is harder to do
work that ought to be accomplished automatically if much attention is
given to it, but also nature resents the surveillance. Not only the
brain does not work so well if watched to see whether perhaps it is
working too much, or whether there are too many feelings in our head
while we are doing things, but even the stomach resents being watched
and does not do its work as well. The same thing is probably true for
every one of our organic functions. In the chapters on the heart we
call attention to the fact that surveillance makes a perfectly healthy
though nervous heart miss beats. There is a dual waste of nervous
energy then. We are employing our attention watching things done that
need not be watched, and by that fact we are inhibiting natural
processes and requiring that more energy shall be put into them for
their accomplishment, and even then accomplishing them with
discouraging imperfection.


_Mental Short-Circuit_.--The reflex mental process that particularly
affects many individuals in our time and makes it hard for them to do
their work, has been well described under the figure of a
short-circuit in an electrical dynamo. The short-circuit diverts the
current so that instead of acting outside the dynamo and performing
useful work, it is discharged within the machine, brings about
deterioration of its elements and soon leads to a reduction in the
amount of electrical energy that that particular dynamo can develop.


Association Fibers Diversion.--Prof. Michael Foster in the Wilde
Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote
44] has many valuable suggestions with regard to the mechanism of
mental operations on the neuron theory. He has particularly dwelt on
the function of the association fibers in connection with mental
operations, or with the raising of sensation to the plane of
mentality. A portion of the brain that is originating impulses,
instead of sending them down to the periphery, through the projection
fibers, to lead to the accomplishment of external work, may have its
messages diverted through the association fibers to other portions of
the brain and thus do harm rather than good.

  [Footnote 44: _Proceedings of Manchester Literary and Philosophical
  Association_, 1898.]

Occurrence of Psychasthenia.--It must not be thought that these
curiously interesting conditions occur only among people of low
intellectual caliber, or in those of narrow intellectual interests,
mere specialists who may have acquired a reputation for doing one
thing well. They are frequent among the most intellectual classes.
Brain workers of all kinds, unless they are careful to vary the
interests of life, unless, as suggested in the chapters on Occupation
of Mind and Diversion of Mind, they have a hobby besides their usual
occupations, are likely to suffer in this way. As a matter of fact,
many intellectual people have had what are called nervous breakdowns
of this kind. A biographical dictionary shows any number of them. Dr.
Gould's Biographic Clinics furnish many documents for the study of
these conditions. A typical instance, told by the sufferer himself,
the distinguished Sir Francis Galton, is of special significance for
the psychotherapeutist. I {602} quote because it illustrates the fact
that such breakdowns do not portend a short or subsequently listless
life, for Sir Francis, a most successful scientific investigator,
lived well beyond fourscore years in the full possession of health of
mind and body.

  It was during my third year at Cambridge that I broke down entirely
  in health and had to lose a term and go home. I suffered from
  intermittent pulse and a variety of brain symptoms of an alarming
  kind. A mill seemed to be working inside my head; I could not banish
  obsessing ideas; at times I could hardly read a book, and found it
  painful to look at even a printed page. Fortunately I did not suffer
  from sleeplessness, and my digestion failed but little. Even a brief
  interval of mental rest did me good, and it seemed as if a long dose
  of it might wholly restore me. It would have been madness to
  continue the kind of studious life that I had been leading. I had
  been much too zealous, had worked too irregularly and in too many
  directions, and had done myself serious harm. It was as though I had
  tried to make a steam-engine perform more work than it was
  constructed for, by tampering with its safety-valve and thereby
  straining its mechanism. Happily the human body may sometimes repair
  itself, which the steam-engine cannot.

The physician with experience in such cases would be much more apt to
say, "Happily we can learn to control our mental energy and not let it
go to waste by foolish persistence at one set of ideas constantly, nor
be dissipated in surveillance of functions that work automatically if
left to themselves."


Etiological Factors.--This form of mental incapacity develops
particularly in people after they have gone through a prolonged period
of hard work and then have come to a time when they are much freer
than they were before. They are prone to think that they exhausted
their nerve force during the preceding period of labor and that now
they are paying for it. Almost invariably what is really happening is
that they now have much more time to occupy themselves with themselves
and about themselves and to worry over their ills, real and imaginary.
This is the typical nervous breakdown, as it used to be called, of
elderly retired merchants or bankers. They have looked forward all
their lives to a time when they could enjoy themselves doing nothing.
They retire from business and then their troubles begin. It is no
wonder that the old proverb, "A machine rusts out much sooner than it
wears out" should have been so often quoted with regard to this
condition. A man who has been working busily at something all his life
cannot stop all at once and do nothing. He cannot learn to occupy
himself with trivial things. Commonly, he has few, if any, interests
apart from his business and he very soon wears the novelty off these
and then introspection comes to make him exaggerate the significance
of every feeling that he has, every stiffness that occurs, every
muscle twinge due to change in the weather, until he becomes supremely
miserable.

As a rule, these patients are simple, practical, common-sense,
business men, and it is hard for the physician to think that there is
nothing more than a functional neurosis present. It is even more
difficult for the patient to be made to appreciate that his ills are
mainly due to his own over-attention to himself in this idleness that
he has looked forward to with so much pleasure. Ordinary medicines
fail to relieve and the regular professional man seldom succeeds in
doing these patients much good. They constitute the richest material
for the quack and the charlatan. Much occupied with their ills they
tell their friends all about them. Whenever a strong impression is
produced {603} on their mind by a promise to cure them with some new
wonderful remedy they are favorably influenced, often get better and
then are walking advertisements for the particular quack who has
happened to benefit them. It is this class of people that has given
more trouble to legislative committees of medical societies than any
other. Some of them appeal to legislators whenever a bill for the
admission of some new form of practitioners of medicine comes up with
the story of how much benefit they derived from the treatment. Since
they have been successful business men their word carries weight. It
is curious how little the making of money, though often presumed to be
so, is a test of real intelligence. It is often the man of one idea
with no intellectual breadth who is the best money-getter.

These conditions develop almost entirely in predisposed individuals
who, for some reason, are trying to overdo the energy they possess,
and who, as a consequence, have lost a certain control over
themselves. At times, of course, they occur in persons who have so
little occupation of mind that thoughts of various kinds along these
lines become insistently suggestive and cannot be thrown off because
the patients' interests are not sufficiently deep or sufficiently
varied to occupy their attention. The rational treatment of them,
then, must be founded on a careful study of individual cases, the
recognition of the special cause, and also the occasions at work in
each case, a neutralization of unfavorable suggestion and a provision
of such favorable suggestions and occupation of mind as will enable
the patient to rid himself of the annoyance occasioned by these and
the physical symptoms that so often develop as a consequence. In a
certain number of cases a history of corresponding or equivalent
affections in preceding generations will be found. In many patients,
however, there is no such history, though there is usually the story
of symptomatic mental conditions of one or other of the types
mentioned, earlier in life. When in good health physically the patient
has very little bother from them. When run down in weight or when
worried or anxious about business or from the stress of important
responsibilities these symptoms may become bothersome mentally and
physically. Often it will be impossible to obliterate them entirely,
but always they can be greatly improved and the patient can be made to
realize that they are not seriously significant, that in mild form
they are rather common and that, above all, they are not so peculiar
to the individual as he is likely to think, with consequent increase
of the unfavorable suggestion.



CHAPTER II

HALLUCINATIONS


Hallucinations Differentiated from Illusions and
Delusions.--Hallucinations are vivid impressions on the consciousness
which appeal to their subject as strongly as if they were really the
result of sensory impressions, though those who experience them know,
either at the moment, or on investigation afterwards, that they had no
objective reality, that is, were not due to any external physical
cause. Illusions are deceptions of the senses, due to the imperfection
of the senses or the conditions in which the perception occurs. {604}
Delusions are mental states in which ideas are accepted, or
conclusions drawn, or information assumed to be gained, though the
whole process is mental and has no relation to reality. (For
illustrations of illusions see chapter with that title in the
Appendix.)

Hallucinations lie in between illusions and delusions as a mode of
deception. They are mental occurrences, but they seem to come from the
senses and probably the best explanation for them is that a previous
sensory impression is vaguely aroused and then finds its way into the
consciousness as if it were coming through the senses. It has been
suggested that they might be due to a reversal of the nervous process
by which a sensation reaches the brain. The external object produces
the sensation, this travels along a nerve causing a perception, this
perception is stored in the memory, and then, when very vividly
reawakened, causes impulses to travel backward along the nerve to the
periphery with the production of a feeling very like sensation.


Frequency.--While hallucinations are often supposed to be only
incidents in the life of the insane, or at least of those who are in
the danger zone near mental disequilibration, carefully collected
recent observations show that many perfectly sane people have
experienced them, and some of them have been much disturbed by them
for fear they portended loss of mental control or some developing
pathological condition. A certain number of men and women have seen
things that either had no existence or existed only for them and for
the moment, and that evidently were due to some state of mind rather
than to their senses. They have heard things that were not said or
that were not audible to others, or that were only reproductions of
their memory of previous sounds and quite naturally such mysterious
manifestations disquiet them. It was the rule in the past to dismiss
such phenomena without serious consideration, or at most to consider
that they were only subjective manifestations not worth discussing, or
to go to the opposite extreme and say that they were due to mental
disturbances.

Of course, as a rule, hallucinations are an index of mental
disturbance. No matter how apparently sane the patient, this must be
the first thought and must be carefully excluded before proceeding
with the case. The subject of hallucinations is larger than that,
however, and it is a mistake to brush it aside in every case as if it
were either very serious or of no importance and that in either case
nothing can be done to relieve solicitude about it. Physicians can
often do much, first to prevent hallucinations by getting at the
physical causes of them; second, to prevent them from disturbing
patients seriously by showing them how common are such experiences and
by indicating their possible physical significance; third, by securing
such mental discipline and control as will render their recurrence
much less frequent; and, fourth, they can make the almost inevitable
unfavorable effect upon the mind of the patient and then reflexly upon
his body, much less than it would otherwise be, by sympathetically
discussing and entering into the details of them enough, at least, to
explain their significance or throw some light on their origin in
physical conditions.

Hallucinations of vision, the seeing of things and persons that have
no real existence at the time and place they are seen, are usually
considered to be rather uncommon and to occur only in those whose
mentality is seriously disturbed. Careful studies of the subject,
however, show that at least one in ten {605} of educated people
consulted have had some hallucinations of vision. Either they have
wakened up, or they have dreamt that they waked in the early morning,
and have seen some one whom they knew, but knew to be at the moment at
a distance, standing near them. Such visions have gradually faded away
or suddenly disappeared. Occasionally these persons have in full light
had some appearance, wraithlike or otherwise, some manifestation that
appeals to vision, yet that they knew at the time or learned
afterwards was non-existent.

Many people are backward about confessing that they have had such
experiences, for they fear that it will make them ridiculous or even
cause them to be suspected of disturbed mentality. Just as soon as it
is made clear to them that their admissions will be taken as evidence
for a phenomenon to be discussed seriously, many more than would
otherwise be thought confess to such hallucinations. Most of these, it
may be said at once, are quite sensible people, a great many of them
belong to the educated classes; all of them are trustworthy witnesses
as far as good will goes, and the circumstances of their
hallucinations are such in many cases that there cannot be a mere
mistake, or error of judgment.

The frequency with which hallucinations occur may be appreciated from
the investigation made some years ago at the instance of the Congress
of Experimental Psychology. The following question was put to 17,000
persons, mostly residents of Great Britain, and answers received:
"Have you ever, when believing yourself to be completely awake, had a
vivid impression of seeing or being touched by living beings or
inanimate objects, or of hearing a voice, which impression, so far as
you could discover, was not due to any external physical cause?" The
answers showed that 655 out of 8,372 men and 1,029 out of 8,628 women
had experienced a sensory hallucination at some time in their lives.
Some of them had had a number of them. That is, one out of ten in the
educated classes has had some hallucination, and nearly one out of
every eight women. An analysis of the statistics, however, brings out
some interesting suggestions. There were nearly twice as many
hallucinations related as having occurred during the year before the
question was asked as in the preceding years. There was a definite
reduction in the number that had occurred in all the preceding years,
except the fifth and tenth, and these were evidently due to
uncertainties of memory, so that five- and ten-year periods seemed
about the length of time that had passed since the event.

It is evident then that in spite of the fact that an hallucination
would seem to be very important and surely startling enough to be well
remembered, it is yet easily forgotten, since even a year's interval
made so much difference in the number that were remembered. The
committee, after considering this easy forgetfulness in the matter,
considered that to arrive at the actual total of visual hallucinations
experienced by this group of 17,000 persons during the ten-year period
in question, the numbers in the table should be multiplied by four.
That means that probably very nearly one in three people have had an
hallucination of some kind within ten years. The great majority of the
visual hallucinations consist of apparitions of human figures. Other
forms that are seen are so few, as Mr. Podmore has insisted in his
"Telepathic Hallucinations, The New View of Ghosts,"   [Footnote 45]
that they are almost negligible. A frank {606} discussion of these
details with a person who is much disturbed by having experienced an
hallucination is the best possible remedy for the physical and mental
disturbance that may result.

  [Footnote 45: The Twentieth Century Science Series, New York, 1910.]

Sir Francis Galton, well known for his investigation of many subjects
and who may well be called the father of biometrics or statistical
biology, in his "Memories of My Life"   [Footnote 46] tells of his own
investigations of the visions of sane persons. The fact that he
delivered a lecture on this subject at the Royal Institution of London
shows how seriously his studies were made and how much value
scientists placed on them. Galton's well-recognized training in the
careful weighing of evidence and his ability to strip phenomena of
everything that might divert their significance from what they really
were, add to the worth of his conclusions. Those who care to study the
subject further will find his discussion in the _Proceedings of the
Royal Institution_ (London, 1882).

  [Footnote 46: New York, 1909.]

There are few people beyond middle age who have not had one or more
curious experiences in the matter of visions or appearances. Mostly
these have been vague and have not proved a disturbing element in the
minds of the subjects. Many more than are thought, however, have seen
visions vividly and with a detail that makes it almost impossible for
them to believe that what they saw was merely an externation of ideas
already in their mind. In this matter it must not be forgotten that
the dreams of many people, especially nervous people, often present
themselves with marvelous vividness of detail. They see people or
places in their dreams and reason about them quite rationally.
Occasionally a dream will bring back details that have been forgotten.
The dreaming state seems in some people to have wonderful power over
the subconscious. Things that are not remembered at all in the waking
state sometimes come back in dreams, and only then are recalled by the
individual as representing past events in his life. He is apt to
wonder where the details could possibly come from, since he had before
no conscious memory of them. This same thing holds for the day-dreams
or sudden visual appearances that come when the attention has been
wrapped in something else.

A typical example of such visual hallucinations is the following
incident told by a prominent London physician of himself:

  One afternoon at tea time, before a meeting of the Royal Society,
  Sir Risdon Bennett (1809-1891, a well-known physician. President of
  the College of Physicians in 1876, and a fellow of the Royal
  Society), drew me apart and told me of a strange experience he had
  had very recently. He was writing in his study separated by a thin
  wall from the passage, when he heard the well-known postman's knock,
  followed by the entrance into his study of a man dressed in a
  fantastic medieval costume, perfectly distinct in every particular,
  buttons and all, who, after a brief time, faded and disappeared. Sir
  Risdon says that he felt in perfect health; his pulse and breathing
  were normal and so forth, and he was naturally alarmed at the
  prospect of some impending brain disorder. Nothing, however, of the
  sort had followed. The same appearance recurred; he thought the
  postman's knock somehow originated the hallucination. ... I heard
  the story at length, very shortly after the event, told me with
  painstaking and scientific exactness and in tones that clearly
  indicated the narrator's earnest desire to be minutely correct.

Those who are especially interested in this subject will find any
number of similar stories, some apparently rich with meaning, most of
them quite {607} meaningless, in the volumes of transactions of the
English Psychic Research Society, in F. W. H. Myers' "Human
Personality," in Podmore's "Naturalizing the Supernatural," in
Flammarion's "The Unknown," or many other books published in recent
years. It is quite easy to get sufficient material to bring
reassurance to any patient that visual hallucinations, at least, mean
nothing serious for the mind or body of the individual having the
experience.


Hallucinations in the Past.--It must not be thought, however, that
this subject of hallucinations is new. Literature is full of it and
from the earliest times we find traces of it. Egyptian, Babylonian and
Chaldean writers mention them. Nor indeed is the scientific
consideration of the subject new. Aristotle speaks of them and it is
evident that many of the old writers thought of them as psychic
incidents on some physical basis, or at least due to some
predisposition in the individual or in some special state of his
senses. Two generations ago Johann Müller, the great German
physiologist, discussed the whole subject at length in a monograph,
and considered it of so much importance for physicians that he
introduced a résumé of it into his great text-book of physiology. His
explanation of the occurrence of visual hallucinations is not only a
striking illustration of the thoroughly scientific character of his
treatment of the subject, but it serves to show how well men
considered these subjects long before the present fad for the study of
abnormal psychology or mental influence came in. His discussion of the
subject is sufficient of itself to make any patient understand his
hallucinations and keep them from bothering him better than anything
else I know:

  The subjective images of which we are speaking have sometimes,
  however, both color and light; different particles of the retina, of
  the optic nerve, and of its prolongations to the brain, being
  conceived as existing in special states of action. This happens
  rarely in the state of health, but frequently in disease. These are
  the true phantasms which may occur to the sense of hearing and other
  senses as well as to that of vision. The process by which
  "phantasms" are produced, is the reverse of that to which the vision
  of actual external objects is due. In the latter case particles of
  the retina thrown into an active state by external impressions, are
  conceived in that condition by the sensorium; in the former case,
  the idea of the sensorium excites the active state of corresponding
  particles of the retina or optic nerve. The action of the material
  organ of vision, which has extension in space, upon the mind, so as
  to produce the idea of an object having extension, form and relation
  of parts, and the action of such an idea upon the organ of vision so
  as to produce a corresponding sensation, are both equally wonderful;
  and hence the spectral phenomena or visions are not more
  extraordinary than the ordinary function of sight. (Vol. II, p.
  1393, Eng. transl., 1842.)


Apparitions and their Explanation.--In spite of suggested explanations
on physical grounds, some of these apparitions that appear to people
seriously disturb them. They cannot get them out of their minds. They
are sure that they portend evil. Hence worries, and the more nervous
the people are and the more worried already, the more likely is such a
thing to recur and then to be made much of. Only through their minds
can these people be treated, and it must be made clear to them not
only how common are hallucinations, but that there is an easy psychic
explanation of most of them. Sir Arthur Mitchell, K. C. B., in his
book "About Dreaming, Laughing and Blushing," [Footnote 47] tells a
story and then gives his explanation of it in such a way as to
illuminate many of these occurrences:

  [Footnote 47: Longmans, London, 1900, page 21.]

{608}

  Perhaps I should illustrate how I think that apparitions may be
  nothing more than dream hallucinations. A. B., a gentleman of
  culture and strong character, called one hot day, after a hearty
  lunch, on an ecclesiastic in a high position, who happened to be
  engaged in his library at the time of the call. A. B. was shown into
  a room opening off the library, and requested to wait. He sat down
  beside a table, and with his elbow resting on it, he leant his head
  on his hand. While in this position he saw a man in clerical costume
  come through the door communicating with the library, without any
  opening of the door. A. B. was absolutely certain that he had seen
  an apparition, and was surprised and hurt when I expressed a doubt.
  He called on me to explain, and I said that it was at least possible
  that he had been asleep for some moments, that if he had slept at
  all, however short the dream of the sleep, he must have had a dream,
  if I am right in thinking that there is no dreamless sleep, and that
  thus what he regarded as an apparition might be nothing more than a
  dream hallucination. He assured me persistently that he was
  continuously wide-awake, but I assured him that these moments of
  sleep often occurred without any consciousness that they had
  occurred. He refused to be deprived of his ghost, and I refused to
  believe in the supernormal when the normal was sufficient.

Such wraith-like appearances are supposed to occur especially in
connection with the deaths of persons at a distance. Startling stories
are told, particularly of those who are very near relatives, husbands
and wives, mothers and sons, and, above all, twins, who have been very
closely associated with one another during life. There are a large
number of stories of this kind, however, that have been collected by
the Psychic Research Society and other agents with strong evidence in
their favor, in which the appearances have had no ulterior
significance at all and have evidently been mere figments of the
imagination, the externation of images from memory so vividly that
they seem to be the reseen. Reassurances in this matter are the best
possible source of relief from the sense of impending ill for many
patients. The physician who wishes to relieve such symptoms must
familiarize himself with some of the many stories that have been
investigated and that serve to prove that these and like appearances
must not be taken as significant of anything more than a definite
tendency, that exists in human nature at moments of day dreaming or
when one's attention is suddenly turned from a book in which one has
been absorbed, to see externally what is really passing through the
imaginative memory.


A Disappearance.--A very interesting commentary on some of these
appearances is to be found in Mark Twain's story of a disappearance,
which could probably be duplicated many times if experiences in this
line were collected and collated. Mr. Clemens, sitting on the porch of
his residence one day, saw a stranger of rather peculiar appearance
come up the walk toward the front door and he expected to hear him
ring the bell and have the servant come to the door and usher him in,
and then perhaps be called to see him. About the middle of the walk,
however, the stranger disappeared and Mr. Clemens was quite surprised
to come to himself, rub his eyes and conclude that he had had one of
these curious visions or hallucinations, in which the Psychic Research
Society would surely be interested. He had plainly seen the stranger
enter the gate, come up the walk, and then disappear. He was so
impressed by the disappearance that he roused himself to go into the
house to get his notebook, so as to make notes of what had happened
before the details escaped him. To his surprise he found the stranger
in conversation {609} with the servant in the house. There had simply
been a lapse in Mr. Clemen's vision of him. He had had a disappearance
phenomenon instead of an appearance. The story will be found to amuse
patients who complain of appearances disturbing them, though Mr.
Clemens always told his disappearance story very seriously, and it is
as interesting a psychic phenomenon as any told of the wraith-like
appearances.


Treatment.--Considering how frequent are such phenomena, the physician
must be prepared to treat those who are disquieted by them. A
wraith-like appearance, for instance, will disturb many people very
seriously and often for days, sometimes for weeks, make them nervous,
excitable, and impair their appetite, disturb their digestion and
sleep and often such unfortunate occurrences are prone to come just
when they are run down in weight and when they need the help of every
factor that makes for improvement of health. Simply to dismiss such an
appearance as if it were quite imaginary, that is, non-existent in
some form of reality, or quite baseless and trivial, serves no good
purpose, for, as a rule, the persons concerned are deeply impressed
with what they have seen. The only way to remove the unfavorable
impression produced by it is to discuss it straightforwardly on the
basis of what we have come to know as the result of recent
investigations and the collation of the literature which has been
published by the various psychical research societies and authorities
on the subject. We know now that while occasionally such wraith-like
appearances seemed to have a definite significance, because of
something that happened simultaneously or shortly afterwards, this is
mere coincidence and there are literally thousands of such cases in
which a well authenticated wraith-like appearance was followed by no
serious consequence, was never shown to mean anything beyond a curious
psychic phenomenon, and was evidently merely due to some personal
subjective influence, some externation of an image in the memory,
unusual, but not at all unique, or even very rare, and evidently due
to a curious peculiar externalizing power with which certain
intellects are gifted.


Auditory Hallucinations.--Hallucinations of hearing are more common
than those of vision. Many people have had the experience of waking up
thinking that someone was calling them. A great many people are sure
that they have, at some time or other, heard a voice when no one was
near enough to them to have said anything. They have even recognized
the voice. Some people, when thinking deeply about a person, have the
voice of that person occur to them so clearly that they cannot quite
make out whether they have actually heard it or whether it has only
been very vividly reproduced in their memory. Such experiences are so
common as to be well known, though many people hesitate to tell the
stories of them, for hearing voices is rightly looked upon as a
frequent preliminary symptom of insanity.

Hallucinations of hearing are the most common early symptom of
insanity. The hearing of voices must always arouse suspicion at once.
It must not be forgotten, however, that a great many recognizedly sane
people who have remained so for life, have thought that they heard
voices. Of course, we have no definition for insanity, and it is
difficult to draw the line. We have no definition for health either,
yet we have a practical working standard for the recognition of it, as
also for insanity. These hallucinations then, both of vision and
hearing, deserve to be discussed seriously, and in {610} nearly every
case, even though there is some mental disturbance, the physician can
in this way benefit his patients and keep them from being overmuch
distressed by their hallucinations.

There is an expression in such common use that it is evidently the
result of an almost universal experience, according to which men
sometimes explain, after having acted in a particular way, that
"something told them to." What they mean, of course, is that a
conclusion formed in their minds the reasons for which they could not
understand, but which yet had force enough to cause them to follow it
to a practical application. When we hear of Socrates being advised in
life by a demon, a so-called familiar spirit, we are apt to wonder
whether by this term is meant anything more than just this curious
feeling of aloofness from ourselves that we sometimes have when we are
trying to make up our minds, or, indeed, not infrequently when we are
deeply engaged in any intellectual occupation. As discussed in the
chapter on Unconscious Cerebration, our minds seem in a certain way to
act independently of us. Occasionally they draw us to conclusions
quite different from those which we previously expected to reach.
There seems to be a something within us that works quite of itself and
beyond our will. Whether under these circumstances there may not
occasionally come so vivid a feeling of this power within us
impressing itself upon us, that it seems to come from without, must
always be taken into account in the effort to get at the real
significance of these curious hallucinations. Only thus are we able to
come to the relief of patients who are bothered by them.


_Explanation by Sound Reproduction_.--Auditory hallucinations are
probably not more than reproductions of sounds heard before recalled
vividly and apparently heard again at moments when attention is not
attracted to actual auditory sensations and we are in receptive mood.
Some of them are very startling because they are apparently warnings
of future events, as is proved by their fulfillment. These, however,
do not seem to be more than coincidences noted with regard to similar
events connected with Premonitions, Dreads and Dreams (see chapters on
these subjects). There is, for instance, a well authenticated story
published by the English Psychic Research Society of a woman who was
about to take a dose of what she thought was some ordinary home
remedy, when she distinctly heard a voice telling her to taste it. The
dose to be taken was a tablespoonful, and when she tasted it she found
that by mistake she had placed her hands on a bottle containing a
rather strong poison and a tablespoonful of it would almost inevitably
have killed her. Unfortunately, such occurrences are so rare and the
reason for them is so hard to find that their consideration as
anything more than coincidences seems out of the question. Every
medical journal almost brings the story of someone who has taken a
dose of medicine that proves fatal, and there is no warning. If such
warnings came with definite frequency, it would be easier to
appreciate their significance.

There are similar stories with regard to other warnings. There is the
story of the young man who in a storm drove under a shed for
protection. Just as he did so he heard his mother's voice--she had
been long dead--distinctly say "Drive out!" Ho drove out at once in
the teeth of the storm, so deeply impressed was he, and was scarcely
beyond the entrance when the shed fell, crushing everything within it.
Similar warnings of impending {611} accidents are rather frequent in
certain people's minds, yet it is hard to think of them as anything
else than premonitions. These somehow take on the character of
auditory hallucinations in certain sensitive minds. Compared to the
whole number of accidents, however, such incidents are extremely rare
and follow no law, and while there are those who like to think that
perhaps such phenomena are due to the solicitude of some being in the
other world, this is extremely doubtful. In that case, as St.
Augustine suggested, they would be much more frequent and have a
clearer significance than is at present the rule. St. Augustine,
discussing the possibility, was sure that he would have had
communications from his mother. Most men would re-echo his feeling.


Coincidences.--Most of these stories as they have been analyzed by
careful investigators are indeed such trivial unmeaning things that it
would be too bad to let people be bothered by them. They have
occurred, however, from time immemorial. Veridical warnings are a
commonplace in the literature of all countries. Undoubtedly some may
suggest the action of a Higher Power, but the more one knows of the
conditions in which they happened, the people to whom they came and
their ultimate effects, the less will they seem providential. It is
evident that under certain conditions they may be produced even at
moments when men are not particularly excited and when they think that
they are perfectly calm and self-possessed. Each story must be
discussed in its own merits. The only thing to do, then, is not to
make too light of them and, above all, not to treat them as merely
imaginary or as utterly illusory; for they are often natural
phenomena, the reasons for which and the conditions of their
production we do not as yet fully understand. If patients can be
brought to this viewpoint, they may even become interested in
searching out just what it was that caused each particular
hallucination. Over and over again it has been found that a moonbeam
or a peculiar unexpected reflection of the sun, or the light shining
through an unnoted aperture, or any or several of these in connection
with a mirror has been the main cause of the wraith-like appearance.
When they happen during the day it is sometimes at the moment of
passing from very bright light to a darker hall that the occurrence
takes place and evidently there is some physical occasion for the
appearances in the eye itself. Unusual noises of various kinds are
responsible for the auditory hallucinations.


Dangers of Serious Considerations.--There is one serious aspect of
these hallucinations and supposed warnings--they tend to paralyze
action. If a person allows himself to become firmly persuaded that
doubts and premonitory possibilities must be weighed and solved before
he may dare to act with assurance, then action becomes almost
impossible. Premonitions may serve to bring people into danger, or at
least keep people from having such presence of mind as will enable
them to get out of it, as they otherwise would. Doubts lead to
inaction and make a state of mind that is eminently miserable. The
patient's one hope is to put aside resolutely such hallucinations if
they rise to the level of a disturbing doubt or a paralyzing
premonition and to discipline himself against being influenced by
them. In many persons this is a difficult matter, but it represents
the only efficient path to the regaining of mental health and
strength.

{612}


CHAPTER III

DREADS


In any discussion of the influence of mind over body, favorable and
unfavorable, too much emphasis cannot be placed on the hold that
dreads have over a great many people and how much they mean, not alone
for the mental state, but also for the physical sense of well-being or
of ill-feeling in the individual. The expression attributed to the old
hermit who had lived to the age of one hundred and had spent some
sixty years of existence in the solitude of the desert, with all the
opportunities for introspection that this afforded, is the best
illustration even in our day of what dreads signify in life: "I am an
old man," he said to the young solitary who came to him for advice,
"and I have had many troubles, but most of them never happened." We
are nearly all of us, or at least those of us who spend most of our
time in sedentary mental occupations, prone to fear that something
untoward is preparing for us and in many cases to dread lest some
serious ailment or other is just ahead of us. We are afraid that
certain feelings, though we like to call them symptoms, due to some
trivial cause or other as a rule that deserves no notice, may mean the
insidious inroads of a constitutional disease destined to shorten
existence. A little fatigue, over-tiredness of particular muscles, the
straining of joints, the discomforts due to overeating and
undersleeping, that are meant as passing warnings of nature for the
necessity of a little more care in life, are exaggerated into symptoms
that have a more or less serious significance.


DEFINITE DREADS

Besides these rather vague dreads, however, there are certain special
disquietudes peculiar to individuals, even more groundless, if
possible, than the generic apprehension just spoken of and that have
been dignified in recent years by the name of phobias. Phobia means
only "fear" in Greek, but the term is much more satisfying to nervous
people than the shorter but too definite English term, dread, or fear.
There is acrophobia, or the fear of looking down from a height;
claustrophobia, or the fear of narrow places, as the dread of walking
through a narrow street because of the sense of oppression that comes
with the shut-inness of it. Then there is agoraphobia, market-place
dread, or the fear to cross an open space because one has, as it were,
grown accustomed to be near buildings and misses their presence. There
are many others, indeed as many as there are dislikes in human nature,
for any dislike apparently may be exaggerated into a dread. I mention
a few at the beginning of the alphabet and some of special
significance. There is aerophobia, dread of the air, a symptom
sometimes mentioned in connection with hydrophobia; aichmophobia, the
dread of pointed tools; ailurophobia, the dread of cats; anthrophobia
or the dread of men; pathophobia or the fear of disease, microbophobia
or bacillophobia; kenophobia or the dread of emptiness; phthisiophobia
or the dread of consumption; zoophobia or the dread of animals;
sitophobia or the dread of food, and even phobophobia, the dread of
{613} dreading. Neuropsychologists seem to take a special pleasure in
inventing some new phobia or at least giving us a fine long Greek name
for a set of symptoms by no means new and that might well be explained
in simpler terms. The most familiar examples are: the fear of
lightning, which is more frequently brontophobia, the fear of thunder.

These learned words are all formed on the same etymological principle
as hydrophobia, but they are entirely psychic in origin, while
hydrophobia, as it is well to explain to patients who think of the
word phobia in connection with their symptoms, is, of course, a
misnomer for an infectious disease--rabies--which develops as the
consequence of a bite of a rabid animal, and the principal symptom of
which is not fear of water, but the impossibility of swallowing any
liquid because of spasm of the esophageal muscles.

Almost any function of the body may become the subject of a dread or
phobia that may interfere even seriously with it. Any disturbance of
any function is likely to be emphasized by such dreads. The French
have described the basophobia, which makes the patients suffering from
beginning tabes dread so much walking that it becomes a much greater
effort than it would otherwise be and often interferes with walking
rather seriously. Then there is the fear of tremor which exaggerates a
tremor due to some organic cause, but yet not necessarily of grave
import, nor likely to increase rapidly. Many of the hysterical palsies
are really due to dreads, consequent upon some incident, motor or
sensory, which produced a profound effect upon the patient's mind. A
patient who has been surprised by a digestive vertigo while descending
a stairs, even though nothing more happened than the dizziness which
required him to grasp the balustrade, will sometimes develop a fear of
vertigo that will actually make it difficult for him to go down stairs
without such an effort of will as is very exhausting. Even the
slightest functions may be thus disturbed. Pitres and Regis described
some ten years ago what they called the obsession of blushing, or
erythrophobia, the fear of turning red. Patients make themselves
extremely miserable in this way. Only training and self-control will
help them.

These names are long and mouth-filling and consequently satisfying,
and most people who are suffering from a particular phobia are almost
sure to think that they have a very special affliction. When the word
dread is used instead of the word phobia they are less likely to
misunderstand the character of their affection and to realize that it
is not a disease but only an unfortunate mental peculiarity that needs
control and discipline, and not fostering care. Neurasthenia only
means nervous weakness, as we have pointed out, but most people are
rather rejoiced when informed that they have so high-sounding a
disease as neurasthenia, while to be told that they are nervously weak
or suffer from nervous weakness seems quite a come-down from their
interesting Greek-designated affection. Most psychiatrists feel that
it is better not to give the long Greek term, but to state in simple
short Saxon words just what is the matter with the patient. They are
suffering from the dread of a height, or the dread of a narrow street,
or the dread of open spaces, or the dread of dirt, or of cats, or of
whatever else it may be. This makes it easier for them to begin to
discipline themselves against the state of mind into which they allow
themselves to fall with regard to these various objects, and mental
discipline is the only therapeutic adjuvant that is of any avail in
{614} lessening these conditions. With reasonable perseverance most
people can, if not cure themselves of these affections, at least
greatly lessen the discomfort due to them. A consideration of
particular dreads brings out the specific suggestions that may be made
with regard to each and the directions that may be helpful to the
patients. Probably the commonest is acrophobia, so that the detailed
consideration of it shows the indications for other dreads.


Dread of Heights.--Almost without exception men have a sort of
instinctive dread of looking down from a height. In most people this
can be conquered to such a degree that almost anyone, if compelled by
necessity, can learn to work on a skyscraper and continue to do good
work without much bother about the height, though he may have to go up
ten to twenty stories, or even more. When he takes up the work at
first every workman finds it difficult. It gives most of us a trembly
feeling even to sit in our chair and think of looking down from such a
height. To see pictures of men standing on the iron frames of
skyscrapers twenty or thirty stories up in the air looking down 300 to
500 feet below them gives one a series of little chilly feelings in
the back and in many people a goneness or sense of constriction around
the abdomen that is almost a girdle feeling. To sit at a window
opposite where a skyscraper is going up and to see the men lean over
the edge of a beam calling directions of various kinds to workmen
below will give most people, even those who are not nervous or
especially sensitive, creepy feelings with sometimes a little catch in
the breath and an iciness in the hypochondria. It would seem
absolutely impossible that we should ever be able to perform these
feats of looking from a height, yet experience shows that most of us,
after a little training, learn to do it without difficulty.

Even the men who work most confidently have some creepy feelings
return to them whenever they stop and think about this and let their
eyes wander to the distance below them. It is not difficult for us to
walk across a plank raised a foot or two from the ground, though to
walk across the same plank at a height of ten feet may be quite a
trial and at thirty feet may become quite impossible. This is all due
to lack of confidence on our part and there is no reason in the world
why, if the plank is amply wide for us at two feet from the ground, it
should not be just as wide and safe at 30 or 60 or even 100 feet. This
is what the men who have learned to work on skyscrapers have
disciplined themselves to. They have learned to disregard the wide
vacant space around them and the yawning chasm beneath their feet;
they keep their eyes fixed on something in the immediate vicinity,
excluding thoughts of all that might happen if they should lose their
balance.


_Physical Basis_.--There is a physical basis in many of these cases
that constitutes the underlying occasion, at least, for the
development of the psychic dread. Our eyes have grown accustomed to
being fixed on near objects. Whenever they are not so fixed we get a
feeling of trepidation. Even those who have done a little day-dreaming
know that sometimes when they have been looking into space, objects
around them have suddenly seemed to be transferred to a long distance
and at the same time a curious sense of insecurity came over them.
Anyone can get this feeling experimentally by making two large dots on
a piece of paper about two inches apart and then gazing between the
dots into vacancy beyond the paper as it were, until the dots have a
tendency to become four because of the fact that each eye sees {615}
each of the dots on a part of the retina not corresponding to that on
which the other eye sees it (see Fig. 25).


  [Illustration: Fig. 25. (Two solid black dots about 1/2 inch
  diameter and 4 inches apart.)]


When the experiment is successfully performed the dots begin to float
before the eyes, then they may coalesce into one or become three, but
any number up to four may readily be seen. This will give the sense of
insecurity that comes from the eyes not having any fixed object to
look at and illustrates the discipline of the eyes that must be
learned in order that looking down from a height may not be productive
of the usual dread.


_Dread of Small Heights_.--It is often thought that acrophobia, or the
fear of a height, concerns only great heights and that ordinary
elevations produce no discomfort. I have had patients, however, who,
when compelled by circumstances over which they had no control or at
least by social obligations that were hard to break, to sit on the
front row of even a low balcony, have been extremely uncomfortable.
There was a sense of tightness and oppression about the chest that
made it difficult for them to breathe, that disturbed their heart
action and gave them a general sense of ill-feeling. I have had a
curiously interesting series of cases in clergymen who found it trying
to say Mass or conduct services or to preach from the step of a high
altar. One would be inclined at first to make little of their
description of their utter discomfort. There is no doubt at all,
however, of their real torture of mind and of the extreme effort
required to enable them to support themselves in the trying ordeal.
They are often so exhausted because of the effort required that only
with difficulty can they do anything else during the day.

To most people such a state of mind is inexplicable. There are deeply
intellectual men who, in my experience, are quite disturbed by
apparently so simple a thing as having to say Mass on an altar that
has three or four steps to it and is elevated five or six feet above
the surrounding floor. As for higher altars, like the main altar of a
cathedral, they usually find it quite impossible to conduct services
unless they are in company with others, when their feelings are much
relieved. This same thing is true of agoraphobia in some people. To go
alone across an open place or square is agony, but even the company of
a little child is sufficient to relieve them to a great degree. I told
a distinguished American prelate of this curious dread in priests so
often called to the physician's attention, and he said that he had
never heard of it. To his surprise some of his clergymen present at
the table told him that there were two examples of it in brothers in
his own diocese.


_Mental Discipline_.--The lesson of the many men who, by discipline,
have succeeded in conquering the aversion and the dread of heights
that everyone has to some extent at least, shows the possibility there
is for even those who are extremely sensitive in this matter to so
lessen their timidity and the uncomfortable oppression that comes over
them, as to make it possible to accomplish whatever is in their line
of duty. It is no more difficult for the sensitive clergyman to learn
by practice and discipline to walk with confidence on a reasonably
high altar or platform, than it is for the workman to learn to {616}
walk a beam on the top of a twenty-story building without a thought of
the dangers of his position, or at least putting the thought away from
him so that it does not interfere with his work. At the beginning he
cannot do it, but he disciplines himself to form a habit that makes it
easy. Yielding to his feelings makes it difficult to withstand the
discomforts that come to him. After an accident on a high building, as
a rule, men have to be sent home for the day to get their nerves
settled by the night's sleep before they can work with sufficient
confidence, and yet accomplish their usual amount of work.


So-called Misophobia--Dread of Dirt.--Misophobia, or the fear of dirt,
has grown much more common in recent years, and the spread of the
knowledge of the wide diffusion of bacteria has added to the
unreasoning dread that possesses these people. Some of them wash their
hands forty to fifty times a day, and one young man who was brought to
me with the worst looking hands, because of irritation from soap and
water, that I have ever seen, seemed to be always either just plunging
his hands into water or wiping them dry. These people make themselves
supremely miserable. They do not care to shake hands with friends and,
above all, with physicians, and they invent all sorts of excuses so as
to wait outside of doors till someone else opens them so as to avoid
touching the knob or door pull, "which" with a poignant expression of
repugnance they tell you "is handled by so many people." When the
patients are women, getting on and off cars becomes a nightmare to
them, because they do not want to touch the handle bars and unless
they do they find it difficult to ascend and descend. The curious
excuses they offer for their peculiar actions in avoiding the touch of
objects around them are interesting.


Claustrophobia.--This sort of dread seems quite irrational to most
people and many would probably conclude that individuals thus affected
could not possibly be quite in their right minds, or must surely be
rather weak-minded. On the contrary, many of the people who are
affected by these curious dreads are above the average in intelligence
and sometimes also in their power to do intellectual work. A typical
example, for instance, of claustrophobia, or the fear of closed
spaces, is found in the life of Philip Gilbert Hamerton. He was a
distinguished painter and essayist, editor and novelist. Few men of
his generation were able to do better intellectual work than he. His
book on "The Intellectual Life" was more read perhaps than any work of
its kind in the last generation. He was not a profound thinker, but he
was a very talented practical man. The fact that besides being a
writer whose books sold he was a painter whose works were in demand,
shows a breadth of artistic quality that is quite unusual. His was not
the sort of genius, however, that is so often supposed to be allied to
insanity, for he was rather a worker who obtained his effects by
plodding, than a brilliant genius that got his thoughts by intuition.

In a word, in spite of the fact that he was just the sort of man that
one would not think likely to be affected by a phobia, he had a series
of attacks of claustrophobia, some of which were intensely annoying to
him and seriously disturbing to his friends. His wife has described
some of them in his "Life and Letters." Once after crossing the
English Channel, he had a severe attack in the railroad carriage on
the way up to London. He had not been nervous {617} on the voyage and
had not been seasick. He was returning from a vacation and was in the
best of health and spirits, yet suddenly the feeling of inordinate
dread that he was shut in came over him and he could scarcely control
himself or keep from plunging out of the window in order to get into
the open. His wife says that "His hands became cold, his eyes took on
a far-reaching look, his expression became hard and set and his face
flushed." He seemed "as if ready to overthrow any obstacle in his way;
and indeed it was the case, for, unable to control himself any longer,
he got up and told me hoarsely that he was going to jump out of the
train. I took hold of his hand and said I would follow him, only I
entreated him to wait a short time, as we were near the station. I
placed myself quite close to the door of the railway carriage and
stood between him and it. Happily the railway station was soon
reached, when he rushed from the train and into the fields." His wife
followed him like one dazed, and almost heart-broken. After half an
hour he lessened his pace, turning to her and said, "I think it is
going." For two hours they continued to walk, at the end of which
Gilbert said tenderly in his usual voice, "You must be terribly tired,
poor darling. I think I could bear to rest now. We may try to sit
down."


Dread of Cats.--One of the most interesting of dreads, very frequently
seen and producing much more discomfort than could possibly be
imagined by anyone who had not seen striking cases of it, is the dread
of cats which has been dignified and rendered more suggestively
significant by the Greek designation ailurophobia. While the great
majority of individuals suffering from this unreasoning dread of cats
are women and usually of a delicate nervous organization, it must not
be thought that it is by any means confined to them or has any
necessary connection with hysterical symptoms. One of the most
striking cases of this dread of which I know personally occurs in a
large, rather masculine-looking woman, who cannot abide being in a
room with a cat, and who is quite unable to do anything while one of
these animals is within sight. Yet she is not at all what would be
called timorous and she has more manly than womanly characteristics in
every way. She once proceeded to thrash within an inch of his life a
small burglar who entered her house and she rather prides herself on
being able to protect herself. Nor is this dread necessarily
associated with any other disturbances of mind or nervous system. Some
of the patients I have seen, who confess to suffering from it, were
thoroughly sensible, brave little women, able to stand suffering well,
not at all hysterical in nature, and who in the midst of worries found
time to be thoughtful of others and not to have that selfishness
which, even more than physical symptoms, is so apt to characterize
hysterical patients.

I have had men confess to me their dread of cats, and while, as a
rule, they were of delicate constitution and inclined to be nervous
and did not have the phobia to an inordinate degree, there was no
doubt that they were extremely uncomfortable whenever a cat was near
them. On the other hand, some of them were vigorous, husky men with
strong aversions. One of the most marked cases of ailurophobia that
was ever brought to my attention was in an army officer who had
exhibited bravery in battle on many occasions, and what requires much
more strength of mind, calm fortitude in difficult campaigning, yet
for whom a cat had many more terrors than the battery of an enemy or
even an ambuscade of Filipinos. More cases of this particular {618}
aversion seem to occur in clergymen than in other men, yet one of the
worst cases I ever saw was in a priest of great moral courage, who had
served a pest-house over and over again in smallpox epidemics.

All that can be said about such a dread is that it exists, that it is
unreasoning, that some patients have been known by discipline of mind
to overcome the abhorrence to a great degree but never quite entirely.
In this regard, however, it must not be forgotten that there are many
things abhorrent to human nature that seem impossible to overcome the
aversion for, yet discipline does much to relieve them. For instance,
the handling of dead bodies so familiar to physicians brings with it
an aversion that we never quite get over and which resumes most of its
original strength with disuse, but that can be overcome to such an
extent as to make pathological work produce very little aversion. Even
Virchow, after all his years of occupation with pathological material,
confessed toward the end of his life, that whenever he was away from
his work for a few months his aversion had to be overcome anew.


_The Spectator on Dreads_.--There might be a tendency to think that
these curious dreads came only as the result of the individualistic
over-occupation with self and the introspective sophistication of the
modern time, but the dread is not confined to our time nor special to
it in any way, for we find Shakespeare talking of those who cannot
bear a harmless, necessary cat. A number of other writers of different
periods refer to it. As in so many other things _The Spectator_
reflects his time in this and so we have a letter with regard to the
dread of cats. It would not have been a subject for discussion in one
of these popular communications only that the writer felt that a good
many people would realize how like it was to things that they
themselves knew of. In number 609 the following letter, supposed to be
from a correspondent, seems worth giving in full, because it touches
on other subjects in which uncontrollable, unreasoning feeling plays a
role:

  I wish you would write a philosophical paper about natural
  antipathies, with a word or two concerning the strength of
  imagination. ... A story that relates to myself on this subject may
  be thought not unentertaining, especially when I assure you that it
  is literally true. I had long made love to a lady, in the possession
  of whom I am now the happiest of mankind, whose hand I should have
  gained with much difficulty without the assistance of a cat. You
  must know then that my most dangerous rival had so strong an
  aversion to this species, that he infallibly swooned away at the
  sight of that harmless creature. My friend, Mrs. Lucy, her maid,
  having a greater respect for me and my purse than she had for my
  rival, always took care to pin the tail of a cat under the gown of
  her mistress, whenever she knew of his coming; which had such an
  effect that every time he entered the room, he looked more like one
  of the figures in Mrs. Salmon's wax-work than a desirable lover. In
  short, he grew sick of her company, which the young lady taking
  notice of (who no more knew why than he did), she sent me a
  challenge to meet her in Lincoln's Inn Chapel, which I joyfully
  accepted; and have, amongst other pleasures, the satisfaction of
  being praised by her for my stratagem.


_Cat Fear and Furs_.--This dread of cats is sometimes exhibited to a
surprising degree under rather unexpected circumstances. For instance,
it is not unusual, since the fashion for the longer-haired furs came
in, to find that some of these patients cannot wear certain supposedly
elegant furs, since they are really dyed catskin. At times this is not
suspected until other possible causes for the discomfort have been
eliminated. Some women cannot even bear to be near catskins in muffs
and other such furs, though the imitation {619} may be so good as to
deceive any but an expert, and they apparently had no suspicion at the
beginning of the presence of cat fur near them. I have been told by a
physician the story of a man, poignantly sensitive to cats, who
purchased a fur-lined coat and found it quite impossible to wear it
because of the sensations it produced in him, though he had no
suspicion of any connection between cats and the fur when he purchased
it.


_Recognition of Presence_.--Why this dread of cats occurs and, above
all, the reason for the ability to know that a cat is near when the
animal is concealed and others are not at all aware of its presence,
or that its fur should produce a disagreeable sensation, is not easy
to decide. Its discussion is suggestive for other forms of dreads, for
there are probably like refinements of sensation, normal and abnormal,
connected with them. Much has been said about this as a reversion to
powers possessed by man in a savage state when there was necessity for
guarding against animal attacks. Unfortunately for any such
supposition as this, these people, who are most fearful of cats, that
is, of the ordinary domestic animal, have no uneasiness in the
presence of the huge cats in the menageries--the lions and the tigers.
It is with regard to these that such a specialization of scent would
be particularly valuable for men. There seems no doubt but that it is
an odor or a sensation allied to an odor, though perhaps below the
ordinary threshold of recognition as such, that enables these people
to detect the presence of a cat. Dr. Weir Mitchell in his article on
"Ailurophobia and The Power to Be Conscious of the Cat as Near While
Unseen and Unheard," in the _Transactions of the Association of
American Physicians_, 1905, discusses odor in this connections as
follows:

  To be influenced by an olfactory impression of which (as odor) the
  subject rests unconscious, may seem an hypothesis worthy of small
  respect and beyond power of proof. Nevertheless it seems to me
  reasonable. There are sounds beyond the hearing of certain persons.
  If they ever cause effects we do not know. There are rays of which
  we are not conscious as light or heat, except through the effects to
  which they give rise. There may be olfactory emanations
  distinguished by some as odors and by others felt, not as odors, but
  only in their influential results on nervous systems unusually and
  abnormally susceptible. No other explanation seems to me available,
  and this gains value from certain contributory facts.

  We must admit that all animals and human beings emit emanations
  which are recognizable by many animals and are in wild creatures
  protectively valuable.

  This delicate recognition is commonly lost in mankind, but some
  abnormal beings like Laura Bridgeman and a perfectly normal lad I
  once saw, have possessed the power of distinguishing by smell the
  handkerchiefs of a family after they had been washed and ironed. In
  this lad I made a personal test of his power to pick out by their
  odor from a heap of clean handkerchiefs mine and those of others,
  the latter two belonging to his father and mother.

  I have seen a woman, well known to me, who can distinguish by mere
  odor the gloves worn by relatives or friends. This lady, who likes
  cats as pets, is able to detect by its odor the presence of a cat
  when I and others cannot.

  Two French observers believe that they have proved the sense of
  olfaction to be nine times more acute in women than in men.

  So far as the present paper might serve in evidence, I should be
  inclined to say that the sense of smell was keener in women than in
  men, but as to this there is extreme diversity of opinion and the
  whole question awaits further investigation.    [Footnote 48]

    [Footnote 48: This question of the varying acuteness of smell in
    different people is very interesting to the psychotherapeutist for
    diagnosis and therapy. We have a number of striking cases of very
    acute olfactory power. This is what might be expected since
    animals whose respiratory and smell apparatuses are very like our
    own show extreme differences. The extent to which human power to
    recognize odors can go is marvelous. In his "Thinking, Feeling,
    Doing," Prof. Scripture says: "I have a case--reported by a
    perfectly competent witness who lived for years with the person
    mentioned--of a woman in charge of a boarding school who always
    sorted the boys' linen after the wash by the odor alone."
    Personally, I have sometimes wondered whether this power, like
    that of feeling in the blind, could not be developed. The blind
    are supposed actually to bring about an evolution in their nerves
    of feeling. No such thing happens, however. An examination of them
    by means of an esthesiometer shows that their nerves are no better
    developed than those of other people, though they may be able to
    recognize much minuter differences between the "feel" of things
    and may be able to read raised type, which the seeing cannot. This
    is all due to a training of their attention to note slight
    differences in sensation, however, and not to improvement in the
    nervous apparatus. ]

{620}

Dread of the Dark.--The discipline suggested with regard to overcoming
the dread of heights must be applied to any of these dreads if
patients are to be made comfortable. They can form the opposite habit
and by refusing to yield to their fears can do much to lessen them.
Nearly everyone who is unaccustomed to sleeping in a dark house alone
has dreads that come over him when he first tries to do it. Every
noise is exaggerated in significance and the creaking of stairs and
rattling windows and doors and the wind through the trees are all made
significant of something quite other than what they are. Nearly
everyone knows, however, that this can be overcome simply by refusing
to pay any attention to the idle fears that come over us as a
consequence of the tension due to loneliness, and after a time,
sleeping in a strange room and a strange house in the dark is not a
difficult matter. It is harder for some people to accomplish than
others, but it is impossible for none. Here is the lesson that all the
sufferers from dreads must learn. Gradually, quietly, persistently,
they must resist the dreads that come over them, must deliberately,
without excitement, do the opposite to that suggested by their
apprehension, until habits are formed that enable them to accomplish
without discomfort what was before a source of even serious
ill-feeling.

The dread of darkness that so many people have is usually supposed to
be cowardice. It is not, however, in most cases, but is due to
idiosyncrasy or to certain special physical factors in the
environment. If children have been brought up so that when they were
small a light has been constantly shining in their eyes, even though
only a dim light, it will often be difficult to accustom them to be
quite comfortable in the dark. Much depends on habit in this matter. I
have known men, who, when they came from Ireland, feared the darkness
of the coal mines very much and their dread was increased by the awful
horror of possible ghostly appearances, since so many accidents had
taken place where they worked. After some years, however, they were
quite placid about it and would calmly go into the mine as fire bosses
at three and four in the morning, long before others were to go in,
examining absolutely dark passages by the mile, with no human being
near them and with the creaking of the pillars, the dripping of water,
the rumbling of the sides and the occasional fall of a small particle
from the roof, besides the noises of rats to add to the disturbing
factors. Like going up on a high building, one may get entirely
accustomed to it so as scarcely to notice it at all.

When the fear is allowed to take hold of one, however, and no effort
is made to overcome it, it may prove quite seriously disturbing. The
unaccustomed, however, means more than anything else in this matter.
Sometimes, {621} indeed, people have a dread of the dark that seems to
be inborn and that apparently cannot be overcome, that, like the fear
of cats or of lightning, may be quite beyond rational control. Hobbes,
the English philosopher, was so perturbed by darkness that he kept a
light in his bedroom all night. I know this to be the case in a
clergyman who had been quite undisturbed about darkness until he was
awakened one night by a burglar. He demanded "who's there?" and
received as answer without further parley a bullet that fortunately
struck only the head of the bed, but so close that it singed him. The
burglar escaped, but the clergyman was never afterwards able to sleep
without a light. Rousseau, the French philosopher, was also much
afraid of darkness. Ordinarily it is presumed that superstition has
something to do with this fear and that the victim of it has ghosts in
mind or at least dreads spirit manifestations. Neither Hobbes nor
Rousseau, however, was likely to be timorous about ghostly visitants.
It was with them a physical idiosyncrasy.

Associated with dread of darkness is the fear of finding some one in a
dark room whose presence may startle us. Sir Samuel Romilly, famous
for his labors for the reform of the English criminal law, and who
must be considered one of the great humanitarians of the nineteenth
century, had this dread to an acute degree. It went so far that
whenever he slept in a strange place he carefully examined all the
possible hiding-places in the room and in wardrobes or closets
connected with it and, as a last precaution, never failed to look
under the bed. He did this even when he was in his own house.
[Footnote 49] This, however, is not so unusual, even among men, as
might be thought. Most women who sleep alone want to investigate under
the bed and in a hotel closets and wardrobes and even bureau drawers
are likely to be examined. Habit in this regard may make one quite
miserable and over-solicitous. I have had patients whose sleep was
seriously disturbed by the remembrance that they had not looked under
the bed and who feared to get up and light a light to do so lest there
should be someone there. Indeed, the idea of putting their feet on the
floor before the light had come to reassure them seemed quite out of
the question.

  [Footnote 49:  Curiously enough. Sir Samuel Romilly, in spite of his
  dread of the dark, committed suicide and went prematurely into the
  darkness of the beyond, apparently without his usual tendency to
  precaution.]


Dreads Connected with Water.--Strange as it may seem, water
constitutes a source of dread for some people. We have the records of
it in the peculiarities of great men and it is not unusual to meet it
in common life. Dropping water is a source of disturbance for most
people. It is quite impossible for the majority of men and women to go
on writing or reading with any comfort if water is dropping near them.
Dropping water, when one is trying to go to sleep, is one of the worst
of awakeners. The Chinese are said to put people to death in horrible
torture by having a drop of water fall at regular intervals on their
heads. Robert Boyle, the great father of chemistry and a very sensible
man in many ways, is said to have been thrown into convulsions by the
sound of water dropping from a faucet. The splashing of water on some
people is a poignant source of torture. I have had a woman patient who
could not go to services where there was a sprinkling of water, for it
seriously disturbed her and gave her a sense of depression that would
not be overcome for some time. Peter the Great, though the father of
the {622} Russian navy, and though he passed many years of his life in
Holland, used to shudder at the sight of water, and if, when out
driving, his carriage passed near a stream or over a bridge, he would
close the windows and be overtaken with terror that brought the
perspiration out all over him.


Dread of Death.--The fear of death is one of the dreads that bothers
young as well as old, and, curiously enough, as its inevitable
approach becomes more certain, men are prone to dread it more. Long
ago Sophocles said:

  None cleave to life so fondly as the old,

-- and this has remained true for all the centuries since. A young man
is quite ready to throw his life away, but the old man hesitates and
even in the midst of suffering, if it is not absolutely continuous,
craves that death shall not come. Sophocles' great rival, the elder
Greek dramatic poet AEschylus, had said:

  How far from just the hate men bear to death
  Which comes as safeguard against many ills,

-- but his message was only for those with the character to face the
worst. One may reason with the dread of death, however, and patients
can be given motives from philosophy, literature, religion and
experience that will help to relieve, though it will not entirely cure
them. Shakespeare said in "Julius Caesar":

  Cowards die many times before their deaths.
  The valiant never taste of death but once,

-- and people may be aroused to appreciate this.


_Fear of Early Death_.--Many fear that if they have shown symptoms of
delicacy of constitution at some time in life or suffered severely
from some serious disease, that they are not likely to live long and,
above all, that they are almost sure not to be able to accomplish
anything worth while in life. The old proverb is "a healthy mind in a
healthy body." This is, however, the ideal. There are very few ideals
realized in life. Just because a man has a weak body is no argument at
all that his mind may be weak and some of the world's finest work has
been accomplished by men whose bodies were always delicate.
Metchnikoff is the apostle of old age to our generation, but it is he,
also, who has pointed out that many distinguished workers in science,
in poetry, in art, men who have left a precious heritage in succeeding
generations, were delicate all their lives. He cites such typical
examples as Fresnel, the great French physicist; Giacomo Leopardi, the
distinguished Italian poet; Weber and Schumann, the great German
musicians, and Chopin, the Polish composer and pianist, all of whom
did work that the world would not willingly miss, in spite of delicacy
of health and weakness of body which shortened their lives.
Intellectual power is not dependent on bodily energy and
accomplishment is not a question of years of work, but intensity of
work.

It would not be difficult to add many other names to those mentioned
by Metchnikoff. Naturally his thoughts recurred to men of distinction
on {623} the Continent, but in English-speaking countries we have a
number of typical examples of strong minds doing fine work in weak
bodies. Robert Louis Stevenson is the best remembered by our
generation. Elizabeth Barrett Browning, delicate all of her life, a
neurasthenic during the precious adolescent years that are supposed to
mean so much for future accomplishment, always an invalid to some
degree at least, did some of the best work that was given to any woman
to do during the nineteenth century. J. Addington Symonds, the
historian of the Renaissance and of Italian literature, is another
striking example of a man who had to do his work under great physical
difficulties, yet who left a long bookshelf of large volumes after him
as the product of the hours that he could cheat from caring for his
health. Henry Harland, whose recent death all too young was a blow to
the English-speaking world, is another striking example. The names of
such men and women and their stories must be made familiar to people
who are themselves delicate in health and who fear for their future
and, above all, are despondent about the possibility of ever doing
anything worth while.


Dread of Insanity.--People who have relatives who are already
sufferers from such severe forms of insanity as require asylum
treatment are often likely to be much disturbed over the possibility
that they themselves should become insane. Of course, there is no
doubt but that these people are much more liable to suffer from
insanity than others, but their worrying over the matter is sure to do
them harm rather than good. There are quite enough sources of worry in
life without the additional one of dread of a future event that may
not occur, and this must be made as clear to them as possible. The
people who have no obligations on them, who have nothing to do that
they feel they have to do, are especially likely to suffer from such
obsessions. The best possible relief for them is afforded, not by the
effort not to worry about their dread, which usually has exactly the
opposite effect and emphasizes their fear by the constant effort which
they make to put it aside, but by getting something else to interest
them. This must not be merely a passing interest, if possible, but a
serious attraction of some kind that fully occupies the mind. A hobby
is an excellent thing for this, but alas! a hobby must be cultivated
for many years, as a rule, to become powerful enough to bring relief
in such serious matters.

Occasionally the thought of the insane asylum or the sight of an
institution of this kind passed even at a distance in the train is
enough to give some people a fit of depression that may last for some
time. The thought of going to visit their ailing relatives is enough
to make them even more depressed. I have sometimes found that in
chosen cases, especially among women and those of sympathetic
disposition, the apparently heroic remedy of making them visit their
relatives in the asylum was excellent for them. It is the usual rule
for people who are themselves sane to consider that it is the greatest
hardship of asylum confinement for the patients to be associated with
those whom they recognize to be insane. Exactly the opposite effect is
the usual result. To be among people, many of whom are more irrational
than themselves and some of whom are quite beside themselves, proves a
stimulus and an encouragement. Contentment has been defined by a cynic
as the feeling that things might be worse.


{624}

DREADS OF MEN OF GENIUS


The insane are particularly prone to suffer from dreads, so that some
people argue from their dreads to the thought of insanity. It is quite
a mistake, however, to think of dreads as necessarily connected with
insanity in any way. They are irrational though they will commonly be
found to be dependent on some special physical condition. This is
usually some exaggeration of attention to a sensation natural enough
in itself but disturbing when dwelt on to such a degree that it
produces a much greater reaction in these individuals than in other
people. These dreads have existed in all sorts of people. It is said
that they are more frequent in the highly intellectual, especially in
the class known as geniuses, and they are often said to represent the
definite evidence of a relationship between genius and insanity. I
have always felt, however, that they are quite as common among
ordinary people who have no genius and no signs of it as among the
so-called geniuses. They are not so much spoken of by ordinary people,
however, because they are rather ashamed of them. Genius, on the
contrary, is quite willing, as a rule, to exploit its peculiarities
for the benefit of the public, or what is even more true, its
peculiarities are remembered and commented on as details of history.

With this in mind the following paragraph from Dr. Dorland's book on
"The Ages of Mental Virility"   [Footnote 50] deserves to be
recalled. He has gathered a number of examples that are very
interesting:

    [Footnote 50: The Century Co., New York, 1908]

  Fear has played an important rôle in the development of the
  antipathies of the great--fear that was often groundless in its
  origin and inexplicable in its manifestation. The unaccountable fear
  of dogs is not so common as ailurophobia, although it is said that
  De Musset cordially detested them, and Goethe despised them,
  notwithstanding, forsooth, he kept a tame snake. Much more frequent
  is the fear of spiders, centipedes, and other insects. Charles
  Kingsley, thorough naturalist though he was, entertained an
  unconquerable horror of spiders, even the common house spider;
  Turenne became weak when he saw a spider; while the author of the
  "Turkish Spy" once asserted that he would far prefer, with sword in
  hand, "to face a lion in his desert lair than to have a spider crawl
  over him in the dark." Lord Lauderdale, on the contrary, while
  declaring that the mewing of a cat was "sweeter to him than any
  music," had a most intense dislike for the flute and the bag-pipe;
  and Dr. Johnson was so fond of his cats that he would personally buy
  oysters for them, his servants being too proud to do so.

There are curious contradictions to be found in these matters.
Montaigne confesses that he did his best writing and was in the best
humor for keeping at his Essays while stroking his favorite cat with
his left hand, his other being occupied with his writing. This would
be seriously disturbing to many people, but apparently occupied
certain distracting sensory tendencies and enabled him to concentrate
his mental energies. To many people the very thought of doing anything
like this would put all ideas for writing out of their mind. Other of
Montaigne's peculiarities are quite as interesting. He always refused
to sit down with thirteen at table, his liking for odd numbers was so
great that he made all sorts of excuses in order not to use {625} even
numbers and his aversion for Friday made the quota of work that he
could do on that day much less than any other day of the week.


OBSESSIONS

There are many curious obsessions that disturb people and that are
often extremely difficult of explanation even by themselves. Dr.
Johnson, one of the most sensible men in many ways in his time in
England, could not, it is said, pass a post on the street without
touching it. At least if he did so he felt that somehow he had omitted
to do something that he ought to have done and it would make him
uncomfortable. There are many people who have some idea that it is
lucky to touch posts as they pass along and the number of people who
do things like this is larger than might be imagined. Many people put
themselves out of the way in order to avoid letting a post come
between the person with whom they are walking and themselves because
it is said to be unlucky. Most of them will laugh at it, but still
they continue the practice in spite of the bother it may occasion
them. Occasionally there is some incident in their past life which
accounts for such obsessions, though the patients themselves are
occasionally not quite conscious of them. Dr. Boris Sidis tells the
story of a man who could not take a car with an odd number.
Psycho-analysis showed that he had once seen a child run down by an
odd-numbered car.

In such cases there has been a long series of suggestions that have
created a dominant state of mind. The only way to overcome this when
it becomes a serious annoyance is to undo the influence of the
suggestions by a continued series of counter-suggestions, and by such
discipline of mind as will prevent the former suggestion from exerting
itself. The cure can be accomplished in this way, though, as a rule,
the patient will need the help of someone else.


FORGOTTEN FRIGHTS AND DREADS

Dreads founded on terrifying or seriously disturbing incidents of the
past, the details of which at times have gone out of the patient's
mind, are not infrequent. It is probable that many of the unreasoning
dreads have some such foundation and occasionally, if patients'
memories are carefully searched, the whole story can be reconstructed.
All that is needed, as a rule, is to get the patients interested in
conjunction with the physician in tracing the origin of their
affliction and not infrequently an interesting story will turn up.
Hypnosis used to be considered of great value for such
reconstructions, but unfortunately patients then become so suggestible
that it is often difficult to decide how much of what is brought out
by questioning is due to the suggestive quality that cannot well be
kept out of questions, and how much to a true redintegration of
memory.

Frights in children may for a time be forgotten and yet the memory of
them may come back, or a dread connected with them develop, that will
make the patient profoundly miserable. One of my patients slipped and
fell on a smooth steel plate at the head of a coal breaker and was
only saved by good fortune from falling a long distance. This happened
when he was a {626} boy of ten. There were times when the memory of
this recurred so vividly as to set him all atremble and he could not
look down from a height without something of the feeling of goneness
coming over him that he felt at the time of the accident. The calling
of his attention to the fact that his memory probably exaggerated the
danger he had been in as a boy led him to go back and have another
look at the conditions in which he had fallen some thirty years
before. He found that they were not so dangerous as he thought and
that while he would have been scratched and his clothes would probably
have been soiled and torn, he would not have been seriously injured.
This has greatly diminished his dread of heights.

Various physical manifestations may be due to dreads which are often
supposed to be the result of some physical process in the nervous
system. Occasional fits of trembling, for instance, are, in sensitive
people, due to more or less forgotten memories of dangers or frights.
Occasionally even slight convulsive seizures may follow such recurrent
dreads. Not a few of the cases of so-called hystero-epilepsy in the
borderland between hysteria and epilepsy but always one or the other,
are due to such mental states rather than to any physical conditions.
Such incomplete memories are sometimes spoken of as subconscious. The
word subconscious has been so much abused, however, that I prefer not
to use it. The reminiscences have been obscured by an accumulation of
other facts but may with an effort of attention and concentration of
mind be recalled. Hypnosis, or the milder form of it spoken of as the
hypnoidal state, may enable the patient to recall them more vividly by
enabling him to concentrate his attention, but there are always risks
that suggestion will vitiate the old story in these cases. With care
all the details can usually be recalled and the patient is thus given
renewed confidence in himself and his own powers and does not learn to
lean on someone else in the process.


TREATMENT

The most important psychotherapeutic factor for the relief of the
discomfort due to dreads is the knowledge that there are so many and
such different varieties of them and that so many people suffer from
them. Many of those afflicted are inclined to think that their cases
are almost unique. To have them know that there are all forms and
phases of these curious aversions is to make them laugh a little at
their own because they laugh so readily at others, and it gives them
new courage for the attempt to conquer them. The aversion cannot be
entirely overcome, but it can be prevented from seriously influencing
sleep or appetite or occupation. This is after all the important
feature of the case from the standpoint of psychotherapy. Besides,
patients are encouraged not only to take up, but, above all, to
continue, the practice of that mental discipline and self-control
which will enable them to lessen their natural aversion, if not to
remove it entirely. I have many cases in which patients' aversions
have been entirely overcome. Curiously enough, there are rather often
relapses when the patients are run down in weight, or are in an
irritable condition from worry or emotional stress, and then something
of the former mental discipline has to be reinstituted to make them
once more free from disturbance.

{627}

I have sometimes found that the recommendation to patients suffering
from dreads to read Mary Wollstonecraft Shelley's "Frankenstein" has
proved an excellent therapeutic agent. This is particularly true when
the patients are women, for it is likely to bring them close to the
sad lives of the Shelleys. The circumstances in which the book was
written add to the appeal. "Frankenstein" itself is interesting, so
that the mood created by this combination of interests is excellently
therapeutic. It will be recalled that in "Frankenstein" the inventor
seeking to make a man does make an automaton that is able to move and
to talk, but that then haunts its inventor, demanding of him a soul.
It proves a plague to him, but he cannot escape from it. Fly where he
will his creation follows him and bothers the life out of him, killing
a friend, strangling his bride, and making existence intolerable. The
symbol is complete and to the point. The things that bother us in life
are to a great extent of our own invention. The dreads that make so
many people miserable are practically always without any groundwork in
reality, figments of our imagination without the soul of real life,
but capable, as was Frankenstein's monster, of making their creators
intensely miserable and with them, to an even greater degree, their
friends.



CHAPTER IV

HEREDITY


There are so many false and, indeed, from a scientific standpoint,
utterly groundless notions with regard to heredity which, as a result
of the popularization of science, have become widely diffused, that
notions about inheritance are a most copious source of dreads and
discouragement and even produce inhibition of resistive vitality
against disease on the part of many patients. At first it seemed to me
as though the subject should be treated in the chapter on Dreads. It
is so much more important than the other dreads, however, and there
are so many people with so many different notions as to the evil
influence of heredity that it seems advisable to devote a special
chapter to it in which to provide contrary suggestion. Many patients
are constantly suggesting to themselves that, because they are
suffering from certain symptoms due to real or supposed hereditary
conditions, there is little or no hope of their recovery or of any
effective relief. In the old days, when tuberculosis was considered to
be hereditary, it was almost hopeless to try to rouse patients into a
state of vital resistance to their disease because of this overhanging
dread. Such a prepossession of mind must be overcome.

In spite of all that has been said about the power for evil of
heredity, and in this as in every other phase of pseudo-science, the
reason why there are false popular notions is because the medical
profession first cherished them and then they spread popularly, we now
know that it means comparatively little in pathology. The false
notions will continue, however, to be popularly diffused probably for
another generation, at least, and will have to be combated. Their
force must be lessened, for they are a heavy incubus on the patient's
mind, imposing a burden on vitality that inhibits normal, vital
reaction. This can only be done by a frank and complete statement of
{628} our present knowledge of heredity, which is even yet not nearly
so definite as we would like to have it, but which contradicts
entirely most of the older impressions. In the matter of disease what
we know of heredity, instead of being a source of distress and
discouragement for patients, provides rather new incentives for
vigorous reaction, since nature helps rather than hampers the effort
of the individual to throw off disease from generation to generation.


False Impressions and Expression.--Probably the commonest expressions
that the physician hears from his patients, though we hear many
stereotyped phrases in our time when patients so freely discuss their
ills and their physicians' opinions among themselves, are such as: "My
father suffered from rheumatism, and I suppose I must expect to be
bothered by the same ailment." "My mother died of heart disease and I
think I have a weak heart; I suppose that we have weak hearts in the
family." "I have had three relatives die of cancer in the last three
generations, so I presume that cancer is in the family, or at least we
are much more liable to cancer than the generality of people." And,
finally, what used to be the commonest of all, but fortunately we have
changed that at least, though we sometimes hear it still:
"Tuberculosis runs in our family, my mother and an uncle died of it
and one of my brothers is suffering from it, so I suppose I must just
make up my mind that I, too, am sure to get it." Even the rarer
affections, like kidney disease, liver disease, various nervous
troubles, stomach and intestinal disturbances of many kinds,
flatulence, constipation or diarrhea, are all supposed to be
hereditary and patients explain their ill feelings by an appeal to the
supposed principle of heredity and its application to themselves and
their families.

In many chapters in this book the subject of heredity has been
considered with regard to specific affections. We have no evidence at
all, or the evidence is so trivial as to be quite negligible, that
anything acquired by the individual, be it for good or evil, is ever
transmitted to the next generation. That acquired characters are not
transmitted is now almost a universally accepted principle among
biologists. The more a biologist knows of recent biological research
and investigation the more will he be likely to consider this
principle of the non-transmission of acquirements as definitely
settled. According to this, then, no disease is ever transmitted to
the next generation. This is such a complete reversal of former
opinions, such an open contradiction of popular beliefs, that the
subject merits thorough discussion from this newer standpoint for
medical applications. We must not forget that popular medicine, even
when egregiously wrong, is founded on opinions held by the medical
profession aforetime and, indeed, on this subject of heredity many of
the medical profession still cling to the former opinion.

Tuberculosis, which used to furnish the most serious argument in this
matter, has now come to be the best possible explanation that we have
for the fallacy of the transmission of anything acquired. The disease
followed families so constantly that it seemed impossible to explain
it unless the principle of its heredity was conceded. Now that we know
its contagiousness, however, it is comparatively easy to explain its
occurrence in families. When we recall how carelessly people coughed
and even expectorated around the house, while children crept on the
floors and carried the germs of the disease to their mouths on their
hands, the wonder is, not that so many members of the family acquired
the disease seeing the manifold opportunities for contagion, but that
{629} any of them ever escaped. We know now that practically every
adult above the age of thirty either has or has had tuberculosis.
Careful autopsies show us remains of the disease even in the bodies of
those who, without any history of tuberculosis, die from other
diseases. One out of eight of the population dies of tuberculosis, but
the remaining seven are quite capable of resisting the disease and so
we find healed lesions at autopsies in this proportion of cases.


Family History Favorable.--It is certain, then, that tuberculosis is
not hereditary. On the contrary, as we have learned more about the
disease in recent years, it has been recognized by specialists that
patients who have a family history of tuberculosis are notably less
likely to succumb to the disease early than those who have no such
history. An acute case of tuberculosis with considerable loss of
weight has a very unfavorable prognosis unless there is a history of
the disease in the preceding generation, when at once the outlook
becomes more hopeful. This newer view is confirmed by what we have
learned from the ethnological pathology of the disease. Peoples
exposed to the disease for the first time rapidly succumb to it. This
is practically true for all the infectious diseases. Our American
Indians succumbed in large numbers not only to tuberculosis but also
to smallpox and even to measles when each was first introduced among
them. The same thing was true in the South Sea Islands. Where nations
have been exposed to the disease for some time they have acquired not
an immunity, but at least they possess a greater resistive vitality to
its ravages and while they still may be susceptible they are not so
subject to the fatal forms of the disease, and even if they acquire it
they live on for many years.

Many people may insist that this immunity or comparative immunity to
tuberculosis and increased resistive vitality against the disease is
transmitted and illustrates the principle of heredity. The reaction of
the system to the disease increases in each generation and this
increase is an acquired character which passes down with the family
strain. This immunity should be viewed from another standpoint,
however. Certain families possess a resistive vitality to the disease;
others lack it. The resistant families do not succumb to it, and
propagate themselves. The others gradually die out. What caused the
resistant families originally to possess this quality we do not know.
We have no trace of its being acquired. Like so many other characters
by which men differ from one another, we do not know the beginning of
it. Once it comes in as a family trait it is transmitted. In
successive generations we have no evidence that it is stronger, only
the danger is recognized from experience and better precautions are
taken; the consequence is that the original resistive vitality has a
better chance to make itself felt and so the family is preserved. This
is as true with regard to the conquest of the tendency to excess in
the taking of toxic substances, as alcohol and opium, as with regard
to disease. It is not the transmission of an acquired character, but
the descent of a family trait the origin of which we do not know.


Hereditary Syphilis.--Many physicians will protest that, at least, we
have ample evidence for the transmission of syphilis by heredity. We
have for many years talked of hereditary syphilis as if it were
absolutely sure that its transmission by inheritance took place. There
is no doubt, of course, that the disease is conveyed from mother to
child. If a mother is actively syphilitic, {630} then her child will
surely have syphilis when it is born. This, however, is no argument
for the hereditary transmission of syphilis. We know now that if a
mother is tuberculous, in an active stage of that disease, her child
will almost surely have the disease, but this is a question of
contagion not of inheritance. If a mother with active tuberculosis
nurses her child she is likely to give it tuberculosis. Usually the
idea is that the milk is not infective unless there are tuberculous
lesions in the breasts, and in cattle it is well known that such
lesions in the milk apparatus inevitably bring tubercle bacilli into
the milk. The demonstration of tubercle bacilli in the blood of
patients in the active stage of the disease is now much more frequent
than used to be the case and there seems no doubt that the bacillus
can pass through glandular structures into the secretions.

In the same way syphilitic nurses are likely to infect nurslings,
though, of course, in this case there are usually syphilitic sores on
the nipples which directly communicate the disease. It is almost
impossible for a syphilitic woman to nurse a child, if she is in an
active stage of the disease, without the production of such infective
sores on her nipples. When children are born with syphilis it means
only that in the process of feeding the child through the placental
tissues, a mother has infected her child quite as she might infect it
by nursing afterwards, in case she acquired syphilis after the birth.
Lesions corresponding to those on the nipple occur in placental
tissues and can be demonstrated without much difficulty. Congenital
syphilis, however, can always be traced to contagion and the being
born with the disease or having the manifestations of it occur shortly
after birth is no argument for heredity at all. It merely emphasizes
the danger of contagion.


_Mothers of Syphilitic Children_.--But there are some cases in which
the child who shows symptoms of syphilis after birth is born from a
mother who never had any manifestations of syphilis and therefore it
has been supposed that the infection must have come from the sperm,
and that in these cases, at least, there is a true heredity. It is
perfectly possible, however, that syphilitic infective material may
accompany the spermatozoon and so bring about the occurrence of
syphilis in the offspring. Even this would be infection, however, and
not heredity. Much more frequently it would seem that the disease in
the infant was contracted from the mother while suffering from a
latent form of syphilis, rather than from the paternal contributory
particle to its existence. The mother gives no sign of the disease,
but Colles' Law is that the mother of a syphilitic child may, without
danger to herself, be allowed to nurse her own infant even though she
herself has never had any symptoms. This can only mean that she is
thoroughly protected against the disease. We would not think for a
moment of allowing an ordinarily healthy women to nurse a syphilitic
child. Such immunity in the mother of the syphilitic child can only
come, so far as the present state of our knowledge goes, from her
having had the disease. It has been said that as the result of the
intimate communication with her child in utero she has acquired an
immunity by the passage across the placental membrane which separates
maternal and fetal blood of protective substances of various kinds due
to the reaction against the disease already beginning in the child. As
a matter of fact, however, there is no evidence of any such reactive
substances in the blood of the child which after birth proceeds to
have a series of acute lesions that are, as a rule, indicative {631}
of almost complete lack of resistive vitality. Maternal immunity is
evidently due to the occurrence of the disease in some form within the
maternal tissues which produces the usual protection against the
disease in a briefer time than usual. This certainly seems to be a
more satisfactory explanation than that of a transmission of an
immunity from the child to the mother which the child itself does not
possess. It is easier to understand the transmission of an infection
that does not manifest itself externally than of an immunity which
there has been no time to acquire. Both explanations leave a mystery,
but the mystery in the second case can be explained more in consonance
with what we know about syphilitic transmission and immunity than in
the other case. It does away with the transmission directly from the
father almost completely, of course, leaves practically no ground for
the heredity of syphilis, but it accords much better than older
explanations with biological principles.


_Late Lesions and Heredity_.--Many physicians will be likely to insist
that the late developments of syphilis in children, in which not only
three or five years afterwards, but even fifteen or twenty years after
birth, there are syphilitic manifestations, are beyond all doubt
examples of heredity. In the last twenty-five years, however, our
ideas with regard to the after-effects of syphilis have been entirely
modified by what we have learned of such diseases as locomotor ataxia,
paresis and the like. These are undoubtedly parasyphilitic diseases in
most cases, yet they not infrequently develop from ten to twenty years
after any manifestation of syphilis and they seem to occur, by
preference almost, in cases where the preliminary symptoms have been
very mild. In not a few cases, indeed, the symptoms of syphilis have
been so transient in these patients that the true significance of them
was missed until the later developments showed their real character.
Krafft-Ebing, at the International Medical Congress at Moscow in 1897,
detailed some experiments that he had made on paretics in Vienna. They
were patients in whom no history of syphilis could be found, yet they
were suffering from typical paresis. As they were in the ultimate
stage of the disease it did not seem unjustifiable to inoculate them
with syphilis, and in most cases it was found that they would not take
the disease, showing that they were probably protected by a previous
attack, though there was no history of it.

The development of the late symptoms of syphilis in the second
generation can then be much more satisfactorily explained on the basis
of a mild infection with very few primary symptoms, almost lacking in
secondary symptoms, yet followed by subsequent symptoms of great
severity consequent upon the deterioration of vitality produced by the
disease. As for the manifestations in the third generation, they are
not directly syphilitic, but are, whenever they occur, due to
conditions consequent upon the degeneration that had been effected in
the preceding generation and which directly weakened the offspring--on
the same principle that weak parents give birth to weak children, and
starving parents cannot have strong, healthy children--but not because
of any direct influence of the disease. It is worth while to discuss
this subject from this standpoint, since it disposes of the only
supposed evidence left for the hereditary transmission of disease that
we now have, though only a few years ago most diseases were supposed
to be hereditary.


Heredity in Cancer.--With regard to other diseases, the evidence for
any inheritance has been founded entirely on coincidence. All the
human race {632} dies and must die some way, and so in families a
certain number will die of the same disease. The argument for heredity
in cancer is extremely weak. When all the relatives of a person
afflicted with cancer as far out as the third generation are taken
into account, only about one in five of them are found to have
suffered from cancer. When we remember, however, that more than one in
thirty of all those who die, die of cancer and that the death-rate of
this disease is greater than that of typhoid fever, smallpox, scarlet
fever, measles, and all other infectious diseases put together, it is
easy to understand how large a role coincidence plays in any such set
of statistics, and how little the significance of the occurrence of
cancer in different members of the same family means, unless possibly
there is an occasional element of contagiousness which must not be
left out of the reckoning.


Heredity in Other Affections.--Other ailments present much less
possibility or probability of any element of heredity. For instance,
over-indulgence in meat or drink may readily bring about various
ailments of the gastro-intestinal tract. These are, of course,
definitely acquired conditions, some of them temporary and some
persistent, that will continue to give trouble so long as the patient
continues to produce irritation of them. They may, of course, lead to
permanent pathological conditions. To say that any of these are likely
to be inherited would be quite as absurd as to say that a corn could
be inherited, or the permanent deformities produced in toes by wearing
badly-fitting shoes could be transmitted to the next generation. We do
not think for a moment that because a man has lost a finger his
children are likely to be born without a finger, and still less if by
some accident or abuse he has been deprived of the use of an arm or
leg, that that is likely to be transmitted to the next generation. Yet
people calmly talk of the heredity of similarly produced conditions
within the body, and even physicians are not entirely free from the
superstition, for such it is, of the influence of heredity in
producing pathological conditions.

Habits of various kinds, physical and mental, are calmly accepted by
many people as influenced by or having their origin in heredity. Under
Alcoholism and Drug Addictions we have discussed this phase of the
subject, but a word or two more may make it clearer. A tendency to
form the same habits may be a family trait and descend from one
generation to another. That a specific habit should be the subject of
heredity or transmission is as much out of the question as that a
facility for doing anything should be transmitted. The son of an
acrobat must practice quite as faithfully as did his father in order
to secure his father's skill. He may inherit from his father that
particular constitution of body, that specific combination of muscle
and sinew and bone that enables him to become an acrobat by practice,
though with a different kind of body it would be impossible, but his
father's acquired facility influences in no way the son's ability. We
often hear of a man being the descendant of a series of generations
each of whom has gone to the university, as if that somehow assured
him a readier and better facility for education, but we know very well
that this is not true and that the boys straight from the soil are
often the best students and far ahead of the scions of long-time
academic families.


Inheritance of Defects.--Acquired characters are not transmitted,
though family traits are the subject of inheritance. Disease is not
hereditary, but {633} defect is. Crossed eyes occur very commonly in
families and are evidently a subject of transmission. Family noses are
often very peculiar and may be traced for many generations. The
Hapsburg lip has been noted in sixty per cent. of the Hapsburgs since
the family came into prominence in the thirteenth century. Features of
all kinds are inherited, as anyone who has ever spent some time in a
family portrait gallery where the ancestors were genuine and the
paintings reasonably true to life, knows very well. Certain features
of European families can be traced for many generations. The tendency
to have six toes or to have an extra finger runs in certain families.
So small a thing as a patch of white hair in a particular part of the
head may be the subject of hereditary transmission. Moles on a
particular part of the body are inherited. All these, however, are
characters with regard to the acquisition of which we know nothing,
but that have somehow found their way into the family strain and have
become subjects of transmission from generation to generation. They
provide no evidence, however, as to the transmission of acquired
characters.


Variation.--What is even more surprising in biology, however, is that
there is another marvelous force at work quite as incomprehensible in
its way, perhaps even more so, than that of heredity. This is
variation. All creatures have a tendency to vary from their parents. A
very small proportion of the offspring resemble parents so closely as
to be quite similar. The great majority of them, however, have
noteworthy, individual, distinctive qualities. Occasionally these
qualities may be traced to the less immediate ancestors and then we
talk about reversion. Occasionally there appears in a child some trait
or anomaly supposed to be remotely ancestral and it is spoken of as
atavism. Whenever there is a tendency of the offspring of exceptional
parents to regress toward the racial average, we talk of regression.
Tall parents often have tall children, some of them may, by a special
tendency of heredity, be taller even than themselves. Most of them
will be shorter, however, and tend to regress toward the racial
average.

Few people understand what a wonderful power among living things is
exerted by this very opposite of heredity--variation. All the
possibility of improvement not only in humanity but among all living
things is dependent on variation. It does not seem difficult to
understand how offspring resemble parents. They are of them, therefore
they are like them. When we analyze the problem of heredity, however,
and find that the connecting link between offspring and parents is
always only a single cell of less than one one-hundredth of an inch in
diameter, the mystery of heredity looms up in all its immensity. This
minute bit of protoplasm, so small that it requires a rather strong
power of the microscope to see it, somehow contains compressed within
itself all the qualities that characterize the parent and are to be
transmitted to the offspring. Among animals, the color of the eyes and
hairy covering, the form and height of the animal, its generic
characteristics, and its individual characters--all are contained
within this minute spherule. The white blaze on the horse's hind leg,
the black blotch on the puppy's face, the white lock on a human head,
are all carried over from one generation to another with all the other
qualities in this small package. That is the mystery of heredity.

To this must be added another mystery quite as great and even more
{634} difficult to understand--variation. This tendency to vary is the
basis for whatever evolution there is in the world. Some living things
vary in such a way as to be better suited to their environment than
they were before and then these outlive others because more favorably
situated, and natural selection brings about a maintenance of the
favorable variation. Instead, then, of patients being impressed with
the unfavorable influence of heredity, they should rather be made to
feel the weight of the idea that whatever evil tendencies the parent
has the child is more likely to have less of them than more, so that
variation tends to make the race better. We have had too much stress
laid on the heredity of unfortunate qualities and entirely too little
made of the variation tendency, which is constantly lifting the race
up. It is, of course, only what happens in everything else,
unfavorable are likely to have more weight than favorable suggestions,
and unless these latter are emphasized their influence becomes
swamped. This has happened with regard to variation. It is quite as
important a biological element as heredity and it makes for the
removal of unfortunate qualities, yet it has never become a popular
idea and is little appreciated even by physicians.

Patients who are worried about their heredity will, after a frank
discussion of our present knowledge of heredity and its co-ordinate
factor of variation, lose most of their dread of this specter of
supposed evil influence which so often proves the source of
discouragement and failure to react properly against pathological
conditions. There is probably no phase of modern biology in which the
so-called popularization of science has done more harm by providing an
abundant source ol unfortunate suggestions. Whatever influence
heredity has in relation to disease is favorable to the human race. It
is true that this is exerted by the elimination of the unfit, yet the
very consequence of this is that the children of parents who have
suffered from a particular disease are likely to have greater average
resistance to it than the generality of mankind, since their parents
passed the age up to reproductive activity without succumbing to it.
For cancer, tuberculosis and syphilis this teaching is of special
value and is probably more effective than any other single means could
be to prevent the ravages of the disease if it should occur, since it
keeps the patient from interfering with his own resistive vitality by
the discouraging conviction that there is no possible hope for him
because his parents also suffered from the disease.



CHAPTER V

PREMONITIONS


A state of mind that disturbs many people seriously, sometimes even
producing physical results, because of the burden of dread that hangs
over them, is that in which attention is paid to premonitions of evil.
There are two of these general conditions to be considered. In the one
there is a definite feeling that some special evil, occasionally very
particularly outlined in the mind, as a railroad accident, fire, or a
street accident of some kind, is to occur. In another mental condition
there is a generic premonition of evil, {635} as if the worst were
sure to happen and the patients must be constantly preparing for it.
Occasionally this takes on some such form as an assurance of early
breakdown in health, or of death at an untimely age, or of some
crippling infirmity. This represents, of course, only one form of lack
of control over the mind, but it is surprising how much physical
suffering it may occasion. Only those who have had much to do with
patients who suffer from this state of mind realize it. Sympathetic
knowledge of the conditions that bring it about and of the real
significance of premonitions will do more to help patients than
anything else.

Every now and then newspapers tell the story of someone who had an
impending sense of danger, perhaps of a particular form of accident or
misfortune, which he could not shake off and which finally came true.
Sometimes it is a fire that was anticipated, though without any reason
except the dread, and precautions that eventually proved life-saving
to the patient were taken, or at least friends were told of it so that
the person seemed actually to have had some warning beforehand of the
danger that was to come. Sometimes it is the story of a railroad
accident, which some particularly fortunate individual escaped,
because of a premonition that made him take another train or make a
happy change of cars. Nothing is said of the times when premonitions
failed, nor of the disappointments of such dreads. Most people laugh
at the stories, but a few individuals become seriously impressed with
the possibility of such warnings and then make themselves miserable by
having frequent premonitions.


Etiology.--As to the origin of these premonitions it is hard to say.
They occur more frequently on dark days than in bright weather and are
complained of much more in spring and fall than during the cold brisk
winter or during the summer time. A succession of very hot days,
however, brings a series of premonitions, especially with regard to
accidents by heat, that is not surprising since the newspapers have
many accounts of sunstrokes and there is every suggestion of the
possibility of danger of this kind. How large a role suggestion plays
in the matter can be realized from the fact that after some
particularly serious railroad accident many people have premonitions
that they may be hurt and occasionally they put themselves to
considerable inconvenience in choosing the car in which they will sit,
if the last serious preceding accident of which they have heard
happens to have brought death mainly in a particular car of a train.
It is always suggestible people who are likely to have premonitions.
The thought comes very simply at first, they dwell on it a little
unwillingly, then they find it impossible to banish it and finally it
may become a positive obsession. The soil and the seed for suggestion
are both needed to produce premonitions.

Royce suggests that many of the supposedly fulfilled premonitions are
really only pseudo-presentiments and represent an instantaneous and
irresistible hallucination of memory, which may give rise to the
impression that there has been a previous dream or other warning
presaging the facts, though no such phenomenon actually took place. In
other words, there would be an auto-suggestion consequent upon the
hearing of other fulfilled presentiments that sometime some such thing
must also occur to us, and then when a happening that reminds us of
something in the previous stories of {636} presentiments comes there
is the sudden responsive feeling "why, this is what I saw or must have
seen in my dream."

Podmore suggests an illusion of memory magnifying or rearranging the
details of a recent dream or premonitory impression, so as to make it
fit into the happenings. Dreams are so vague that unless they have
been written down we are not quite sure of them an hour after they
occurred and a day or two later we have only the merest hint of what
they were. If this can be made to have any connection with a casualty
of any kind that happens subsequently we may very readily recreate the
dream with its details concordant to the event. Certainly no reliance
can be placed on a story of a dream fulfilled unless the dream was
told before the happening.


Premonitions of Death.--Certain premonitions are common and are
frequently brought to the physician's notice. Among old people it is
not unusual to find that a premonition of death will hang over them
for days, seriously disturbing them and their friends, hampering often
a healthy reaction against disease and always lowering resistive
vitality. Many of them have heard stories which make them credit the
belief that such premonitions are likely to come true and therefore
they cannot shake them off. They have heard stories of people who have
become convinced that they were going to die at a particular time on a
particular day and whose conviction has been proven by the event. Like
all the other premonitions, whatever truth there may appear to be in
them, is due entirely to the fact that nearly everybody has
premonitions and occasionally, therefore, one of them must come true.
Those that are fulfilled create such an impression that they are
remembered, while those that fail are forgotten, until, though it is
not realized, it becomes true that fulfilled premonitions represent
exactly that much misunderstood principle that the exception proves
the rule. The rule is that premonitions fail. Exceptionally, however,
a premonition comes true. Instead of proving that premonitions mean
anything, the rarity of their fulfillment proves the rule of their
non-significance and demonstrates that they are merely coincidences.


Persuasion of Short Life.--Much mental suffering occurs in nervous
people as a consequence of a premonition or persuasion which comes to
them in middle life that they are destined not to live very long. This
is a commoner impression than is usually thought and comes to nearly
everyone at some time in life. Especially is it likely to come to
those who have suffered some severe illness and who know how weak they
were during their convalescence and, in spite of their thorough
recovery of strength, cannot quite persuade themselves but that an
ailment which made them so weak must surely have sapped their vitality
so as to make long life for them impossible. It is, of course, one of
the vague dreads that men always seem to be harboring, but there are
times that it becomes so prominent and so influential in the
production of depressive feelings that it is worth while to have the
means at hand to counteract it as far as possible. In the last ten
years I have made it a practice to ask, not only all my patients but
most of my acquaintances above 70 years of age whether they had ever
experienced such a premonition. I have particularly asked what were
their feelings with regard to the hope of long life for them when they
were in their forties and fifties. Without exception I have been told
by all those who had the education and leisure to {637} be at all
introspective, that they had felt sure that they would not have long
life.

Most of the men consulted took out life insurance in such a way as to
benefit their families after their death rather than themselves during
life. Indeed it seems not an unusual thing for men to have some
experience with an ailment between 40 and 55 which makes them realize
their mortality much more than the deaths of their friends around them
had succeeded in doing. Premonitions and impressions, then, of this
kind evidently mean nothing, so far as the prospect of long life is
concerned. Practically everyone has them, and since, of course, the
great majority of men do not live to die of old age, it would seem
that their premonition of comparatively short life was fulfilled.
Occasionally a man will be found at the age of fifty unwilling to take
up further work or develop his business because of the dread that has
come over him that he may not live long enough to make it worth the
while. Where there is serious kidney or heart trouble such an
abstention from business is commendable, but in many cases it leaves a
man without occupation or with insufficient occupation and he becomes
short-circuited on himself with more serious results from worry than
would have come from work.


Publication of Fulfilled Premonitions.--The publication of fulfilled
premonitions has always seemed to me to be an especially fertile
source of premonitions for other people. Every now and then someone
goes to bed in a hotel having communicated to friends the idea that he
fears there may be fire before morning. I do not suppose that one out
of ten people who sleep in a strange hotel fail to have some such
thought, they do not consider it a premonition, however, but only a
suggestion for the taking of proper precautions so as to know where
exits and fire escapes and other means of escape are situated, so that
in the excitement of the fire they may not have to do any thinking,
but may have already made up their minds what they shall do. This sort
of premonition, if we call it by that name, has a definite useful
purpose. Occasionally it seems marvelously provident. The other makes
its possessor toss sleepless a portion of the night, does no good and
much harm. If, however, the premonition has been communicated to
someone else and then a fire should occur, the reporting of the
fulfilled premonition comes to a lot of weak-minded people as a
confirmation of their worst fears. It is, of course, only a question
of coincidence in a succession of events by no means connected in any
causal relation, yet by the unthinking set down as showing the
possibility of such premonitions being supremely significant. If we
had all the stories of unfulfilled premonitions also published then
the true significance of the others would be clear.


An Unfulfilled Premonition.--There is an excellent story of a strong
but unfulfilled premonition told by Carl Schurz in his
"Recollections," which seems to me such a good antidote to the
influence of supposed premonitions, that every physician should know
its details for their psychotherapeutic value with patients prone to
be troubled in this way. The ease with which the depression consequent
upon the premonition was relieved as soon as another forcible
suggestion that the danger was past took possession of him, shows how
such states of mind can be altered with no more real reason for the
alteration than there was for the original depression.

{638}

On the morning of the battle of Chancellorsville General Schurz awoke
with the absolute persuasion that at last his time had come and he was
to be killed that day. He had never had such a premonition before. He
had heard of many cases in which such premonitions proved the
forerunner of death. He realized how ridiculous was the idea that he
should know anything about what the future held for him, even vaguely,
and he tried to shake it off. He found it impossible to do so. He
thought that after he took up the routine work of the day the force of
the premonition would be lost. It was not, but, on the contrary,
seemed to increase in power over him. Finally the idea became so
imperative that he sat down and wrote letters of farewell to his wife
and friends, telling them that he had been tempted to do so because of
this premonition of danger. When he went into battle--and it may be
recalled that the Eleventh Corps did some fighting at Chancellorsville
that day--he was sure that now the end was not far off. It did not
take away his courage, however, and though he was well in the zone of
danger, he issued his orders and kept his troops well in hand as we
know from the history of the battle.

Finally his aide-de-camp, riding toward the front of the line beside
him, was killed by a cannon ball. All in an instant the thought came
over him that this was the only danger that was likely to be near him
for the day. The burden of premonition lifted from him as if the fact
that a friend had been killed beside him gave him an assurance that he
himself was not to be taken. There was absolutely no reason for his
thinking so, but his feelings of solicitude with regard to himself and
his fate faded completely and at once. He continued in the thick of
the fight and of danger and was untouched. He himself called attention
to the fact that if his premonition had come true, as well it might in
the midst of the very serious danger which he faced, it would have
seemed a strong confirmation of the impression that premonitions have
a meaning other than that of coincidence. It was, however, a
magnificent example of a failed premonition quite as striking as any
of the stories that are told about premonitions that came true.


Rôle of Coincidence.--This must be remembered in many of our arguments
in medical and other scientific matters. Most diseases are
self-limited, therefore anything that is given as a remedy for them
just about the time that nature has succeeded in conquering the
virulence of the disease and bringing about the cure of the patient,
seems to be curative. Such cures, often remedies of supposed wonderful
potency, come and go in medicine by the hundred every ten years. Such
curious doctrines as that of the influence of maternal impressions in
producing deformities and defects in the unborn child are founded on
nothing better than these coincidences. They are often very startling,
but the rule by which they must be judged is the number of times in
which in spite of similar conditions no premonition takes place.
Literally thousands of people go to bed every night who are to be
waked by the danger of fire before morning and yet have no premonition
of it. Literally millions of people have gone to bed in recent years
without any premonition of earthquake, yet have been wakened before
morning with their houses tumbling around them. If a few people have
premonitions in these cases it is easy to understand that it is
coincidence and not anything else, for these are exceptions, and this
again is a case of the exception proving the rule.

{639}


Premonitions and Superstitions--Thirteen.--Occasionally premonitions
are connected with certain events that are themselves, even though
happening quite accidentally, supposed to be portentous. How many
people, for instance, feel quite uncomfortable if they sit down
thirteen at a table. The very fact of the gathering of thirteen is
supposed to be a spontaneous or automatic premonition that is a
forewarning of evil that has to come to some of them. Unfortunately,
this superstition continues to have a vogue and an influence over
people's minds because stories are told that are supposed to confirm
it. Needless to say, when these stories are true, they are merely
coincidences. Out of any baker's dozen of people who sit down to
dinner it is not surprising if one should die or be killed during the
year. Some of the stories, however, are merely sensational inventions
worked up to be given to the public because a number of people are
interested in this sort of thing. Probably one of the stories that has
gone the rounds most and that has served to confirm many people in
their uneasiness over the number 13 is that which is told as happening
to Matthew Arnold and some friends, supposedly the year the great
English litterateur died.

The story runs that just as Mr. Arnold and his friends were about to
sit down to the table it was discovered that there were thirteen
present. According to the old tradition in the matter it is the one
who first gets up from table under these circumstances that is likely
to be affected by the malignant influence. When the end of the dinner
had arrived, by previous arrangement Mr. Arnold and two very healthy
friends, brothers, arose simultaneously. According to the widely
diffused newspaper account of years afterward, Mr. Arnold himself died
within the year and one of the brothers was lost in the wreck of an
English passenger vessel off the coast of Australia in six months,
while the other brother committed suicide before the end of the year.
Careful investigation of the details has shown, however, that the
story was made out of whole cloth. Mr. Arnold himself, who was
suffering from heart trouble towards the end of his life, was not
likely to take part in any such arrangement because of the constant
danger, well-known to himself, of sudden death in his case. This might
happen at any time and might seem to confirm the superstition. The
dates of the story, moreover, are all wrong. Matthew Arnold's death
and the loss of the English passenger vessel in Australian waters,
referred to, do not occur within five years of each other. The story
has gone round the world. The correction will never reach so far. The
story is startling; the explanation commonplace. Many people will
continue to believe that here, at least, was one striking confirmation
of their superstition.

It is curious how the force of this "13" superstition has continued in
spite of education and enlightenment. Most passenger vessels now built
have no staterooms numbered thirteen. On certain streets in large
cities one finds the number 12-1/2 (until this year it was so on my
own) substituted for thirteen. Sometimes one finds "twelve a" or
something similar. In the large hotels, where they have immense
banquet halls with the tables numbered so that guests may be able to
find their places, I have often noted that there was no table number
thirteen. It is said that in some of the new skyscraper buildings
twenty stories and more in height there has been question of skipping
the thirteenth floor as a designation, because while most {640} people
would be quite undisturbed about it, some do not care to have an
office on the thirteenth floor, giving as an excuse that clients or
patrons do not care to come to the thirteenth floor. In automobile
races men are willing to risk their lives by going a hundred miles an
hour on roads never intended for such performances, but they refuse to
race behind the fell number thirteen. This, after all, can be readily
understood. The slightest thing that takes away a man's complete
confidence in himself may be serious in an automobile going as fast as
these. Men must not think of fear or they lose some of their power and
control over themselves and their machine. They must simply forget
everything except the task before them.

The belief in the thirteen superstition is one form of acceptance of
premonitions. That of itself should be enough to enable sensible
people to throw them off. Above all, it must be remembered that such
supposed malignant influence, when allowed to affect people, impairs
their presence of mind and may thus lead up to the accident or mishap
which it is supposed to foreshadow. This is the serious feature of
such premonitions and dreads. Unless people can be persuaded sensibly
to be rid of them they handicap themselves whenever they are placed in
danger that causes them to recur to the thought of the premonition or
dread. While there is absolutely nothing but coincidence in even the
supposed true stories, and many of the stories are merely sensational
inventions, yet people need to be persuaded to rid themselves of the
incubus that settles over them because of such ideas.


Premonitions and Telepathy.--There are many people who think that
premonitions have something to do with telepathy. Somehow the future
event is supposed to be able to send some message to specially
susceptible minds. Either that, of course, or there is some being in
another world whose interest is sufficient to convey some inkling of
the future. A little consideration of this subject, however, shows the
utter lack of rationality in any such opinion. Future events, having
as yet no existence, cannot in any way influence intelligence. Such
future events, when dependent on human free will, are quite impossible
of being foretold and, as has been said, no being except the Creator
Himself knows anything about them. It would be only from Him, then,
that information might be supposed to come and it would be hard to
think such information would be so vague and indefinite as to leave
room for doubt and, besides, often defeat its purpose of protection by
seriously disturbing patients and lessening their presence of mind.
There is no reasonable explanation by which a human being can be
supposed to obtain knowledge of a future event unless there is a
complete overturning of the ordinary laws of nature and then it would
be reasonably supposed that no doubt of the significance of the event
would be left.

Nearly all of us have premonitions that fail. Only a few especially
introspective people who are constantly afraid of what will happen to
them, and who are sure that the worst is always preparing for them,
have their premonitions come true more than once or twice in life. The
striking fulfillments of a few premonitions could be paralleled by an
endless number of just as striking failures, only that most people
dismiss the idea completely from their minds as too foolish to be
further talked about. It is quite the same with dreams. All the world
dreams and there would be a serious violation of the theory of
probabilities if some dreams did not come true. The great {641}
majority of mankind, especially after the age of thirty, is fearful
lest something ill is going to happen to them and their premonitions
are rather frequent. If some of these did not come true then the
mathematics of coincidences as based on the theory of probabilities
would prove false.



CHAPTER VI

PERIODICAL DEPRESSION


Fits of periodical depression, familiarly known as "the blues," occur
in the experience of practically everyone. In some people they are
only slight and passing. In others they last for hours and make the
individual quite miserable. In still others, without actually running
into melancholia, they produce serious discouragement and continuous
discomfort which persists even for days and makes life intolerable.
They come and go quite unaccountably. During their occurrence all
vitality is lowered, appetite lessened, aches and pains are
emphasized, sleep may be disturbed, exercise becomes distasteful, and
they usually present an interval when health is at a low ebb.
Ordinarily when described as "the blues" they have no definite
connection with any known physical cause. They are passing incidents
which seem to recur at irregular intervals. When connected with
physical ills they are thought of directly as symptoms of these ills.
All forms of disease may be associated with such fits of depression
and many physical symptoms seem to be due to the fact that during
these periods there is a distinct lowering of physical vitality so
that the nerve impulses which ordinarily enable functions to be
performed without interference are interrupted, or at least are
inhibited, to a noteworthy degree. While to a certain extent the
condition is a mental disease, it may be modified by the correction of
physical derangements, by stimulation and, above all, by suggestion
and a change in the point of view.


Serious Pathological Conditions.--Of course, such periodical fits of
depression are associated with various serious progressive ailments
and then are primarily physical, and are only secondarily psychic.
From the standpoint of psychotherapy it is important to remember that
certain serious organic lesions may show their first signs in the
patient's mental state. It is not unusual, for instance, for the
disposition of a patient suffering from kidney disease to change so
materially that the attention of friends is called to the change
before any physical symptom of the nephritis has been noted. Sometimes
for a year there will be a progressive clouding of what had previously
been a rather happy disposition. Decisions will be made more slowly
than before. The judgment will be impaired. There are some striking
examples of this in history, of which the unfortunate Athenian
general, Nicias, put to death for incapacity that was undoubtedly
pathological, is one. Pleasures will be taken half-heartedly; men who
have been bright and jovial will now become saturnine. Men who have
been the life of parties will try to hold the place they acquired
before, though all around them will perceive how difficult it is for
them to maintain the role they have set for themselves. Whenever there
is a notable change in disposition, it is well not to attribute it to
some passing mental condition and, above all, not to dismiss {642} it
as a peculiarity unamenable to treatment, but to look for the
underlying pathological basis of the new condition.

In this way physical disease will sometimes be discovered long before
it otherwise would be. This must be particularly noted when there have
been a series of worries. Occasionally it seems enough to many people
to ascribe a change of disposition to the troubles that have come over
a patient. If a business man fails or passes through a crisis in his
affairs in which failure is very near, or he has many business worries
over a prolonged period, these are sometimes thought to be quite
enough to explain a change of disposition. They are, but not to the
degree that is often noted, for, in excess, melancholic tendencies are
always pathological, that is, they have some basis in a serious mental
or physical change. If there is an insidious nephritis already at
work, its symptoms will be much exaggerated and its progress
accelerated by the worries and disquietude of such a time. If a wife
loses her husband, or an only son, or a favorite child, the occurrence
of a prolonged period of depression should lead to a careful
investigation of physical conditions and of the underlying mental
state in the hope of guarding against serious developments.


_Heart Disease_.--Periods of depression are also common in heart
disease and are often the first symptom of the beginning of a break in
compensation. This effect is not so simple and direct, however, as in
the case of the kidneys. Probably the first physical symptom of a
break in compensation, where there is real valvular heart disease, is
a decrease in the amount of urine. This points to an insufficient
elimination of the products of metabolism and to the retention in the
circulation of toxic substances. The reason for this is the lessened
circulation through the kidneys because of the diseased heart. There
is also a lessened circulation through the brain. This impairs the
function of the brain and quite naturally leads to mental depression,
slowness of decision, and unwillingness to occupy one's self with many
things. Besides, because of the lessened function of the kidney the
circulating blood not only does not nourish so well but it tends still
further to depress the brain cells by the toxic substances that are in
it. Depression in such cases is rather to be expected and at the
beginning is not continuous but comes in ever longer periods with
shortening intervals as the disturbance of the circulation progresses.
At first, like other diminutions of function, it is conservative in
order to spare the heart work.


_Respiratory Affections_.--Very curiously an affection of the lungs
has exactly the opposite effect and is likely to create in the patient
an artificial sense of well-being. _Spes phthisica_, the
characteristic hope of consumptive patients, is well known, and has
been described by many a careful observer from Hippocrates and Galen
to our own time. A lessened amount of oxygen in the blood produces a
certain sleepiness, but this seems to be preceded by a period of
slight excitation. The most familiar example of this occurs at the
beginning of the inhalation of laughing gas. Practically the only
direct physical effect of the inhalation of nitrous-dioxide is to shut
off our oxygen and it is a slight period of deoxygenation that
produces the anesthesia by this agent. Whether we have not in this the
explanation of the feeling of the consumptive, so that often on the
day before his death he plans a number of things that he is going to
do next year, may require more careful {643} investigation, but the
suggestion may serve to show how much disposition, both lively and
serious, depends on physical factors as well as on the natural state
of mind.


MENTAL STATES OF DISAPPOINTMENT


Quite apart from these serious ailments, however, there are passing
phases of depression that come to nearly everyone after adult life is
reached that are likely to be somewhat more frequent as years go on,
but that are not entirely unknown even in early years. They are more
likely to come to those who feel that life has been somewhat of a
failure and that they have accomplished very little in spite of all
that they have tried to do. Not infrequently they come, however, to
those who in the estimation of other people have made a magnificent
success of life. The rich man, after he has made his fortune, unless
he continues to engross himself with some time-taking and
interest-claiming work, may be the subject of repeated attacks of
mental depression. Social leaders among women who begin to feel
something of the emptiness of social striving, after they have made
what is called a success in society and at the time when they are the
envy of many on the social ladder below them, are particularly likely
to be subject to attacks of "the blues." The only men and women who
are free from them to a great extent, and even they not absolutely,
are those who are busily engaged with some occupation not entirely
selfish in which they can see that what they are doing is
accomplishing something for the people around them.

Very often an attack of depression is ushered in by some small
disappointment. As a rule, however, this is not the causative factor
but is only an occasion which makes manifest the depressed state that
has existed for some time and that now declares itself openly. In the
same way only a slight occasion is necessary apparently to dispel
clouds that hang over a person in the milder attacks of depression,
because, for some time before, relief has been preparing itself and a
livelier phase of existence has been gradually coming on. Relief can
be promised with absolute assurance, but freedom from relapse cannot
be assured and the only true source of consolation that is helpful is
the frank recognition of the fact that these are successive phases of
existence quite as likely to be periodic as certain physical facts in
life. Depression is likely to be a little more manifest in the morning
than at other times, partly because the interests of the day have not
yet come to occupy the mind, but mainly because the physical life as
indicated by the pulse and the temperature is lower during the morning
hours than in the afternoon and evening. Just as soon as people
realize the physical nature of certain dispositional changes they give
much less depressive significance to them.


Occupation of Mind.--The most important feature of the treatment of
depression of mind is to secure somehow such occupation as will catch
the attention and arouse the interest. This is not always an easy
matter. How effective it is, however, can be best judged from what one
notes of the effect of such things as physical pain or great
solicitude for someone else besides themselves. I have known a mother,
whose fits of "the blues" were getting deeper and the intervals
growing shorter to be roused from her condition when all means had
failed by the elopement of a daughter who had been partly pushed into
leaving because things had become so unpleasant around home {644}
during her mother's depression, and any change seemed welcome. On the
other hand, I had a doctor friend who felt quite alarmed about his
growing depression and who even had some fears lest, if it continued
to deepen, he might commit suicide. He was completely lifted out of
his increasing depression by the occurrence of pneumonia in his boy of
sixteen. The pneumonia did not end by crisis but by lysis and for
weeks he had very little sleep. He confessed that the intense
preoccupation of mind had completely driven away his blues and had
even done much to relieve him of various digestive symptoms to which
he had previously attributed his depression.

Again and again I have known men who, in the midst of prosperity,
found life dull and rather hard to bear, and who just as soon as a
crisis in their affairs compelled them to pay attention to other
things than themselves and the state of their feelings, grew better
mentally and physically. It seems almost a contradiction in terms to
say that it is the man of little occupation, as a rule, or at least of
occupations that are not insistent, who is likely to be troubled with
insomnia, while the very busy man, especially the man busy not about
one or two narrow interests, but about a number, is seldom so
bothered. Nothing contributes more to the depression of mind than loss
of sleep or supposed loss of sleep. Even women who, while living in
ease and comfort, had much to complain of as regards depression, often
lose entirely their tendencies to "the blues" or have fits of them at
much longer intervals, when necessity compels them either to earn
their own living or, at least, to occupy themselves much more with
absolutely necessary duties.


_Provision of Occupation_.--It is a hard matter to create such
occupation of mind as will be satisfactory. Patients have to be tried
by various suggestions. The tendency to periodic fits of depression
deep enough to be called to the physician's attention is much more
noticeable in recent years than it used to be, and seems to me at
least to bear a corresponding ratio to the decrease of home life. Home
duties usually mean joys and of late there has been a neglect of the
joys of life while seeking its pleasures. Certain phases of city life
are responsible for much dissatisfaction with existence and depression
of spirits. Most of the women who live in apartment hotels have
practically no serious occupation of mind. They need not get up if
they do not feel quite right or quite rested--and who after the age of
forty ever does feel quite all right in the morning hours unless sleep
has been in the open air? Nothing is so likely to start a day of
depression than failure to get up promptly, lounging around with forty
winks here and there, reading in bed, and the like. If breakfast is
taken in bed, then some reading indulged in, and then some sleeping,
and only an hour or two of dawdling around comes before lunch, that
meal is not properly enjoyed and the afternoon is started badly;
unless there is some special diversion of mind depression is almost
sure to get the upper hand.


_Place of Children in Psychotherapy_.--Where there are children the
interests are much more urgent and there is little time for such
preoccupation with self as gives one "that tired feeling." We are very
interesting to ourselves, but just as soon as we have no other subject
to occupy us than ourselves we soon grow very tired of the subject.
Children are the best interest that one can think of, for women
particularly. When they have none of their own an interest in orphan
asylums, in day nurseries, in various children's {645} institutions,
and, above all, in the adoption of a child, will do more than anything
else to relieve the tendency to blues. Of late years the adoption of
children has been much less frequent than used to be the case in
childless families, and doctors see the result in mental depression.
Children are a great care, but they are a great blessing to women, and
while the present trend of social life eliminates them as far as
possible, this elimination, beginning with their relegation to nurses
when they are infants, to nursemaids as they grow a little older, and
then to the kindergarten up to six years of age, far from adding to
comfort rather increases the discomfort of many mothers. Nature takes
her revenge. The reason why the mothers of past generations could
stand the suffering that they must have borne with patience before
gynecology developed to relieve them, was that they had their children
around them, and their minds and their hearts and their hands were so
full that they had no time to think of themselves, to brood over their
ills, and consequently these troubled them much less than would
otherwise have been the case.

Delicate mothers really interested in their children undoubtedly
suffer very little compared to delicate women who are alone in life,
and what is thus true of the mother is true also of those who have the
care of children. It is not alone a satisfaction of the maternal
instinct, but it is an occupation of mind and heart with cares for
little ones. Other people's children serve just as good a therapeutic
purpose, if only their necessities are imposed on the attendant. The
reason why women in religious orders have such happy peaceful lives
and are happier in spite of a routine of life that would seem to be
fatal to happiness, is that their minds are filled with the interests
of others, every moment of their time is occupied, and, above all,
they have to care for children, the ailing, the poor, sometimes the
vicious, who make many demands on them, many calls on their sympathies
and keep them from thinking about themselves.


_Occupation with Living Things_.--After occupation with human beings
the most important therapeutic factor against periods of depression is
occupation with living things of various kinds. Horseback riding is an
excellent remedy for the blues and the outside of a horse in the old
axiom is literally very good for the inside of man or woman. There is
a sympathy between man and animal that in itself means much, but the
most important element is the absolute impossibility of preoccupation
with oneself and one's little troubles and worries while one is trying
to manage a somewhat restive animal. If the horse, however, is old and
very quiet--so that one can throw the reins on his neck and allow him
to jog on for himself, then horseback riding may mean very little.
Where the care of the animal is entirely taken off the rider's
shoulders by a groom who brings him to a particular place and takes
him afterwards, then, also, much of the benefit of horseback riding is
lost. Care for other animals as well as the horse is of great service
and especially is this true if the owners feel the duty of exercising
the animals. Many a downhearted person finds that to take an animal
out for a stroll will do much to lift the clouds of depression.

With the disappearance of children from the families of the
better-to-do classes, pet dogs have grown in favor mainly because of
this influence. They awaken sympathies and so keep people from
thinking too much about themselves, For many an elderly woman who is
alone in the world her dogs or her {646} cats or a combination of both
are the best possible remedies for depression. At times it will be
found necessary to prescribe them. There is no better way to get an
elderly person to go out at certain times than to have them feel that
their pets need exercise.


_Garden Cures_.--After animals the next best thing is the care of a
garden. Here once more human sympathies with living things are aroused
and it is easier to cultivate a forgetfulness of self while
cultivating flowers and plants. Growing plants do not arouse the
interest that growing animals do, but still they have advantages over
things that do not vary, and their growth is a subject of day-to-day
interest and the effect on them of vicissitudes of the weather arouses
feelings of solicitude which help to dissipate the little insistent
cares for self that depress. The care of a garden is the very best
thing for the "pottering old." Younger people are too impatient to get
much benefit out of a garden, but after middle life many an hour of
depression will be saved in the care of plants.


_Intellectual Occupations_.--It might be expected that intellectual
occupations would serve to brush away "the blues" for educated people.
They are perfectly capable of doing so, but they must be of the kind
that grip attention and must be undertaken seriously, usually with an
appeal quite apart from mere cultural interests. Hobbies of various
kinds, especially the making of collections, even of such trivial
things as stamps, will often serve the purpose of distraction from
gloomier thoughts. Unfortunately, a hobby cannot be created all at
once and usually does not take a strong enough hold to be available
for mental therapeutic purposes unless it was acquired when the person
was comparatively young and has been indulged in for many years.
Reading and study utterly fail unless there is some end in view apart
from the reading and study itself. The reading of novels and
newspapers is particularly likely to be a failure. The gloomier
thoughts obtrude themselves in the midst of the reading and very often
what is read proves suggestive of melancholic thoughts and all the
time the mind and the person are not occupied seriously enough to push
away the state of depression which exists. The mind must be
interested, not merely occupied superficially, or the depression will
continue.

It might be thought that the reading of books that concerned human
suffering might have a similar appeal to that to be obtained from real
touch with human suffering. This is true to a certain extent when the
books concern real and not fictitious suffering. For this reason the
trials and hardships of travelers at the North and South poles or in
the heart of tropical Africa--Nansen and Peary and Stanley and
Livingston--have all been excellent therapeutic agents. The stories of
mountain climbers have something of the same effect. Adventures in
Alaska and in the Far North, especially, come in the same category.
Novels, however, even though they use the same material, soon fail to
have a corresponding effect. Even when the novel does touch the
emotions deeply it is prone to make the reader forget the suffering
around him and does not prove a good diversion from his own feelings.
In his play, "The Night Asylum," Maxim Gorky, the Russian novelist and
playwright, brings this out very well. One of his characters, a young
scrubwoman, wears her fingers to the bone during the day for a
miserable pittance and sleeps in a squalid night lodging house, yet
this comparatively young creature, {647} crouched near the only light
in the room, sheds tears over the imaginary sufferings of the
fictitious people that she reads about, while the real human suffering
around her fails entirely to arouse her sympathy or affect her
emotions, except to anger her if lodgers come in between her and the
light or when the complaints made by some of those who are suffering
around her annoy and distract her from her reading.

In younger folks, study, provided there is some definite object to be
attained by it, is often helpful. Correspondence schools are of value
by setting a definite purpose before the mind. In a number of cases I
have found that the suggestion to make translations from a foreign
language when the patient knew that language even tolerably well,
afforded excellent relief from that over-occupation with self which
was the real cause of the depression. There are many people who know
enough French to be able to translate fairly well and there are many
articles and books a translation of which may at least be submitted to
editors and often proves available for publication. To have some such
end as this in view is of itself one of the best means that can be
provided for these people to relieve their tendency to depression.
Occasionally even the suggestion to write stories may prove helpful.
One hesitates to add to the number of story-writers in this country,
but it may be remembered as a last resort. I know at least two people
saved from themselves by even a very moderate success as writers of
short stories.


_Consolation from History_.--Perhaps the most serious thing about
depression is the feeling of those afflicted by it that they are
singular in this respect and that other people who seem gay never have
depressed states. There is probably no one who has not periods of
depression. They may not be very deep and "the blues" may be only of
a light tinge, but they are there. The higher the intelligence, as a
rule, the more tendency there is to feelings of discouragement and
depression at intervals when one is not occupied. Those who have the
artistic temperament and the striving after the expression of the
beautiful as they see it, whether it be in art or in letters or in the
betterment of humanity, usually suffer more than others because they
realize poignantly their failure to reach their ideals. This is well
illustrated by the experience of writers and artists. As a rule, most
men and women look forward to the completion of any intellectual work
with confidence that after it is finished they will have a period of
rest and peace. Commonly just the opposite is true. The completion of
any work leaves one with a sense of dissatisfaction with what has been
done, for no man of real intelligence ever thinks that he has so
realized his ideals as to be satisfied, and only the foolishly
conceited fail to feel the many defects that there are in their work.

There is abundance of evidence, however, that it is not alone artists
and writers who thus feel the hollowness of life and the tears there
are in things. Many of the men who have accomplished great things in
science and in politics have been prone to times of depression.
Virchow told me there were moments when life seemed very empty to him
and that he had to shake off feelings of depression in order to be
able to go on with his work. At one time in the sixth decade of his
life he suffered considerably from what we would now call neurasthenic
symptoms, gave up his medical work and spent a long time with
Schliemann in the Troad. His presence was valuable to the excavator in
his work at Troy, and the change gave Virchow back his health.

{648}

Even more striking is what we know of Von Moltke, who seemed in many
ways to have an ideally happy life. He had had the fulfillment of all
his desires or, at least, the fruition of all his hopes, and the
successful accomplishment of what he worked for beyond what is usually
given to man. He had come to be one of the most highly respected men
of Europe and was the subject of veneration on the part of his own
German people and of intimate affection from his sovereign, who loaded
him with honors. He was a man who had probably no enemies and many,
many firm friends. It was said that "he could keep silence in eleven
languages" and so he had avoided most of the pitfalls of life. His
domestic life was ideally happy and his letters to his wife for over
fifty years read like those of a lover, before all his great battles
his last thought and written word was for her, after them his first
thought and message was for her. In spite of this, towards the end of
his life, when the question of reincarnation was a subject of
discussion in Berlin and it was brought particularly to his attention,
he declared that looking back on his career, in spite of all its good
fortune, there seemed to him to be so many chances in life, so many
possible sources of failure, so many springs of discouragement, that
he would prefer not to have to live again. Surely, if anyone, he might
be expected to be ready to take the chances of re-incarnation after
such happy experiences of life, yet he was not. Such an expression
could only come from a man who had looked depression often in the
face, who had shaken off the blue devils and who knew that even the
joy of success was followed by the gloom of uncertainty as to the
future and solicitude as to the real significance of accomplishment.


_Literature and Life_.--We have many examples of this tendency to
depression that come to the literary man in the lives and letters of
distinguished writers that have been published so frequently in recent
years. Perhaps one of the most striking is to be found in the life of
Robert Bulwer Lytton, the second Lord Lytton, so well known as a
diplomatist in European circles and throughout the English-speaking
world as a poet, under the pen name of "Owen Meredith."   [Footnote
51] It might be thought that Lytton would be one of the men safely
harbored from storms of depression and discouragement, for his life
seemed ideally situated to enable him to get the best out of himself
without worry or dissipation of energy in occupation with mere
personal matters. His father had made a distinguished success as a
literary man and a politician, had been raised to the peerage and the
son began life with every possible advantage. He made a distinguished
success in literature so that he even converted his father to praise
him and as a diplomatist he occupied nearly every important post in
English diplomacy and had hosts of friends all over the world.

  [Footnote 51: Personal and Literary Letters of Lord Lytton,
  edited by Lady Betty Balfour. New York, 1909.]

It is all the more surprising, then, to have many passages in his
letters refer to periodic attacks of depression. He says, for
instance, "My physical temperament has a great tendency to beget blue
devils and when those imps lay siege to my soul they recall those
words of Schopenhauer's and say to me 'thou art the man.'" Perhaps the
price that the artistic temperament pays for the satisfaction that it
gets out of life in other directions is this occasional tendency {649}
to depression because achievement does not equal aspiration. Certainly
the price often seems excessive to those who have to pay it. In the
same letter to his daughter, Lytton continues:

  When my blue devils are cast out, and I recover sanity of spirits,
  then I say to myself just what you say to me in your letter--that
  the main thing is not to do but to be; that the work of a man is
  rather in what he is than in what he does; that one may be a very
  fine poet yet a very poor creature; that my life has at least been a
  very full one, rich in varied experiences, touching the world at
  many points; that had I devoted it exclusively to the cultivation of
  one gift, though that the best, I might have become a poet as great
  at least as any of my contemporaries, but that this is by no means
  certain to me for my natural inclination to, and unfitness for, all
  the practical side of life are so great that I might just as likely
  have lapsed into a mere dreamer; that the discipline of active life
  and forced contact with the world has been specially good for me,
  perhaps providential, and that what I have gained from it as a man
  may be more than compensation for whatever I may have lost by it as
  an artist.

It is surprising to think of a man of this kind becoming so depressed
by the death of a son that all the world and the meaning of life took
on a somber hue for him. In 1871 Lord Lytton lost a young boy by a
very painful illness which had probably been more painful for
sympathetic onlookers than for the patient himself. The incident
proved sufficient, however, to make the father think that there could
not be a beneficent Providence ruling over the world. He felt sure
that somehow God's power must be shortened, if such suffering, for
which he could see no reason, had to be permitted. He was much
depressed after this and never was quite the same in his outlook upon
the world and the significance of life. It was easy to understand that
this was due rather to his character than his intellect, but it
illustrates forcibly how much a deeply intelligent man may be affected
by something that seems after all, only the course of nature.

It is sometimes surprising to find from the life stories of men how
often those who would be thought least likely to suffer from
periodical depression were victims of it. Few Americans in our time
have apparently had a more satisfying career than that of James
Russell Lowell, a successful author as a young man, then a successful
editor, a teacher whom his students appreciated very much, and in
later life the subject of many honors and such honors as provided him
with splendid opportunities for the exhibition of his special genius.
He would seem to be the last who should suffer from depression. His
post as Minister to Spain gave him an opportunity which he took
magnificently to study the great Spanish authors and to store up
material for writing about them. As Minister to England few men were
so popular. He was constantly in demand for occasional addresses and
his special style enabled him to respond to these demands with
brilliant success. Here in America no great occasion was complete
without Lowell. In spite of all this that would surely seem ample to
satisfy the aspirations of any man, Lowell was often depressed and
sometimes even talked about the possibility of suicide. Life seemed at
times very empty to him. The story of the lives of such men, if made
familiar to patients, proves a source of consolation, for it makes
them realize that they are not alone in their experiences, that
depression at some times is the lot of man, and that very few people
are without the sphere of its influence.

{650}

Depression an Incident, not a State.--This suggestion may, in the case
of some of those inclined to longer periods of depression, lead to
indulgence in the luxury of being depressed and so putting off the
doing of things. It must be pointed out, however, that just inasmuch
as depression has this effect it is pathological. It seems to be
natural to man to suffer from periods of discouragement and depression
which keep him from devoting himself too persistently to lines of work
that may be insignificant and make him take cognizance of the real
values of what he is doing. Depression, however, that continues after
the recognition of this takes place is morbid and must be actively
resisted. Just inasmuch as depression precedes and prepares patients
for a reaction, it is an incident in practically all lives. Indulged
in as a luxury, it is abnormal.


Suggestive Treatment--The most important thing for patients who suffer
from periodic depression is to make them understand that this state of
mind, far from being personal to them or very rare, or even uncommon,
is an extremely frequent experience of men and women. There are
certain men and a few women eminently occupied with the external life,
busy with many things, though often they are trivial enough, and even
when they are important, significant only in a financial or a social
way, but meaning nothing for the great realities of life, who seem
during their younger active years to escape the periodical attacks of
depression that come to most people and come almost without exception
to people who think seriously. Some of the best thoughts and
inspirations of men come to them as the result of the serious mood
that follows an attack of depression. A butterfly existence lacks
these sources of inspiration. Far from being objectionable then,
attacks of depression, if not allowed to proceed too far, and if kept
from paralyzing activity, prove to be intervals when life values are
seriously weighed and when a proper estimation of such values is come
to. Men are prone without such interruptions to get too interested in
trivial concerns that seem to them important because they are occupied
with them to the exclusion of other ideas, but that prove to be of no
real import when seen on the background of a certain hollowness that
there is in human life, if lived merely for its own sake.

The occurrence of periodical depression is a part of the mystery of
life and it affords us a better opportunity to get a little closer to
the heart of the mystery than almost anything else. It is out of such
periods that men have risen "on stepping-stones of their dead selves
to higher things" and have even risen to the highest that there is in
life. Geniuses have nearly always had deep periods of depression, but
in the midst of them have read new meanings into life and have read
the lessons of humanity in their own souls better than at any other
time. Depression throws a man back on himself and makes him think
deeper than in his mind--in what has been called his heart. "The
fascination of trifles obscures the good things in life" are words of
old-time wisdom and men are weaned from this by fits of depression
that are really moods of precious dissatisfaction with their work
inasmuch as it falls short of the best accomplishment. Without
periodic depression, apparently, a man never gets as close to the
heart of life as he otherwise would. Far from being an unwelcome
visitant, it should be rather welcome as a stimulus to the possibility
of further study of self and the realities of life.


{651}


CHAPTER VII

INSOMNIA


To the minds of many people insomnia is one of the most serious ills
to which human nature is heir. Most of this quite false impression is
due to the sensational cultivation of dreads with regard to insomnia
by newspapers and in general conversation. If we were to credit such
impressions, there is a certain number of unfortunates who, for some
unknown reason, find it impossible to sleep and who, night after
night, drag out the weary hours wooing sleep that does not come, until
when daylight dawns they are in despair, distracted by lack of rest.
This is presumed to occur night after night, until finally the
worn-out mind succumbs to the intolerable anguish of being kept
constantly on the rack of wakefulness and the patient becomes insane
or saves himself from that by suicide. No wonder, then, that many a
one of these patients takes to the use of habit-forming drugs to
produce sleep. These, though effective only to a small degree, soothe
him for the time, but finally render him such a wreck that there is
not even will power enough for him to take his own life and end his
intolerable suffering.

Such gruesome pictures of the awful effects of insomnia run rife and
produce dreads in the community until just as soon as the ordinary
nervous supersensitive person loses an hour or two of sleep two or
three nights in a month, he begins to conjure up the specter of
insomnia with its awful terrors and still more awful possibilities,
and begins to bewail the fate that has chosen him as an unfortunate
victim. This exaggerated dread that slight losses of sleep, for which
there are often excellent reasons, will develop into an incurable
condition of persistent wakefulness has more to do than any other
single factor with the production of the state called insomnia which
is, however, never half as bad as it is pictured.


Absolute Sleeplessness.--A certain number of patients insist that they
sleep very little at night and some tell their friends and even their
physicians quite ingenuously that they sleep none at all, and that
this has been the case with them for a prolonged period. Practically
every physician has heard such stories, and at the beginning of his
professional career has usually wondered how the patients continued to
live and enjoy reasonably good health in spite of the lack of
absolutely necessary brain cell rest. After the physician has the
opportunity to investigate some of these stories he understands them
better. Patients in hospital, who insist that they are wakeful all the
night, prove usually when faithfully watched by a nurse to be wakeful
for an hour or two at the beginning of the night and then to sleep for
hours at a time, and all of them sleep for intervals more or less
prolonged, though they may wake a number of times during the night and
may think that they have not been asleep because they hear the clock
regularly or some other recurring noise. It is improbable that
patients ever spend several nights in succession without sleep and
their story is only an index of the persuasion that they are under
that they do not sleep, though they are having so many thoroughly
restful intervals that their brain cells suffer but little from {652}
the need of sleep. _Indeed, the principle source of nervous wear and
tear for them consists in their persuasion that they do not sleep and
the resultant impelling suggestion that a breakdown must before long
be inevitable._


Individual Differences.--There are too many safeguards in nature's
ordinary dealings with human beings for us to think that people can
pass many nights absolutely without rest. Brain cells may apparently
be very wakeful, they may be quite ready to take up at once and
seemingly without a break trains of thought interrupted sometime
before, yet somehow they succeed in obtaining their needed rest. In
this matter, as is well known, though it needs to be emphasized again
for the benefit of nervous individuals, different people have very
different needs. Some require many continuous hours of sleep or they
soon begin to have symptoms of nervous exhaustion. Others live on only
with snatches of sleep at intervals, or with interrupted sleep during
a limited portion of the twenty-four hours, yet enjoy good health for
many years. A few seem to be able to live in health and strength with
but a few hours of sleep. It may possibly be thought that those who
are living their lives with a small amount of sleep are drawing drafts
on their future vital powers, and that what they make up in intensity
of activity now by shortening sleep, they will discount by shortness
of life. How utterly untrue this impression is, however, will be best
understood from the fact that many of the men who have worked hardest
and slept the least number of hours in the day, have lived to be
eighty or even ninety years of age and some of them have even been
centenarians.


Cell Rest.--The great differences in the brain cells of different
individuals in what concerns sleep becomes more readily intelligible
when we recall the extreme differences as regards the need of rest of
the various cells in the same individual. While the brain cells seem
to require for healthy life, as a rule, nearly one-third of the time,
and a man who is constantly taking much less than eight hours of sleep
is probably hindering rather than helping his productiveness,
especially if his work is intellectual, there are cells in the body
that need no such amount of rest as this. Peristaltic movements occur
in the digestive tract almost constantly, with only short intervals,
and these cells get their rest between their movements. Pulmonary
cells and tissues must do the same thing, and are able to do it
without any special strain being put on them. The extreme example of
the lack of need for prolonged rest is found in the heart. Two-fifths
of every second the cells of this organ have a rest during the
diastole, but during the remaining three-fifths of every second for
all of life they must not only be ready to work but actually engaged
in it or serious symptoms ensue. The cells in the brain that subtend
cardiac and respiratory activity must be even more able to do without
rest, since their action is ceaseless during life. By analogy with
these it is not difficult to understand that the brain cells which are
involved in consciousness should on occasion be able to stand
prolonged periods of activity, or at least of wakefulness. Persistent
wakefulness does not appeal to us as so surely destructive after this
consideration.


Solicitude Over Sleep.--For those who are much disturbed by the loss
of even slight amounts of sleep and who are prone to complain rather
bitterly if they are not able to get more than five or six hours a
night, I find it a useful preliminary to any more formal treatment of
their so-called insomnia {653} to recall the examples of some of the
great workers who succeeded in accomplishing marvelously good work
though they took much less sleep than the amount the patient secures,
yet seems to think inadequate. In spite of such lack of sleep, these
workers lived to advanced old age. There are many well-authenticated
illustrations of this in recent times. Perhaps the most striking
testimony to the power of the human mind to continue work without
requiring the refreshment of sleep, except for very short periods, is
that of Humboldt, the great traveller, scientist writer and diplomat.
Max Müller, in his autobiography tells the story. It was when he
himself was about forty. Humboldt said to him: "Ah! Max, when I was
your age I had time to accomplish something, now I find that I must
take at least five hours of sleep every night." At the moment
Humboldt was over eighty. Müller said to him: "But, Your Excellency,
how much sleep, then, did you take when you were my age?" "Oh!" he
said, "I used to turn the light down, throw myself on the lounge for a
couple of hours, and then get up and go on with my work again."
Humboldt, after a life full of the hardest kind of work of many kinds,
lived well past ninety in the full vigor of his intellectual powers.

There are many other examples that might readily be quoted. The
traditions of the University of Berlin contain many illustrations of
men who did very little sleeping, yet succeeded in accomplishing an
immense amount of work and lived far beyond the Psalmist's limit.
Virchow, whom I knew very well, did not take more than four or five
hours of sleep on most nights in the year. He would be in the Lower
House of the Prussian Legislature, which, like the House of Commons,
holds its meetings late at night, until one A. M. or later and would
be at his laboratory shortly after seven. There was a tradition at the
University of Berlin in my time there of one of the older professors
in the theological department who went to bed only every alternate
night. He had a forty-eight-hour day for work with a seven-hour break.
He lived to the age of eighty-five. I know one of our most
distinguished workers in medicine here in America who was so busy and
so tired at the end of his day that he could not write his book. He
would fall asleep on his chair at his desk to wake up only when the
milkman came in the morning. He had constructed for himself a special
stool without back or sides, shaped like a bench, so that whenever he
fell asleep on it he fell off. The fall would wake him up and he would
then go on with his work for some hours. He did this sort of thing for
many years, and yet he is alive and in the full possession of
intellectual health at the age of eighty-three. He learned this
expedient from a German professor of medicine who told him of it and
at the same time told him that it was no uncommon practice among
German professors. Indeed, most of the famous long-livers of the
nineteenth century were also well known for the small amount of sleep
they required, and apparently there is no need of being anxious lest
loss of sleep should prove serious, unless one is adding to whatever
detriment to health it may be by worrying about it find so setting two
damaging factors at work.


TREATMENT

Probably the most important immediate assurance that can be given to
those who come complaining of insomnia is that practically no one has
ever {654} been seriously hurt by the wakefulness called insomnia.
Patients suffering from brain tumors, from serious disturbance's of
cerebral circulation that give objective signs, from various organic
diseases, as of the heart or liver, or certain constitutional
diseases, have been made worse by the wakefulness induced by their
affections. In the cases where there were no definite objective signs
and wakefulness was the only symptom we have no cases on record of
serious injury resulting. Men have come complaining of wakefulness for
days or weeks and sometimes, though it is strange to understand it,
for months or even years, and yet have lived their lives without
serious developments and have neither gone into insanity nor into any
premature loss of vitality, much less a fatal termination. It is not
subjective symptoms but objective signs that are of value for the
diagnosis of the serious organic conditions. This reassurance lifts a
load from patients' minds at once and does more than anything else to
relieve them of the burden of solicitude which is the main factor in
the continuance of their insomnia.


Suggestive Treatment.--The psychotherapy of sleep consists in changing
the patient's attitude of mind toward his sleep. It is quite
impossible for him to sleep normally and regularly if he worries much
about it and if the afternoon and evening hours are mainly spent in
wondering whether he will sleep, anxious as to when he is going to
sleep like other people, marvelling how long he will last in health
and sanity if his tendency to wakefulness continues. There is no
factor so strong in insomnia as getting one's self on one's mind. It
weighs as an intolerable burden, an incubus that is sure to keep its
subject awake. Insomnia is a mental and not a physical ailment in much
more than nine out of every ten cases. It is not the brain but the
mind that is at fault. Patients must be made to realize that if they
go quietly to bed, confident that if they do not sleep the early part
of the night they will sleep later, and that in case they should lose
considerable sleep, so long as they lie quietly for eight hours in
bed, their physical organism is not likely to come to any serious
trouble. They must be quiet, peaceful and unworried. They must not
begin to toss at the first sign of not going promptly to sleep for by
so doing they may put off completely the possibility of falling to
sleep. Finally they must prepare for sleep by passing a quiet evening,
as a rule, occupied with diversions of various kinds.

There are many factors which inhibit sleep that must be removed or at
least obviated. These are very different in different individuals and
the suggestion of getting them out of the way helps a great deal in
making people realize that they are better prepared for sleep than
before. They have been keeping themselves awake by contrary
unfavorable suggestions. They must be taught to aid themselves in
going to sleep by a series of favorable suggestions attached to the
doing of certain things that are helpful and, above all, avoiding acts
of various kinds that have an unfavorable suggestive influence. In
this way an accumulation of suggestions can be secured that will prove
helpful.


Drugs.--Of course, patients must be warned with regard to the taking
of drugs. Certain drugs may be taken for an occasional loss of a
night's sleep, where the loss of sleep is regular and frequent,
however, drugs are sure to do more harm than good. Opium leads to a
serious habit, chloral is dangerous because it must be increased, most
of the coal-tar somnifacients produce {655} serious after results and
their physical effect is in the end probably more deleterious than
would be the loss of the sleep which they are supposed to counteract.
This is true for even the vauntedly least harmful of them, and it is
important to make patients understand it.


External Conditions to be Inhibited.--In the treatment of insomnia two
sets of inhibitory conditions are particularly to be looked to, those
external to the patient, and those internal. Unless every possible
obstacle is removed there can be no assurance of the relief of
sleeplessness, while very often the careful regulation of a few
conditions that are disturbing the patient will bring sleep fully and
promptly. It is curious what small annoyances will sometimes prove
disturbing.


_No Pillow_.--I have found patients who had heard somewhere the idea
that it was natural for man to sleep without a pillow. The pillow in
this theory was supposed to be an added refinement of men in a state
of luxury, but a real degeneration opposed to nature, and the many
presumed benefits of sleeping on a perfectly level mattress with the
head no higher than the rest of the body was emphasized. While in
ordinary health these patients had found that after the preliminary
discomfort of getting used to sleeping without a pillow, they were
apparently the better for it. People will feel better for almost
anything if they are only persuaded that they ought to. After a
certain length of time, however, worry or work had a tendency to keep
them more or less wakeful and then insomnia came on, that is, for
several hours at the beginning of the night they did not go to sleep
and became very much worried about it.

In several of these cases I have found one of the most helpful
adjuncts to more direct treatment of their wakefulness was the
restoration of the pillow. Just how the hygienic theory of pillowless
sleep originated, or on what it is supposed to be founded, I do not
know. The only theory of sleep that seems to have many adherents at
present is that it is due to brain anemia. With the head a little
higher than the rest of the body the force of gravity tends to help in
the production of this brain anemia. The experience of mankind seems
to confirm this. Certainly, from the earliest records of history men
have slept with something under their head, even though they could
find nothing better than a log or a stone. To sleep without a pillow
is, owing to the conformation of the head and neck and shoulders,
almost inevitably to sleep mainly on the back. From the anatomical
relations of the internal organs it is easy to understand that
sleeping on the side is more comfortable and healthy than sleeping on
the back and hence most people naturally take this position.
Relaxation is much more complete and comfort is greater. What the
majority of men do is almost surely dictated by instinct, and instinct
is the most precious guide we have in the natural functions of life.
We are not so differently formed from the animals that the analogy
from their habits should not have some weight for us. Patients should
then be advised always to sleep with a reasonably firm pillow, not too
low, so that the head is a little higher than the body and the lateral
position perfectly comfortable.


_Too high Pillow_.--There is an abuse in the other direction of too
high a pillow that deserves to be noted. Occasionally the physician
hears complaints of waking up with tired feelings in the large muscles
of the back of the neck near their insertion into the occiput. This is
sometimes complained of {656} as an occipital headache. Not
infrequently it will be found that these people are sleeping on
pillows that are too large, or that they pile up several of them. Most
physicians have found in their experience that having the head quite a
little higher than the rest of the body materially aided sleep,
especially in elderly people. This is true even when there is no
distinct heart lesion, but this favorable position is best secured not
by means of one or more high pillows, but by raising the head of the
bed, or by the insertion of bolsters beneath the mattress, so that
there is a gentle slope upward from the hips to the head. High pillows
should, as a rule, be discouraged, especially in young folks where the
assumption of the strained positions which they cause, may encourage
various deformities in the anatomy of the head and shoulders so that
stoop shoulders or a craned neck result. On the other hand, before
attempting to give drugs to elderly people, the arrangement of the
mattress so as to put the head a foot, or even more, higher than the
body should be tried and will often be found to give relief where
other things fail.


_Discomfort Due to Cold_.--In order to sleep well patients must be
thoroughly comfortable in bed. In recent years as the very hygienic
practice of having a window in the sleeping apartment open has become
a rule among intelligent people, sleeping rooms have been much colder
than they used to be. Care must be taken lest the active factor in
causing wakefulness should be cold. Over and over again I have found
that patients who complain of wakefulness, in the latter part of the
night particularly, that is, in the early morning, were awakened by
the increasing cold because they were insufficiently clothed. Whenever
the sleeping room becomes very cold, then, the patient should not
sleep between cotton or linen sheets which are likely to induce
sensations of chilliness, but in a light woolen nightgown. It is
curious what a difference in the patient's feelings is produced by the
touch of wool to the skin in cold weather as compared with cotton.
Thin, anemic patients are especially likely to suffer from chilliness.
It must not be forgotten, however, that some stout people, in spite of
an accumulation of fat, are really anemic. Their red blood corpuscles
and hemoglobin are distinctly below normal. These constitute some of
that large class of stout women in whom reduction cures fail because
of the anemic tendency. They must be as carefully protected from cold
as thinner persons, yet they need fresh air for their comfort and
health almost as much as tuberculosis patients. The experience of
sanatoria in the Adirondacks and at altitudes generally shows that for
quiet, undisturbed sleep, if the room becomes distinctly cold during
the night because of an open window, a hood or night-cap and gloves,
as well as the wearing of woolen underclothing, even to stockings, is
almost indispensable. In older times, when houses were not well
heated, many persons very sensibly wore night caps. Now that a return
to cold fresh air in the sleeping room has come many will have to
resume the old night-cap habit in spite of cosmetic objections to it.
These may seem little things, but they count very much in relieving
disturbed sleep. The curious thing about them is that patients
themselves seldom realize that certain common-sense regulations are
more important for sleep than formal remedies. They want to be "cured"
of their insomnia, not relieved by suggestion.


_Cold Feet_.--A large number of people have their sleep at the
beginning of the night seriously disturbed by cold feet. Some cannot
get to sleep for {657} an hour or more, because their feet are cold.
If the patients become worried over this loss of sleep, a real
insomnia may develop. It is for these people that the old-fashioned
warming-pan was invented and it should not be forgotten that the
symptom can be relieved very promptly by means of a hot-water bag or a
hot brick wrapped in flannel at the foot of the bed. An excellent
practice for very sensitive persons, is to have the sheets warmed
thoroughly for a couple of hours before bedtime. This is especially
important in damp weather.

The distinguished English surgeon. Sir Henry Thompson, who lived well
beyond eighty years of age (when surely he would seem to have some
right to do so), wrote a little book on how to be well and grow old
and describes a habit which he had acquired and that I have often
recommended to patients and friends as well as used myself with
advantage when there is a tendency to cold feet, either habitually or
occasionally. It is, moreover, useful whenever there is a tendency to
insomnia because some exciting occupation has preceded going to bed.
Before retiring Sir Henry used to sit beside his bath tub and let the
hot water flow into it over his feet, gradually becoming warmer and
warmer, until he could no longer stand the heat. A temperature well
above 120 degrees may be borne with comfort after a while, though at
the beginning it would seem entirely too hot. The feet are kept in the
hot water at least five minutes. When taken out they should be
thoroughly red and show evidence of a good deal of blood having been
attracted to them. If they are now carefully wiped and rubbed
vigorously there will usually be no further tendency to cold feet that
night and sleep will come naturally. Sir Henry said that when he had
been out at meetings where he had to make an address or had to take
part in business of any kind that inclined to make him wakeful, he
found this an excellent method of preparing himself for immediate
sleep.

It must not be forgotten that the worst forms of cold feet are found
among those suffering from flatfoot. The dropping of the arch
interferes with the return circulation and also with lymphatic
circulation. These individuals feel very tired because of their foot
condition, yet their cold feet often disturbs their sleep at the
beginning of the night. The only effective relief for this is afforded
by proper treatment of the feet. (See the chapter on Foot Troubles.)


_Lack of Air_.--On the other hand, occasionally it happens in spite of
all that has been said in recent years about fresh air in sleeping
rooms, windows are hermetically sealed and even then people cover
themselves with many thicknesses of bed clothing and are too warm. I
have found over and over again that where people could not be
persuaded to leave a window open all night (and when they are old and
deeply prejudiced in the matter I do not insist, for the suggestion of
possibly catching cold would almost surely keep them awake), the
thorough airing of rooms before retiring made a great difference in
the sleep of elderly people. When patients are young, I simply insist
on the window being wide open for some time before they go to bed and
slightly during the night, except in extreme cold weather. Many a
patient who complains of waking several times during the night and
being awake for some time on each occasion will begin to have longer
periods of sleep without a break if such a change in the ventilation
of the room is effected. {658} Anyone who has seen fever patients who
had been restless, disturbed and wakeful, sink into a quiet slumber
after the room has been thoroughly aired and the temperature of it
reduced ten or fifteen degrees, will realize how helpful this same
method of treatment will be in nervous, wakeful irritability.

How important air is for the obtaining of the power to sleep for many
hours every day can be best understood and appreciated from the habits
insisted on for patients in tuberculosis sanatoria as a result of
experience. When there is any tendency to a rise in temperature in
these patients they are kept absolutely without exercise. They are
either in bed or on a lounging chair all day, but they are out in the
air or at least close to an open window. As a rule, they sleep some in
the morning and then they sleep again in the afternoon. This would
ordinarily be fatal to sleep at night in even healthy people taking
considerable exercise and therefore presumably tired and more likely
to sleep than these patients who had made no exertion during the
twenty-four hours; but it is not often, after patients have been for
ten days or two weeks at the sanatorium, that there is any complaint
of lack of sleep at night. This is true in spite of the fact that
patients are often wakened by coughing during the night, yet after a
comparatively short interval they go to sleep again and sleep until
morning. This is not true when patients do not pass most of their time
in the open air and when their rooms are not well aired.


Sleep at Sea.--I know nothing that is more effective in doing away
with insomnia than a sea voyage. The passengers sit on their lounging
chairs all the morning in the open air, usually sleeping for some
time, often for several hours. During the afternoon this is repeated.
In spite of this extra sleep they turn in, not long after ten, and
sleep well until morning. There is practically no exercise and the air
usually excites such an appetite that five and even six meals a day
are consumed. There is no disturbance of digestion unless some special
excess is indulged in, and, above all, sleep is rather favored than
impaired by the large amount of food taken. This experience which is
so common, is very valuable as indicating just what is the best
pre-requisite for sleep. It is not exercise and tiredness to such a
degree that one fairly drops from fatigue, but such an oxidation of
all tissues by the breathing of pure air that there are no toxic waste
products left in the system to act as excitants for disturbance of
sleep.


Cold Water.--In summer, when wakefulness is due to heat, a cool bath,
or at least a rub down with cold water and going to bed without drying
is an excellent method of inviting sleep. Under these circumstances
the sheet acts as a soothing cool pack and people who have been
wakeful for hours before, or at least have found considerable
difficulty in getting to sleep, sleep promptly. The mechanism of
sleep-production is easy to understand. There is less blood to go to
the brain when the little capillaries at the surface are pretty well
extended and after the application of cool water the reaction which
follows the closing of the capillaries in response to cold leaves them
of sufficient size to accommodate a large amount of the blood of the
body. Of course, in both cases there is the suggestive value of a
proceeding of this kind so well calculated to predispose the patient's
mind to go to sleep without solicitude.

{659}

Diet.--As has already been outlined in the hints that precede, the
first thing in the treatment of insomnia is to remove any causes that
may be at work in producing wakefulness. Among the most common of
these in our modern life is the taking of coffee or tea, important in
the order mentioned. Every physician has frequent experiences of
people who complain of insomnia, yet who take a cup of coffee late at
night. A large proportion of humanity cannot do this with impunity and
expect to go to sleep promptly. Occasionally one finds that patients
complaining of sleeplessness are taking three to five cups of coffee a
day. This must be stopped. A physician may be told by such patients
that they cannot get along without their coffee. I have only one
answer for this and it is meant to show patients that if they want to
sleep they must take the means to secure it and, above all, must
remove all disturbing factors. I tell them that if they cannot do
without coffee they may continue to do without sleep. If they want to
sleep they must give up coffee or at least must limit the amount. I
have found it comparatively easy to get people to limit coffee-taking
by the suggestion that there should be one tablespoonful of strong
coffee taken to a cup of hot milk. This gives the taste, or rather the
aroma of coffee, for coffee has properly no taste to speak of, and
while, at first, patients crave the stimulation they have been
accustomed to, it takes but a few days to overcome this craving
entirely.

Usually it is easy to get people to confess that they are taking too
much coffee. For some reason not easy to understand it is harder to
get them to acknowledge that they are taking too much tea. Coffee is
taken with a certain amount of deliberation. Tea may be and often is
taken at odd intervals for friendliness' sake and sometimes patients
do not know how much they are taking. Six or seven cups a day may be
their usual quota, yet they do not realize it and at first are
inclined to answer that they take it only two or three times a day,
forgetting the little potations between meals. Tea is not so prone to
cause wakefulness as coffee, yet the toxic irritant principle in both
is the same and when the amount of tea and its strength are
sufficient, the same results follow. The tea habit must always be
given up if there is complaint of lack of sleep, especially early in
the night.

There is a very common persuasion that the eating of food in any
quantity shortly before going to bed, and especially the eating of
certain materials, will keep people awake. It is well known, however,
that there are a great many people who can eat anything and sleep well
after it and young children sleep best when their stomachs are full.
There are undoubtedly idiosyncrasies in this matter that must be
respected, but many patients are deceiving themselves. They are eating
too little and their wakefulness is more due to the mental state than
to anything else. As this contradicts a very prevalent impression, I
may say that it is said deliberately and only after much experience
with people inclined to be over-solicitous about their diet and their
health generally and who were actually producing wakefulness or at
least very light dreamful sleep, by their elimination from their diet,
and especially from their evening meal, of many nutritious substances.
I make it a rule to insist with patients that if it is more than five
hours since their last meal they must take a glass of milk and some
crackers or a cup of cocoa and something to eat before going to bed.
This is particularly important if they have been out in the air much
between their last meal and bedtime.

{660}

The Evening Hours.--The use of the hours after the evening meal is an
extremely important factor with regard to insomnia. If the patient
tries to read the paper or some conventionally interesting magazine or
book, thoughts of the possibility of his not sleeping will surely
obtrude themselves and he will fail to get to sleep when he lies down.
As a matter of fact, he will have so disturbed himself as to
predispose to insomnia. Some quiet occupation, interesting yet not too
interesting, that diverts the mind from the thoughts about itself and
about sleep possibilities, yet does not excite it, is the best
possible auxiliary and preparation for sleep. Prof. Oppenheim has, as
usual, said this very well in his "Letters to Nervous Patients," to
which we have turned so often:

  A great deal depends upon the right use of the evening hours. On no
  account let yourself occupy them with anxious forebodings about the
  night. But, on the other hand. It is not at present wise to take up
  your mind with too exciting thoughts, as the strong after-impression
  of feeling and fancy may counteract the tendency to sleep. You must
  find out for yourself whether a quiet game (cards, halma, chess, or
  patience), the reading of a serious or an amusing book, the perusal
  of an illustrated paper, or a chat with a friend will be most
  certain to give you that tranquillity of mind through the vestibule
  of which you will pass into the temple of sleep.


Direct Sleep Suggestions.--Many plans are suggested by which people
are supposed to be able to get to sleep. A favorite and very old
suggestion is that of counting sheep go over a fence or something of
that kind that is merely mechanical, yet takes the mind from other
thoughts. As a rule, any plan involving mental occupation that is
meant to produce sleep is likely to react and do harm rather than
good. Sleep must not be wooed deliberately but must be allowed to come
of its own sweet will. It is extremely important that exciting
thoughts and bothering interests be put aside, not at the moment when
we want to go to sleep, but some considerable time before. This is not
always an easy matter and often requires careful planning. It is worth
while doing it, however, in order to secure sleep promptly and not
allow a prolonged period to pass while one is lying awake, for if
nervous irritability ensues wakefulness is still further prolonged and
the patient may begin to toss and so disarrange the bedclothing and
disturb himself as to prepare for several hours of sleeplessness which
would not have occurred if there had been an appropriate interval
given to preparing the mind for sleep.


Diminishing Solicitude.--Patients must not be too anxious for sleep.
If they worry themselves over the possibility of not sleeping then
they will almost surely disturb their sleep, or at least delay its
coming. The ideal state of mind is not to bother one's head about it,
to lie down habitually at a given hour, compose one's self to sleep
with assurance and then wait its coming without solicitude. Many
people will say this is not easy to do, but habit makes it easy. Most
of our animal life is lived by habit. We are hungry at certain times
by habit. Our bowels move at a particular time by habit. We can sleep
by habit. If we try to use our intellect solicitously with regard to
any of these habitual functions we do much more harm than good. The
more anxiety there is about sleep the more likely it is to be
disturbed. When the habit of sleep at a particular hour has been
broken the best way to regain it is to lie down at that particular
hour and then wait patiently for {661} the advent of sleep. If
impatience gets the better of us sleep is kept off and will not come
for hours. If the patient can lie down feeling "Well, if I do not
sleep now I will to-morrow morning" then there is usually little
difficulty about sleep.


_Dread of Consequences_.--Many people who suffer from insomnia fear
that their loss of sleep will injure their intellectual capacity or
make them prematurely aged, or drain their vitality so that they will
not have health and strength of mind and body when they grow old. This
adds to their solicitude about themselves and inveterates their
condition. There is only one answer to this dread, which has no
foundation in what we know of actualities, and that is, to tell them
the experience of certain persons which absolutely contradicts such a
notion. One distinguished physician who, at the age of seventy-five,
is writing books that are attracting widespread attention and is doing
an amount of work that many a younger man might envy, has told me of
all that he suffered from insomnia between the ages of thirty and
fifty-five. His mental productivity was much hampered at that time by
his wakefulness and anxiety with regard to it. He feared the worst as
regards advancing years, yet he is in the full possession of mental
and bodily strength well beyond the Psalmist's limit. His is not an
exceptional case, for there are many others in my own personal
knowledge. Virchow once told me of years when he suffered from
insomnia, yet he lived to be well past eighty and then died, not from
natural causes, but from an injury. A man who accomplished an immense
amount of work in his day in the organization of a great university
suffered from insomnia in his younger years to such a degree that his
friends and even he himself feared for his mental stability,
eventually overcame this symptom completely and went on to years of
great active work, dying in the end, not from his head, but his heart.
We have records of a number of such cases. Few of the hard students of
the world went through life without having some bother from insomnia.
It is well-known, however, that many of the great thinkers,
investigators and discoverers in philosophy and in science have lived
long lives well beyond the age of the generality of mankind.


Mental Diversion.--The main thing is to banish the thoughts of one's
ordinary occupation as far as that can be accomplished without
laboring so intently at this as to give the mind another bothersome
occupation. Many people find that a game of cards just before going to
bed takes their thoughts off business and worry almost better than
anything else. Something like this is needed in many people. Most
people must not write for some time before retiring, because writing
proves so absorbing an occupation, as a rule, that the mind becomes
thoroughly awake and then remains so for some time afterwards. Reading
is better, but the reading must be chosen with proper care. An
exciting story, for instance, may serve to keep one awake for hours,
as everyone knows who has tried and found himself still reading at
three in the morning after having begun an interesting book. The
reading of works of general information, of travels, of description of
places, where it is comparatively easy to stop at any place, of short
stories which do not hold the interest beyond a brief period, is much
better. Osler's recommendation to have a classic author beside one's
bed to be read for a few minutes every night after retiring as a
preparation for sleep is an excellent remedy for the milder forms of
insomnia, as well as a stepping-stone to scholarship.

{662}

William Black in one of his books has a description of an old man who
had suffered from insomnia very severely until he discovered a plan of
his own to enable him to get to sleep. This consisted in reading the
Encyclopedia Britannica. He began at the beginning and read straight
ahead, article after article, and volume after volume. He never even
by any chance departed from this routine either to look up cross
references, or read anything further about men who were mentioned in
the article he was going through at the moment and whose names
occurred in another volume. He read straight on until his eyes got
heavy and then he went to sleep. At the time he was introduced into
the story he had already read the whole work through twice and was, I
think, at "D" on the third reading. He had had considerable bother
about getting to sleep before he adopted this plan, but it proved an
always efficient somnifacients. There is a story about an old American
farmer who said that he read the dictionary over and over again for
the same purpose. The stories were short and disconnected, but they
never bothered his sleep, while his wife and daughters were sometimes
kept up more than he thought was good for them by their interest in
the story paper.


Treatment of Early Morning Wakefulness.--With regard to the
disturbance of sleep in the early morning hours there are certain
instructions to patients that have always seemed to me extremely
important. Most of the patients who complain of wakefulness in the
early morning hours are really suffering from hunger at that time.
This is especially true with regard to those who stay up rather late
at night. They have their last regular meal about seven or a little
earlier, they get to bed at eleven or even later, and some of them,
following the old maxim that eating before sleep is likely to disturb
it, go to bed on an empty stomach. Whenever more than four hours have
passed since the last meal the stomach is quite empty, and after the
preliminary fatigue has worn off and the sleep has become lighter and
the lack of nourishment more pronounced a vague sense of discomfort in
the abdominal region wakes them, though most of them do not realize
that they are disturbed by a craving for food. In a large number of
these cases I have found that the recommendation of a glass of milk
and some crackers, or some simple cake, just before retiring does more
than anything else to lengthen sleep and prevent what has been
learnedly called matutinal vigilance.

After emptiness of the digestive tract, the most prominent cause of
wakefulness in the early morning is anxiety about the hour of rising
or about some engagement that has to be kept in the early morning. I
have known patients who worked themselves up so much thinking over the
necessity for rising at a particular hour to catch a train, that they
were awake for several hours before they needed to be. Some are much
more inclined to this over-anxiety than others. If they move to the
country where trains have to be caught regularly, their sleep may be
seriously disturbed by this circumstance. If the trouble becomes acute
they must simply change their residence. If it is absolutely necessary
that they stay, then they must have someone to wake them at a definite
time. This must be someone on whom they can absolutely depend,
otherwise the old solicitude will reassert itself. This seems a small
matter, yet I have known serious cases of neurasthenia with annoying
digestive symptoms due to nothing else than this morning wakefulness
consequent upon overanxiety with regard to trains and other morning
engagements.

{663}

Habits.--In the correction of troubles of sleep one of the
difficulties that the physician has to contend with when patients have
grown accustomed to staying up late and finally have so disturbed
their sleep mechanism that symptoms of insomnia develop, is the
declaration that there is no use for them going to bed early since
they cannot sleep. If a man has been accustomed for a long period to
go to bed between midnight and 2 a. m. and his habits are suddenly
changed so that he goes to bed at ten or even eleven, it is very
likely that for some time after retiring he will not sleep. If he
grows over-anxious he may toss and become somewhat feverish and then,
even when the accustomed time for sleep comes, he may not secure it.
Besides, the depression consequent upon failure to sleep when he has
fulfilled his physician's directions and when he knows that this is
considered an important adjuvant in his treatment, acts as a
distinctly discouraging factor. Under these circumstances it is
important to recall to him that one habit can only be removed by the
making of another. It may be necessary to send him to bed for awhile
only an hour earlier than before until he has grown accustomed to
going to sleep somewhat sooner, and then this habit, in turn, be
changed to an earlier hour so as to secure all the sleep that is
necessary.

In a word, insomnia is not a definite affection to be treated by
giving one or the other of one's favorite drugs, or if these should
fail trying still others, but it is a condition of mind very often
predisposed to by certain conditions of body. If this condition of
mind can be adjusted by careful attention to the correction of
whatever may be physically out of order, then there is every reason to
look for definite improvement very soon and complete cure without any
delay. Insomnia is not the awful ailment that it is sometimes
pictured, nor all that it appears to the excited imagination of the
young person who loses a few hours' sleep; but a manifold condition to
be dealt with very differently in different individuals, according to
the indications of the case. If the patient's confidence can be
secured that means more than almost anything else that can be done. If
a little patience is exercised in obtaining such definite details of
the mental state and of certain physical factors as may seem quite
trivial to the patient yet are really predisposing elements for his
affection, the therapeutics become comparatively simple. It is the use
of tact and judgment in this matter that means most, however, and then
very few drugs will be required. Between the habits consequent upon
the opiates and certain of the serious hemolytic conditions due to the
abuse of coal-tar products, this is a consummation that may well be
worked for assiduously.



CHAPTER VIII

SOME TROUBLES OF SLEEP


Certain annoying incidents in connection with sleep annoy those
affected by them so much as to arouse them very completely from sleep
and make them wakeful for a time. Nothing disturbs most people so much
as the thought that some passing incident, a little out of the common,
is quite individual and peculiar to them. If they are at all nervous
they are likely to think that it portends some serious ailment, either
present or about to {664} develop. Nothing reassures them more than to
learn that these incidents are not so uncommon as they imagine, indeed
that many of them are quite frequent, and, above all, that many people
who have had them are still alive and well beyond threescore and ten,
and laughing at the fears of their earlier years.


Starting.--Perhaps one of the most annoying of these incidental
troubles is starting in sleep. It occasionally happens that just about
the time a person is dozing off he suddenly starts and, almost before
he realizes it, is fully awake, his heart beating emphatically and
there may even be a little feeling of oppression on the chest. The
cause is not the same in all cases and individual differences are
worth investigating. In most people this starting means that there is,
for the moment, some mechanical interference with the action of the
heart and that a systole has been delayed and has been pushed through
with more force than usual because of this delay. A full stomach will
occasionally cause this, especially if patients lie on their left
sides. In some people even a drink of water taken just before retiring
will be sufficient weight to cause this interference with heart
action. An accumulation of gas in the stomach will do it by pushing up
against the diaphragm. Where there is a distinct tendency to the
accumulation of gas in the stomach I have sometimes been sure that the
expansion of the gas consequent upon the cozy warmth of the patient in
bed, or its greater effect upon the stomach because the relaxation of
sleep affected even the stomach walls slightly, was the cause of it.
It happens more frequently in the old than it does in the young, but
it is observed at all ages and patients are usually quite disturbed
about it, as, indeed, they are likely to be with regard to anything
that affects their hearts.

The thought that this forcible beat must mean some serious
pathological condition will obtrude itself on many people, and if it
does sleep is sure to be disturbed. Even though there may be no
discoverable lesion of the heart, these patients often, though they
are physicians, will worry lest some underlying condition should be
developing. The first patient who ever described this symptom to me
told me of it while I was a medical student and he is still alive and
in good health, though he is past seventy. At the time I went over him
rather carefully with the idea that there might be an organic heart
lesion, but found none. The prognosis of these cases is always
favorable, for there are many who suffer yet live long. I have found
if to occur particularly in elderly people when they were a little
overtired on going to bed, or in anemic young people when they had had
somewhat more exertion than usual during the day. Unless there is
really some demonstrable heart lesion the start does not mean anything
and patients can be reassured at once. They should be counselled
against lying on the left side, though in some of them it will occur
even while lying on the right side and then the mechanism of its
production seems to be the gaseous over-distention of the stomach.
Patients may be told at once that it occurs in a large number of
people and then, instead of lying awake and worrying about it as they
often do, they learn simply to place themselves in a more comfortable
position and go to sleep again without solicitude. They would learn
this for themselves in the course of time, but the physician's
reassurance will enable them to anticipate the lessons of experience
and they will thus be saved worrying.

At times this starting from sleep seems due to some unusual noise. In
{665} certain nervous states even slight noises produce an exaggerated
reaction and there seems to be a surprising, almost hypnotic, acuity
of hearing just at the moment when all the other senses are going to
sleep. Any of the small noises that sound so loud in the stillness of
the night may serve to wake the patient so thoroughly after a
preliminary doze that sleep is disturbed for some time. As a rule,
however, such noises would not disturb people if they were in normal
healthy condition, or at least the disturbance would be only
momentary. The solicitous effort that some people make to get away
from every possible noise is an attempt in the wrong direction. We
have heard of people building special houses, or noise-proof rooms in
the center of houses where they hoped it would be impossible to be
disturbed. What is needed is not so much an effort to secure
absolutely noiseless surroundings, which is almost impossible in any
circumstances, be it city or country, but to change the patient's
physical condition so that slight noises are not reacted to so
explosively. There are many general directions for this and certain
drugs, as the bromides, are of distinct service. On the other hand,
the taking of cinchona products seems often to emphasize it.

I have found that two classes of nervous patients particularly were
likely to be disturbed by these starts in their sleep. The first class
is perhaps the larger. They are the patients who do not eat enough.
They will usually be found to be underweight and to be nursing some
thought with regard to their digestion, or some supposed idiosyncrasy
towards food that is keeping them below the normal weight for their
height. Nothing makes sleep lighter than a certain amount of hunger.
This hunger may be disguised so completely, or so covered up by the
patient's persuasion that more food cannot be taken without serious
gastric disturbance, that it may pass utterly unnoticed. When such
patients are disturbed early in the night, it usually means that
besides taking a not quite sufficient amount of food they are taking
more tea or coffee or some stimulant than is good for them. I say some
stimulant because in several cases that I investigated rather
carefully the cause seemed to be the alcohol taken with one of the
largely advertised patent medicines, a supposed digestive tonic,
consisting mainly of dilute alcohol, and really about as strong as
whiskey. When the tendency to be startled occurs in the early
mornings, then people need to eat something simple just before they go
to bed.

The other class of cases who are likely to start at night in their
sleep are those who do not get out into the air enough during the day
or who sleep in rooms insufficiently ventilated. At the beginning of
the night the lack of ventilation makes the sleep light and easily
disturbed. After a certain number of hours have been spent in a badly
ventilated room the patient sinks into a rather deep sleep, which is
likely to be dreamy, however, and then he is rather hard to waken, but
wakes not feeling rested, but on the contrary often heavier and more
tired than on retiring. In these cases an investigation of the amount
of air the patient is allowing to enter his sleeping room or that his
circumstances provide him with is extremely important. As for those
who do not get out enough during the day, it is easy to understand
that their sleep may be light. To them, as a rule, it will be a
surprise to find how much depth is added to their sleep by an
additional hour or two in the air. Commonly, people who do not get out
much during the day are shivery and {666} suffer from cold, especially
in the winter time, and so they are likely to keep their rooms rather
tightly closed. In this case they have two reasons for a tendency to
be wakeful, which is emphasized if there are noises near them or if
there is anything that disturbs their sleep.

In young children, of course, it must not be forgotten that starting
in sleep may be due to the twitching pains of a beginning tuberculous
joint disease. At times the children are so young, or the symptoms so
vague and the tenderness, if there is any, so deep, that the real
significance of this may not be recognized. The most successful
treatment for these starting pains in children that has thus far been
found, forms a striking commentary on what we have just been saying
with regard to fitful sleep when ventilation is insufficient or when
the patient has not been out of doors enough during the day. The
children from the New York hospitals who in recent years were taken
down to Sea Breeze during the autumn and winter and made to live in
wards, the windows of which were constantly open so that the
temperature was often below fifty, so that doctors and nurses had to
wrap themselves up warmly and sometimes cover their heads and their
hands, had all been sufferers from these starting pains before this
experience, but gradually they lessened in frequency until after a few
months the crying of a child at night because of these pains was
extremely rare. The lesson is evident, and abundance of air not only
cures tuberculous conditions, but also makes the nervous system so
much less irritable that starting pains do not so easily affect it.


Noise.--Slight noises often make it impossible for nervous people to
sleep. This is much more a question of personal sensitiveness and
anxious expectancy and over-irritability than anything else. One
distinguished physician whom I knew was extremely sensitive to noise
and would be awake for hours if wakened up early in the night by the
slamming of a door or a call in the street or anything of the kind. He
suffered from insomnia to a noteworthy degree and found to his
surprise that he could sleep better on a train than anywhere else.
After he had lost two or three nights of sleep he actually used to
make arrangements to take a berth on an express train going out of his
city, ride until the morning and then come back. He usually slept well
amidst all the noise and jar of the train, though he would be quite
sleepless at home as the result of even slight noises. I have known
people suffering from insomnia who took a long ocean trip on a slow
vessel and who slept well amidst all the noises of shipboard, but were
light sleepers after landing, and felt that they missed the noise and
bustle. Of course, in these cases the rocking movements sometimes
predispose to sleep. It is not the custom now to rock infants to sleep
and a very definite agreement seems to have been come to among
pediatrists to forbid the practice as harmful. It is probable,
however, that the instinct of the race in the matter was not at fault.
Rocking seems to relax a certain tension of muscles that of itself
prevents the brain anemia which is the physiological basis of sleep.
It is extremely difficult for nervous people to relax themselves
completely, and the rocking movements, by tending to help them in this
matter, are excellent predisposing factors. A rocking chair or a
hammock furnish abundant proof of this.

Noise in general, as regards its relation to sleep, is an extremely
individual matter. Habit plays the largest role in the matter. We all
know the {667} stories of men who have gone to great expense in order
to build noise-proof rooms and yet have found afterwards that they did
not sleep well. The rustle of the bedclothes as their thoraxes rose
and fell in respiration was enough to disturb them when they allowed
themselves to become over-sensitive about noise. We all know how
impossible sleep becomes with a rustle of a mouse in the wastepaper
basket, or the scratching of one on the wainscoting. On the other
hand, anyone who has lived in a large city where past hundreds of
thousands of homes the elevated trains thunder every few minutes all
during the night, or the trolley goes rolling by within a few feet of
the bed, knows, too, that a great many people become accustomed to
noises so as to be utterly undisturbed by them, though at the
beginning any such insensitiveness to noise seemed out of the
question.

I remember having a patient who insisted that he could not sleep so
near the elevated. At the end of a week he had lost so many nights of
sleep that he was almost in despair. If he did get sound asleep he
said he used to hear the thunder of the elevated train coming toward
him in his dreams and he would begin to pull his feet up so as to get
them out of the way of the train, yet always with the feeling that he
could not get them quite far enough, until his knees were almost to
his chin. Under the influence of a little bromides, two hours more of
outdoor air than he had been accustomed to before, and some
reassurance that noise need not disturb sleep at all if taken
philosophically, he learned in the course of two weeks to sleep quite
peacefully and now has lived for ten years where the elevated passes
within ten feet of his window, which is wide open for seven months in
the year and always at least slightly open, except in the most stormy
weather. It is a question, then, of the individual much more than his
surroundings. The problem is to predispose the mind to sleep and then
the senses will not disturb it except under special circumstances.

As a matter of fact, noises usually disturb people very little at
night. The most surprising things can happen between 12 and 3 o'clock
and attract no attention. Burglars calmly blow up a safe in a hotel
confident that if there is no one awake when the explosion occurs
there will be no investigation, because even though people wake up at
the noise, they will wait for its repetition in order to see what it
means, will not get up to investigate, especially in cold weather, and
usually promptly go to sleep again.


Lying Awake.--There are many people to whom lying awake carries with
it a sense of discouragement and dread. They seem to forget that lying
awake and occupation with pleasant thoughts may be made a very
agreeable pastime by those who are not over-anxious to sleep and who
let the pleasant thoughts that may be suggested by the environment or
the noises that are heard flow through consciousness. Everyone knows
how pleasant it is or may be to listen to the rain patter on the roof
of a country house, or to hear the murmur of the ocean or of the wind
through the trees when there is not too much anxiety about to-morrow
and to-morrow's occupations and the necessity for sleep to be ready
for them. Stewart Edward White, in his series of essays on "The
Forest," has a chapter on Lying Awake at Night that can well be
recommended to the attention of those who complain bitterly of an hour
of sleeplessness. Of course, in his case the lying awake is in the
midst of the forest with all the witchery of wind in the trees and the
{668} unusual sounds of forest life, while ordinary lying awake is in
the rather monotonous environment at home, but still there is much
that can be said for his insistence that in peaceful brooding,
faculties revive while soft velvet fingers are laid on the drowsy
imagination and you feel that in their caressing vaster spaces of
thought are opened up. The impatience that comes to so many almost at
once if they fail to go to sleep promptly only serves to keep them
awake just that much more surely.

Very often, as suggested by Mr. White, this wakefulness occurs just
when a good night's rest is surely expected. There is sometimes even a
preliminary period of drowsiness. Then some little noise that
ordinarily would not be noticed at all floats into the consciousness
with a vigor that indicates that one sense is thoroughly awake. The
very surprise of it wakes up the other senses with a start and then
comes the thought that there is to be no sleep for some time. If this
is resented, the period of wakefulness will be all the longer. If,
when it has proved to be inevitable, one sits up quietly, reads a book
for a time, plays a quiet game of solitaire, it may be on a board kept
beside the bed for such purposes, or in some quiet way succeeds in
bothering away the thought of insomnia, then almost surely sleep will
come after a time, quietly and restfully, and the lost period will not
prove harmful. If nature does not want to sleep she must not be forced
into it, but gently led and after a time the wakefulness will
disappear.


Night Terrors.--One of the troubles of sleep that is more often called
to the attention of the physician than almost any other, is the
so-called "night terrors" of children. Little ones wake with a scream,
sit up in bed, evidently terrified, usually trembling, and ready to
seek refuge from something that has seriously disturbed them. Under
Dreams we have called attention to the fact that usually these terrors
are due to a dream. Sometimes the dreams are the ordinary experience
of supposed falling in sleep, from which the patients wake very much
startled, or they are repetitions of exciting scenes through which
they have passed, or of stories that they have heard, or, above all,
plays that they have seen. Ghost stories, for instance, told shortly
before they go to bed will often disturb children. Fairy stories and
the ordinary myths of childhood, usually with a happy ending and
without any serious terrors in them, are not so likely to disturb
them. Melodramatic theatrical performances to which children lend
themselves and their attention with great concentration of mind, have
nearly as much effect on them as if they passed through the actual
scenes. Every physician knows how much a fright is likely to disturb a
child and cause it to wake many a night afterwards in a state of
terror.


Respiratory Interference.--It is particularly important to remember
that any interference with breathing will almost surely wake the child
in a seriously startled condition. Adults are often affected by this
same sort of dream, due very often to some pathological condition in
the throat around which a series of dream ideas collect with somewhat
poignant results. I have known a man suffering from elongated uvula
wake up thinking that he was suffocating because, as he thought, he
had nearly swallowed his tongue, or at least had been trying to do so.
The sensation was so startling that it brought him to his feet at
once. I have known a patient traveling a long five-days' railroad
journey and suffering severely from train catarrh, come to the {669}
persuasion that he might suffocate during sleep because his nose was
completely stopped up and he had not the habit of sleeping with his
mouth open. As a result his sleep was as much disturbed by his mind as
his breathing. If these affect adults so strongly, it is easy to
understand why children should be so frightened by them. Children who
are mouth-breathers from adenoids or nasal obstruction, and still more
those whose nasal breathing apparatus is not completely stopped up,
but who are frequent intermittent mouth-breathers, are especially
likely to be troubled in this way. The neurosis known as nervous
croup, due to a spasm of the vocal cords, occurs oftenest in this
class of children and is an associated phenomenon to that of night
terrors.


Sleeping in the Light.--The habit of accustoming children to sleep
with a light in the room nearly always lessens the depth of their
sleep. They are more easily wakened and their sleep is not so
refreshing. Besides, if they do not grow accustomed to the dark when
they are young, they may always retain a dread of the dark and will
require some light in the room where they sleep. Nature intended that
the eyes and the optic nerve should have as complete a rest as
possible and even with the lids lowered some light stimulus, if it is
present, finds its way to the nerve fibers. Hence the desirability of
having as far as possible an absolutely dark room. For some very
timorous children, this may seem impossible. Many mothers will recall
how awful the dark seemed to them and what shadowy shapes loomed up in
it. It will usually be found on inquiry, however, that in these cases
the children, after having been accustomed to sleep with some light
and after having had all sorts of exciting pictures shown them and
stories told them, were asked to sleep in the dark. From the very
beginning they should be accustomed to sleeping in the dark and then
it has none of the terrors thus pictured.



CHAPTER IX

DREAMS


Dreams, that is, thoughts and illusions and mental phenomena of
various kinds that occur during sleep, have always been interesting to
the psychologist, and have usually been related to physicians by
patients either because they were thought to have a significance
related to disease, or because something in them disturbed the
patient's mind. This is almost as true in the modern time as it was
long ago. It is curiously interesting to note that the very latest
development of psychotherapy includes the use of hints obtained from
dreams in order to determine the origin of psycho-neurotic conditions
and certain of the minor psychic disturbances, and also as a
foundation for treatment. The oldest stories of therapeutics that we
have are those of patients waited on by the priest physicians of the
olden times in the temples, who were supposed to be greatly helped by
information obtained from the patient's dreams. It is interesting to
read such recent studies as that of "Incubation in the Old Temples,"
by Miss Ingersoll, with the thought in mind that we are once more
analyzing dreams in order to accomplish a similar purpose.

{670}

Dreams are so often a source of disturbance of mind for patients, lead
to such disturbed sleep, or even so affect the bodily health that it
is important for anyone who wants to influence patients through their
minds to know the significance attributed to dreams by the most recent
studies of them. This is all the more important because dreams are
such a universal phenomenon. From our earliest years we dream. The
night terrors of children are probably due to dreams and show that
even as early as the age of three we dream vividly. Doubtless some of
the terrifying dreams of childhood are similar to those that we
experience later. Dreams of falling, dreams of being cold, of being
out of breath, with vivid repetitions of exciting scenes through which
they have gone during the day, or which they have seen in picture or
been told in story, form the substance of these dreams. Children are
likely to be much disturbed by them. They wake in a terror of anxiety,
in cold sweat, and crying bitterly because of their dream visions.
Older people are not so much disturbed at the moment, but often brood
over dreams and may be seriously affected by them.

It is difficult, however, to persuade many people that their dreams
have no special significance, either of present or of future evil, and
to many the fact that they dream much becomes a suggestion of
wakefulness that disturbs sleep and makes them quite unequal to the
next day's work, because they have the feeling that, as they have been
dreaming all night, they must be quite tired. Tiredness in nervous
people is often a matter of the mental state rather than of physical
exhaustion or genuine mental weariness. The actual place of dreams in
psychology, then, becomes an important consideration in
psychotherapeutics.

Our real advances in the knowledge of the significance of dreams have
come from the study of the dreams that are common to most people.
These show us exactly how and why dreams occur and just what their
meaning is. Probably the most familiar dream common to all the human
race is that of falling from a height. Everyone has been wakened with
a startled sense of intense relief that the sensation of falling was
illusory. The waking came just before the bottom was reached. There is
a tradition that if one ever did strike the bottom in one's dream it
would be the end and that death would result as surely as if the fall
were real. So far we have had no one come back to tell us of that, and
the tradition is reasonably safe from direct contradiction. It serves
without any reason, however, to disturb timorous people and make them
dread to fall asleep again. Often this dream-falling so seriously
affects sensitive individuals that they do not get to sleep for an
hour or more and occasionally those with an inclination to insomnia
may even suffer for the rest of the night from the effect of it. It is
important to explain, then, what we know about the causation of the
dream. In nearly all cases the subject on waking finds himself on his
back, and then the inclination is at once to turn over to the side
with a sigh of relief. Commonly the dream occurs rather early in the
night, when a rather heavy meal has been taken shortly before
retiring. The weight in the stomach, particularly if considerable
liquid has been taken, seems to press upon the abdominal aorta and
interferes, to some extent at least, with the circulation to the legs.
This deprives little nerves at the periphery of the body of some of
their nutrition and causes a tingling feeling in them. This is quite
different from pressure {671} on nerves, which gives the sensation
termed "being asleep" to a limb. This tingling feeling resembles that
which we experience when going down rapidly in an elevator. It is the
falling sensation. This sensation tries to force its way into the
consciousness and in this process does not completely wake
consciousness up, but brings about an association of ideas connected
with falling--hence the dream of being on a height and of falling
therefrom out of which we wake so startled. The whole process instead
of being injurious is really conservative. It is important that the
aorta should not be pressed upon and this is the mode by which
awakening is brought about and the position shifted so that further
interference is stopped, though we ourselves are quite unconscious of
the real purpose that has been accomplished. An explanation of this
kind usually makes people who suffer from such dreams and have been
disturbed by them much more tolerant of the phenomenon and more ready
to go to sleep again, since evidently nature can be trusted to care
for them even during sleep.

After the sensation of falling probably the commonest dream that
humanity has, at least in the civilized state, is that of being out in
some public place without sufficient clothing. Usually we wake just to
find that some portion of our anatomy has been exposed to the air and
that it is cold. It is this sensation gradually forcing its way into
consciousness that has gathered around it a group of ideas that form
our dream.

Among men, a familiar dream is that of running for a car, or away from
something, or to catch someone, and finding that it is almost
impossible to move. We are so out of breath that we are scarcely able
to drag one foot after another and, indeed, sometimes we seem to be
actually rooted to the spot. We cannot move at all. When we wake after
this dream we find that, because of a cold in the head, our nose is
stopped up by the secretion and that our mouths are shut and
consequently we were getting no air. When that sensation tries to
break into the consciousness there gather around it certain familiar
ideas usually associated with being out of breath and hence we have
the dream of trying to run without being able to move.


Frequency of Dreams.--Nervous people often complain that they dream
all night or else very frequently, and that as a consequence their
sleep is not restful. It is probable that there are always ideas in
the mind and that literally we dream without ceasing. These ideas,
however, do not get into our consciousness except just during the
process of waking. All those who have investigated the subject of
dreams are practically agreed on this. In subsequent paragraphs we
quote a number of good observers on this subject. Certainly this is
what we should expect from what we all know about day-dreaming. We can
never catch ourselves during the day without finding some thought
wandering through our minds. If we want to understand dreaming during
sleep this day dreaming is instructive. We jump from one idea to
another, apparently without a connection; yet there is always some
connecting link. We have just read in the paper of someone in Cairo,
and we think of old Egypt, and then of old Babylonia, and the Code of
Hammurrabi, and the laws of the Medes and the Persians, and Xenophon
and our school days, and of an old schoolmaster now a missionary in
Japan, and of Japanese art and of an American artist much influenced
by it, and of one of his great windows in a church in New York and of
social work in connection with that church, {672} and of settlement
houses and then Hull House, Chicago, and then of the Adamses in
Massachusetts, and so on.

Thus, also, do our minds go flitting round apparently during the
night. We remember only such things as are brought into our
consciousness directly and emphatically during the process of
wakening. During our day dreaming we recall only those things which
for some reason led us to think consciously about them and then follow
out our thoughts to definite conclusions. It is an interesting study
to follow back our day dreams through their wanderings to the origin.
As a rule, however, we lose track of the connections and after a time
remember only some of the wonderful transformations and
transmigrations of thought; and so it is in our dreams.

With regard to the frequency of dreaming. Sir Arthur Mitchell in his
book "Dreaming, Laughing, and Blushing" (London, 1905), insists on the
great probability of the constancy of our dreaming during sleep. He
says:

  It seems to me that there is no such thing as dreamless sleep.
  During the whole continuance of sleep, the mind, I believe, is
  occupied with a certain kind of thinking which works round what I
  have called hallucinations. I do not expect to be able to prove the
  correctness of this opinion as to the persistence of dreams all
  through sleep, but I think that it can easily be shown to be
  possibly correct. I go further, and say that many things show that
  it is probably correct. I may not be able to prove absolutely its
  correctness, but it is proper to bear in mind that it is quite as
  difficult to prove absolutely that it is not correct. My difficulty
  is frankly avowed. Many things, however, are taught in biology as
  being certainly true. In regard to which a like avowal could be made
  but is not made. There is what has been called a "conjectural
  biology."

  We do not and we cannot remember much of what we have been thinking
  about while we are awake. This is unquestionably true in a large
  sense. But, nevertheless, we do not doubt that we have been thinking
  continuously. We do not suppose that at any time all thinking had
  ceased, though we may be completely unable to recall what it was
  about.

He shows further that many writers on dreams and careful students of
the subject in the past have come to the same conclusion. Robert Dale
Owen, for instance, deliberately endeavored to find out whether he had
always been dreaming just before he awoke. After months of observation
he records that in every instance he was conscious of having dreamed.
Hazlitt, a century ago, tried the same thing for a prolonged period
and notes that whenever he was waked, and immediately recollected
himself as to possible dreaming, he was always aware that he had been
dreaming. Sir Arthur Mitchell himself has tried this same experiment
on himself and for a considerable time has scarcely ever failed to put
to himself this question about dreaming when he awoke and always got a
satisfying affirmative answer. Personally, for several years, I have
been interested enough in this subject to recur frequently to it
immediately on awaking and I cannot say that I have ever, under those
circumstances, failed to find that there had been some vague dream
fancies at least running through my mind before I was fully awake.
This opinion as to the constancy of dreaming during sleep has many
authorities in its support. Sir Arthur Mitchell has quoted a number,
some of them distinguished physicians, who add the weight of their
testimony to this view:

  It is not a new thing to hold that there is no sleep without
  dreaming--in other words, that dreaming goes on unceasingly all
  through sleep. I have stated my own {673} opinion strongly, but the
  same opinion has been nearly as strongly expressed by others. Sir
  Benjamin Brodie, for instance, may be said to express it when he
  writes, "I believe that I seldom if ever sleep without dreaming."
  Sir Henry Holland expresses it still more plainly when he says: "No
  moment of sleep is without some condition of dreaming." Goodwin says
  much the same thing when he asserts that "sleep is not a suspension
  of thought"--in other words, that dreaming is sleep-thinking. Dr.
  John Reid still more clearly holds the opinion, though he does not
  furnish me with a short apt quotation. Hazlitt, too, may be taken as
  holding that there is no such thing as dreamless sleep.

 Descartes and his followers may, perhaps, be regarded as holding that
 the mind is unceasingly at work in sleep--even in the "profoundest
 sleep," though "the memory retains it not," and Isaac Watts says that
 "the soul never intermits its activity," and that we may "know of
 sleeping thoughts at the moment they arise, and not retain them the
 next moment."

  Hippocrates, Leibnitz, and Abercrombie have also been quoted as
  holding that there is no dreamless sleep, and so far as they express
  themselves on the subject they appear to do so.

A strong weight of opinion in all ages favors the view that during
sleep dream-thoughts are constantly running through our mind, though
we recollect only those which are impressed upon us at the moment of
awaking. We do not even recall those unless, for some reason, we have
paid special attention to them. That is just exactly what is true of
day dreaming. After it is over we have no idea at all of the thoughts
that occupied our minds for hours, though we are all aware that at any
given moment, if we turned our consciousness inwards we found that
there was something that we were thinking about.


Short Duration of Dreams.--This view of the constant occurrence of
dreams during sleep is confirmed by other things that we have come to
know as to dreams and dream states. Probably the most interesting of
these is with regard to the length of dreams. As our memory of dreams
is only such as we have from the thoughts of sleep getting into our
consciousness just at the moment of awaking, dreams are never as long
as they sometimes seem to be. As a matter of fact, they occupy but a
few moments, though in that time a long story may seem to unroll
itself. Probably nothing gives more assurance to people who are
persuaded that they are losing much rest because of their dreams than
this explanation of the brevity of the phenomena. Nervous people wake
frequently. Whenever they wake they find themselves dreaming. As a
consequence, they acquire the persuasion that they have been dreaming
"all the night long," and it is not hard for them to suggest to
themselves in the early morning that they are not rested. Nervous
people seldom feel rested in the early morning, it is their worst
time, and with the occurrence of dreams as a suggested reason for
this, they exaggerate the feeling of tiredness with which they get up.
A frank discussion of this question of the duration of dreams is often
the best possible therapeutic auxiliary for such cases. It gives them
a new series of suggestions and, above all, relieves them of
unfavorable suggestions.

Prof. Maury of the University of Paris tells a striking story of a
very brief dream of his own which shows how short may be the time
occupied by what seems surely a long dream. He had been reading before
going to bed a very striking book on the Reign of Terror. He dreamt
that he himself was arrested during the Terror, taken to prison, that
his name was called on the list of the condemned, that he was carried
to the guillotine, fastened to the {674} board, pushed beneath the
knife and that he woke just as the knife struck his neck. Of course he
awoke with the usual sense of thankfulness and relief that comes at
such times. When he awoke he found that a light curtain rod had fallen
from the bed above him and had struck just across his neck. His dream
evidently had all come to him during the extremely short time
necessary for him to become fully awake after the rod had hit him. His
mind was occupying itself with the history that he had read before
going to bed. When the rod struck him the long story of his arrest and
imprisonment, the journey to the place of the guillotine and the
preparations for execution, all came to him as a series of rapid ideas
during his coming to consciousness.

It is probable that most of our dreams are not much longer than this.
One of my earliest recollections is of an old gentleman coming into
the country school during my first year as a pupil and telling us the
story of a dream of his of the night before quite as brief as that of
Professor Maury. He had fallen asleep after dinner in his chair and,
having a cold that stopped up his nose and his mouth being shut, he
had the usual dream of being out of breath from running. It took him
back to the story of the massacre of Wyoming, near the scene of which
the school was situated. He dreamt that for hours he had been running
away from the Indians and seemed at last utterly unable to escape them
because he was out of breath. He made such efforts in his chair that
his wife awakened him and then he found that he had been asleep
altogether only a very few minutes.


Significance of Dreams.--Many people are quite sure that their dreams
have a definite significance quite apart from any mere wandering of
the mind or the suggestion of half-waking and the ideas that gather
round sensations not fully in the consciousness. A number of people,
for instance, have dreams of events that are happening at a distance
at the moment that they dream. The Psychic Research Society of England
has gathered a number of these and it is indeed difficult to
understand many of them. There seems no doubt, however, that in many
cases there is an illusion of memory, by which, after an event, dreams
that might be taken to refer in some vague way to the happening, are
clothed with a wealth of detail which appears to make them wonderful
premonitory representations of future events or repetitions of
simultaneous events. One of the most familiar of this form of dreams
is what has been called a phantasm of the dying. People dying at a
distance seem to have some wonderful power of making themselves appear
to very near friends, especially brothers and sisters, and, above all,
twins, and to friends with whom they have been very intimately
associated. Occasionally such phantasms are seen during waking hours,
or what are supposed to be waking hours, though it must not be
forgotten that dreams may come very easily and almost unconsciously in
short naps, but much more frequently in what are known to be dreams.

Nearly always these partake of the nature of the ordinary dream, as
can be seen by a careful analysis of their conditions, and are mere
coincidences occupying a very brief space of time. A typical example
of this is to be found in one of the stories told by Camille
Flammarion, the French astronomer, in his book "The Unknown." A young
man who had fallen in love with a young woman was deeply grieved to be
parted from her by the injunction of parents. Separated by a long
distance, they kept up a clandestine {675} correspondence for more
than a year. For a considerable period, however, he had not heard from
her, and he was beginning to be anxious lest anything had happened to
her. One night she appeared to him in a dream in his room in white
garments with a pale face and, placing her cold hand in his, she bade
him good-bye. He awoke with a start. He found it difficult to sleep
and was very anxious about her. The next day he learned that she had
died the night before and concluded that his dream was a last message
from her. The end of the story, however, as it is told, spoils this
nice sentimental conclusion. When he awoke he found he had in his hand
a glass of ice water which had been standing on the table beside him.
The grasping of this had awakened him. During the awakening process
the thoughts of her in his mind gathered round the cold sensation in
his hand and gave him the dream of her and the last farewell.

There are many instances in which dreams of future events seem to come
true. Indeed, so many of these stories have been told that it is hard
to persuade some people that dreams have no meaning and can have no
meaning. By this we mean that they can by no possibility represent
prophetic foresight. What patients need to be made to understand is
that dreams represent only straggling sensations trying to get into
our consciousness, just barely succeeding, and then arousing trains of
ideas unconnected in themselves, but which we connect afterwards when
we recollect our dreams. This whole subject has been studied so
thoroughly in Maury's work on _"Le Sommeil et les Rêves"_ about the
middle of the last century and Freud _"Ueber den Traum"_ and Sante de
Sanctis' _"I Sogni"_ Turin, 1899, at the end of the century, that
there can be no further doubts about the matter for those who are open
to conviction. Most people, however, want to believe that their dreams
mean something. They like to think that they are in some way picked
out from the multitude and that their dreaming has a significance more
than is accorded to other people. It is, indeed, this
self-centeredness that makes for the belief in premonitions and
prophetic dreams and, as in all cases, these feelings work out their
own revenge.

If they will listen to reason, however, most people may be rather
readily convinced that their dreams cannot have any serious
significance. In the chapter on Premonitions we have already called
attention to the situation that exists with regard to the possibility
of future events giving information of themselves in advance of their
happening. Simultaneous events may perhaps in some way give warnings.
The possibility of action on the mind at a distance, especially where
minds are involved, has been discussed and admitted. The cases in
which it is supposed to have happened are, to my mind, all dubious and
are mere coincidences. For future events, however, there is no
possible physical explanation. When we turn to explanations in the
borderland between spirit and matter we find nothing satisfactory. The
future event exists nowhere. No spirit even knows it; it is dependent
on human free will. To the Creator it is known only as a contingent
possibility dependent on free will. The information does not come from
Him, for then there would be more design in these incidents. Such
dreams would effect some serious purpose, while usually they have but
minor significance in the stories as told and they often concern only
the most trivial things.

What is thus true of premonitions can readily be applied to dreams.
{676} There is no reasonable source of information with regard to
future events. What, then, are we to say of the dreams that come true?
There is no doubt that dreaming is extremely common. Probably, as was
said, we never sleep without dreams. There are a billion dreams at
least, probably many billions of dreams every night, then, in this
little world of ours. When these are startling they cling to us. It
would be surprising if some of them did not come true. Indeed, it is
inevitable, according to the theory of probabilities, that some of
them will connect themselves directly with future events. We have a
few thousands of such startling coincidences in the history of the
race. Out of these have been made all the data supposed to underlie
the teaching that dreams have a prophetic significance. It is much
easier to understand with regard to dreams than even with regard to
telepathy coincidence explains all the supposedly wonderful warnings
of events that actually happen after we have had apparently
premonitory dreams.

An interesting example of a premonition that did not come true, the
subject of which was sure that it was a waking premonition and not a
dream, though it seems more likely that it was as suggested by the
narrator a sleep vision, is told by Sir Arthur Mitchell in his
"Dreaming, Laughing, Blushing" (London, 1905). A number of scientists
who discussed the story declared that if it had only come true it
would have been one of the most startling manifestations of
premonition and of the clairvoyant power of dreams, or at least of
their telepathic significance, that we have ever had. It involved so
many distinguished scientists that there could have been no doubt
about it. It was so detailed and those details were known to so many
authorities in science, that it would have carried great weight and it
would have been extremely difficult to have people accept it as a
mere coincidence. It is easy to see now after the event that, if it
had been fulfilled, it would have been, in spite of its startlingness,
a mere coincidence. Since it was not fulfilled, however, it represents
one of the best evidences that we have for the insignificance of
premonitory or telepathic dreams.

  Sir William T. Gairdner, K. C. B., whose interesting typhus delirium
  experience appears in the paper by Professor Coates on "Sleep,
  Dreams and Delirium" (_Glas. Med. Jour.,_ Vol. xxxviii, 1892, pp.
  241-261), has written to me about his dreams generally, and he
  concludes his letter with the narrative of a dream, which, as he
  correctly says, "if it had only fulfilled itself, might have become
  famous." He prefaces the narrative by this statement: "In all my
  individual experience, now extending over more than the usual term
  of life, I have never met with anything suggestive in the remotest
  degree of telepathy or second sight, or of dream prophecies or any
  other fact bearing on the marvellous." He then goes on to tell the
  dream to which I have referred. "In crossing the Atlantic In 1891,"
  he says, "in delightful weather and perfect bodily health, and
  without a shade of anxiety on my mind so far as I was aware (in
  waking consciousness), I was suddenly aroused in the very early
  morning, say, three or four a. m., out of a perfectly sound, and, as
  I should call it, dreamless sleep, by the apparition of a telegram
  written on the usual paper, and presumably from home, in these
  words: 'Miss Dorothea died at ----,' all the rest being blurred and
  indistinct, but these words having a startling distinctness and a
  vivid sense of reality. I was not, I think, in the least degree
  alarmed at first, and certainly had no superstition about it on
  discovering that it was only a dream; but, failing to get any more
  sleep, I rose early, took my bath as usual, and went on deck, where
  I had to repeat the story of my dream to each one of some three or
  four companions who were on board, of whom I will only mention Sir.
  John Batty Tuke, Professor Young of Owens College, and Professor
  {677} Cunningham, then of Trinity College, Dublin. Any of these
  gentlemen will confirm my saying that I attached no special
  importance to this dream in the way of a scare or a superstition,
  but in this way it got abroad to a certain extent within a small
  circle on board in such a way as would have ensured it a widespread
  fame had it only come true. In discussing the matter at breakfast I
  remarked (alluding to telepathy) that the telegram was clearly,
  judging from its terms, not from my wife or any member of my
  immediate family, and could only have been despatched by a servant
  or some one with whom I could not be supposed to be in telepathic
  rapport. From this point of view it clearly refuted itself, and yet
  the effect upon my mind was such that, upon arriving at New York, I
  at once despatched a telegram announcing my arrival and making
  inquiry, the reply to which showed that the family were pursuing a
  quite undisturbed course at St. Andrews."

  Sir William describes himself as aroused out of sound sleep by the
  apparition of a telegram, but I think this only means that he became
  suddenly awake on seeing the telegram during sleep. He does not say
  whether he knew in his dream that he was a passenger on a great ship
  on the mid-ocean, but he says that the telegram was written on the
  usual paper by which I take it that he means the paper used here on
  shore.

  If it happened that the death of Miss Dorothea took place about the
  time of the appearance of the telegram to so distinguished a man as
  Sir William in his sleep, I scarcely think there would be any more
  startling record of a so-called telepathic message. But most happily
  the death did not take place, so that the story of the dream will be
  forgotten. Tens of thousands of similar dream stories have that
  fate.


Children's Dreams.--There is an old tradition that to tell our dreams
causes them to come back, or at least to recur in some other form.
This tradition is so old and so universal that probably there is more
in it than might at first be thought. This emphasizing of certain
forms of unconscious cerebration probably encourages their repetition,
or, at least, the repetition of further processes of the same kind.
There seems to be no doubt, too, that the reading of certain kinds of
imaginative writing and the looking at exciting pictures sometimes
leads to dreams about them. Certainly children should not be told
terrifying stories and the more nervous they are and the more affected
they are by such stories, which to some people make renewed
temptations to tell them, the more should they be avoided.

Any physician who has had much experience with city children,
especially in New York City, is likely to know how exciting, tragic
and, above all, melodramatic scenes serve as the basis for disturbing
dreams and night terrors. They will not, of course, in vigorous,
healthy and strong-minded children, but these are the ones who are
most prone to play out of doors and so are likely to be less bothered.
Just the nervous, old-fashioned, delicate children who prefer the
theater to sports of other kinds, are likely to be most affected in
this unfortunate way. The scenes become so real to children that they
impress them very deeply and are readily rehearsed in the unconscious
cerebration of sleep. Many a child sees in its dreams someone, often a
near relative, fastened on the carriage of a sawmill and inevitably
approaching a buzz-saw, or fastened inextricably to the rails while an
express train thunders down on them. That they should wake up with a
start and a scream of terror and lose most of their night's sleep and
disturb that of others, is not surprising. It is well known how
witnessing actual danger, as of an automobile accident, or a railroad
wreck, disturbs a child's imagination for long after; and its theater
experiences are almost as actual as the reality.

{678}

Many of the colored supplements of Sunday newspapers seem to be
particularly undesirable literature for children in this respect,
though, of course, there are many other reasons why children should
not be encouraged to look at them. It is not unusual for the
newspapers to give lurid pictures of wonderful dreams or things that
happen in dreams. This is undoubtedly a suggestion that acts in
causing nearly all children, but especially those of nervous
organization, to dream much more than would ordinarily be the case. It
recalls the old warning about telling dreams. These sets of pictures
certainly serve to develop the imagination of the child along
undesirable lines. Possibly some of them which emphasize the fact that
after eating certain very undesirable foods, dreams are much more
likely to come than at other times may not be without their
prophylactic sanitary value, but this is a doubtful advantage compared
to the psychic harm that they bring. I am not of those who would limit
the fairy stories and other pleasant essays in imagination which
delight children so much and form a desirable part of their education,
but artistic effort that is terrifying or deterrent, whether with pen
or brush, should be kept away from them until after their mental
control is well established. Children will probably dream anyhow, and,
therefore, should have a pleasant fund of imaginative material as a
basis for their dreams.



CHAPTER X

DISORDERS OF MEMORY


Many patients suffering from various nervous symptoms insist that they
are losing their memory or that it is becoming notably deficient in
some ways. If they are a little on in years they are sure that their
memory is not as good as it used to be and that they now forget many
things that were formerly remembered without difficulty. Especially
are they likely to assert that the names of people and certain words
will not come to them when they want them, that they often have to
seek for facts and dates that should be quite familiar, that they fail
to remember acquaintances and the like. These symptoms of which they
complain are often sources of considerable worry and serve to
emphasize in them the idea that there is something serious the matter
with their general health, or some pathological condition developing
in their brain. They have heard much of loss of memory as a sign of
degenerative nervous diseases and they are prone to think that their
own special loss of memory, be it real or imaginary, must be a
forerunner, or perhaps even an early symptom, of some important
organic lesion.

This idea of progressive memory disturbance as a preliminary of
nervous breakdown often becomes so firmly fixed as to be of itself a
profound source of anxiety to patients, and an almost unspeakable
dread. So it is important to make them understand what the real nature
of their condition is and what their loss of memory, supposed or real,
is due to. As a matter of fact, what many of these patients need is
not treatment for a diseased memory, but reassurance from what we know
about the psychology of memory, that their troubles are only quite
natural incidents in the life history of their particular memory {679}
faculty. Many a man who is worrying about his supposed loss of memory
or, at least, impairment of it in some way, is not suffering from a
true pathological condition, but is usually the victim only of some
functional disturbance of the nervous system with the neurotic anxiety
and heightened introspection that accompanies such a condition.


Reasons for Memory Difficulties.--Nervous patients particularly
complain that they do not remember what they wish to as easily as they
used to a few years before. They say that it is much more difficult
for them to impress things upon their memories and, in addition, that
it is much easier for them to forget. There are three quite natural
reasons for these phenomena as far as they actually exist, which
should be pointed out to these patients. The first and most important
is that they are incapable of that concentration of mind which they
had in earlier years and which enabled them to give themselves up so
completely to the consideration of a particular subject that it could
not help but be impressed on their minds. They are now so much
occupied with many other things, and, above all, most of these
patients are so preoccupied with themselves that they cannot hope to
have the concentration of mind that was comparatively easy when they
were younger and is now impaired, but which is so necessary for the
enduring remembrance of things. Secondly, their over-anxiety to
remember things sometimes acts as an inhibitory motive in securing
that deep, impression that will enable them to remember details very
well. Thirdly, their supposed impairment of memory is due to a false
judgment with regard to themselves. They are not comparing their power
of memory now with what they used to have, but owing to anxiety about
themselves they have taken to comparing themselves with others and,
after all, the faculty of memory acts very differently for different
people and it is well known that what one man remembers with ease
another recalls with difficulty, or only because of special attention.


_Attention and Memory_.--The first of these causes for supposed
impairment deserves to be discussed further. It is often said that as
we grow older our memory is not so retentive as it used to be, and
that while we remember the events of boyhood and the things we learned
in the early years of school life, our recollection of recent events
and things learned in later years is much less vivid. This is all very
true, but the reason usually given, that in the meantime our memories
have failed in power is inconclusive. What we learned in early
childhood came to us with the surprise of novelty and for this reason
we paid close attention, it was new and impressed us with its
importance, it was dwelt upon for long periods and often, because
there was little else to think about, has been frequently recalled
since and, of course, is indelibly impressed upon our memories. The
same thing is true with regard to early acquaintances. We got to know
them so well that, of course, we cannot forget them. What we have
learned in later life, however, has come in the midst of many other
things, has not been dwelt on very long, has not been often recalled
and, of course, occupies much less place in the memory than the things
of earlier life. That is not, however, because of any defect in
memory, but because of lack of attention and repetition that means so
much for memory.


_Age and Memory_.--It is often said that people do not learn so
readily when they get older. This is, of course, a truth of common
experience, but {680} it is not because of dullness of the faculty of
memory, but failure to concentrate the attention sufficiently for
memorizing. I have known old men who could learn things just as well
as any young man and indeed better than most of them. They were men
who had been accustomed all their lives to concentrate attention on
the subject they had in hand and who did not allow the cares and
worries of life to intrude on their studies. Cato learning Greek at
eighty is often quoted as an exceptional example, but I have had some
dear old friends who could learn things quite as readily as younger
men and whose minds were just as bright and clear. Whenever they
devoted as much attention to anything that they wanted to remember as
they did when they were younger men, I am sure that they remembered
quite as well. It is a question of attention and not of any loss of
faculty that makes the difference between the memory of the young and
the old until, of course, senile impairment actually comes.


_Solicitude and Memory_.--Everyone who has had to depend much on his
memory knows that over-anxiety with regard to the recollection of
anything may seriously inhibit the power to recall it. Public speakers
know that to hesitate is to be lost. If they want a particular name or
word which they know often escapes them, they must with confidence
begin the sentence in which it is to occur, though perhaps wondering
all the time whether the word will be on hand or not for them to use
it. Occasionally it will not come, but as a rule it turns up just in
time. If they allow themselves to be disturbed by the thought that the
word or expression may not come, then they know the hopeless vacant
blank that stares them in the face when they want it. They have to
make a circumlocution in the hope that it may turn up. Some let it go
at that, but many start another sentence in the hope to tempt it to
come and often it will eventually come, but sometimes it persistently
refuses to come. That is not a loss of memory but a failure of neuron
connections. There are some of us who know that certain words will
always do that with us. Archimedes has bothered me for years and his
name will often not come when I want it. Then there are certain words
with regard to which transposition is likely to take place. We
involuntarily and unconsciously substitute one word for another. We
call one man by another's name. We have done it before and we know
that we are likely to do it again. Somehow the connections in memory
exist along these wrong lines and are constantly mismade. The name of
something a man has written comes up instead of his name. This
heterophemia is often noted in men of excellent memory.


Peculiarities of Memory.--Memory is an illusive and elusive function
at best. All of us have had the sensation of having a word, and
particularly a name, on the tip of our tongues. We often know the
first letter and sometimes the first syllable of it. What memory
brings to us, however, may not always be the first syllable of a word
or name, though we are prone to think it must be, and we may go
looking for it in the dictionary of names only to discover after a
time that we are many letters away from its beginning. Very often we
have to give up seeking in sheer inability to get a hint of it and
then of itself it will come a little later. Sometimes it will come
when we no longer want it. As a rule, words that have escaped us once
in this way are prone to do so again. Over and over again the
experience will be that {681} a particular word or group of words
escapes our memory, or at least fails to be at our command, as most
other things are. Those of us who are not much given to introspection
take no notice of these difficulties which are common-place
experiences enough, but the man or the woman who is looking for
symptoms, who is prone to believe for some reason or other that his or
her memory is failing, will take these hints of the more or less
natural fallacy of memory as confirmations, strong as direct proof of
the fact that memory is seriously deteriorating.

Such pauses and lapses of memory are much more likely to occur if we
are nervous and over-anxious about possible loss of memory. I was once
asked to attend for a few hours before the time fixed for his oration
one of the greatest orators of this country, who was about to talk at
a university commencement. What surprised me was that this practiced
speaker, who had often appeared before very large audiences, took a
very light meal in considerable trepidation, immediately after asked
to have certain books brought to him and certain facts looked up for
him, took notes in a hurried, feverish way and generally displayed all
the over-excitement of the schoolboy about to make his first oration.
He was a magnificent occasional speaker, often called upon, yet he
assured me that it was always thus with him and that the reason for it
was that in spite of previous preparation--and the finish of his
orations made it clear that he had devoted much thought to them
beforehand--certain of his facts and names and dates had the habit of
slipping from him in the midst of the development of his theme, unless
he had refreshed his memory with regard to them immediately before,
and that he feared that sometime he would find himself in the midst of
an address with an absolute blank before him and that he would be
compelled to sit down in disgrace. He had never done so and never did
in the many years that he, lived afterwards, though always with this
dread, never trusting his memory as most people do.


_Name Memory_.--There are certain circumstances in which memory may
fail and yet no significance of a pathological nature can be
attributed to the fact. All of us probably have had the disturbing
experience of undertaking to introduce two friends whom we had known
for many years and yet having to ask at least one of them for his name
before we could make the introduction. It is not that we did not know
the name, but at the moment we were utterly unable to recall it. After
this has happened once or twice it is prone to happen again, because
when we set about introducing people the thought of the previous
unfortunate occurrences of this kind comes to our mind and acts as an
inhibition of memory, making it impossible for us to recall names. Not
infrequently if we are brought to the pass of having to ask one of the
parties for his name we have to ask the other, though it was on the
tip of our tongue a moment before, because in the meantime the
disturbance of mind incident to having to ask has interfered with the
train of recollection. Men have been known to forget their own names
under circumstances of great excitement and such a forgetting is not
pathological, but only a physiological disturbance of function because
of secondary trains of association set to work in the brain which
disturb ordinary recollection. Of course, some people have an
excellent memory for names and never have such experiences, but they
are very rare, though practice in recalling names does much to keep
{682} people from such embarrassing situations. On the other hand,
there are some people especially gifted with name memories. Napoleon
could recall all his soldiers' names.


Fatigue and Memory.--Occasionally it happens quite normally that when
we are very tired certain portions of our memory at least become vague
and indefinite and may even fail to respond to any excitation on our
part. Under these circumstances we seem to be able only with
considerable effort to exert the effort necessary to bring about such
connections of brain cells as will facilitate recollection and
reproduction and we may fail entirely. In a foreign country it is, as
a rule, much more easy to talk the language in the morning when we are
fresh than in the evening when we are tired. Especially is this true
if we are asked to pass from one foreign language to another, which
always requires a special effort. Everyone who has traveled must have
had the experience that on crossing the frontier suddenly to be
addressed in German after he has been talking French for weeks, may
quite nonplus the traveler, even though he knows German as well or
even better than French. This is especially true if much depends on
the answers, if he has been addressed by a railway official or customs
inspector. Apparently there must be a momentary wait until some
shifting operation takes place in the brain before the German memory
can get to work to establish the connections necessary to enable him
to talk German. After a man has been talking to a number of people in
one foreign tongue he is likely to be quite lost for words for a
moment if he has to use another. The effects of fatigue and excitement
and unusualness upon memory then must be remembered in order to be
able to reassure patients who pervert the significance of the
phenomena.

Ribot gives an excellent personal illustration of this peculiarity of
memory in his "Diseases of Memory," which is worth recalling here. He
says:

  I descended on the same day two very deep mines In the Hartz
  Mountains, remaining some hours underground in each. While in the
  second mine, and exhausted both from fatigue and inanition, I felt
  the utter impossibility of talking longer with the German inspector
  who accompanied me. Every German word and phrase deserted my
  recollection; and it was not until I had taken food and wine, and
  been some time at rest, that I regained them again.


Sensations and Memory.--Just as soon as people compare their memories
with others, as they do when they worry and begin to grow
introspectively self-conscious, they find noteworthy differences and
because of differences they will be prone to think that their memory
is pathologically defective when it is only different, or, still more,
that because they are not able to remember some things, as others do,
their memory must be failing. It is well known that some people have a
good memory for things seen, others for things heard, and still others
only for things in which they have taken actual part. These are spoken
of as visual, auditory and action memories. Memories for things seen
are divided into special classes. Some people remember forms very
well, while others remember colors. It is evident that our memories
are somehow dependent on the special mode in which sensation affects
us and that our acutest sensations are the sources of our longest and
best memories. Color vision defectives are not affected much by colors
and easily forget them. The tone-deaf have no memory for tunes. Every
sense defect affects the memory. Sense defects are often unconscious.
Their effect on memory may {683} only be noted when introspection
begins to bring out the special sensation and memory qualities of the
individual. Nature, not disease, may be the basis of some memory
troubles thus brought to recognition. All these curious phenomena with
regard to memory need to be recalled whenever there is question of a
supposed deterioration of it, for it is not easy to decide such a
question.


Limits of Normal Forgetfulness.--Curious instances of forgetfulness
may occur in the experience of men with excellent memories, which,
when they happen to persons morbidly inclined to test their every act,
are interpreted to signify something much more serious than they
really mean. Nearly everyone has had more than once the experience of
telling a story to a particular group of people and then forgetting
all about having told it and coming back a few days later to tell it
over again. Occasionally a teacher hears the same lesson a week apart
and yet does not remember that he went over it before, though the
class is almost sure to do so. A man may repeat a lecture that he has
given before to the same audience without realizing it. The story has
been told more than once of a clergyman delivering the same sermon on
two Sundays in succession and, though such lapses are very rare, they
do not necessarily indicate a failing memory, but may only mean a lack
of concentration of attention on the part of the human mind. Prof.
Ribot in his "Diseases of Memory" tells the story of one such case in
which the subject was quite alarmed lest it should indicate that he
was beginning to suffer from some serious memory disturbance due to
brain disease, though there was no ground for his fears:

  A dissenting minister, apparently in good health, went through the
  entire pulpit service one Sunday morning with perfect
  consistency--his choice of hymns and lessons and extempore prayer
  being all related to the subject of the sermon. On the Sunday
  following he went through the service in precisely the same manner,
  selecting the same hymns and lessons, offering the same prayer,
  giving out the same text, and preaching the same sermon. On
  descending from the pulpit he had not the slightest remembrance of
  having gone through precisely the same service on the preceding
  Sunday. He was much alarmed and feared an attack of brain disease,
  but nothing of the kind supervened.


Attention not Memory.--When patients come with complaints of the loss
of memory, the most important thing is to analyze their symptoms
carefully. This will usually enable us to give patients ample
reassurance. I have known men who were convinced that they were losing
their memories because of their failure to recall important details in
their business affairs in the midst of much hurry and bustle in the
winter time, find that when they were living a simpler life in the
course of travel or life in the country during the summer time under
conditions different from the ordinary, their memory could be
absolutely depended on for trains and travel details and all important
matters to which they were now devoting attention.


Cultivating Looseness of Memory.--Many people complain of loss of
memory in the sense that they do not now remember when things took
place as well as they used to. For instance, I have had men of fifty
tell me that they were sure that their memories were growing weaker
than they used to be because a number of times within a year they had
found that events which they thought had taken place only a year or
two ago really dated four or {684} five or even more years in the
past. Some are considerably disturbed by this. As a matter of fact it
is only another instance of lack of attention. Most of what we read in
newspapers attracts so little of our serious attention that it is no
wonder that we do not recall with exactness when events took place.
Events crowd each other out of memory. Newspaper reading is, indeed,
the best possible cultivation of looseness of memory that we could
have. We do not expect to remember what we read. We would probably
grow distracted if we did. At the end of the day if you ask a man what
he read in the morning paper he will have no idea at all, unless
something especially startling or particularly interesting to him has
turned up. After a week we could no more separate Monday's from
Tuesday's news of the week before than we could recall a random list
of events, having heard it but once. We cultivate looseness of memory
with great assiduity. Let us not be surprised if, to some extent, we
succeed.


Memories Individual.--People are often much worried over children's
memories and may communicate this worry and anxiety to the children
themselves, making them solicitous. It is probable that our memories
are like our stature. They are what they are. By thinking we cannot
add a cubit to the one nor facility to the other. The training of the
memory is a very small element compared to the natural faculty. It
must not be forgotten, however, that many distinguished men have been
noted for rather bad memories when they were young and yet these
faculties have developed quite enough to enable them to accomplish
good work afterwards. The memory is, after all, a comparatively
unimportant faculty in itself and other intellectual faculties surpass
it in significance. It is the faculty that first develops, however,
and so a child is often thought to be intellectually slow when it has
not so bright a memory as its companions, though a little later its
other faculties may develop so as to put it on a plane above its
fellows. Memories, too, are very individual and may not retain any of
the ordinary subjects, while they may be very attentive for certain
special lines of thought. This form of the faculty is better, for the
encyclopedic memory is usually of little use and, except in high
degrees, encourages superficiality rather than real knowledge.

As a matter of fact, few of our greatest thinkers have had what would
be called brilliant memories and it would almost seem as though the
diversion of mental energy to this faculty rather disturbed the
development of the others. Many a distinguished man has been rather
notorious as a child for bad memory, so that in the early days when
memory was the only faculty called upon at school he was set down as a
dunce. Perhaps the most striking example of this was Sir Isaac Newton,
who was actually called a dunce, and yet the world would welcome a few
other such dunces. Thomas of Aquin, the great medieval writer on
philosophy and theology, who still influences philosophy so much, was
so slow as a young man that he was called by his fellow pupils "the
dumb ox." His great teacher, Albertus Magnus, recognized the depth of
mind that his fellow students could not see and declared that the
bellowings of that "ox" would be heard throughout the world. Sir
Walter Scott was spoken of as a very backward child. This is all the
more surprising to those who know and appreciate the wealth of
information that he put into his Waverley Novels. Goldsmith, than whom
we have no more brilliant writer in English, seemed not only a dunce
as a child, but all his {685} life, so far as outward appearance went,
was a numbsknll. This was due to a lack of readiness rather than any
lack of wit.


Tricks of Memory.--Some tricks of memory may be very disturbing to
those who are over-occupied with themselves and with the possibility
of losing their memory. For their consolation it is well for the
physician who hears their complaints to have at hand some stories that
illustrate certain of these curious tricks of memory. I had been
trying to persuade a literary woman for some time that it was not her
memory that was playing her false, but merely her habit of attention
and lack of concentration of mind on things because she is occupied
with a great many interests, when one day she came to me with what she
thought was absolutely convincing proof that her memory was going. She
had read a passage in a newspaper the day before which she liked very
much, but after reflection it sounded strangely like some of the
things that she had thought along these lines herself. It was a
quotation, but there was no indication to tell whence it came. A
little inquiry, however, showed that the quotation was from an article
of her own written only two years before. Here was definite proof of a
failure of memory. Strange as it may seem, however, this experience is
quite common. I feel sure that there is not a single writer for
periodical literature who has not had similar experiences. Anyone who
writes much editorially, where the articles are unsigned, finds it
rather difficult two or three years later, as a rule, to be absolutely
sure which editorials are his. Occasionally it happens that even by
the time the proof comes back for monthly periodicals, say six weeks
or two months, some at least of what was written may seem quite
unfamiliar. This will be particularly true if phases of the same
subjects have been treated in successive articles and thus repetitions
are caused.

There is plenty of good warrant for such occurrences in the lives of
distinguished writers. Scott once heard a song in a drawing-room that
he did not care for very much and he said rather contemptuously, "Oh!
that's some of Byron's stuff." His attention was called to the fact
that he was the author of the stuff himself. Carlyle confessed to
Froude when Froude went over some of the passages of Carlyle's own
autobiography with him, that he had quite forgotten some of the things
written down there. Manzoni, the distinguished Italian writer, whose
"I Promessi Sposi" has probably been more read throughout Europe than
any novel written during the nineteenth century, except possibly some
of Scott's, tells some stories of his own lapses of memory and, above
all, of having once quoted a sentence of his own to confirm something
that he was saying, though he confessed that he did not know by whom
the quotation had been written.


Memory and Low Grade Intelligence.--There are many people who complain
of their memory and of their inability to recall many things which
others recall without difficulty. They are prone to think that this is
some defect in them and not infrequently, as a consequence of
comparisons, they persuade themselves that their memory was better and
that it has lost some of its qualities. Until they became familiar
with some of the feats of memory possible of performance by others,
they were quite satisfied, but now they find in every instance of
forgetting a new symptom of an increasingly deficient memory. I have
found in these cases, that setting before such people some of the
curiosities of memory, and especially the fact that memory is by no
{686} means necessarily connected with profound intelligence, so that,
indeed, its presence is quite compatible with a low grade of
intelligence or even with what is practically idiocy, will do much to
rob these gloomy forebodings of their terrors with regard to their own
supposed deterioration of intellect. Ribot, in his "Diseases of
Memory"   [Footnote 52] has an excellent passage in which he sums up a
number of these peculiarities of memory that are likely to be
especially consolatory to people of ordinary memory who are worrying
about themselves.

    [Footnote 52: International Scientific Series,
    D. Appleton & Co., New York.]

  It has long been observed that in many idiots and imbeciles the
  senses are very unequally developed; thus, the hearing may be of
  extreme delicacy and precision, while the other senses are blunted.
  The arrest of development is not uniform in all respects. It is not
  surprising, then, that general weakness of memory should co-exist in
  the same subject with evolution and even hypertrophy of a particular
  memory. Thus certain idiots, insensible to all other impressions,
  have an extraordinary taste for music, and are able to retain an air
  which they have once heard. In rare instances there is a memory for
  forms and colors, and an aptitude for drawing. Cases of memory of
  figures, dates, proper names, and words in general, are more common.
  An idiot "could remember the day when every person in the parish had
  been buried for thirty-five years, and could repeat with unvarying
  accuracy the name and age of the deceased, and the mourners at the
  funeral. Out of the line of burials he had not one idea, could not
  give an intelligible reply to a single question, nor be trusted even
  to feed himself." Certain idiots, unable to make the most elementary
  arithmetical calculations, repeat the whole of the multiplication
  table without an error. Others recite, word for word, passages that
  have been read to them, and cannot learn the letters of the
  alphabet. Drobisch reports the following case of which he was an
  observer: A boy of fourteen, almost an idiot, experienced great
  trouble in learning to read. He had, nevertheless, a marvelous
  facility for remembering the order in which words and letters
  succeeded one another. When allowed two or three minutes in which to
  glance over the page of a book printed in a language which he did
  not know, or treating of subjects of which he was ignorant, he
  could, in the brief time mentioned, repeat every word from memory
  exactly as if the book remained open before him. The existence of
  this partial memory is so common that it has been utilized in the
  education of idiots and imbeciles. It is worth noting that idiots
  attacked by mania or some other acute disease frequently display a
  temporary memory. Thus, an idiot in a fit of anger told of a
  complicated incident of which he had been a witness long before, and
  which at the time seemed to have made no impression upon him.


Training Memory.--In recent years in many departments of therapeutics
training has been found to be of value. This is especially true with
regard to nervous defects. Probably one of the greatest surprises that
nervous specialists have had in the last twenty-five years in the
domain of therapeutics came from the introduction of Frenkel's methods
of retraining the muscles in locomotor ataxia. This idea of retraining
has been found useful in such distinct departments as the use of the
eye muscles, the co-ordination of the muscles of speech, so as to get
rid of stuttering and stammering, and the muscles of the hand for
writing. We are only just beginning to realize that retraining can be
of great value in psychic affections also. Patients may be disciplined
against their dreads and tremulousness due to over-apprehension and
against even certain defective uses of their intellect. Urbantschitsch
of Vienna showed that by training defective hearing it might in many
cases be very much improved. What he accomplished, however, was not
{687} any better use of the external auditory apparatus, but a more
intense attention of mind which enabled the patient to catch and
understand sounds which had hitherto been so vague that their
significance was lost.

In a number of cases of complaint of loss of memory I have
deliberately set patients to retrain their memories and have at least
relieved their apprehensions if I have not always succeeded in
increasing their actual memory power. It has even seemed, however,
that in old people some actual improvement of the memory faculties was
thus brought about. Under the head of Occupation of Mind I have
referred to the exercise of memory in younger people as representing
an excellent form of mental diversion. When the idea first suggested
itself it seemed as though patients would not take to it at all, and
yet I have found that with a little persuasion they become much
interested and find a great deal of pleasure in their gradually
increasing power to recall the great thoughts of great authors in the
literal original words. A reference to that chapter will tell more of
my experience. This made me more confident of the possibilities there
were of making people understand that if they were losing their
memories they could bring them back by proper exercise. In this way
many of the modern evils of lack of attention and of failure of
concentration of mind can be corrected.

My rule now is to tell patients who come complaining of loss of memory
that if there is any real loss of memory it is due to their improper
use of the faculty, or perhaps to their failure to exercise it
sufficiently, for the proper performance of function depends on
adequate exercise. They are then instructed to take certain simple
classical bits of literature and commit them to memory. At the
beginning such short poems with frequently repeated rhymes of the
modern poets as are comparatively easy to learn are set as memory
exercises. Later Goldsmith's "Traveler" and "Deserted Village" are
suggested. Then passages from Shakeaspeare are given. Just as soon as
the patient finds that he can commit to memory as he used to, if he
only gives himself to the task, a change comes over his ideas with
regard to the loss of memory. For many of these people the occupation
of mind is an excellent therapeutic measure. Besides selections can be
made in such a way as to keep before their minds the thoughts they
most need in the shape of memory lessons. It is a discipline of memory
that revives it and also a constant exercise in favorable suggestion.

Gregor in the _Monattschrift für Psychiatrie und Neurologie_, Band
XXI, has detailed some of his experiences with the retraining of the
memory of patients suffering from Korsakoff's Psychosis--alcoholic
neuritis with psychic disturbances, especially of memory. The patient
was required to learn words and then after a certain length of time
was tested to see if he could learn a similar series with fewer
repetitions than at first. The memory increased in capacity with the
exercises and there was evidently a definite gain in the faculty. In
this disease patients have also lost the power to some degree at least
of recognizing objects. After exercises in recognition they are much
more capable in this matter, however, and it is evident that in every
way the memory can be improved. This experience, with a serious form
of disease that gravely impairs the memory, shows how much can be
accomplished in circumstances far more unfavorable than are those
which usually bring patients to the physician complaining of
deficiencies of memory.



{688}



CHAPTER XI

PSYCHIC CONTAGION


The term psychic contagion is often thought of as merely figurative.
It is, however, quite literal. Many minds are influenced by what they
see happening round them and induced to imitate the activities of
others. The term psychic contagion is so thoroughly descriptive of
what happens that it deserves the place that it has secured.

Everywhere and at all times we find historical traces of psychic
contagion compelling people to perform in crowds or groups the most
curious and inexplicable and sometimes the most horrible things. Even
in the old myths before the times of the Trojan War, we have the story
of hysteria spreading among the daughters of King Proteus, so that the
famous old physician, Pelampus, had to administer white hellebore in
goat's milk in order to relieve them. It is probable that this rather
heroic remedy with its definite effect upon the bowels produced such a
revulsion of feeling as to cure the hysteria. Anyone who has read the
awful tragedy that Euripides has written in the _Bacchae_ will have
had brought home to him a typical example of psychic contagion. The
queen mother in the midst of one of the Bacchic orgies kills her own
son in the frenzy that has come from the religious excitement
exaggerated by the association of a number of women in the religious
rites of the god Bacchus. It is well understood that this was not a
case of drunkenness, but of psychic intoxication.

Phrygian Bacchantes are described as overcome from time to time by
paroxysms of curious uncontrollable automatic movements with or
without disturbance of consciousness. This represents the earliest
form of what came to be known afterwards as St. Vitus Dance when it
spread among a number of people. Such manifestations were not at all
uncommon in the East in the earlier days and they have continued
during all history. In Hindustan epidemics of automatic movements,
evidently choreic in character, have been known for many centuries
under the name of _lapax_. Outbreaks of this kind were common in the
Middle Ages and Paracelsus has described them as happening early in
the sixteenth century. At any time the occurrence of an hysterical
seizure in a crowded hall, and especially in a schoolroom, will lead
to other hysterical manifestations. A case of chorea will induce
imitative movements in susceptible bystanders that may be quite
uncontrollable. Tics of various kinds are readily picked up by
children and special care must be exercised to prevent their spread.
In general the state of mind is extremely important in all these
conditions and they can be influenced favorably only through the mind.


Contagions Trifles.--Perhaps the extent to which psychic contagion
influences us can be seen better in little things than anywhere else.
Everyone knows how contagious yawning is. Again and again observations
have been made while actors were yawning upon the stage. Nearly
everyone in the theater begins to yawn in a few minutes and, in spite
of the most determined {689} efforts, every now and then even the most
serious-minded elderly gentleman in the audience finds himself
unconsciously joining in. It seems foolish and to an onlooker appears
almost prearranged. It is only necessary, however, to yawn a few times
in a street car, especially at night, to have many imitators. Nearly
the same thing is true of all respiratory phenomena. Sighing, for
instance, is quite contagious. Coughing is often as much the result of
imitation as anything else. At certain pauses in church services a
preliminary cough is heard and then some scattering coughs here and
there, like the musketry of scouts, and then a whole battery of coughs
is let off, especially if it is in the winter time, because nearly
everybody within hearing is tempted to cough. To talk about yawning or
coughing or sighing before some people is almost sure to produce a
tendency to these manifestations. These apparently trivial happenings
help to explain many phenomena of human imitation in more serious
things.

Most of the phenomena associated with expression are liable to be
initiated as the result of imitation. Laughing, for instance, is
particularly contagious among young folks and is especially likely to
be insuppressible when they wish to be particularly solemn. At
religious services it takes but little to make people laugh and
giggle, no matter how much they may wish to be dignified and
reverential. A few giggling girls will sometimes disturb a serious
service. Extremes are particularly prone to meet in this matter and
the sublime easily becomes the ridiculous. A titter will set off even
the best intentioned of young folks in spite of resolutions to the
contrary. Crying has something of the same contagious nature, though
it is not quite so strong, but among women tears are particularly
likely to evoke tears. The epidemic of curious manifestations of
expression, usually of an hysterical nature, that we know by tradition
to have spread in communities in the Middle Ages and much later, are
only typical examples of this tendency for modes of expression to be
contagious to an exaggerated degree.

Expectoration is largely dependent on imitation, sometimes conscious,
of course, but often quite unconscious. In the recent crusade
organized to prevent the spread of tuberculosis the question of
expectoration as a diffusing agent of the bacilli has given a new
importance to observations on this subject. It is recognized that we
have "a spitting sex" and that men spit from force of habit, boys
imitate them, while women and girls almost never spit. There is no
reason in the world why when men and women are engaged in the same
occupations there should be any difference in this regard between
them, yet employers know how hard it is to keep corners and by-places
in the rooms where men work free from expectoration, while no such
difficulty is found where women work. We have a spitting sex because
of psychic contagion, and in spite of the fact that there are serious
dangers connected with the habit. What is true of spitting may also be
true of other habits relating to the respiratory passages. Hawking and
blowing the nose more frequently than is needed are spread by psychic
contagion and certain habits in these matters that are injurious to
the respiratory apparatus often require considerable effort to break.


Fads and Health.--Enlightened as we think ourselves, we have many more
examples of psychic contagion in the present than we would perhaps
care to admit, unless the facts were called to our special attention.
{690} At a particular period in the modern time it becomes the fad to
do things in a special way. We write alike, we build our houses after
a common type. We take our recreation in a particular fashion.
Bicycling comes in and goes out; roller skating attacks nearly every
one of the young folks and then is abandoned. There are fashions in
everything and fashions, after all, are recurring instances of psychic
contagion. The mental influence spreads from one to another. It may be
that a particular fashion, as in houses or in clothes, is especially
ugly. That makes no difference. After a time taste revolts against it,
but in the meantime the psychic contagion is enough to overturn the
canons of taste. There are fashions in literature, or at least what is
called literature. The nature novel comes and goes, then the novel of
adventure has its place, then the detective novel, after a time the
little-country prince or princess and their romance comes into
fashion. After a time we realize that these are passing fancies, but
in the meantime they have influenced many people.

Some of these fashions bring conditions that are deleterious to
health. The moving-picture show in places that almost never have a
stime of sunlight in them and are, in their way, quite as bad,
especially for respiratory troubles, as the dust-laden atmosphere of
the roller-skating rink, become the fad of the moment in spite of
knowledge or ignorance of hygiene. Just now we are in the midst of a
fad for fresh air, that, unfortunately, goes and comes with the
centuries and we have no guarantee that people will not learn again to
live in closely sealed houses. High heels come and go, as do corsets
of various kinds, more or less injurious, in spite of the admonition
of the physician. In fact, one of the most interesting studies in
psychic contagion is the history of the fashions. A particular
fashion, especially in its exaggerated forms, will probably look well
on about one-fifth of the women at a given time. About four-fifths of
them, however, adopt it in spite of the fact that on three-fifths it
emphasizes certain qualities that it would be well to keep in the
background. It is woman's principal desire to please, yet this is
completely perverted by the psychic epidemic of fashion which causes
people to follow after others quite as much as did the medieval people
in various fads that attracted attention and have come down to us.

Our enlightenment, at least in as far as that word means general
diffusion of the ability to read, has rather added to the power of
psychic contagion. People accept ideas from others almost as
unconsciously as they catch disease from those suffering from it. The
psychology of advertising shows how easy it is to make people accept
things just by insisting on them and by frequent repetitions of
statements. The psychology of the proprietary medicine business in
modern times is about as typical an example of psychic contagion
induced deliberately as one could well imagine. Those who stop to
reason do not fall victims. Most people, however, do not stop to
reason. They have not the mental resistive vitality to render them
immune to the influence of certain irrationalities and so literally
hundreds of millions of dollars have been spent on perfectly useless,
oftentimes harmful drugs, which people had become persuaded through
the psychic contagium of printer's ink were sure to do them good. The
psychology of the mob has been studied somewhat in recent years and it
shows how clear it is that men follow after one another in doing
foolish things even more than in doing wise ones. Psychic contagion is
a prominent factor in life, it always has been, is now, and evidently
always {691} will be, and must be reckoned with by anyone who wishes
to recognize the principles that underlie psychotherapy.


Suicide Contagions.--It is with regard to much more serious things
than fashions, however, that psychic contagion is most manifest. For
instance, there is no doubt that suicide is frequently the result of
such psychic influence. Seldom does it happen that a very queer
suicide is reported without there being certain imitations of it more
or less complete in various parts of the country afterwards. There is
no doubt that the reporting of suicides has a serious effect in this
matter. Perhaps the most striking example of this that we have ever
had in America was the well-known suicidal epidemic at Emporia,
Kansas, which reached its height just about the middle of June, 1901.
Two or three well-known people in town committed suicide at the end of
May and the beginning of June. A veritable epidemic of suicide broke
out as a consequence. Nothing seemed to stop it and the authorities
were much disturbed. Finally it was agreed that the most potent
influence in bringing about the imitation of the epidemic was the
publication of the details of the suicides in the papers. The Mayor of
the city, after consulting with the Board of Health, decided to issue
the following proclamation:

  I have consulted the Board of Health, and if the Emporia papers do
  not comply with my request I shall have a right to stop, and I will
  stop summarily, the publication of these suicide details, under the
  law providing for the suppression of epidemics. There is clearly an
  epidemic in this city, and although it is mental, it is none the
  less deadly. Its contagion may be clearly shown to come from what is
  known in medicine as the psychic suggestion found in the publication
  of the details of suicides. If the paper on which the local Journals
  are printed had been kept in a place infected with smallpox, I could
  demand that the Journals stop using that paper, or stop publication.
  If they spread another contagion--the contagious suggestion of
  suicide--I believe the liberty of the press is not to be considered
  before the public welfare, and that the courts would sustain me in
  using force to prevent the publication of newspapers containing
  matter clearly deleterious to the public health.


Murder.--In almost the same way murders prove contagious. Especially
is this true of murder and suicide together. These occur notably in
groups. A man who is downhearted and for whom the future looks blank,
will, out of a sense of pity for those who are dependent on him,
murder them and himself; then the brutal story is reported and another
tottering intellect gives way and a similar story has to be told
within a few days. A mother who is melancholic about her health and
includes her children in her gloomy outlook makes away with them and
herself. Within a few days a similar story is reported because of the
influence of psychic contagion. Very often there are distinct
imitations of the methods employed in the first case. Often, however,
it is only the idea itself that has proved contagious. There is no
doubt that this suggestion brings about subsequent cases when
otherwise such an awful thought might not occur. The connection is too
clear for us to doubt the reality of it or to think that it is mere
coincidence. As in Emporia, doubtless the suppression of the
description of such events would have a beneficial effect. There are
many disequilibrated minds, apparently just tottering on the verge of
an insane act of this kind, that are pushed over by the suggestion
furnished by the details of another story.

{692}

Place of Psychic Contagion.--The physician who would treat nervous
patients successfully and use psychotherapeutics to advantage must
recognize the place that psychic contagion has in influencing the
generality of mankind. We know that direct suggestions are profoundly
influential. It must be constantly kept in mind, however, that
indirect suggestion, suggestion that does not come by any formal
method, but that is represented by the examples of those around, also
has great weight.


Favorable Influence.--Fortunately it is not alone for evil that
psychic contagion is manifest. People in a crowd stand fatigue better
than when alone. Soldiers marching in step do not notice their
tiredness to such a degree and even forget their sore feet. People
suffering from hunger, so long as there is a good spirit among them,
will help each other to bear it. The accidents in coal mines in recent
years in which men have been imprisoned for considerable periods have
shown that in groups they stand the hardships of confinement and of
lack of food and water better than they do when alone, men live
longer, they do not suffer so much or at least their suffering is not
so insistent, and they bear up better.

This has been particularly noticed in the cures at various watering
places. The very air of the place takes on a favorable suggestion that
is helpful to patients. The routine, the hopefulness of those who are
completing the cure, the stories of improvement, the evident
betterment, all these things combine to give a psychic contagion of
health. Health is, in this sense, quite as contagious as disease. This
must be taken advantage of just as far as possible for the advantage
of patients. On the other hand, ideas are contagious for ill and
patients may derive from their environment notions that prove
auto-suggestive and against which it is extremely difficult to work.
Ideas derived from the general feelings of those around, without any
direct suggestion, may become obsessions. The physician, therefore,
must be ready to secure prophylaxis against psychic contagion and then
by counter-suggestion relieve the patient, who has become afflicted by
it, of the resulting disturbance of mind. It must not be forgotten
that, instead of being less susceptible as education and civilization
progress, people really become more susceptible.


Psychology of the Mob.--The most interesting instance of psychic
contagion is the tendency just hinted at for crowds to run away with
the sober judgment of serious sensible people that happen to be among
them and do things that may be extremely regrettable. A mob always
follows the suggestions of the worst elements in it unless perchance
there is some extremely strong character who asserts himself and
imposes his views on the rest. The tendencies to panic, to cowardly
flight, sometimes to destructiveness, that come over crowds represent
the power of psychic contagion to override reason. An alarm of fire
will, if a few persons lose their heads, lead to the most serious
consequences. Persons trample over one another, pull and maul one
another, sometimes even pulling out hair or pulling off ears in their
insane efforts to escape what is often an imaginary danger, though a
few moments before they were rational beings and they will be quite
reasonable a short time after. It is possible, however, to overcome
even the worst tendencies in human nature by the suggestive power of
discipline. Fire drills in schools enable children to get out in a few
minutes without confusion when without them the most serious results
could be looked for. Discipline and training, {693} following commands
and observing tactics, helps an army almost more than the individual
courage of soldiers. The suggestive influence of the thought that now
is the time to do something that has often been done before at the
word of command is enough to enable the soldier to control his panicky
feelings. The difference between the trained soldier and the raw
recruit is great, but it consists only in this mental discipline and
self-control.


Prevention.--Evidently, then, in the many circumstances in life in
which psychic contagion manifests itself it is perfectly possible to
overcome its influence by such discipline and mental training as gives
the individual control over himself. In children corporal punishment
is often not effective in breaking up habits and tendencies and the
motive of fear often lessens self-control and makes conditions worse.
In older people the fear of punishment is likely to be forgotten,
whereas the suggestion of discipline will assert itself powerfully.
Psychic contagion can be neutralized by psychotherapy, but its force
in life must be recognized and its unfavorable influence guarded
against. While it concerns mainly the less serious things of life, it
may affect the most serious and imitation leads even to such serious
criminal acts as suicide and murder. The modes of psychic contagion,
then, must be constantly under surveillance.

With this before us it is extremely interesting to realize how
unfavorably suggestive for human health and happiness are our
newspapers. They are constantly suggesting disease and suicide and
murder and sex crimes and crimes against property, by giving all the
details available with regard to these subjects. Such news can do no
good, only excites morbid curiosity which requires still further
satisfaction in the same line, and keeps thoughts with regard to these
things constantly before the mind. We have had many burglaries and
holdups and stealings of various kinds as a consequence of boys and
even girls seeing the pictures of crimes in the moving-picture show.
The saturation of mind with disease and crime produced by daily
reading of unsavory and sensational newspaper accounts is sure to
produce evil effects. There seems to be consolation for some people in
reading of the crimes and punishments of others because they feel
that, bad as is their own state, there are others who are worse. This
_schadenfreude_, "harm-joy" as the Germans call it, is not satisfying
to think of for human nature and it has an inevitable reaction through
the unfavorable suggestion of these crimes.

I have found over and over again that the prohibition of reading the
newspapers for a time did many nervous people much good. This is
particularly true for sufferers from such forms of psychasthenia as
bring down on them dreads and premonitions of evil in fears for the
development of disease and in general a sense of instability with
regard to the future, lest dreadful things should happen to them. At
first patients object strenuously and seem to be deprived of a great
satisfaction. After a time, however, they are invariably persuaded of
the fact that the absence of mental contact with human misfortune, in
this morbid way, is doing them good and that their dreads and
premonitory feelings of evil drop from them.

{694}

SECTION XIX

_DISORDERS OF WILL_


CHAPTER I

ALCOHOLISM


In recent years so much has been said about addiction to alcohol as a
disease rather than as a habit that the treatment of it frankly as a
disease in psychotherapeutics, even though there be not entire
readiness to agree with those who emphasize exclusively the
pathological interest of these cases, will not seem surprising. It is
with regard to the various habits, drug and alcoholic, occurring in
neurotic subjects that psychotherapy proves most effective and has
secured some of its real triumphs. As a matter of fact, it has long
been conceded that all of the so-called cures for alcoholism are
dependent for their success upon the mental effect produced upon the
patient. Most of them emphasize the necessity for building up the
physical condition of the patient as a necessary preliminary to any
lasting cure. There is no doubt that the powers of resistance of a man
whose physical health has been seriously impaired by over-indulgence
in alcohol and the lack of food and irregular sleep and exposure to
the elements that so frequently accompany it, will not be sufficient
to enable him to break off the alcohol habit, nor afford him the
ability to inhibit the craving for stimulants, that he would have in a
state of health. On the other hand, even in good health, unless his
moral character is braced up, there will surely be a return to his old
habit.


Historical Résumé of Cures.--We have had many different cures for
alcoholism exploited during the last half century. The older method of
the first inebriate asylums founded in this country was to give a man
a disgust for liquor, as it was then called, by putting a small amount
of alcohol into practically everything that he consumed. This did not
give him enough to satisfy his craving, but it did create in him an
intense distaste for it by constantly keeping the flavor before him.
There was a drop or two of whiskey in his tea, there was some whiskey
in his milk, there was a taste of it in the water that he drank, there
was some of it mixed even in the gravy of his meat, and he always had
weak brandy sauce on his dessert. The consequence was, in most cases,
such a complete disgust for liquor that men were sure that they would
never touch it again. Of course, in the meantime they were fed well
and heartily, they were kept in an environment free from temptations
to excessive indulgence in alcoholic drinks, they had brought home to
them what a mess they were making of their lives and their health,
they had time to reflect what ruin they were bringing on themselves
and their families and usually they {695} recognized that they were
the kind of men who must stay away from alcohol absolutely, for whom
there could be no such thing as a moderate indulgence in stimulants.
This, with the intense distaste for alcohol, amounting almost to
nausea at the sight of it, acquired from the system in vogue, started
them well on the road to reform.


_Moral Cures_.--It was the moral elements in the cure, however, that
were the most important, though its inventors were sure that the
physical elements played the largest role. The physical disgust for
alcohol consequent upon having its taste constantly recur in
everything at table passed off in a few weeks or at the most a few
months. It was then that the moral uplift came in and had to be
effective if the patient was to be preserved for the future from his
old habit. If he was of a weak and flabby character, if,
unfortunately, he was placed in circumstances where temptations were
frequent, if, owing to the enforced absence in the inebriate asylum
his business affairs had become involved and he was subject to many
worries, then almost surely he dropped back. As a result his case was
even more hopeless than before and, indeed, second cures were seldom
of much benefit, for the man's confidence in himself was gone.

All in all, however, this old-time, simple method probably produced as
large a proportion of "real cures" as any other method, even the much
advertised and discussed scientific discoveries of modern times. All
of us have heard stories of men who had seemed to be hopeless
drunkards, who were thus reformed and hundreds of men who appeared to
be drifting into hopeless inebriety were reformed to such an extent
that they became not only useful members of society and supports to
their families where they had before been a drain, but even became
leaders in the work of uplifting the character of others to resist the
temptation of over-indulgence in stimulants.


_Modern Cures_.--Of late we have had a number of "cures" for
alcoholism widely exploited by well-directed advertising in the hands
of men who realized what a fortune there was in this sort of thing and
who actually have made immense sums of money out of them. Needless to
say these "cures," though supposed to be secret, did not long remain
so. Perhaps the most famous of them, the one whose institutes were
found all over the country, was said to have used only two drugs,
strychnin and apomorphin. The strychnin was given as a needed and
well-chosen tonic for the physical condition of the patients who came
to the institution usually in a rather seriously broken down
condition. When patients began the treatment they were distinctly told
that if they wanted whiskey at any time they could have it, but that
the next injection of the "cure" after they took the whiskey would
show how directly opposed to alcohol the ingredients of it were, by
producing vomiting and prostration.

As a rule, the patients came in perfectly confident of the effect of
the remedy they had heard so much of. The strychnin injections made an
excellent tonic for these nervous wrecks, bracing them up at once so
that they felt better from the very beginning and this betterment was
confirmed by the growing assurance from the physician and the patients
around them that now, at last, they were to be relieved of their
degrading habit. To those whose craving for alcohol returned in spite
of the favorable condition in which they were placed and the
stimulation of the strychnin, which made up so well, as a {696} rule,
for the absence of their accustomed alcohol, whiskey was actually
allowed. When the next time for their injection came, however, these
patients who had been given whiskey on their request did not now
receive an injection of strychnin but instead a small injection of
apomorphin. The apomorphin acted promptly in making the stomach
relieve itself and produced a complete and immediate sense of
prostration. The limpness and discomfort of seasickness is as nothing
compared to the state that, as a rule, develops after such treatment.
Anyone who has ever had to handle, in a hospital, a wildly drunk,
long-shoreman, whose brute strength in his irrational condition made
him a dangerous object for patients and physicians, who has seen even
large doses of morphin fail to produce quiet, and then has felt bound
for the patient's sake as well as those around him, to administer a
tenth of a grain of apomorphin with the result of having an eminently
tractable patient in a few minutes, will have a good idea of what
happened to the poor alcoholic who got apomorphin instead of
strychnin.

After that the inebriate knew that any further indulgence in liquor
would be followed by this extremely unpleasant result and so he had a
new argument for avoiding it. After a month or six weeks of careful
treatment, the preliminary rest that would restore physical health and
strength being followed by a course of exercise in the open air with
plenty of good food, pleasant surroundings, and hope constantly held
out to them, it is no wonder that these patients went out of the
sanitariums as a rule confident that their habit was conquered for
good. In many cases this proved to be true. It was soon found,
however, that there were many relapses. This hurt the prestige of the
"cure" and the gradual diffusion of this idea spoiled its
effectiveness. It still continued to do good, however, and though it
has been modified in various ways, and, indeed, in various parts of
the country is said to be applied quite differently, there are still
many reformations worked by these cures every year and they
undoubtedly do good. The secret of its success, however, is not any
marvelous drug or other mode of treatment that is employed, but is
because the victims of alcoholism are given an opportunity to retrieve
their physical condition and then to brace up their moral characters
so as to resist their craving for alcohol.


_Mental Influence_.--Other so-called cures and treatments have
followed almost exactly similar lines. The main element in the cure
has been the producing in the mind of the patient a definite idea that
he can stay away from liquor if he really wishes to and then helping
his run-down physical condition so that he craves stimulants less than
before. Whenever such "sure cures" are used on the worst forms of
alcoholic patients as we see them in the large general hospitals of
our greater cities, the bums of the streets, the drunkards of a score
of years or more, they have practically no effect. The man must have
moral stamina, he must have some character left, besides, as a rule,
he must have some good reasons in worldly interest to help him to
brace up and then he may get away from alcoholism if he sincerely
wills to reform. The important element, however, is the will to do so.
If he is firmly convinced that he cannot stay away from liquor, if he
feels in spite of all that has been done for him that he cannot resist
his craving, then, of course, he will not reform. Men, however, who
have sunk to the lowest depths, who, according to their own and
others' testimony, have scarcely drawn a {697} sober breath for ten or
even twenty years, sometimes have something happen to them, often it
seems very trivial to everyone but themselves, that stiffens their
relaxed moral fiber, that wakens their sense of manhood, that serves
quite beyond expectation to give them a new purpose in life, and they
reform and never drink again.

It is this successful phase of the cure of alcoholism, however it may
be explained, that is most interesting. It represents the most
encouraging aspect of the whole question. Probably nothing more
harmful has ever been done than the public proclamation that
alcoholism is often an hereditary disease against which it is hopeless
to struggle, and that the poor victims of it are to be pitied and not
blamed. Except in those of low mentality, whether of intellect or
will, or in the actually insane, there never was a case of alcoholism
that did not deserve at least as much blame as is usually accorded to
it. This is said after making due allowances for temperament. It is
quite clear that for one man alcohol has no attractions at all, while
for another the craving for it is almost an insuperable temptation. It
is idle to say that these two contrasted men are equally free as to
whether they shall take alcohol or not. Of course they are not equally
free. If the man who has no craving for alcohol prides himself on his
power of resistance against the vile habit, he is simply fooling
himself. He probably knows nothing about the real nature of the
temptation of alcohol. The Spaniards have a proverb: "He who doesn't
drink wine and doesn't smoke, the devil gets by some other way." There
is probably something else with regard to which the non-alcoholic has
quite as little freedom as the poor victim of alcoholism and the great
law of compensation comes in to make up to both of them, for their
failings. Man has the defects of his virtues.


Supposed Inheritance.--No man is such a slave to the habit, however,
that he cannot correct it if he will. We have heard much about the
inheritance of this disease. We have heard even more about its
essentially morbid character, though people used to think it a moral
defect. It must still be considered a moral defect, however, even
though we all concede that there is an element of the pathological in
it. We are getting away entirely from the ordinary idea of inheritance
of disease. There is no inheritance of acquired characters. The fact
that a man's father acquired the drinking habit because he was placed
in circumstances where it was easy for him to indulge himself and
because he did not have the moral stamina to resist, is no reason why
his son should have an unconquerable or even a very strong craving for
alcohol. One might as well say that because a father lost a finger
when he was young his son would be born without that finger. Alcohol
destroyed certain cells in the father's body and injured certain
others, but produced no change deep enough to lead to hereditary
influences.


_Contagion More than Heredity_.--Perhaps some tendency to take alcohol
runs in a family, that is, perhaps there is lessened resistance to the
craving for stimulants that awakens in every human being if it is once
aroused. This is what is true in tuberculosis. Some people have less
resistive vitality to it than others. Careful autopsies show that
practically every man who lives to be over thirty has or has had
living tubercle bacilli in his tissues. Seven-eighths of us are
thoroughly able to resist them. The other eighth succumbs. Their lack
of resistive vitality may in some degree be due to hereditary taint,
{698} but that is doubtful and we know that they acquire the disease
by contact with others who have it already and, as a rule, it is able
to work its ravages because they are not living in conditions that
would help them to resist it. If they live in the free open air and
have plenty of good, simple food, the disease will not run its fatal
course, but nature will cure it. If the craving for alcohol is lighted
up by association, aroused by indulgence, rendered strong by
environment and by exposure to temptations of all kinds with regard to
it, then the resistive power of the individual is so lowered that the
alcoholic habit rules him instead of his being able to command it.


_Inherited Resistance_.--The most curious fact that has come out in
our studies of heredity in recent years has been that far from
heredity working its will in causing degeneration and deterioration of
mankind, immunity, for the race at least, is acquired in the course of
subjection to disease and to various morbid habits. Nations, for
instance, that have been subjected to diseases for long periods no
longer display the susceptibility to them which they formerly
possessed. After a disease has been endemic among a people for many
generations that people gradually becomes quite insusceptible to its
effects and suffers much less from it than before.

Just this same thing is true of alcoholism. Nations that have been the
longest in a position to be subject to the temptation to use alcohol
in its stronger forms suffer least from the ravages of alcoholism. The
southern nations of Europe using wine daily and knowing well the
process of distillation to help them to make stronger drink for many
hundreds of years, now exhibit much less tendency to over-indulgence
in strong drink than the northern nations whose ancestors have only in
comparatively recent times been subjected to the temptation of craving
for strong alcoholic liquors. The attitude of any nation toward
alcohol is a function of the length of time that nation has had a
chance to procure strong drink easily. Our American Indians
discovered, as has every people at some time, that intoxicating liquor
could be made by allowing solutions of starch and sugar to ferment. It
was only with the coming of the European, however, that they were
provided with "fire water"--strong drink--in quantities. Its effect on
them is a matter of history. Two things the white man brought his
Indian brother to which the Indians were unaccustomed and that
gradually obliterated the original inhabitants of this
country--infectious diseases and strong alcoholic liquors. They proved
equally fatal because of Indian susceptibility to them.

From these considerations it is clear that just such an immunity to
the effect of alcohol is produced in a people exposed to its effects
in concentrated form for a long time as with regard to an infectious
disease when they have been correspondingly exposed to it. Heredity,
then, instead of playing a role that brings about deterioration in the
race, on the contrary, carries on the higher qualities and gives us,
as might be expected in the course of evolution, a better, that is, a
more resistant, race. Most of what is commonly said as to alcoholism,
and unfortunately most of the recent so-called popular scientific
articles on this subject, seem to point to just the opposite
conclusion to this. Men are supposed to be condemned by heredity to an
inevitable craving to take alcoholic drinks that, in certain of them
at least, cannot be overcome by any natural power of resistance. At
this stage of our western civilization this is not true for anyone, as
the more susceptible families have been long {699} since eliminated
and it is a personal weakness and not a family characteristic that
leads people to indulge this appetite to their own destruction.


_Unfavorable Suggestion of Heredity Idea_.--An alcoholic patient, or
even a man with only a moderately strong tendency to take alcohol to
excess, who harbors any such notion as this, has a serious impediment
to the full exercise of his will in overcoming the difficulties that
he encounters in any attempt at reform. In going counter to so much
that has been written and still more that has been said and generally
accepted on this subject I feel it necessary to quote a good recent
authority on the matter and so here insert these passages from "The
Principles of Heredity" by Dr. Archdall Reid.   [Footnote 53] He says
(p. 157):

  [Footnote 53: Author of "The Present Evolution of Man," "Alcoholism,"
  "A Study in Heredity," etc. Chapman and Hall, London, 1905. ]

  Formerly all the world believed in the transmission of acquirements,
  and consequently all the world was constantly finding conclusive
  evidence of its constant occurrence. To-day there is hardly a rag of
  that evidence left, and, with rare exceptions, only certain French
  medical observers are able to discover fresh evidence. It is a
  remarkable fact, however, that the problem of evolution--of
  adaptation--has excited singularly little interest in France, and
  it is equally curious that these French observations relate almost
  entirely to laboratory work which it is not easy to repeat. In Great
  Britain or Germany, you may cut off the tails of a thousand dogs, or
  amputate the limbs of a thousand men, or observe the non-infected
  offspring of a thousand tuberculous patients, and get no evidence of
  transmission.

With regard to alcohol Dr. Reid in the same volume insists on the
proposition that alcohol does not cause degeneration of a race,
creating, as is claimed, ever more and more a tendency for people to
take it because their immediate ancestors have taken it, but, on the
contrary, there is a distinct evolution against it, and that what is
hereditary, not by acquisition, but by family trait, is an immunity
against the disease which eventually protects the nations that have
been longest exposed to the effects of alcohol from the evil
consequences of the substance. He says (p. 196):

  How, then, has alcohol affected the races that have used it? Are the
  Jews and the races inhabiting the South of Europe the most
  degenerate on earth? Are North Europeans only less degenerate? Are
  the races that have never used alcohol, the Terra del Fuegians, the
  Esquimaux, and the Australian blacks, for instance, mentally and
  physically the finest in the world? We have only to state the
  proposition to see its absurdity. There is no evidence that the
  hereditary tendencies of any race have been altered by alcohol
  circulating in the blood and acting directly on the germ plasm. Once
  again the sufferings of the peoples have produced no effect, but the
  deaths among the peoples have produced an immense effect. Every race
  that has had experience of alcohol is temperate in the presence of
  an abundant supply in proportion to the length and severity of its
  past experience of the poison. The South Europeans and the Jews are
  the most temperate peoples in the world. West Africans also are very
  temperate. North Europeans are not drunken. Those savages, and those
  only, who have had little or no experience of alcohol--Esquimaux,
  Red Indians, Patagonians, Terra del Fuegians, Australian blacks--are
  beyond all the peoples the most drunken on earth.

Lest it should be thought that this discussion of the subject is only
of significance with regard to nations and does not touch the
individual, and, therefore, has but little significance for the
problem that we are treating here. Dr. Reid's succeeding paragraph
deserves attention:

{700}

  Stated in this brief and direct way, the thesis is apt to excite
  incredulity. It is sharply opposed to popular beliefs, though that
  need not trouble us. Popular notions on abstruse points of science
  are occasionally erroneous. Of more importance is the fact that a
  mass of statistics purporting to prove that the children of
  drunkards tend to be degenerate has been compiled, especially by
  medical men in charge of lunatic asylums. But no "control"
  observations appear to have been made. We know that many drunken
  parents have normal children; certainly, therefore, parental
  drunkenness is not invariably a cause of filial degeneration. We
  know also that many temperate parents have defective children. There
  is nothing to show that the proportion is greater in the one case
  than in the other. Even were it established that the proportion of
  defective children is higher in the case of drunken parents, it
  would still have to be proved that the relation is one of cause and
  effect. People who have an inborn tendency to mental defect, who are
  abnormally depressed, nervous, restless or irritable, are often so
  constituted as to find solace in drink. Their children are liable to
  inherit their inborn mental defects with spontaneous
  variations--that is, to inherit the defect to a greater or lesser
  extent. The unborn child of a drunken and pregnant mother is
  practically another drunken person, as liable, or more liable to
  suffer from the effects of drink; but in such a case the resulting
  defect, though a mere acquirement, is tolerably certain to be
  regarded as a congenital (i. e. inborn) defect by the medical man
  who sees it. Mere acquirements, also, are the defects due to the
  ill-treatment, want and neglect to which the children of drunken
  parents are particularly exposed. Indeed, were it fully established
  that drunken parents, other than pregnant mothers, tend to have an
  excessive number of their children "congenitally defective," it
  would still be a question whether the filial defects were not mere
  acquirements. Prof. Cossar Ewart's observations on diseased pigeons
  renders this not unlikely. All these sources of error render the
  success of a statistical inquiry peculiarly difficult, if not
  impossible, but there is no indication that they ever occurred to
  the minds of the compilers.


Warnings as Suggestions.--I have a case in my notes in which a rather
prominent professional man insists that he is quite sure that the
alcoholism from which he suffered during the ten years between
twenty-five and thirty-five was entirely due to suggestion. As a boy
of sixteen he had gone off to boarding school, but not until his
mother had taken him aside, told him that his father had drunk himself
to death, had done it by secret tippling, and that they had found that
for many years he had been accustomed to have whiskey near him in his
office and take it rather frequently. He had never tasted spirituous
liquor at this time and his mother begged him not to, for she felt
sure that if he did his father's craving would awaken in him and would
become uncontrollable. The day that he went away his father's eldest
brother took him aside and said practically the same thing to him. A
maiden aunt was not quite so emphatic, but she, too, pleaded with him
to understand all the dangers. For his first year at school he did not
touch liquor, but in his second year he tasted it once or twice but
had no particular craving aroused in him. By chance when he was home
at Christmas time some college mates who were visiting him gave his
mother the impression that he belonged to a rather jovial set. Once
more he was warned by mother and uncle. Above all they told him never
to keep strong drink near him because that was what his father used to
do. During his college years the fear of this hung over him. He
resented it and probably took more liquor than he would have so far as
actual craving went. After getting out into active life once more he
suggested himself into the habit of taking an occasional glass of
whiskey by himself. After a time he was constantly taking too much.
For {701} ten years he hurt all of his prospects, broke his mothers
heart, and was looked upon as a hopeless alcoholic. Then one day the
thought came to him that it was not that he craved alcohol so much,
but that his thoughts turned on it constantly and at first he dreaded
it overmuch, then wondered what attraction there could be and then
acquired a habit by suggestion. Once this train of thought worked
itself out in his mind, he quit spirituous liquors for good. For ten
years he has not touched them, he does not care for them, they do not
constitute a temptation.

It must not be forgotten that many warnings may so preoccupy the mind
with regard to a danger as to constitute temptations by suggestion.
This is eminently true of alcoholism, the drug habits, sex habits and
the like, in spite of the foolish present-day notion that information
and warning must necessarily be helpful. In all these, teaching may be
suggestively harmful.


Prophylaxis.--The most important part of the treatment of alcoholism
through mental influence is by prophylaxis, and that, to be effective,
must begin very early. Just as with regard to overeating, as I have
pointed out in the chapter on Obesity, it is extremely important not
to permit children to acquire habits with regard to alcohol when they
are young. During the growing years the system, indeed one may say all
the systems of the body--the nervous, the muscular, the digestive and
the mental systems--are all more or less unstable. Deep impressions
may be produced on them then, and if children are allowed, much less
encouraged, during their growing years (and this includes practically
all the years up to twenty-five) to indulge in alcohol, then one can
look for the development of a craving very hard to eradicate later in
life. Many of them will be able to conquer the desire thus awakened,
but a great many of them will not. We have some very definite evidence
on this point and some of it collected here in America is very
valuable. Dr. Alexander Lambert of New York made a study of over 250
cases of alcoholism seen in the wards at Bellevue Hospital, paying
special attention to the age at which the patients remembered they had
begun the use of alcoholic liquors. If anyone doubts the influence of
youth in this matter, then his statistics should be read:

  Of 259 instances where the age of beginning to drink was known, four
  began before six years of age; thirteen between 6 and 12 years;
  sixty between 12 and 16; one hundred and two between 16 and 21;
  seventy-one between 21 and 30; and eight only after 30 years of age.
  Thus nearly seven per cent. began before 12 years of age, or the
  seventh school year; thirty per cent. began before the age of 16;
  and over two-thirds--that is, sixty-eight per cent.--began before 21
  years of age.

Dr. Henry Smith Williams, commenting on Dr. Lambert's study of this
subject in his article on "The Scientific Solution of the Liquor
Problem,"  [Footnote 54] states emphatically the conclusion so
inevitable from these statistics that more than anything else
alcoholism is the result of habits and occasions created in early
years. He adds some remarks that are worth noting for those who are
interested in the prevention and cure of alcoholism, not only in
particular cases, but also for the community:

    [Footnote 54: _McClure's Magazine_, February. 1909.]

{702}

  In the light of such facts, it is clear that the drink problem is
  essentially a problem of adolescence. The cumulative effects of
  alcoholic poisoning frequently fail to declare themselves fully
  until later in life; but the youth who does not taste liquor till
  his majority minimizes the danger of acquiring the habit in its most
  insistent form; and the man who does not drink until he is thirty is
  in no great danger of ever becoming a drunkard. As to the man who
  has passed forty--well, according to the old saw, he must be either
  a fool or his own physician. His habits of mind and body are formed,
  and if he becomes a drinker now he can at most curtail by a few
  years a life that is already entering upon the reminiscent stage. As
  factors in racial evolution, the youth of each successive
  generation, not its quadragenarians, are of interest and importance.


Treatment.--The conclusions that naturally flow from the historical
introduction to this chapter which show mental influence as the basis
of all cures, simplify very much the treatment of alcoholism on
psychotherapeutic principles. There is no doubt that moral means are
the only really effective remedies in this matter. They fail often,
not because of any lack of power, but because of lack of co-operation
on the part of the patient. There are men whose mentality and
responsibility is breaking down, and who are on the way to the insane
asylum for various causes, who cannot be thus influenced. They are,
however, not alcoholics, but incipient insane patients likely to go to
excess in any line. There is no pretense that psychotherapy will cure
mental disorder that rises to the height of real insanity. On the
other hand, just as after several relapses of tuberculosis due to the
foolishness of the patient, further improvement by sanatorium
treatment is usually out of the question, so each relapse of the
alcoholic patient makes it increasingly difficult to bring about
noteworthy improvement. There are examples, however, which demonstrate
that even after seventy times seven relapses men may still encounter
something that rouses their dormant wills to real activity and then
their alcoholism is a thing of the past, for good and all.


_Sanitarium Question_.--There always comes the question whether these
cases need to be sent to a sanitarium or can be treated at home. The
answer to this question is the same for alcoholism as it is for
tuberculosis or, indeed, for any of the exhaustive diseases. It all
depends on the individual's physical condition and his circumstances.
If tuberculosis is discovered, as it should be, at a very early stage
in the disease--not when the patient is coughing up bacilli in large
numbers and already has many physical signs in his lungs, but when he
has a slight unproductive cough and over-rapid pulse and some
prolongation of expiration at one apex--then he may be cared for at
home, if the physician is confident that he can make his patient feel
the absolute necessity for following instructions and can make him
realize the seriousness of his condition in spite of the few symptoms
that are present. If his environment is unfavorable, in a crowded
tenement house or where an abundance of fresh air cannot be readily
obtained, the patient may have to go to a sanitarium for proper
treatment even at this early stage, or at least he will have to change
his living conditions.

This question has received a very different answer in recent years
from what used to be given to it. Formerly the physician hesitated to
say "tuberculosis" to his patient until the disease was well advanced
and then he advised the distant West or some other change of climate,
though, as a rule, this brought only a palliation of symptoms, the
case being too far advanced, and {703} the fatal termination came in
the course of two or three years. Now the careful physician diagnoses
tuberculosis much earlier, detects the disease in its incipiency, and
is able to treat the patient at home quite successfully, if conditions
are at all favorable. It is true he has to make him give up fatiguing
occupations, and especially those in dusty places; he has to insist on
his living out of doors a good part of the day, even though there
should be no better means of securing this than the roof or a
fire-escape, and on keeping his windows open all night. He has to
watch his nutrition carefully and see that he gains in weight. If all
this can be accomplished, however, there is no reason why a
tuberculosis patient in the incipient state should not get better at
home almost as well as he would at a sanitarium. The only difference
between the two methods of treatment is that in a sanitarium the
patient realizes that his one duty in life is to care for his health
and he does not bother about other things, as he is likely to do if he
remains at home.

If this precious development of teaching with regard to tuberculosis,
which is founded on such thorough-going common sense and the
application of good therapeutic principles to the treatment of the
disease, be transferred to the sphere of alcoholism, then the answer
to the question whether there shall be sanitarium treatment or not is
practically arrived at. If the patient is in an early stage of his
alcoholism, if the pathological character of his tendency to take
intoxicants has been recognized and made clear to him early, then
there is little difficulty in treating him at home. The crux of the
problem is just that which occurred with regard to tuberculosis years
ago. The physician does not take the early symptoms of the affection
seriously enough. He does not want to disturb his patient's equanimity
by the suggestion that he is in the incipient stage of alcoholism any
more than a few years ago the family physician cared to suggest the
awful thought of tuberculosis until the condition had reached a
serious stage. But this is the essential preliminary to the successful
treatment of alcoholism just as it is to the successful treatment of
tuberculosis.

It is almost useless to send advanced cases of tuberculosis, in which
cavity formation has already occurred, to a sanitarium. The course of
their disease may be delayed for a while, but scarcely more than that.
Their resistive vitality has been so overcome by the ravages of the
disease that their ultimate cure seems beyond hope, yet not
infrequently wonderful results are obtained even in these cases. Just
this same thing is true with advanced cases of alcoholism. No one can
do anything with them, though careful treatment in a sanitarium may,
on a number of occasions, afford them opportunity to brace up and be
themselves, i.e., their better selves, for several months. Just as
with tuberculosis, however, even the quite advanced cases will
sometimes be so much bettered by sanitarium treatment that, though
their prognosis seemed absolutely hopeless and was so pronounced by
good authorities, all the symptoms are relieved and the patients get a
new lease of life that may last for many years.

In the same way some apparently hopeless cases of alcoholism will
brace up after sanitarium treatment and have many years of useful
sober life without a break. In alcoholism, as in tuberculosis, the
will of the individual is the all-important consideration. Someone has
said that tuberculosis takes away mainly the quitters. Those who have
the courage to insist that they {704} _will live_ in spite of
everything being apparently against them, pull through crises that
seem absolutely hopeless and survive for years. Robert Louis Stevenson
bravely doing his work, living on in spite of fate and disease, is the
typical example. Alcoholism completely overcomes only the quitters. If
a man wants to give up drinking even when he seems practically a
hopeless wreck from the effects of alcohol, he can do so if he has a
physician in whom he has confidence, who will relieve him from
depressing symptoms due to previous excess, who will lift him up and
strengthen him by food and stimulation, and, above all, by faithful,
unending, never discouraged assurance that he can conquer the craving
which has such a hold of him, if he only persists a little and does
not give up the struggle. The victory is worth while and it is not
hard to lift a man up if he has any remnants of character left.


_Confidence_.--In the treatment of alcoholism, then, just two things
are necessary. One of these is that the patient has confidence in
himself, the other that he has confidence that his physician can help
him over the hard spots on the road. There is no doubt that many drugs
can be used that will lessen the patient's irritability, increase his
nerve force, stimulate organs which are depressed by the reaction
against over-stimulation, arouse appetite and correct disturbed
functions. All these things must be done. It is no use laying down any
set of rules as to how they shall be done, for they must be done
differently in individual patients. It is not alcoholism that is
treated nor the effects of alcoholism, but an individual alcoholic
patient, and a set of symptoms that are very different in every
individual. The more physiological disturbance can be relieved by
proper drug, dietetic, hydropathic and remedial measures, the more
chance is there for the patient to get over his habit without trouble.
Every ill feeling that he has tempts him to think of alcohol. Above
all, he must be made to sleep, his bowels must be thoroughly
regulated, and he must be made to eat heartily. For stimulation full
doses of nux vomica, not less than thirty drops three or four times a
day or even oftener, are probably best.

For cases of alcoholism in the earlier stages there is but little
difficulty. Those who try the effect of favorable suggestion, of
confident assurance, of constantly repeated encouragement on
individuals who have begun to be afraid that they cannot break the
habit, will frequently have the most gratifying results. The important
point to remember is that men are suffering from alcoholism who are
indulging in alcohol every day and to whom it has become more or less
of a necessity, though even as yet its effect upon their business is
not marked and they are not known, even among their acquaintances, as
drunkards. Whenever a man must have three or four whiskeys a day or he
cannot do his business and his appetite fails him and he does not
sleep well, he is an alcoholist. He has the cellular craving that
later may become an absolute tyrant. If we can educate the community
generally to realize this as we are gradually educating them to the
knowledge that tuberculosis must be caught in its incipient stage and
that pulmonary consumption begins in very mild symptoms after a person
has been exposed to it, we shall have little difficulty in curing
tuberculosis or in treating alcoholism successfully by suggestion.

For alcoholism, as for the drug habits and also the sex habits, moral
influences are all-important. Hence the necessity for exercising them
{705} frequently. It is probable that the best way to break any of
these habits is to have the patient come regularly to the physician's
office, at least once, and at the beginning twice a day. In cases of
alcoholism the method of giving for the first week, at least, the dose
of the stimulant drug which replaces the alcoholic stimulation
directly to the patient is often of great service. It seems a good
deal to ask the patient to come three times a day just to get a drug
(tonic), but it is comparatively easy to resist the craving for liquor
for four or five hours, that is, until the doctor is seen again, while
sometimes twenty-four hours will seem a long while. The personal
element in this matter is extremely valuable. It is this that has made
the efficiency of all forms of cures, and it is only this that can be
successfully used.

How much can be accomplished for even the worst forms of drunkenness
and under extremely unfavorable circumstances once a really strong
impression is made on the individual's mind and his will is aroused to
help himself seriously may be readily learned from the lives of any of
the great temperance advocates. Their experience is illuminating. It
shows clearly that strong personal influence will do more than
anything else for these sufferers. Sometimes their efforts are
supposed to affect only certain classes of individuals who have
character but who, for some reason, have fallen into an unfortunate
habit. A little investigation will show, however, that they affect all
classes and kinds of individuals and, indeed, may reform a whole
community. The story of Father Matthew is very interesting in this
regard because there is some striking testimony as to his reformation
of whole neighborhoods that had been given over to drink before and
that among a people especially emotional and susceptible. The movement
that he initiated still lives in the temperance societies of the
English-speaking peoples everywhere which help by prophylaxis in youth
and the moral force of association in later life.


After-Treatment.--In alcoholism the most important feature of the
treatment is what has come to be known in our time as the
after-treatment. This department of therapeutics has taken on great
importance in recent years in every form of disease. For early and
middle life most diseases have a definite tendency to get better,
though many of them leave distinct pathological tendencies. The
after-treatment, then, has become much more important than the cure
for the patient during the existence of the acute or sub-acute stage.
Even in children's diseases it is now generally recognized that while
measles and whooping cough are not dangerous affections as a rule,
they may prove the forerunners of tuberculosis, because of the
weakened pulmonary resistance consequent upon their invasion. For
scarlet fever, the possibilities of injury to the kidneys after the
great irritation to which they have been subjected, is now recognized
and convalescence is prolonged. In typhoid fever we realize that not
weeks but many months of convalescence are needed to put the patient
beyond the risk of various degenerative processes that may be serious.
There is even question in the minds of many observant physicians
whether the weakness incident to typhoid fever may not, if a premature
return to work is allowed, prove a potent cause of precocious
arterio-sclerosis.

In a word, after-treatment has become one of the most interesting
subjects of modern therapeutics. It will not be surprising, then, if
we insist that the after-treatment of the alcoholic is the most
important part of the remedial methods to be employed. If a man who
has suffered from tuberculosis because {706} he was working in one of
the many dusty trades and living in a badly ventilated tenement house
is restored to health or at least has all his symptoms disappear as a
consequence of sanitarium treatment, it is almost needless to say that
he must not be allowed to return to the conditions in which his
disease originally developed. If he does, he is absolutely certain to
have a relapse. This phase of tuberculosis has been much discussed in
recent years. It is often said that it is impossible to keep working
people from a return to their occupations. Just so far as that is
impossible, so far will any real hope of keeping their tuberculosis in
abeyance be reduced. They are much more likely to suffer from the
disease, as a rule, after their return from the sanitarium than they
were before they originally contracted it, because apparently some of
their immunity has been destroyed by the invasion of the bacillus.

It is only recently that we have thus planned for the after-treatment
of tuberculosis. If we are to be successful in the after-treatment of
alcoholism, at least some of this same thoughtfulness must be
exercised. The victims must be discouraged from going back into the
conditions in which their habit developed. It is comparatively easy,
especially at the beginning of his alcoholism, to stimulate a man back
to normal physical condition, to reduce his craving for intoxicants,
give him back his appetite and set him on his feet again. The
affection is quite curable. If a man returns to the conditions in
which it originally developed, however, it will develop again quite as
inevitably as tuberculosis does under similar conditions. We do not
blame the sanitarium if, after having given a man a new lease of life
in spite of tuberculosis, he resumes the unsanitary life in which his
disease originally developed and has a relapse. It is not the fault of
the system of treatment for alcoholism if men relapse, but the blame
is upon them that they do not take their danger of relapse seriously
enough, permit themselves to get into an unfavorable environment, and,
as a consequence, suffer once again from their affection.


_Religious Motives_.--More and more we are realizing the place of the
higher motives of life in the reform of alcoholic patients. Religious
motives probably form the best possible source of suggestions that
enable a patient to lift himself out of the slough of despond of
chronic alcoholism. Many of the best workers for the reform of the
drunkard were themselves drunkards for many years. The motive of
helping others is particularly important in its effects upon any
alcoholic. Some motive apart from himself is more helpful than any
appeal to his selfishness or even to what he can do for his children
and his wife. It is the newer motive that appeals most strikingly. In
recent years certain church movements have done much for alcoholic
patients. In this they are only repeating the effect of other great
church movements and the effect of the lives of apostles of temperance
in recent generations. Without these higher motives cure is probably
impossible in many cases. With them it not only becomes possible but
even comparatively easy in the most hopeless-looking cases.

In the light of what we have heard recently of the success of the
Emanuel movement in the treatment of alcoholism, it is interesting to
recur to what was said in this relation by Prof. Forel of Zurich on
the treatment of alcoholism, in a communication read to the South
German Neurologists and Psychiatrists at its meeting in Freiburg over
twenty years ago. Prof. Forel, who is not what {707} would be called a
particularly religious-minded man, insisted that "an inebriate asylum
can only with great difficulty be successful without religious
auxiliaries, since most inebriates, and especially at the beginning of
their reformation, are entirely too weak to get along without
religious consolation. To secure this, however, the nicest tact is
required in order to permit the practice of all the different nuances
of faith that men have, in peace and comfort. This can only be secured
if in practice faith is subjected to charity for one's neighbor as the
basis for religion."

Many such expressions have been used before and since in practically
every country in Europe. The assertion that physicians have failed to
recognize the part that religion plays in such cases is entirely
without foundation and can only be made by those who are quite
ignorant of our medical literature.



CHAPTER II

DRUG ADDICTIONS


Much of what has been said with regard to alcoholism finds ready
application to the treatment of drug addictions. At the very beginning
it must be realized that there is no specific remedy that will enable
the patient to overcome his craving for a drag to which he has become
habituated. There is no method of treatment that will infallibly and
without serious and prolonged and determined effort on his part enable
him to overcome his craving. The first and most important thing in any
system of treatment is the patient's good will. If the patient is not
ready to give up the drug, then nothing that a physician can do for
him will make him do so, or will turn him against it; above all,
nothing will make the process of cure so easy that there will be no
trouble involved or only a passing period of struggle required to
accomplish it. There have been many claims made in this matter. We
have wanted such remedies and methods of treatment so much that it has
been rather easy to persuade us sometimes that they have been
discovered. It is like the question of specifics in medicine. For
centuries men devoted themselves to trying to find a specific remedy
for each disease. It was thought they must exist in nature. Now we
know that they probably do not exist, though those who claim to
discover them find an easy livelihood exploiting the credulity of
those who still cherish the belief in them. Scientific students of
medicine have practically given over the search for them in order to
devote themselves to strengthen the patient to resist the disease
rather than spend more time trying to find something to give him that
cures it.


Treating the Patient rather than the Habit--This principle holds with
special force with regard to drug addictions. We do not treat the
patient's habit, but we treat the patient. He must be braced up, must
be made to understand that if he wants to quit the habit, no matter
how slavishly he is addicted to it, he can do so. He must be told of
men who had habits like his, often of longer duration and to a greater
degree, yet gave them up when firmly resolved and properly stimulated.
It is not hard to find such examples, since medical and even ordinary
literature abound with them and every physician's experience furnishes
him with instances. The first and {708} most absolutely necessary
preliminary of the treatment is to lift up the patient in his own eyes
and make him understand that, low as he has sunk, his case is not
hopeless, that his degradation is not at all uncommon nor so rare as
he might think, and that men and women have succeeded in lifting
themselves out of conditions worse than his. The psychotherapeutist
must, above all, not be of those who insist that human nature is
degenerating and that people are much weaker physically and morally
than they used to be, though of course he must be thoroughly aware
that drug habits are more frequent than they were and are quite
alarmingly on the increase. This is not due to any deterioration in
human nature, however, but mainly to the excitement of modern life and
its inevitable reaction, the strenuousness with which men now take
existence and the consequent craving for artificial relief from
over-activity, and then, above all, the facility with which the
habit-forming drugs can be obtained.


Prophylaxis.--This last point accounts for the frequency of drug
habits in our time more than anything else. Men have always been ready
to do something for the sake of novelty and excitement. Everyone is
curious to experience for himself the effects produced by drugs that
can make people such slaves to them. We hear too often of the intense
pleasure that the drug habitué gets from his use of drugs. The
curiosity thus aroused constitutes the suggestion that has led many to
try the effect, confident that he or she would be able to resist any
craving just before it became seriously tyrannous. Psychiatrists agree
that one of the worst elements in modern social conditions is the
impression generally maintained that there is such intense pleasure in
the taking of drugs. A clear statement of the reality of the case is
eminently desirable. It is not positive pleasure that the drug habitué
has, but mere negative pleasure, as a rule. His "dope" does not so
much add to his good feeling as take away the bad feelings that he has
because of depression or ennui at the beginning and later because of
the craving for the drug.

Physicians to whom many drug habitués have told their experience
frankly are not at all inclined to think that the usually accepted
opinion of pleasure in drug taking is true. It is not that it is
heaven to have the drug so much as it is hell to be without it. The
patient's system has learned to crave it so much because of the
surcease of painful consciousness of self it gives and this it is that
compels these unfortunates to go back to ever-increasing doses. The
pleasant side is a very dubious affair at all times, accompanies only
the earliest steps of the formation of the habit at most, and usually
whatever agreeable feelings there are are accompanied by such a
nightmare of solicitude and anxiety as a background that the pleasure
is more poignant than agreeable. As a prophylactic against the
formation of drug habits this aspect of the experience of drug
habitués deserves to be emphasized and knowledge of it widely
diffused. Of course, the morphin fiend brightens up after his dose of
morphin, his eye lightens, his expression becomes happy, and his
nerves get steadier, but that is only because the depression in which
he was sunk before has now been stimulated away, the struggle with his
worst feelings is over and the consequent reaction has developed. Of
course, the cocain-taker is pitiably helpless and downcast without his
"dope," but it is only by contrast with this previous state that his
succeeding condition can be said to be pleasant or agreeable, even to
himself.

{709}

_Favorable Suggestion_.--One of the most helpful sources of favorable
suggestion for these patients is to be found in the stories of cured
drug habitués. These may be used tactfully to bring confidence to
patients that they, too, can be broken of their habit if they are
willing to take the pains to do so. De Quincey, taking his thousand
drops of laudanum a day, represents one of the most encouraging
examples of this since he succeeded eventually in breaking away from
his habit. Coleridge succeeded, also, in breaking his habit more than
once, but unfortunately returned again and again, and illustrates the
danger of the almost inevitable tendency to relapse, if the patient
permits himself to think that now that he has once conquered the habit
he is too strong ever to let it get hold of him again. If he ventures
to think complacently of his self-control and that consequently he may
with impunity--always for some good reason--take a dose or two of his
favorite drug in order to tide him over some crisis of mental worry or
some spell of physical pain, relapse is certain. The tendency of
patients to fool themselves in this way is too well known to need
special emphasis, but it is as well to say that there is scarcely a
single cured case that does not relapse. The relapse is due not so
much to craving for the drug, as to the memory of its previous effects
in relieving discomfort and the unfortunate confidence that the
patient has developed that now, knowing the dangers, he will be able
to resist the formation of the habit before it gets a strong hold of
him.

It is curious how even highly intelligent patients will slip back into
their old habits, sometimes deeper than before, on this reasoning, in
spite of the lessons of experience, even their own as well as others.
Like the drunkard, they persuade themselves that just this once will
not count, and when it would have been comparatively easy for them to
say no they yield once or twice and make self-denial for the future
increasingly difficult. This is especially true if patients have the
drug near them, so that it is not difficult for them to have recourse
to it. Hence doctors and nurses are not hard to cure of such habits,
as a rule, provided they are away from their professional duties, but
they almost inevitably relapse when they go back to work. Every time
the relapse is due to the fact that tired feelings, because of
irregular hours or some physical pain, prompt them to seek relief and
they yield to the temptation of taking the old drug, sure that they
need it, only for the moment. They will all assert that they could
just as well resist as not, that, indeed, had not the drug been so
handy, they would not have taken it, and that if anyone had been near
to help them by a word in the matter even then they would not have
indulged in it.

If patients are to be kept from relapsing, all this must be set before
them frankly. After they have been told once or perhaps twice or
perhaps many times and yet relapse into their habits, they must simply
be told it again a little more emphatically, more encouragingly, up to
seventy times seven, if necessary. Patience is needed more than
anything else in taking care of these cases. Over and over again their
confidence in their power to overcome their habit, if they really wish
to do so, must be reawakened. Without this confidence in themselves
success is hopeless. It matters not how often they have relapsed, they
can still break off the habit, and if they will not fool themselves
into over-confidence in their power to keep away, they need never be
slaves to the habit again. There will be quite as many disappointments
in {710} treating drug addiction as in the treatment of alcoholism.
Those who have most experience insist that there are even more, but
there are some wonderfully encouraging examples of men and women who
have broken from their habit, even after a number of bad relapses, and
have for many years lived absolutely without any of their drug and,
though still not over-confident in their power to resist if once they
should yield (such confidence, it cannot be repeated too often, is
always fatal), do actually keep away from the drug without any other
bother than the necessity of living a regular hygienic life and
exercising a little self-control.

In drug addictions as in alcoholisms, the question of sanitarium
treatment comes up in every case. Much more rarely than in the case of
the alcohol habit is it necessary to send a drug habitué to a
sanitarium. Here once more, however, the patient's circumstances and
the possibility of diversion of mind with reasonable freedom from
temptations to take the drug and from ready access to it, are the most
important considerations. If a patient really wants to break off the
use of a drug, it can be done gently and without much bother in the
course of three or four weeks. I have seen cocain fiends who have
tried many remedies and many physicians completely cured in five or
six weeks without serious trouble. The important thing is perseverance
in the effort and in the treatment and the definite persuasion of the
patient that it is not only perfectly possible to get rid of the
habit, but that it is even easy with good will on his part. If certain
other milder stimulants are supplied for a time so that all the
symptoms due to the physiological effects of the excessive use of the
drug are minimized, the physical trial need not be severe. The
patient's mind, however, must be occupied. Time must not be allowed to
hang heavy on his hands and all physical symptoms must be treated
promptly. Drug addictions are indeed more curable than alcoholism and
the danger of relapse is not quite so imminent. The social temptations
do not exist for drug habitués as they do for alcoholics. As I have
said, however, in the cases of nurses and physicians almost a
corresponding state of affairs obtains and in them the danger of
relapse is great.


Early Treatment.--It is quite as important for drug victims as it is
for alcoholics that the case should be taken under treatment early.
Every physician knows how curiously easy it is for some people, indeed
for most people, to acquire a drug habit. I have seen one of the
solidest men I ever knew, with plenty of character that had been tried
by many a crisis in life, recommended cocain for a toothache when he
was past fifty years of age and in the course of ten days acquire a
thorough beginning of the cocain habit, so that he was taking several
grains a day. He had no idea that he was unconsciously slipping into a
drug habit. When the druggist refused any longer to supply the cocain
solution without a prescription he was quite indignant. It was not
until he had forty-eight hours of nervous symptoms and craving that he
realized that he had created a need for stimulation of his nervous
system by the mere taking of cocain by application on his gums. This
habit was broken up at once and there has never been any tendency to
its recurrence. He had his warning, fortunately, without evil effects.

If the cocain habit can be formed as unconsciously as this, there
should be little difficulty in treating it. It is not a profound
change in the organism, but only a habit. It is not the habit itself
that is hard to break, but the effects {711} upon the nervous system
of the patient are such as to create a series of symptoms that can
only be soothed by the drug. It is these symptoms of depression,
irritation, sleeplessness, lack of appetite, constipation and the rest
that it is the physician's duty to treat in order to help the patient.
The patient breaks the habit by his will-power when properly persuaded
and when it is made clear to him that it is neither so difficult as he
thought, nor is he so likely to fail in the matter as he has imagined,
and as has perhaps been suggested to him even by physicians. The
mental treatment consists in making him realize that he can do it and
that if he wants to get rid of his habit he must do it for himself.
With this must come the assurance that every annoying symptom will be
met, that he need not recur to his favorite drug for this purpose,
that his appetite will be gradually restored and that, though perhaps
for a week he will have considerable inconvenience to bear, after that
it will be plain sailing. Usually three days can be set as the term at
which his craving ceases to be so disturbing as to make the
possibility of his relapsing into the habit a positive danger. As in
alcoholic and sex habits, the patient to be helped in breaking the
habit should be seen once a day at least, usually oftener. If he can
be made to understand that whenever the old tendency seems about to
get the upper hand is the time to see his physician, and if something
physical as well as moral is done for him, the breaking of the habit
is comparatively simple.

This method of treatment looks too simple to be quite credible to
those who have so often tried and failed in the cure of drug habits.
It is not the doctor, however, who fails, but the patient. We cannot
put new wills into a patient, but we can so brace up even an old and
tottering will as to make it possible for the worst victims of drug
habits to reform. The doctor, too, easily becomes discouraged. He has
not confidence enough in his own methods to make assurance doubly sure
for the patient as to his cure. This is what many of the pretended
specific purveyors of drug habit cures have as their principal stock
in trade. They assure patients with absolute confidence, while the
physician only too often says the same thing, but half-heartedly. A
half-hearted physician makes a hesitant patient, and success is then
very dubious from the beginning. Every patient can be cured. They may
relapse, but then they can be cured again. This is the essence of the
psychotherapy of drug habits, but it is also the only successful
element in any treatment of the drug habit that is really effective.
Specifics come and go. Sure cures cease to have their effect. The only
really effective element in any cure is the absolute trust of the
patient.

In his "Drugs and the Drug Habit" (Methuen, London) Dr. Harrington
Sainsbury, Senior Physician to the Royal Free Hospital of London, has
emphasized all these points that can only be touched on very briefly
here. He has called particular attention to the fact that the victim
of one drug habit is rather prone to acquire another if by any chance
he should once begin to take another habit-forming drug. The original
drug habit has broken down the will. It is not so much the craving for
a particular drug as the lack of will power that proves unfortunate
for the patient. He suggests "incidentally, if this explanation hold
good, it proves the solidarity of the will that it works as a whole
and not by compartments." He has dwelt on recoveries from the most
discouraging depths and insists "we must teach that {712} no one is
ever so enslaved by a habit as to be incapable of relief--this alone
is _right_ teaching, justifiable moreover by records well
substantiated of recoveries from desperate plights."


Heredity and Unfavorable Suggestion.--As to the suggestion, sometimes
encountered, of the influence of heredity and its all-powerful effect
in making it practically impossible for the son of a man who has taken
drugs to keep from doing the same thing, we must recall very
emphatically here the principles discussed elsewhere. So far as
concerns heredity, opium and the other drugs are exactly in the same
position as alcohol in their effect upon the human race. Instead of
being justified in saying that by heredity individuals of succeeding
generations are rendered more susceptible to them, just the opposite
is true and, if anything, an immunity is produced. This is not only
racial and general but is personal and actual. In recent years we have
come to realize that individuals born of tuberculous parents who care
for themselves properly are much better able to resist the invasion of
the tubercle bacilli than those who come from stocks that were never
affected by the disease. They are the patients who, in spite of the
fact that their disease reaches an advanced stage, sometimes live on
for years with proper care. Just this is true for drug addictions so
far as we know anything about it. The whole subject is as yet obscure,
but heredity rather favors than hurts the patient in these cases.


Hereditary Resistance.--Instead of being discouraged by the fact that
his father took a drug to excess and that therefore he is weaker
against this than other people, a man should rather be encouraged by
the thought that a certain amount of resistance to the craving has
probably been acquired by the particular line of cells through which
his personality is manifested. Dr. Archdall Reid has said that "the
facts concerning opium are very similar" (to those that concern
alcohol). Then he continues:

  That narcotic has been used extensively in India for several
  centuries. It was introduced by the English into China about two
  centuries ago. Quite recently the Chinese have taken it to Burma, to
  various Polynesian Islands, and to Australia. There is no evidence
  that the use of opium has caused any race to deteriorate. Indeed it
  happens that the finest races in India are most addicted to its use.
  According to the evidence given before the late Royal Commission on
  Opium, the natives of India never or very rarely take it to excess.
  When first introduced into China it was the cause of a large
  mortality; but to-day most Chinamen, especially in the littoral
  provinces, take it in great moderation. On the other hand. Burmans,
  Polynesians and Australian natives take opium in such excess and
  perish of it in such numbers that their European governors are
  obliged to forbid the drug to them, though the use of it is
  permitted to foreign immigrants to their countries. In exactly the
  same way alcohol is forbidden to Australians and Red Indians in
  places where It is permitted to white men.


After-Cures.--I have said so much about the after-cure of alcoholism
that applies directly to drug addictions also, that it does not seem
necessary to repeat it here. Patients must be warned that if they
become overtired, if they lose sleep, if they are subject to much
excitement, if they put themselves in conditions of anxiety and worry,
if any form of recurrent pain develops--headache, toothache,
stomach-ache--they are likely to be tempted to take up their old
habit. If they are in a position where they can easily get the drug it
is almost inevitable that something will happen to make them feel that
{713} they are justified in taking one or two doses and from this to
the reestablishment of the habit is only a small step. Often these
patients need a change of occupation. Some of them are over-occupied,
some of them have not enough to do. In either case it is the doctor's
duty to know enough about his patient to be able to give directions.
We do not treat a drug addiction with the hope of curing it, but we
treat a patient suffering from a particular drug habit and we try so
to modify that patient's life that after we have succeeded in getting
him away from his habit, which is never difficult, he will not relapse
into it. The after-cure is the more important of the two.



CHAPTER III

SUICIDE


In spite of the gradual increase of comfort in life and its wide
diffusion--far beyond what people enjoyed in the past--there has been
a steady progressive increase in the number of suicides in recent
years. It is as if people found life less worth living the more of
ease and convenience there was in it. This increase in suicide is much
greater (over three times in the last twenty years) than the increase
in the population. Surprising as it may seem, prosperity always brings
an addition to the number of suicides. Stranger still, during hard
times the number of suicides decreases to a noteworthy degree. It is
not those who are suffering most from physical conditions who most
frequently commit suicide. Our suicides come, as a rule, from among
the better-to-do classes of people. While suicide might seem to be
quite beyond the province of the physician, it is a duty of the
psychotherapeutist to prevent not only the further increase of
suicides in general but to save particular patients from themselves in
this matter. A careful study of the conditions as they exist,
moreover, will show that he can accomplish much--more than is usually
thought--and that it is as much a professional obligation to do so as,
by the application of hygienic precautions and regulations, to lessen
disease and suffering of all kinds and prevent death.

The same two modes of preventive influence that we have over disease
in general can be applied to suicide. The physician can modify the
mental attitude in individual cases and thus save people from
themselves and then he can, by his influence in various ways upon
public opinion, lessen the death rate from suicide. For this purpose,
just as with regard to infectious disease, it is important for him to
appreciate the social and individual conditions that predispose to
suicide, as well as the factors that are more directly causative. The
more he studies the more will he be convinced that what we have to do
with in suicide is a mental affliction not necessarily inevitable in
its results and that may be much influenced by suggestion. Indeed,
unfavorable suggestion is largely responsible for the increase in
suicide that has been seen in recent years. Favorable suggestion might
be made not only to stop the increase, but actually to reduce the
suicide rate. For this purpose it is important to know just what are
the conditions and motives that predispose to suicide and, above all,
to realize that it is not the result of insufferable pain {714} or
anguish, but rather of the concentration of mind on some comparatively
trivial ailment, or exaggeration of dread with regard to the
consequences of physical or moral ills.

Suicides are often said to be irrational; in a certain sense they are.
No one who weighs reasonably all the consequences of his act will take
his own life. This irrationality, however, is nearly always functional
and passing, not of the kind that makes the commission of suicide
inevitable, but only produces a tendency to it. This tendency is
emphasized by many conditions of mind and body that the physician can
modify very materially if he sets about it. Many of the supposed
reasons for suicide are founded on the complete misunderstanding of
the significance of symptoms and dread of the future of his ailments,
often quite unjustified by what the individual is actually suffering.
Indeed, the desperation that leads to suicide is practically always
the result of a state of mind and not of a state of body. It is
exactly the same sort of state of mind which sometimes proves so
discouraging in the midst of diseases of various kinds as to make it
impossible for patients to get over their affections until a change is
brought about in their ideas. This makes clear the role of
psychotherapy with regard to suicide, and there is no doubt that many
people on the verge of self-murder can be brought to a more rational
view and then live happy, useful lives afterwards. For this purpose,
however, it is important that the physician should come to be looked
upon as a refuge by those to whom the thought of suicide has become an
obsession.

A well-known social religious organization not long since established
a suicide bureau, that is, a department to which those contemplating
suicide may apply with the idea that they would there find consolation
and perhaps some relief for their troubles and thus the idea of
suicide might be dissipated. Many a suicide would be avoided if the
reasons that impelled to it had been known to one or two other people
beforehand, so that some relief might have been afforded to what
seemed an intolerable condition. This suicide bureau is said to have
done much good. There is no doubt that the mere act of giving one's
confidence to another is quite sufficient of itself to diminish to a
marked degree a burden of grief and trial. If anything in the world is
true, it is that sorrows are halved by sharing them with another,
while joys are correspondingly increased. The fact that there is
someone to whom they might go, who would look sympathetically at their
state of mind, who would appreciate the conditions, who had been
accustomed to dealing with such cases, would be enough to tempt many
people from that awful introspection and concentration of mind on
themselves which, more than their genuine sufferings and trials,
whatever they may be, make their situation intolerable.

There has always been a suicide bureau, however, in the office of
every physician who really appreciates the genuine responsibilities of
his profession. More than any others we have the opportunity to
alleviate physical sufferings, to lessen mental anguish and to make
what seemed unbearable ill at least more or less tolerable.
Unfortunately in recent years the change in the position of the
physician in his relations to the family has somewhat obscured this
fact in the minds of the public. The old family physician occupied to
no slight extent the position of a father confessor, to whom all the
family secrets were told, from whom indeed, as a rule, it was felt
that they should not be kept; to whom father went with regard to
himself and mother, to whom mother {715} went with regard to all the
family as well as herself, to whom the boy confided some of his sex
trials and the girl some of the secrets that she hid from almost
everyone else, so that to go to him for anything disturbing became the
first thought. We must restore something of this old-fashioned idea of
the doctor's place in life if all our professional duties are to be
properly fulfilled. If those contemplating suicide learn to think of
us as persons to be appealed to when all looks so black that life is
no longer tolerable, we shall soon be in a position to confer
increased benefits on this generation that needs them so much.


Physical Factors.--As a rule there is a physical element as the basis
for nearly all suicides. With the unfortunate, unfavorable suggestion
that has come from the supplying of details of pathological
information--the half-knowledge of popular medical science--without
the proper antidote of the wonderful compensatory powers of the human
body for even serious ailments, a great many nervous people are
harboring the idea that they have or soon will have an incurable
disease. Physicians have abundant evidence of this. All sorts of
educated people come to us to be reassured that some trivial digestive
disturbance does not mean cancer of the stomach, or, when they are
between forty and fifty, come to make sure that some slight
disturbance of urination is not an enlarged prostate. Brain workers of
all classes come over and over again to be reassured that they are not
breaking down because of organic brain disease, of which they show
absolutely no sign. Sometimes they have been making themselves quite
miserable for a long period by such thoughts. It is easy to
understand, then, how many less informed people, yet provided with the
opportunities of quasi-information that modern life affords, are apt
to think the worst about themselves.


_So-called Insomnia_.--The correction of such preconceived notions
will always greatly alleviate the mental sufferings of these patients.
For this purpose there are many chapters of this book which point out
how various symptoms and syndromes that are often amongst the factors
in the production of suicide may be managed. Perhaps one of the most
frequent of these is so-called insomnia. Most people are insomniac,
mainly because they are overanxious about their sleep. A few of them
are wakeful because of bad habits in the matter of work and the taking
of air and exercise. Essential insomnia is extremely rare and
symptomatic; insomnia is not mental, but is usually due to some
definite physical condition that can be found out and, as a rule,
treated successfully. There is always some other symptom besides loss
of sleep. If men will live properly and rationally there is no reason
why insomnia should be a bane of existence, nor even any reason why
the morphin or other drug habit should be formed which is so likely to
come if inability to sleep is treated as if it were an independent
ailment. In the forms in which it incites to suicide it owes its
origin to a nervous superexcitement with regard to sleep in people
whose daily life in some way does not properly predispose them for the
greatest of blessings on which there is no patent right. Additional
suggestions as to these insomniac conditions are made in the chapters
on Insomnia and Some Troubles of Sleep which make it clear that
suicide, because of insomnia is due to a delusion.


_Headache_.--Persistent supposedly incurable headache is another
prominent feature of the stories of suicides and here once more we
have to deal rather {716} with a delusion of over-attention of mind
and concentration of self on a particular part than a real physical
ailment. Most of the so-called headaches that are supposed to be so
intractable are really not headaches but pressure feelings and other
queer sensations in the head originally perhaps partaking of the
nature of an ache but continued through over-advertence. Severe pain
within the head occurs in cases of congestion and brain tumor, and
without the head in cases of neuralgia, but most of these are only
temporary and long-continued headaches are rather neurotic than
neuritic or due to any real disturbance of the nervous system. This is
discussed in the chapter on Headaches. People commit suicide who have
for a long time been sufferers from headache because they fear that
they may go crazy. There is absolutely no reason in the world to think
this probable, and in the one case of continuance of severe
intermittent headaches for years already mentioned--that of von Bülow,
the Austrian pianist and composer, in which we have the autopsy
record--it was found, after a long life, that his severe intracranial
headaches were due to the pinching of a nerve in the dura and not to
any organic change in the brain itself.


Mental Factors.--While physical factors enter into the suicide problem
to a marked degree, it would be a great mistake to think that physical
conditions or material circumstances are the main causes or occasions
in suicide. It is supposed, as a rule, to be due to depression
produced by incurable disease, oppressive weather, financial losses
and the like. There is no doubt that these are contributing causes,
but the physical conditions have very little influence compared with
the attitude of the patient's mind toward himself. As a rule, it is
not those who are in absolutely hopeless conditions who turn to this
supposed refuge of a voluntary exit from life in order to get out of
trouble, but rather those who are momentarily discouraged and who have
not sufficient moral stamina to face the consequences of their acts.
There was a time when it was considered brave to fight a duel and
cowardly to refuse to do so. Looking back now, we know that they were
the real brave men who dared to refuse when a barbarous civilization
would force them into a false position and who, in spite of disgrace,
ventured to be men and not fools. There are those who used to say that
it was brave to take one's own life rather than bring disgrace on
loved ones, but the mitigation, if there be any, of the disgrace that
suicide brings with it, comes from that lowest of all motives, pity
for the survivors, and the cowardly suicide leaves to others the
thankless task of making up for his faults.


_Suicide and the Weather_.--An investigation of suicide records shows,
as we have said, that it is not nearly so often bodily or material
hardships that lead men to it as mental states. These mental states
are not mental diseases, but passing discouragements in which men are
tempted beyond their strength and do irretrievable things for which
there is no rational justification. It is not in dark damp weather
that men commit suicides most, though this was supposed to be a
commonplace in our knowledge of suicide. Recent investigations show
that quite the contrary is true. Professor Edwin T. Dexter of the
University of Illinois published a very important study of this
question in a paper entitled "Suicide and the Weather."   [Footnote
55] He followed out the records of nearly 2,000 cases of suicide
reported to the police in the City of New York {717} and placed beside
them the records of the weather bureau of the same city for the days
on which these suicides occurred. According to this, which represents
the realities of the situation, the tendency to suicide is highest in
spring and summer and the deed is accomplished in the great majority
of cases on the sunniest days of these seasons.

  [Footnote 55: _Popular Science Monthly_, April, 1901. ]

His conclusions are carefully drawn and there is no doubt that they
must be accepted as representing the actual facts. All the world feels
depressed on rainy days and in dark, cloudy weather, but suicides
react well, as a rule, against this physical depression, yet allow
their mental depression to get the better of them on the finest days
of the year. Prof. Dexter said:

  The clear, dry days show the greatest number of suicides, and the
  wet, partly cloudy days the least; and with differences too great to
  be attributed to accident or chance. In fact there are thirty-one
  per cent. more suicides on dry than on wet days, and twenty-one per
  cent. more on clear days than on days that are partly cloudy.

What is thus brought out with regard to the influence of weather can
be still more strikingly seen from the suicide statistics of various
climates. The suicide rate is not highest in the Torrid nor in the
Frigid zones, but in the Temperate zones. In the North Temperate zone
it is much more marked than in the South Temperate zone. Civilization
and culture, diffused to a much greater extent in the North Temperate
zone than in the South, seem to be the main reason for this
difference. We make people capable of feeling pain more poignantly,
but do not add to their power to stand trials nor train character by
self-control to make the best of life under reasonably severe
conditions. With this in mind it is not surprising to find that the
least suicides occur in the month of December, when the disagreeable
changes so common produce a healthy vital reaction, though the many
damp dark days that occur would usually be presumed to make this the
most likely time for suicides. On the contrary, it is the month of
June, the pleasantest in the North Temperate zone, that has the most
suicides. It is important to remember this in estimating the role of
physical influences on the tendency to suicide.


Social Factors that Restrain Suicides.--_War_.--A most startling
limitation of suicide is brought about by war. For instance, our
Spanish-American war reduced the death rate from suicide in this
country over forty per cent. throughout the country and over fifty per
cent. in Washington itself, where there was most excitement with
regard to the war. This was true also during the Civil War. Our
minimum annual death rate from suicide from 1805 (when statistics on
this subject began to be kept) was one suicide to about 24,000 people,
which occurred in 1864 when our Civil War was in its severest phase.
There had been constant increase in our suicide rate every year until
the Civil War began, then there was a drop at once and this continued
until the end of the war. In New York City the average rate of suicide
for the five years of the Civil War was nearly forty-five per cent.
lower than the average for the five following years. In Massachusetts,
where the statistics were gathered very carefully, the number of
suicides for the five-year period before 1860 was nearly twenty per
cent. greater than for the five-year period immediately following,
which represents the preliminary excitement over the war and the
actual years of the war. This experience in America is only in
accordance {718} with what happens everywhere. Mr. George Kennan in
his article on "The Problems of Suicide" (_McClure's Magazine_, June,
1908), has a paragraph which brings this out very well. He says:

  In Europe the restraining influence of war upon the suicidal impulse
  is equally marked. The war between Austria and Italy in 1866
  decreased the suicide rate for each country about fourteen per cent.
  The Franco-German War of 1870-71 lowered the suicide rate of Saxony
  8 per cent., that of Prussia 11.4 per cent. and that of France 18.7
  per cent. The reduction was greatest in France, because the German
  invasion of that country made the war excitement there much more
  general and intense than it was in Saxony or Prussia.


_Great Cataclysms_.--Even more interesting than the fact that war
reduces the suicide rate is the further fact that a reduction of the
number of suicides takes place after any severe cataclysm. The
earthquake at San Francisco, for instance, had a very marked effect in
this way. Before the catastrophe suicides were occurring in that city
on an average of twelve a week. After the earthquake, when, if
physical sufferings had anything to do with suicide, it might be
expected that the self-murder rate would go up, there was so great a
reduction that only three suicides were reported in two months. Some
of this reduction was due to inadequate records, but there can be no
doubt that literally hundreds of lives were saved from suicide by the
awful catastrophe that levelled the city. Men and women were homeless,
destitute, and exposed to every kind of hardship, yet because all
those around them were suffering in the same way, everyone seemed to
be reasonably satisfied. Evidently a comparison with the conditions in
which others are has much to do with deciding the would-be suicide not
to make away with himself, for by dwelling too much on his own state
he is prone to think that he is ever so much worse off than others.

  If life were always vividly interesting, as it was in San Francisco
  after the earthquake, and if all men worked and suffered together as
  the San Franciscans did for a few weeks, suicide would not end ten
  thousand American lives every year, as it does now.


Individual Restraints.--_Religion_.--It seems worth while to call to
attention certain factors that modify the tendency to suicide and
limit it very distinctly, because it is with the limitation of it that
the physician must be mainly occupied. There seems to be no doubt that
certain religious beliefs, which affect the individual profoundly and
occupy his thoughts very much, furnishing, both by tradition and
heredity as it were, sources of consolation for evils in this life by
the thought of a future life, notably lessen the suicide rate. All
over the world the Jews who cling to their old-time belief have
perhaps the lowest suicide rate of any people. This is true in spite
of racial differences. People who retain the confidence in prayer,
that used to characterize members of all religions a century or more
ago, are likely to be able to resist the temptation to suicide. This
is true particularly for the more or less rational suicide. Oppenheim
has recalled attention to the power of prayer against depression and
in the insane asylums of England its efficiency in this way is well
recognized.


It is well-known that Roman Catholics the world over have much less
tendency to suicide than their Protestant neighbors living in the same
{719} communities. It is true that where the national suicide rate is
high many Catholics also commit suicide, but there is a distinct
disproportion between them and their neighbors. The suicide rate of
Protestants in the northern part of Ireland, as pointed by Mr. George
Kennan, is twice that of Roman Catholics in the southern part. He
discusses certain factors that would seem to modify the breadth of the
conclusion that might be drawn from this, but in the end he confesses
that their faith probably has much to do with it and that, above all,
the practice of confession must be considered as tending to lessen the
suicide rate materially. It is the securing of the confidence of these
patients that seems the physician's best hope of helping them to
combat their impulse and Mr. Kennan's opinion is worth recalling for
therapeutic purposes:

  In view of the fact that the suicide rate of the Protestant cantons
  in Switzerland is nearly four times that of Catholic cantons, it
  seems probable that Catholicism, as a form of religious belief, does
  restrain the suicidal impulse. The efficient cause may be the
  Catholic practice of confessing to priests, which probably gives
  much encouragement and consolation to unhappy but devout believers
  and thus induces many of them to struggle on in spite of misfortune
  and depression.


_Disgrace as a Restraint_.--It is curious what far-fetched motives,
that appear quite unlikely to have any such influence, sometimes prove
able to affect favorably would-be suicides and prevent their
self-destruction. Plutarch tells the story, in his treatise on "The
Virtuous Actions of Women," of the well-authenticated instance of the
young women of Milesia. Disappointed in love, they thought life not
worth living. Accordingly there was an epidemic of suicide among the
young women and it even became a sort of distinction to prefer death
to matrimony. Some perverted sense of delicacy entered into the
feeling that prompted the suicides, as if sex and its indulgence were
something belittling to the better part of their nature. The
authorities in Milesia must have been psychologists. They issued a
decree that the body of every young woman who committed suicide would
be exposed absolutely naked in the market-place for a number of days
after her death. This decree, once put into effect, immediately
stopped the suicides. The young women shrank from this exposure of
their bodies, even though it might be after death, and the suicide
fashion came to an end.

It might be thought perhaps that this incident represented ancient
feeling and that a similar condition in the modern times would not
have a corresponding effect. It so happens that something similar has
been tried. In some of the cities of South Central Europe in which the
suicide rate is almost the highest in the world, it was decided about
a generation ago by the Church authorities of the towns that suicides
would not thereafter be buried in the cemeteries near the bodies of
those who died in the regular course of nature, but must be interred
in a separate portion reserved for themselves. Strange as it may seem,
just as in the case of the young women of Milesia, this proved a great
deterrent to suicide. The suicide rate was reduced one-half the next
year.

As a matter of fact, it only takes some reasonably forceful
countervailing notion to set a train of suggestions at work that will
prevent suicide. If those contemplating suicide are made acquainted
with some of these curious facts we know, then the notion of suicide
loses more than half its terrible {720} attraction by being stripped
of all of its supposed inevitableness. Almost any motive that attracts
attention, even apparently so small a thing as disgrace after death,
makes these people realize the littleness and the cowardice of the
act.


Favoring Factors.--_Psychic Contagion_.--A prominent factor in
suicides that must constantly be borne in mind is the influence of
example or, as we have come to call it learnedly in recent years,
psychic contagion. It is discussed more in detail in the chapter on
Psychic Contagion, but its place here must be emphasized. It has often
been noted that certain peculiar suicides are followed by others of
the same kind. If a special poison has been used, others obtain it and
put an end to their lives in that way. Even such horrible modes of
death as eroding the jugular vein by drawing the neck backward and
forward across a barbed-wire fence have been imitated. If the story of
jumping off a high building is told with lurid details, special care
has to be taken in permitting unknown people to go up to the same
place for some time afterwards. The imitative tendency is evidently a
strong factor. Plutarch's story of the young women of Milesia brings
this out, and it has been noted all down the centuries.

In any discussion of the prophylaxis of suicide the effect of
newspaper descriptions of previous suicides must be looked upon as
very important. The influence of suggestion of this kind on people who
have been thinking for some time of suicide is very strong. There
comes to them the impelling thought that the suicide's miseries are
over and they wish they were with him. From the wish to the resolve
and then to the deed itself are only successive steps when suggestion
is constantly prodding the unfortunate individual. If we are going to
reduce the suicide rate materially or, indeed, keep it from increasing
beyond all bounds, this question must be squarely faced. Accounts of
suicides are not news in the ordinary sense of the word and while they
might find a place for legal and other purposes in a few lines of an
obituary column, the present exploitation of them by the papers makes
them a constantly recurring source of strong suggestion to go and do
likewise. These suggestions come to persons already tottering on the
edge of disequilibration in this matter, and it is like tempting
children to do things that they know are wrong, but that look
irresistibly inviting when presented under certain lights. The very
fact that their death will produce a sensation and will give them so
much space in the newspapers attracts many morbidly sensation-loving
people. Physicians must work as much for this prophylaxis as we have
for the prevention of infectious diseases.


Child Suicides.--Probably the worst feature of the suicide statistics
of recent times in all countries is the great increase of self-murder
among children. Arthur MacDonald in discussing the "Statistics of
Child Suicide"   [Footnote 56] has shown that there is a special
increase of young suicides everywhere. In France there are nearly five
times as many suicides at the end of the nineteenth century as there
were at the beginning of it. In England there is almost as startling
an increase. Though the statistics are not as well kept, child suicide
has increased not only in proportion to the increase of suicide among
adults, but ever so much more. In Prussia the condition is even worse.

  [Footnote 56: "Statistics of Child Suicide," _Transactions of American
  Statistical Association_, Vol. X., pp. 1906-1907. ]


{721}

The French child suicide rate is especially interesting and
disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the
subject of suicide among young people and shows how rapid has been the
growth of the number of such suicides in the last 100 years. The first
statistics available for the purpose that, in his opinion, are exact
enough to furnish a basis for scientific conclusions, are from 1836 to
1840. Altogether during that period in France there were 92 suicides
under the age of seventeen years, 69 of whom were boys and 23 girls.
In 1895 this number had increased to such a degree that in a single
year there were almost as many suicides (90) as there had been in five
years, only fifty years before. In 1895 the proportion of suicides
less than ten years of age was a little more than one in twenty of the
total number of suicides in France. There are countries in Europe in
which the suicide rate among such children is even higher than it is
in France. In every country it has gone on increasing and the awful
thing is that the suicide rate is increasing more rapidly among
children than it is among adults, though among adults it doubles every
twenty years.


_Causes at Work_.--The causes for the increase in suicide among
children were pointed out even by Esquirol, the great French
psychiatrist, nearly a century ago. They are the same to-day, only
emphasized by the conditions of our civilization. He attributed it to
a false education which emphasizes all the vicious side of life, makes
worldly success the one object of life, does not properly prepare the
child for constancy in the midst of hardships, nor make it appreciate
that suffering is a precious heritage to the race, that has its reward
in forming character and fixing purpose. He thought that there were
two very serious factors for the increase of suicide among children
not usually realized. They were in his time literature and the
theater. He said: "When the theater presents only the triumphs of
crime, the misfortunes of virtue, when the books that are in common
circulation because of the low price at which they are issued, contain
only declarations against religion, against family ties and duties
towards our neighbor and society, then they inspire a disdain of life
and it is no wonder that suicide rapidly increases even among the very
young." He was commenting on the case of a child of thirteen who had
hanged himself, leaving this written message: "I bequeath my soul to
Rousseau and my body to the earth."


Cowardice of Suicide.--Of course, the strongest motive for dissuasion
from suicide is the utter cowardice of the act. As a rule, the man who
contemplates suicide is not a sufferer from inevitable natural causes,
but one who for some foolish act has put himself into what seems to
him an intolerable position out of which escape without disgrace is
impossible, and he is afraid to face the consequences of his own acts.
It is from the fear of mental worry and of the condemnation of others
rather than from any dread of physical suffering and pain that men
commit suicide. The suicide leaves those who are nearest and dearest
to him to face the battle of life alone, with all the handicaps that
have been created by their foolishness. Running away in battle is as
nothing compared to the cowardice of the suicide. The deserter is
deservedly held in deepest dishonor, and if there is some little pity
for the suicide, it is because of the supreme foolishness of his act
and the feeling that it only can have been dictated by some defect of
mental equilibrium. A frank recognition of these conditions in their
real significance probably will do more than anything {722} else to
make the prospective suicide realize the true status of his act better
than anything else.

Men sometimes seem to persuade themselves that it is a brave thing
thus to face death. The shadowy terrors of what may come after death
are too little realized to deter a man from his act when compared with
the real disgrace that he is so familiar with and that he has often
witnessed in actual life. It is the man, as a rule, who has most
condemned others when something has gone wrong, who has found no
sympathy in his heart for the slips of his fellows, who discovers no
courage in himself when he has to face disgrace. He does not realize
that for most men there are so many extenuations of any evil that a
man may do, that the large-minded man is ready to forgive and
eventually to forget almost anything that happens. "To know all is to
forgive all," and the more we know of men the readier we are to
forgive them. Little men do not forgive and cannot forget the failings
of their fellows and they think that everyone else looks upon men's
failings in the same way. It is only the small, narrow man who
contemplates suicide as a refuge from disgrace, and the fact that he
can complacently plan the abandonment of others not only to the
disgrace which he himself is not ready to face, but to all the
suffering consequent upon it, is the best proof of his littleness of
soul. The utter pusillanimity of suicide is the best mental antidote
for the temptation to it.

Besides, the thought that deterred Hamlet may well be urged:

                                          There's the rub;
  For in that sleep of death what dreams may come.
  When we have shuffled off this mortal coil,
  Must give us pause;
       . . . who would fardels bear,
  To grunt and sweat under a weary life;
  Cut that the dread of something after death.--
  The undiscovered country, from whose bourn
  No traveller returns.--puzzles the will;
  And makes us rather bear those ills we have.
  Than fly to others we know not of?

It is sometimes said that this is the argument of a coward, but such
cowardice is as reasonable as the dread of touching a wire that may be
carrying a high charge of electricity. Besides it is only such an
argument that will properly suit the man who, in his cowardice, is
ready to let others bear the brunt of his disgrace, flying from it
himself.  [Footnote 57]

  [Footnote 57: Is life worth living? How old this argument as to
  suicide is can perhaps best be appreciated from the fact that it is
  discussed very suggestively in a papyrus of the Middle Kingdom the
  date of which is probably not later than 2500 B. C, which is now in
  the Berlin Museum and is recognized to be the most ancient text of
  its kind that has been preserved in the Nile Valley. I have referred
  to this in the initial historical chapter. I think that I have more
  than once turned men's thoughts from the serious contemplation of
  suicide--always a dangerous thing--by discussing with them this
  fact that men have at all times in the world's history argued just
  the same way on these subjects. Men prefer not to resemble the dead
  ones, and a motive is all that is needed. ]

There has sometimes been an erroneous tendency to confuse suicide and
heroism, but Chesterton, in "Orthodoxy,"   [Footnote 58]
has well expressed the difference:

  [Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John
  Lane Co., 1909. http://www.gutenberg.org/ebooks/130]

{723}

  A soldier surrounded by enemies, if he is to cut his way out, needs
  to combine a strong desire for living with a strange carelessness
  about dying. He must not merely cling to life, for then he will be a
  coward, and will not escape. He must not merely wait for death, for
  then he will be a suicide, and will not escape. He must seek his
  life in a spirit of furious indifference to it; he must desire life
  like water and yet drink death like wine. No philosopher, I fancy,
  has ever expressed this romantic riddle with adequate lucidity, and
  I certainly have not done so. But Christianity has done more: it has
  marked the limits of it in the awful graves of the suicide and the
  hero, showing the distance between him who dies for a great cause
  and him who dies for the sake of dying. And it has held up ever
  since above the European lances the banner of the mystery of
  chivalry: the Christian courage, which is a disdain of death; not
  the Chinese courage, which is a disdain of life.

The feature of incidents in life that bring with them disgrace and
punishment which needs to be insisted on for those to whom the thought
of suicide comes, is that the sensation which the revelation of such
acts causes is but a passing phase of present-day publicity, and that
after all it is not even a nine-days' wonder, but a two- or
three-days' wonder, and then it is forgotten and replaced by something
else. The facing of the condemnation for the moment may seem an
extremely severe trial. The world's blame, however, is largely a
bogey, a dread that is phantom-like and that disappears, or at least
diminishes, to a great degree as soon as it is bravely faced. Besides,
as practically every man who has been carrying around a guilty secret
with him for years is free to confess, there is an immense sense of
relief once the worst is known. At last the effort at concealment, the
nervous tension, the fear of the moment of exposure are all past and a
new set of thoughts can be allowed to come. Those may be unpleasant
and yet they are not so bad as the dread of discovery that hung over
the unfortunate. If a man can be braced up to meet exposure, usually
he will find in a very few days that there are sources of consolation
that make it much easier for him to live than he thought possible
before.


Real Suffering a Tonic.--Probably the best remedy for a man or a woman
who talks of suicide and seems to fear lest the temptation should
overcome them is, if possible, to give them an opportunity to see some
real suffering. I have on a number of occasions had the opportunity to
note the effect on a discouraged man or woman of the sight of a cancer
patient suffering severely, yet bearing the suffering patiently,
wishing that the end might come, yet ready to wait until it shall come
in the appointed order of nature. Suffering, like everything else,
becomes much more bearable with inurement to it. The old have learned
the lesson of not only not looking for pleasure in life, but of being
quite satisfied with their lot if no pain comes to them, and they even
grow to consider that they have not much right to murmur if their pain
is not too severe. It is not among those who have to suffer severe
pain that one finds suicides as a rule. It is true that young, strong,
healthy persons who suddenly find that pain is to be their lot for a
prolonged period may grow so discouraged and moody over it as to take
their lives. The patients that I have seen suffering from incurable
diseases have expressed no desire at all that their life should be
shortened, except during the paroxysms of their pain, unless they feel
that they are a serious burden on others when they may express the
wish to be no more.


Euthanasia.--Every now and then there is a discussion in the
newspapers {724} of the justifiableness of euthanasia, that is, the
giving of a pleasant death to those who are known to be incurably ill
and who are doomed to suffer pain for most of what is left of their
existence. The question usually discussed is whether patients have the
right to shorten their own existence and then, also, whether their
physician might have the right or, even as some people say, the duty,
to lessen human suffering by abbreviating existence for such incurable
cases. The discussion has always seemed to me beside the realities of
things, because physicians do not see many patients, I might almost
say any patients, who really want to shorten their lives or would want
to have them shortened. I have known many physicians die of cancer,
but very seldom is it that one tries to shorten his own existence, or
that even his best friend in the profession would consider that he was
justified in doing this for him. This, it seems to me, should be the
test of the problem. It is true that not infrequently, in the midst of
their paroxysms of pain, patients wish they were dead, but there come
intervals of surcease from discomfort to some degree at least that
make life quite livable for a time again and even occasionally there
is real happiness in these intervals, deep, human, natural happiness
in heroic forbearance and example.

We can recall AEsop's fable of the old man who, gathering wood for the
fire in the winter that he needed so much, finds the burden of his
labor and the wood too much for him and calls loudly for death to come
to him. Promptly Death makes his appearance and asks what the old man
wants. "Oh! nothing," is the reply; "only I would like you to help me
to carry this bundle of sticks." This is the attitude of mind of
practically all who have grown old in suffering. They have learned to
bear with patience, and that patience gives even something of
satisfaction. After all, it is not so often the pleasant things in
life that we look back on and recall with most satisfaction as the
difficulties and trials. Virgil said long ago, _"Forsan et hoc olim
meminisse juvabit"_--perhaps at some future time we shall recall
these, our trials and pains, with pleasure. It is the conquering of
difficulty that means most for men and even the standing of pain is
not without an aftermath, if not of pleasure, at least of broad human
satisfaction. When we talk about euthanasia, then, it would be well to
ask some of these old people whether they want it or not. Seldom will
the answer be found to be that which is so often presumed, by those in
good health and strength, to be inevitable under such conditions.

Physicians have all seen incurable cancer patients who were
approaching their end inevitably and with the fatal termination not
far off, have hours and days of alleviation of suffering and even of
enjoyment that made up for the prolongation of life almost in the
midst of constant agony. The distinguished New York surgeon who had
the pleasure a few years ago of listening once more to his favorite
singer and fairly seemed to get renewed life from the inspiration of
her voice and who for days after had the pleasant consciousness of
smooth running life in improvement so characteristic of convalescence,
is a typical example of what may happen under such circumstances. I
shall not soon forget Dr. Thomas Dunn English, the well-known author
of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the
University of Pennsylvania, that, like Bismarck, he used to think that
all the joys of life's existence were in the first eighty years of
life, but of late years he had found {725} that many of them were also
in the second eighty years of life. He was at the time 83. He made the
most joyous and happiest speech on that occasion. He was quite blind,
was almost deaf, had been reported dying some months before, and had
gone through prolonged suffering, yet he was by his cheeriness and
whole-hearted gaiety on that occasion a joy and inspiration to all the
younger men at the table.


Dread of Suicide.--There are patients who come to the physician worked
up because they fear they may commit suicide. Every now and then the
thought comes to them that some time or other they will perhaps throw
themselves out of a window, or be tempted to drop in front of a
passing train, or over the side of a steamboat, or impulsively take
poison. Some nervous people become quite disturbed by these thoughts.
Every physician is sure to have some patients who must be reassured,
every now and then, that they are not likely to commit suicide. Their
nervousness over the fear of this may serve to make them supremely
miserable and it evidently becomes the doctor's duty to reassure them.
It is not difficult to do this, as a rule, provided the physician will
be absolutely confident and unhesitating in his declaration that there
is no danger that they will commit suicide, since it has almost never
been known that patients who dread it very much and, above all, those
who dread it so much that they take others into their confidence in
the matter, take their own lives. The very fact that the thought
produces so much horror and disturbance in them is the best proof that
they will not impulsively do anything irretrievable in this way.

Prof. Dubois has discussed this subject in his usual thoroughly
practical way and his words serve as an authoritative confirmation of
what has been already said, though as a matter of fact the expressions
and experience of nearly every nervous specialist thoroughly justify
the position here assumed. Besides, it must be realized that this
confident assurance is the best possible prop that doubting patients
can have with regard to the actions they dread, and by positive
declarations the physician will accomplish more than in any other way.

  There are patients who are subject to strange obsessions. They are
  afraid that they will throw themselves out of the door of a car, or
  climb over the parapet of a bridge. They are afraid that they will
  throw their relatives out of a window, or will wound somebody with a
  knife or a gun. There are some with a strong impulse to open their
  veins. But if there is a certain attraction in such things, it is
  really a phobia. It tends to make one shrink back and not to act.

  Nothing quiets these patients like the frequently repeated statement
  that they will not do anything. It is necessary to show them the
  vast distance there is between the impulse toward suicide and murder
  and the phobia which, however distressing it may be, is a safeguard.
  One must keep at this education of the mind with imperturbable
  persistence and use the most forceful and convincing arguments that
  one can think of to correct the judgment of his patient, in order to
  make the strings of moral feeling and reason vibrate in unison.

  It is through lack of courage and perseverance that we err in the
  treatment of these psychoneuroses. We wait too long to distinguish
  the morbid entities that bear on a certain etiology or a different
  prognosis. We do not see clearly enough the bond which unites these
  different affections.

It may seem to some physicians as though they would be assuming too
much responsibility in giving patients such positive assurance that
their dreads {726} will not be fulfilled, but as a matter of fact the
experience of physicians is quite sufficient to justify the confident
statements here suggested. It is true that occasionally a person who
afterwards commits suicide talks the matter over and hints at the
possibility of taking his own life. He does not, as a rule, speak of
it with dread, however, but as one of the alluring solutions of his
difficulties that he sees ahead of him. He is much more likely to
write a letter to his physician telling him that all his arrangements
are made and that by the time this letter reaches him he will be
already dead. The prospective suicide is usually quite secretive about
this purpose, not only to friends, lest he should be prevented from
accomplishing it, but even with his physician, in whom he has had
absolute confidence and to whom he has told practically everything
else. The patients who fear the possibility of committing suicide, who
tell how much they dread the horror of it, and who rush to consult the
physician to help them against themselves, show by the very fact the
unlikelihood of action on their part.


The Physician and Suicide.--By mental influence, then, the physician
may lessen the tendency to suicide in the individual and in the
community. To do this is to save suffering and to help in the solution
of one of the most serious social problems in modern times. It can
only be accomplished by a sympathetic attitude towards the whole
subject and a tactful understanding of each individual case. Every
effort in the matter, however, is well worth while, for there is no
more hideous blot on our modern civilization than the startling
increase of suicide. It is particularly important to bring about
improvement in this regard among young suicides, and fortunately it is
here that the influence of the physician for good is likely to be most
felt. The saving of life is the noblest part of the mission of the
physician and nowhere, perhaps, can this be accomplished more
successfully than with regard to some of these patients whom a rash
resolution, due to a momentary fit of depression and a sense of
suffering exaggerated out of all proportion to their actual pain, is
hurrying out of life.



CHAPTER IV

GRIEF

Grieving would seem at first glance to be one of the conditions for
which the physician, especially if the etymology of the name of his
profession be taken strictly, should not be called upon to minister,
nor his remedies be expected to relieve. Grief is usually supposed to
be due to moral ills and, therefore, at most to come under the care of
the alienist, with the feeling that even he can accomplish very little
for what is an affective rather than a true mental disorder. There is
no doubt at all, however, that grieving, especially in the excess that
shows it to be pathological, is always associated with certain
physical and mental conditions for which the physician can accomplish
much. Indeed more often than not the physical condition of the
grief-stricken person is a prominent factor in the production of the
state of feeling which causes grief to be exaggerated, while, on the
other hand, this state of mind {727} itself reacts upon the physical
being so as to make it more sluggish in all its functions, and as a
consequence a vicious circle of cause and effect is formed affecting
unfavorably both the mental and physical conditions. It is when
patients are run down in health that grief becomes extremely difficult
or apparently impossible to bear and grief itself still further brings
about a deterioration of health that makes the mind's reactionary
power against its gloomy feelings still weaker than they were.

Viewed in this way, grief is an ailment that should properly come to
the physician for treatment and with regard to which that important
principle is eminently true that the physician cannot always cure, but
he can nearly always relieve, and he can always console his patients.
On the one hand, an improvement in the general health always make
grief easier to bear because it increases the resistive vitality of
both mind and body. On the other, any diversion of mind that lifts the
burden of grief even to some degree, releases new stimuli and physical
powers for the restoration of bodily function to the normal and this
brings about an immediate lessening of the depressive condition. In a
word, for the vicious circle of unfavorable influences ever pushing
the victim farther into depression, a virtuous circle, in the Latin
sense of the word virtue, meaning courage, favoring strength, must be
formed, that brings about an immediate improvement in the patient's
mental and physical well-being. This is not a pretty bit of theory but
is the result of the experience of every physician who has ever taken
seriously the problems of caring for the grief-stricken.


Natural and Pathological Grief.--It is, of course, not easy to
distinguish between grief that may be called morbid in the sense of a
melancholy, that is, more than natural--a true mental disease--and
that which represents only an affective state accompanied by
depression from which there will be complete reaction. A mother loses
a favorite, it may be an only son, and is plunged into grief. For
days, even weeks, she refuses to take any interest in life, she thinks
moodily about the awful affliction that has come to her and how blank
the future is, and she cannot be aroused to attend either to her own
affairs or to the duties of life around her. Such a grief is, in many
cases, not more than the normal depression incident to such a loss. If
after months, however, the mother still continues to refuse to take
interest in life and the things around her, especially if, besides,
she now talks of having been visited with this punishment because of
some unpardonable sin in her own life, or because the Deity has been
offended beyond all hope of propitiation, then the case verges over
into one of true melancholy in which the mental depression is not
merely a symptom of a passing condition, but partakes of the nature of
a mental disease, or is the consequence of a profound neurotic
condition.

It must not be forgotten that there is always the danger that
exaggerated grief, as it seems for the moment to be, may be only the
first symptom of a true melancholic condition. Only too often friends
and physicians have been deceived by this. Some of the sad cases of
self-destruction and a few cases of homicide and suicide have followed
a condition that seemed to be only abnormal grief for the loss of a
relative.


Etiology.--The cause of exaggerated, prolonged grief is, in a
considerable proportion of the cases, a melancholic tendency, that is,
a failure on the {728} part of the mind to react against depression.
The weakness of mind that predisposes to this may be inherent or
acquired. Sometimes no special loss is needed to produce melancholia
in susceptible individuals, while occasionally it is precipitated by
some misfortune, inasmuch as this is a mental disease, very little can
be done directly, and yet the patient can be helped and diversion of
mind may bring a good measure of relief. More often, however, the
reason for persistent grieving is that before the disturbing loss came
into the life of the individual there had been a serious deterioration
in health. This was due to the conditions preceding the unfortunate
event. Wives sometimes have worn themselves out physically and
mentally while nursing husbands, or mothers their children, and this
has produced a lack of physical force which prevents them from
reacting with healthy mentality against the subsequent shock of loss.


Prophylaxis..--For the melancholic tendency prophylaxis cannot be
special, but must be general. We cannot prevent people from suffering
serious losses, but we can foresee the possibility of a loss proving
very depressing, and can, therefore, try to keep the individual in
reasonably good physical condition. If this is done the subsequent
depression will be much less than it otherwise would be. Very often
there is little or no recognition of the fact that there is a definite
tendency in some patients to too great an inclination toward
melancholic thoughts, and it is not until an exaggerated manifestation
of it comes that the danger is realized. It is not easy to make
patients realize the dangers, but where the physician talks with
assurance and points out definite things to do in order to prevent
serious developments, patients, or at least their friends, can be made
to appreciate the dangers.

The best demonstration that I know of the value of work as a remedy
for grief is my experience with members of religious orders. For them,
as a rule, there is no interruption in life no matter what the loss
may be. Their work goes on the day after the funeral just as before.
This is the most precious possible arrangement, time and occupation of
mind are the two factors that will dull the edge of grief and while
humanly we may resent the consolation that is thus brought by such
conventional things as the passage of time and humdrum occupations,
they represent nature's resources. Above all, patients must be given
something to do and if that something concerns other suffering human
beings, there is every reason to expect relief.


Treatment.--The most important element in the treatment of grief cases
is to prevent physical running down as far as possible and to build up
the physical condition. Depression that comes to patients who have
lost considerable weight, even though it may show some of the signs of
melancholia, is always hopeful. Where patients are twenty or thirty
pounds under weight the recovery of weight up to the normal condition
will often mean the relief of their depressed condition. The one hope
lies in this physical improvement. Mental treatment by diversion of
mind must, of course, be practiced. This does not mean getting the
patients interested once more in trivial things, but to be successful
it means arousing the deeper feelings of their nature. Above all, the
solace of tears will often save depressed and grieving persons from
themselves. An interest in the sufferings of other people that awaken
their sympathy will do the most to end exaggerated grieving over their
own loss. The self-centeredness of their grief is the principal reason
for its exaggeration. {729} It is because of overestimation of their
own importance and of the importance of their loss that these people
suffer severely.


_Motives of Consolation_.--The main resource of the physician who
would employ psychotherapy for the treatment of those who are grieving
beyond the limit of what is normal, is to supply motives by which they
can understand the real significance of their loss. Very often,
especially in young folks, there is no proper estimation of values in
life and no recognition of the fact that human life was evidently not
meant for happiness since that comes to but few, while suffering and
partings are inevitable. They come to all, and apparently will always
continue to do so. It is the young or, at least, those under middle
age, who are most likely to be affected by exaggerated depression over
losses and disappointments. Older folks have grown more accustomed to
such incidents. These patients must be made to see how many motives
there are to take their grief philosophically and while permitting
themselves the luxury of sorrow, not to let this interfere either with
their physical condition or their mental state to such a degree as to
prevent them from taking the proper interest in their duties in life.

The ethical motives that may be urged to keep people from grieving
over-much are many, but there is sometimes the feeling in the
physician's mind that it is scarcely his business to emphasize them in
any way. It is supposed that to the clergyman must be committed the
task of consoling people for losses in life. This has always seemed to
me a serious mistake. As physicians we know how much the mind
influences the body and since it is our duty to care for the body, we
must, above all and first of all, care for the mind as far as we can.
_Mens sana in corpore sano_ is a very old motto and is usually taken
only in the sense that to have a healthy mind one must have a healthy
body. In its Latin form, however, it might very well also be taken to
mean that to have a healthy body one must have a healthy mind. Since
grief has an untoward influence on the body, physicians are bound to
learn what to do for it in any and every possible way and to exercise
every faculty they have for its relief. This is all the more true
because in recent years many persons have no regular religious
attendant who would come to offer them consolation or to whom they
would go in their trouble. It is not at all with the idea of
infringing on the rights of the clergy or invading his territory that
I would insist not only on the right of the medical man, but even his
duty, to afford consolation to the mind as well as relief for the
body.


_The Family Physician_.--In older times the family physician was a
friend of the family to whom people turned in all troubles where he
might possibly be of aid, with just as much confidence and as promptly
as they did to their religious attendant. Unfortunately, in the
progress of medicine, though still more because of the social
vicissitudes that have taken place in recent years, this relationship
of the family physician has been largely diminished, but that
constitutes only one more reason why every physician, to whose
attention the grief of a patient for any loss is presented as a cause
of ill-health, should know all the means and be ready to employ them
for the amelioration of the condition. As a matter of fact, there is
often a feeling on the part of patients that it is more or less the
business of the clergyman to afford consolation and that the
performance of his duty in this matter is somewhat conventional, not
{730} as if he performed it less thoroughly because of this, but as if
the feeling of the routine practice detracted from its effectiveness.
Some of the motives for consolation advanced by the clergyman, then,
lose in significance, in some persons' minds at least, because of this
feeling, while motives presented by the physician rather gain in
weight because of the impression that he is a thoroughly practical
man, deeply interested in life's problems from a common-sense
standpoint, and who knows the motives for consolation because he has
realized that losses are inevitable, suffering unavoidable, and grief
sure to come, though somehow we must learn to bear up bravely under
life as we find it.

Physicians have always done this in the past, but in more recent years
either they have lost the habit, or have considered it unworthy of
their profession, or else, perhaps, only too often they themselves
have had no motives to offer that might seem sources of consolation
for those in suffering and especially those who are grieved for the
loss of friends. If life were a mere chance, if there were not an
evident purpose in it, if, as Lord Kelvin insisted, science did not
demonstrate (not "suggest" but "demonstrate" is the word he used) the
existence of a Creator and a Providence, Who, while caring for the
huge concerns of the universe, can just as well employ Himself with
the little details of human life, then there would be some reason for
physicians thinking that their science kept them from seeking
consolation from the ordinary motives. Even if they occupy an advanced
agnostic position, however, they may still find sources of consolation
that, if not so effective as those attached to the old beliefs, at
least will provide something for the forlorn to take hold of, that
will mitigate their grief and sense of loss and make the present and
the future look not all too blank.

Few men have been so thoroughly agnostic as Prof. Huxley, yet on the
death of his wife he found that some of the thoughts of the old
beliefs might prove a source of consolation. Huxley had loved his wife
very dearly and their separation by death meant very much. The epitaph
that he wrote for her sums up his doubts yet plucks out of them
something to console, expressed in old Scriptural language:

  And if there be no meeting past the grave.
  If all is darkness, silence, yet 'tis rest.
  Be not afraid, ye waiting hearts that weep.
  For God still giveth His beloved sleep;
  And if an endless sleep He wills, so best.


_Attitude Toward Death_.--The ordinary attitude of people toward death
is a very curious one. Death is the one absolutely certain thing in
life after birth, yet most of us live our lives without much regard to
it, and whenever it comes and under whatever circumstances, at
whatever age, it is always a shock to us. No matter how old people are
it always comes a little before it is expected. When death comes it is
always a shock and all that can be said of it is what Hamlet resents
when the commonplace consolations for the loss of his father, who also
lost a father and so on all down the course of history, are offered to
him. Perhaps, however, as much the reason for his resentment was the
person who offered the consolation as the form of the consolation
itself, which, after all, exhausts nearly all that we can say in this
matter for grief for near and dear ones:

{731}

  King.
    'Tis sweet and commendable in your nature, Hamlet,
    To give these mourning duties to your father:
    But, you must know, your father lost a father;
    That father lost, lost his; and the survivor bound
    In filial obligation, for some term
    To do obsequious sorrow: but to persevere
    In obstinate condolement, is a course
    Of impious stubbornness: 'tis unmanly grief:
        . . . Fie! 'tis a fault to heaven,
    A fault against the dead, a fault to nature.
    To reason most absurd, whose common theme
    Is death of fathers, and who still hath cried,
    From the first corse, till he that died to-day,
    "This must be so."


_Death and Pain_.--One of the most effective consolations in our day
for all classes of people, quite apart from religious affiliations or
beliefs, is the sociological import of death and suffering in the
world. Life, without suffering and death in it, would be a riot of
selfishness. Men, as a rule, would not care for others at all, the
weak would go to the wall, the individuals who possess less efficiency
than others would simply have to make out as best they could, and bad
as social conditions are now, they would be intolerably worse. As it
is the young and strong and vigorous have very little of true
sympathy. Nothing makes a man feel for others like having gone through
some suffering himself. On the other hand, nothing makes him feel the
impotence of struggling ceaselessly for vain success and the futile
rewards of life than to lose near and dear friends whose share in that
success and joy over the rewards would constitute their only real
value and justification. As a man grows older and has gone through
some of the sufferings and has had to bear the losses of life, he
learns more and more to feel for others, he is ready even to make
sacrifices that others may not have to suffer as he has suffered, he
has charity for them for the sake of his own suffering and that of
near and dear ones, and things are much better than they could
possibly be without suffering and death.


_Therapy by Example_.--Many men have taken losses so seriously as to
think that life held no more for them, and have foolishly given up
their occupations, yet have found that Time, the great healer, could
work his marvels in their case as well as in most others and that new
interests and, above all, their life work, could arouse them to a
sense of duty and bring them back to the old routine of life. Dr.
Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how
even that veteran surgeon gave up everything at the death of his wife
and yet found, after a year of idleness, that he had to come back to
the old life again. Dr. Mumford says: "Sir Astley Cooper was an
emotional man. In 1827 his wife died, and the event prostrated him
with grief. He felt that all the interests of life were over for him.
He fell into an acute physical decline, sold his town house, threw up
his practice and other professional employments, and retired to his
country place to pass his last days. Within a year of the sad event he
had returned to town, taken another house, resumed practice with
increased vigor, and married again. He was then sixty years old, he
lived on until 1841, and died in his seventy-fourth year."

{732}

A typical example of how much a strong man whose diplomatic ability
had stamped him as one of the large men of his generation may yet be
afflicted beyond measure by a loss of this kind is to be found in the
life of the second Lord Lytton. I have told it somewhat in detail in
the chapter on Periodic Depression. After the death of his boy Lord
Lytton, who for more than a week of anguish had watched unceasingly at
the death-bed of his dying son, came to the conclusion that God was
not in His world or, at least, that the arm of Providence was
shortened if such (as it seemed to him) needless suffering was
permitted. The boy had probably suffered much less than the bystanders
thought and much less than he seemed to, for in these cases nearly
always there is a merciful deadening of the senses that to a great
extent eliminates suffering, but Lord Lytton could not understand and
refused ever to look at life from the same standpoint afterwards. This
is, of course, only what happens in many cases, but it represents an
exaggeration of grief since death and suffering have always been in
the world and sometimes they will come to those near and dear to us,
much as we may resent it.

Neither profound intelligence nor the sympathetic genius of the poet
or artist is sufficient to safeguard men against the severer forms of
griefs for loss. Louis, the distinguished French physician (to whom we
in America are indebted so much as the Master of the Boston and
Philadelphia schools of diagnosis, and, above all, for his teaching of
the differentiation between typhoid and typhus fever), suffered so
much from the loss of his son that he could scarcely be consoled.
Dante Gabriel Rossetti was so much affected by the death of his wife
that he put into her coffin the only manuscript copy of his poems that
he possessed. It is interesting to learn that some years later he had
the coffin exhumed and took out his manuscript at the urging of
friends, and published the poems. Many other examples of this kind
might be given, for exaggeration of grief affects all classes and
conditions in life. They are practically always pathological, usually
on a basis of somewhat disturbed mentality, though often the real
underlying and predisposing condition is the physical exhaustion that
has preceded the loss and which makes patients unable to bear the
strain of it after weeks of care, solicitude, anxiety and neglect of
eating and sleep.



CHAPTER V

DOUBTING


In recent years the attention of physicians has been called to the
fact that many people are made profoundly miserable by an
unconquerable tendency to doubt about nearly everything that has
happened to them, or is happening, or is about to happen. This is not
a new phenomenon, but introspection has emphasized it, leisure gives
more opportunity for it, and so physicians hear more of it now than
they did in the past. This doubting tendency sometimes makes serious
inroads on the peace of mind of sufferers from it because they cannot
make up their minds to do things, even to take exercise, to eat as
{733} they should in quantity or quality, and to share the ordinary
life around them sufficiently to get such diversion of mind as will
keep their physical functions normal. The state used to be described
as a neurasthenia (nervous weakness), but in recent years has come
better to be designated as in the class of psychasthenias (lack of
mental energy). It is always a mental trouble in the sense that it is
difficult for these patients to make up their minds about things, yet
it is not a mental disease in the ordinary sense of the term, and
these people are often eminently sane and thoroughly intellectual when
their attention has been once profoundly attracted. They may even,
under favorable circumstances, be active and useful helpers in great
causes, yet there is always to be observed in them a certain
noteworthy difference in mentality from the normal. The physician can
do more for an affection of this kind than is usually thought, and he
is probably the only one who can thoroughly appreciate and sympathize
and, therefore, be helpful in the condition.

Sufferers are often laughed at by their friends and relatives and are
likely to be the subjects of at least a little ridicule if they take
their troubles to their physician. As a matter of fact, however,
doubting is a typical case for psychotherapeutics and not only can
much be done for its relief, but it can be kept from disturbing the
general health, which it is prone to do if neglected, and by mental
discipline and acquired habits of self-control, the doubting habit may
be almost completely eradicated.


Exaggeration of Ordinary State of Mind.--The first thing absolutely
necessary to impress upon the minds of these victims of their own
doubts is that their condition is by no means unique, it is not even
very singular, but is only an exaggeration of that hesitancy and
tendency to put off making decisions that practically every person
finds in a lifelong experience. This frame of mind is rather
cultivated by education and by a large accumulation of knowledge. The
less one knows the easier it is to come to decisions about difficult
problems and to form conclusions without hesitancy. The young man will
decide anything under the sun, and a few other things besides, almost
without a moment's hesitation, and after but slight consideration.
Twenty years later he looks back and wonders how he did it, and having
done it, how he succeeded in turning the practical conclusions to
which he came to advantage. The scholar is eminently a doubter and a
hesitater, and we recognize that he loses certain of the qualities
that would make him a practical man of affairs, though he gains so
much more that broadens and deepens life's significance that there can
be no doubt about the value of his liberal education.

"Hamlet" is just the story of one of these doubters and hesitaters. He
saw his duty clearly and that duty was imperative. In spite of
cumulative evidence, however, he refused to go on to the performance
of that duty, urging to himself now one and now another reason of
delay, until finally he wonders whether it would not be worth the
while to take his own life, rather than try any longer to solve the
problems that lie around him demanding solution. When he finally does
something, his hand is forced and circumstances have so arranged
themselves that instead of one clean-cut punishment for a great crime,
there is the tragedy that involves six lives, including his own. The
play seems to involve such exceptional characters and to be written
around such an unusual set of circumstances that it might be thought
{734} that it would prove uninteresting for men and women generally.
As a matter of fact, however, "Hamlet" is the most popular of
Shakespeare's plays and probably the most popular play, both for
readers and auditors, that was ever written. There are commentaries by
the hundred on it in nearly every modern language. Men have been more
interested in this figment of Shakespeare's imagination than in any
man that ever lived. Caesar and Napoleon have not attracted so much
attention. Only Homer and Dante have been perhaps more written about
than Hamlet.

Shakespeare has emphasized the condition of Hamlet by showing us an
eminently well educated man. His deep interest in literature, and
especially in dramatic literature and all that relates to the stage,
can be appreciated very readily from his speech to the players. No one
but a man of profound critical ability and deep intellectual interests
could have so summed up the actors' relation to the drama. Of course,
this is Shakespeare himself talking and unthinking people have said
that this was a purple patch fastened on the play because it gave the
author an opportunity to express his views with regard to actors and
their ways. Instead of that, it is of the very essence of the
development of Hamlet's character and shows us the scholarly amateur
who knows so much about many things that he has become quite unable to
make up his mind about the practical problems that lie before him.
James Russell Lowell says that Shakespeare sent Hamlet to Wittenberg,
though Wittenberg was not founded until centuries after Hamlet
existed--and Shakespeare probably knew that very well--because
Wittenberg in Shakespeare's time, on account of its connection with
Luther and the religious revolt in Germany, had the widespread repute
of occupying men's minds with doubts about many of the things that had
been deemed perfectly settled before, and its popular reputation
serves to give an added hint as to the character of Hamlet as the
dramatist saw it.

Once those who are perturbed by doubts learn that the reason for the
universal human interest in Hamlet is that there is a large capacity
for doubt of self in every man and woman, that we all put off making
decisions whenever possible, sometimes refuse to open letters when
they come if we fear that they will contain some disturbing news, put
off writing letters because we have to state ideas definitely,
apparently hope that the day and the night will bring us counsel and
that somehow the decision will be made for us without the trouble of
making up our minds, then they lose their sense of discouragement over
their condition and appreciate that they are suffering only from an
exaggeration, probably temporary and quite eradicable, of a state of
mind that comes to practically every human being.

This is the important thing, because on it can be founded the only
really hopeful therapy of the condition. Doubting is a habit that may
be increased by yielding to it, but that can be diminished to a very
great extent by constant discipline, which refuses to permit doubts
and hesitancy and bravely makes decisions, even though there may be
the feeling that they may prove to be wrong.


Extent of Affection.--If such discipline is not instituted, then the
lengths to which the doubting hesitant habit may go are almost
incredible. I have had patients tell me that they doubted about nearly
everything in the past. A very dear friend once confided to me that it
was always a source of bother {735} to him that he was not quite sure
whether he was married or not. His marriage I knew had been a public
ceremonial, and he had led his bride down the aisle to the strains of
the "Wedding March" in quite conventional style, but he was hesitant
of speech, especially under excitement, and he was not sure that he
had ever said "I will" to the question of the clergyman, for there was
a constriction at his throat at the moment and he could utter no
sound. The absence of any audible sound from the groom is not so
unusual as to attract attention and, of course, his intention and his
bodily presence and everything else gave the assent without the
necessity for the word, but he could not get out of his mind the
thought that possibly he was not married and at times it gave him
poignant discomfort. He was a thoroughly intelligent man, a teacher
and a writer, with no abnormalities that attracted attention, and his
tendency to doubt was only known to very near friends who laughed at
it and had no idea at all of the annoyance that it often gave its
unfortunate victim.

I have a clergyman friend who has had some serious scruples with
regard to his ordination. He is a Catholic priest and at a certain
part of the ceremonial of ordination it is considered necessary for
the candidate for orders to touch at the same moment the paten, the
small metal plate on which the Host is placed, and the chalice. This
clergyman is not sure that he had done this simultaneously. As a rule,
great care is exercised in seeing that all the details of the
ordination ceremonies are carried out very exactly and as there are a
number of attendants on the altar whose duty it is to see that the
absolutely necessary details are properly fulfilled, it is quite
improbable that any mistake in this matter was made. The young
clergyman, however, had not made an act of conscious attention at the
moment when he was supposed to do this, and consequently he could not
be sure afterwards whether he had done it or not. He thought of it as
the very essence of his ordination and he feared that all his
subsequent acts as a clergyman might be impaired by this negligence.


Trivial Doubts.--It is not alone with regard to important things,
however, that people may doubt and are disturbed by doubts, but with
regard to every trivial thing in life, if they permit the habit to
grow on them. Doubting is, after all, one of the phobias, that is to
say, it is the fear that something may happen if the decision they
make is wrong, that causes people to hesitate so much. There is a
tendency in all of us which, if undisciplined, may make us put off the
doing of things until the last moment. It is easy to resolve the night
before that we will do certain things the next day, but when the next
day comes we find excuses to put them off. I have already suggested as
a symptom that some people put off the opening of letters. There are
probably more who do this than anyone has any idea of. Delay in
answering letters is probably much more often due to hesitancy of
decision than to actual laziness. We doubt as to what we should say
about certain things, and we do not care to take the trouble of making
up our minds, and we fear if we do make up our minds it may be wrong,
so we adjourn the whole matter to another time and keep on adjourning
it. Many people are quite ready to confess that they do not do things
until they have to, though few are ready to acknowledge that it is due
to hesitancy or doubting about themselves and their decisions.

{736}

Of course, the man who doubts whether he has locked the door of his
house after he gets to bed can only satisfy himself by getting up and
actually investigating the state of affairs. Then there is the man who
doubts whether he has locked his safe at the office. He may get his
doubts just as he reaches the foot of the elevator and then if he is
wise he will go back and determine the matter. If he is wise with
experience he will also deliberately determine while he is there
whether the office window is closed and locked and will make a
conscious act when he comes out as to the locking of the office door.
If he does not do all this he will have further doubts on the way up
town and at his home during the evening which will make the doing of
anything else a matter of discomfort and he will spoil the restfulness
of his after-dinner hours. Some men conquer their first doubt, make
their way home only to be beset by so many doubts that at the end of
an hour they go back to their office and determine whether the safe is
locked or not. Finding it locked they may forget to notice other
things about the office and then they will surely have doubts about
these, and they may have to go back again and see about them.

Then there is the man who doubts whether he posted a letter or if he
did post it, who doubts whether it found its way down to the bottom of
the mail box, or whether it may not have caught on a projecting screw
or bolt or some portion of the upper part of the box and so fail of
collection; he may go back several times to determine this. Doubts
about even more trivial matters than this, however, annoy some people.
I have known widows on whom the responsibility of managing the
financial affairs of the household had been thrown for the first time
after their husbands' death, who constantly doubted whether they could
afford to spend this or that, though they were regularly saving money
from their income. Over and over again they would have to go over all
their recent expenditures to decide whether they could afford certain
expenses. Such little things as the sort of paper to use in their
correspondence, the wages they paid their servants, the amount of
waste in the food in the household, all aroused in them doubts and set
them to calculating once more just what was the relation of their
income to expenditure, all to no purpose, for they would have the same
doubts the next week or month.

Then there are people who doubt whether their friends really think
anything of them. They think that though they treat them courteously
this may be only common politeness and they may really resent their
wasting their time when they call on them. They hesitate to ask these
people to do things for them, though over and over again the friends
may have shown their willingness and, above all, by asking favors of
them in turn, may have shown that they were quite willing to put
themselves under obligations. They doubt about their charities. They
wonder whether they may really not be doing more harm than good,
though they have investigated the cases or have had them investigated
and the object of their charity may have been proved to be quite
deserving. They hesitate about the acquisition of new friends, and
doubt whether they should give them any confidence and whether the
confidences that they have received from them are not really baits.
This is, of course, a verging on suspicion as well as hesitancy and
doubt, but the stories of how these people try to conquer themselves,
yet have to make decision after decision, each one requiring time and
a certain resolution of mind, are quite {737} pitiable. It gets worse
rather than better unless a definite discipline of opposition and
control is organized.

What ordinary people do habitually and easily and without any effort
of mind, these people must waste time and mental energy over so that
it is extremely difficult for them to accomplish anything. Training of
mind, as of hand, consists in making certain actions so habitual that
they are accomplished quite automatically. If we have decided that we
are to get up at a certain hour we get up at that hour and do not have
to make up our minds about it again, though this is one of the actions
in which we all have the most lapses and the most need of renewal of
resolution and habit. We make up our mind what we are going to eat and
gradually acquire the habit of eating a certain quantity and a certain
variety at meals and then we do not have to make up our minds about it
every time. We go out, to do whatever must be done in our occupation
quite automatically and there is no need of wasting mental energy over
decisions about it. It is this that the doubter cannot do. He or she
calls every trifling act before the supreme court of last decision,
the bar of intellect, to decide whether it is worth while doing,
whether it is to be done or not, how it is to be done, and then there
is a doubt whether after it is done it may not prove to be quite the
wrong thing to have done. This adds so much to the friction of life
that all the surplus energy is used up in the settling of trivial
matters, and nothing worth while is accomplished.

Sir James Paget once expressed all the realities of the situation of
many of these people in a few terse phrases. It is probably the best
explanation of its kind that we have and it deserves to be in the
notebook and often before the mind of physicians who treat neurotic
patients. Sir James said: "The patient says 'She cannot'; her friends
say 'She will not'; the truth is she cannot will."

The expression, of course, applies to many other phases of so-called
nervous disease besides doubting and especially to the psychasthenias.
It represents, indeed, the keynote of many of these puzzling
affections. The fact that it was uttered more than half a century ago
shows how much better these affections were understood two generations
before ours than we are likely to think, and how well physicians then
got to the heart of them. From this to the re-education of will, that
mental discipline and relearning of self-control which constitutes the
essence of the treatment of them, is but a short step.


Prophylaxis.--_Serious Occupation_.--Of course, the real way out of
the trouble is to have to do certain important things that occupy the
mind and require the doing of many other things as subsidiaries which
must be accomplished in order to carry out the greater resolution. Men
who have important affairs on their hands seldom are bothered by
doubts and hesitancy. Women who have not much to do make mountains out
of the molehills of their little occupations and every trifle must be
adjudged. The larger interests must be cultivated, the smaller ones
must be turned over to the automaton which every one of us can develop
in our persons if we only set about it resolutely. Each thing that
comes up must be settled at once and action must replace
contemplation. The Hamlet in us all must be put down and resolution
must not be allowed to be sicklied over with the pale cast of thought.
We must do {738} things and not think about them too much. The
doubters can learn this lesson. They will never be entirely without
hesitancy, but they can remove many of their difficulties, and live to
accomplish much in spite of their make-up.


Physical Treatment.--The physical treatment of the doubting state
consists, of course, in bringing the individual's physical condition
as near as possible up to the normal. When the state occurs in people
who are under weight its betterment is rather easy. The special
feature of the physical condition that needs seeing to is an ample
supply of fresh air. People who live in ill-ventilated places, or who
do not get out into the air enough, are almost sure to suffer from the
tendency to avoid the making of decisions. The man of decision usually
is a vigorous outdoor-air individual. Even the perfectly healthy man
who has been in the house for some reason for days together gets into
a state of mind where the making of decisions becomes objectionable.
He wants to push things away from him. In individuals who already have
a natural tendency this way this is greatly exaggerated by
confinement. Arrangements must be made, therefore, that will ensure
getting out for some time, not once but twice every day. The regular
making of decisions for this purpose is of itself a good mental
discipline. It must not be omitted even for rain or snow, unless there
are additional reasons of some kind. An abundance of fresh air in the
sleeping-room is extremely important and must be secured.


Mental Treatment.--The mental treatment consists in diversion of mind.
Usually the doubters have no interests that appeal to them deeply and
in which they have to make prompt regular decisions. If possible,
these must be secured. They must form habits of doing things regularly
and of making up their minds to do them, and then not have to repeat
the adjudication and resolution. In recent years people realize, quite
apart from its religious significance, the value of what older
religious writers called examination of conscience. Regularly before
they go to sleep these people must be told to call up what they have
done during the day and to note their faults in the matter of putting
off doing things and making decisions slowly. They must, however, not
only realize their faults, but they must make up their mind to correct
them during the following day. They must not leave the arrangement of
what they shall do next day to chance, but must decide just how and
when they shall do things and then, as far as possible, keep to this
program. The program must, of course, be sensible and considerate.
This preliminary arrangement can be made to mean much more than might
be thought. Some people thus learn to correct entirely their tendency
to doubt whether they should do things or not and lessen greatly the
difficulties they have in making decisions.



CHAPTER VI

RESPONSIBILITY AND WILL POWER


The development of science (meaning by that term knowledge with regard
to physical nature in contradistinction to philosophy or the relation
of nature to man) in modern times has brought about in some minds a
hesitant, if {739} not frankly contradictory attitude towards the
question of free will. There are many scientists who not only doubt
the existence of free will, but insist that there cannot be such a
thing. For them, man like the animals is determined to do things from
without rather than from within. The stronger motive compels him.
There may be a weighing in the balance of motives, but that is a
question of intellect and not of will. It is true that the stronger
motive may be one that is less alluring to nature or to sense than
some of the others which clamor for a hearing, but it is eventually
the stronger motive that compels. A man may desire something that does
not belong to him very much, but the consciousness that it does not
belong to him and that to take things that do not belong to him is
unworthy of him will override his covetousness and so he remains
honest if he has been trained to regard things that way. After all,
the old maxim, "Honesty is the best policy," is founded on some such
reasoning as this, since only one who is at heart dishonest would
consider men as swayed by the thought that to be honest is the most
profitable, instead of being the right, and therefore the only proper
thing.

The argument for free will that appeals to most men is the
consciousness that we are free and that at any given moment we can do
a thing or not do it, just as suits us. If two things are presented
to us we can do that one which seems right to us to do, or we can do
both of them, or we can permit ourselves to be led into the wrong,
though always acknowledging to ourselves that it is the wrong and
feeling downcast, or at least disturbed, that we should let ourselves
be led away from higher motives. Even in this case the determinist
insists that we are determined from without by motives due to our
training, to our education along certain lines with the influence of
the environment in which we live, to the special sentiment that we
have within us as a consequence of the influences of preceding life.
Such determination, however, does not come from without us, but from
within. It is the result of the formation of our wills in a particular
direction. The argument is, therefore, a begging of the question. A
man may have formed the habit of doing evil things and then finds it
easy to do them without compunction. On the other hand, the exercise
of his will in doing what he considers right, in spite of the fact
that it may not be pleasant at the moment, is a training of the will
founded on its essential freedom. There is an essential distinction
between right and wrong, and we have it in our power, as many a man
has done, to follow the right even though it costs our life.


Bad Temper.--A typical example of supposed determinism, which proves
exactly the opposite of what is sometimes urged, may be noted with
regard to exhibitions of temper. As Clouston declares in his
"Unsoundness of Mind" (Methuen, London, 1911), "an uncontrollable
temper is in many cases very like and nearly allied to an unsoundness
of mind. It is certain that bad temper may gradually pass into
technical insanity and that a considerable number of persons who are
passing or have passed into insanity exhibit as the most marked
symptom morbidness and violence of temper. 'It's just temper. Doctor,'
is one of the most common remarks that I have heard made to me by
patients' friends. I think that it is quite certain that in most cases
much might be done in youth to establish a reasonable control over
temper where it is inclined to be uncontrolled, so preventing serious
discomforts in life both to its possessor and to others. In many cases
I am satisfied that {740} this education would have the effect of
preventing unsoundness of mind also, arising out of uncontrolled
temper." There are many examples in the literature of hagiology
particularly, from which it is clear that men have learned to control
even violent tempers and by self-discipline and training in
self-control have even become rather quiet, gentle individuals. The
truth of such examples is attested too well to be discredited. This
question of training, then, is extremely important.

It has been pointed out that the consciousness of freedom to which an
appeal is made in this argument for free will is shared with us by the
insane even in the performance of many acts that we know are compelled
in certain ways. Insane persons reason themselves into a peculiar
state of mind, in which they represent to themselves that they have
been persecuted, for instance, by a particular person and then they
become persecutors in turn and do harm. As they see their act, it is
often a species of self-defense. They themselves have no
consciousness, or, at most, a very dim and hazy realization of the
inner compulsion to which they are subjected at the time of the act
and sometimes talk quite rationally and discuss the motives which
impelled them to do things, just as if they were free. We recognize,
however, the distinction between this delusion of the insane and the
rational state of mind of the sane. We have no definition for
insanity, that is, no formula of words, which will absolutely include
all the insane and at the same time exclude all the sane, but we have
a practical working knowledge that enables us to judge rather well
between those who are compelled to do things by delusions, and those
who do them from motives that are rationally weighed and that
influence a will that is free to follow them as it pleases. We hold
the rational man responsible for his acts because he knows he was free
not to do them. We punish him partly because he should not have done
them and partly because we want him not to do them again, and we know
that punishment will help him to keep from committing crime, because
it will support his free will against his inclinations, when the time
of trial comes again.

Above all, we are conscious of our own responsibility. We know that
when we do wrong we are worthy of blame. We know that when we allow
covetousness to lead us into the appropriation of what does not belong
to us we are deserving of punishment, because we need not have done
it, but we yielded to unworthy motives. We know that while anger may
be blind we can control it, at least those of us who are fully in
possession of our intellectual and voluntary powers, so as to keep
from doing violence, even in the heat of it. This dealing with
ourselves is the best proof that we have of our recognition of our
freedom of will. We are responsible, and what we genuinely do not will
to do is not accomplished. Our will may be bent by many attractions,
but we know that these motives are not compelling unless we allow them
to be. When a child tells us that he did something because he could
not help it, we either feel sorry for him because he is not yet in
possession of his full faculties or else we laugh at this excuse.
There is a tendency to admit this excuse as having a meaning, but only
by those who themselves come into court with hands assoiled in some
way and who are looking for pardon from others for offenses, and who,
above all, want to feel that they can pardon, or at least excuse,
themselves.

In recent years we have seriously impaired the idea of responsibility
in {741} the minds of the general public by a foolishly sentimental
mercifulness to criminals. If a man under indictment for murder can
show that he has ever previously in his life acted even slightly
irrationally, or if he has been peculiar in certain ways, provided, of
course, he has money enough to pay for the opinions, there will be an
abundance of expert testimony to declare that he is irresponsible and
should not be punished. As a consequence, in many cases justice fails.
We are reaping the harvest of this pseudo-scientific invasion of law.
Human life is cheaper in no country in the world than it is in
America. Our murder rate is going up by leaps and bounds, while that
of Canada remains almost stationary, and the reason is that while nine
out of ten of all our murderers do not receive the death penalty and
many of them escape serious punishment of any kind, nearly as large a
proportion of Canadian murderers are punished by death. A man may have
his responsibility somewhat impaired and yet retain sufficient free
will so that he deserves to be punished for serious crimes. It is hard
to decide in certain cases, but in most cases the decision is not
difficult if, with the right sense of justice, morbid sentimentality
is put aside.

    [Footnote 59, the following lengthy citation  is from an article on
    "Responsibility and Punishment," in the _American Journal of
    Medical Science_, 1909.]


  While the doctrine of free will is so clear it is still true that
  the question of responsibility for actions, and above all for
  criminal actions, is not so simple as many people used to proclaim
  it in the past. No two men are free to perform an act or not to
  perform it in quite the same way. Familiar examples are ready to
  hand: One man finds no difficulty at all in resisting the
  inclination to take spirituous liquor to excess; another finds it a
  most difficult feat, often apparently impossible for him to refrain
  from indulging to excess almost whenever the opportunity offers, or
  at least whenever he gets a taste of liquor. This difference between
  the two men is founded in their very nature. It would be utterly a
  mistake to praise the one for his abstinence or to blame the other
  under certain circumstances for his indulgence. Between these two
  classes there are others quite different individually. Some of them
  have a slight tendency, and, fearing the worst, do not indulge in
  it; some of them have a marked tendency which they are able to
  resist under most circumstances without very much difficulty once
  they have made up their minds; some are sorely tempted, fall
  occasionally, yet never become habitual drunkards. For each of these
  men there is a different responsibility, and so far as they are to
  be punished a different punishment must be meted out, for it is our
  effort in the modern time to make the punishment fit the criminal
  and not the crime.

  This same thing holds true for many other forms of crime. Some men
  readily lose sight of the distinction between mine and thine, and
  possess themselves of their neighbors' goods almost without
  realizing that they have done wrong. They are rare, and we have been
  accustomed to call these people kleptomaniacs. Between these and the
  man who hesitates to steal, even when starving or for his starving
  children, there are many degrees of inclination and disinclination
  toward stealing. The same thing is true to a more noteworthy degree
  with regard to anger. Anger, the old saw says, is a brief madness.
  In America we say very frankly that a man who is very angry is mad.
  In this brief madness he may be led to do things which he would not
  do at all in his sober senses. Some men easily get into one of these
  awful fits of anger in which their responsibility is lessened, while
  others have a calm phlegmatic disposition from which they are
  scarcely aroused even by the worst forms of abuse or injury, or even
  physical suffering.

  It is evident in all these cases that in order to measure how much
  of punishment ought to be meted out for acts committed it is more
  necessary to know the individual than his act. This often becomes an
  extremely difficult matter, for {742} after the commission of crime
  every effort is made to make out as little responsibility as
  possible for the criminal. The easiest way to do this has been to
  use the insanity plea. As already stated, we have no definition of
  insanity. It is easy to understand then that there will be a
  disagreement among physicians as to who is or is not insane, and the
  result is almost sure to create doubt which tends to obscure the
  principles on which are based the proper punishment of crime. Now
  this system is founded on certain wrong principles as regards the
  administration of Justice. While it is difficult to decide with
  regard to a man's insanity or sanity, it is not difficult to decide
  with regard to his punishment when the ordinary purposes of
  punishment are kept well in view.

  The old idea of punishment used to be that of revenge. A man had
  done a wrong, and what would ordinarily be held a wrong had to be
  done to him in order that the scales of Justice should be maintained
  level. At the present time we have no such idea at all. Punishment
  has two main purposes--the prevention of further disturbance of
  social order by the particular criminal, and the deterrence of
  others from like acts. If a man takes away the life of another we do
  not take away his because thus Justice will be obtained, but we take
  it away to prevent him from ever doing anything of the same kind
  again. A man who has committed murder is more likely to do it again
  than another. He has committed one breach of social order; we shall
  prevent him forever from committing another of the same kind. This
  is the very best deterrent to such crimes that there is. It will be
  said, of course, that these men could not refrain from doing their
  acts. It is doubtful, however, whether this contention is true in
  the great majority of cases, and the proper punishment of such as
  occur furnishes the best possible motive to help others from the
  commission of like acts.

  This holds true for children at a time when their sense of
  responsibility for their acts is as yet undeveloped. They can be
  taught, even very early in life, by properly applied punishment,
  that need not be severe, that they must not do certain things, and
  then they will not do them, or at least, will do them much less.
  This is true not only for perfectly rational children, but also for
  those that are to some degree irrational. Punishment is of great
  importance in the training of children of low grade intelligence,
  and there is scarcely any child, however wanting it may be in
  intellect, that cannot be disciplined into conduct that makes it
  much less bothersome than would ordinarily be the case. This is well
  known and it is also well known that the attempt to manage such
  children without punishment would be extremely difficult, not to say
  impossible. They do not reason about the thing, they are not quite
  responsible for their acts; but they do connect punishment with what
  they have done, and are in many cases deterred from doing it again,
  especially while they realize that authority is near them and that
  punishment is inevitable. These are the principles on which the
  adjudication of punishment for crime must be measured. There is
  nothing else that can be done if society would preserve itself and
  its members from those who are irresponsible even in minor degrees.

  In this matter practical experience is well worth the while. The
  lower order of creatures, the animals, we do not consider
  responsible for their acts in the same way as human beings. We know
  the value, however, of punishment in deterring them. A dog, for
  instance, by being whipped a few times when he is young, can be
  taught not to steal things to eat, and taught that there is an
  inevitable connection between the taking of such things and the
  infliction of such punishment. I shall not soon forget my first
  lesson in philosophy from a dear old professor, who, talking of the
  memory of animals, demonstrated that they had a memory, from the
  ordinary experience of mankind with regard to them. "If a cat does
  something naughty in your room," he said, "you rub its nose in it,
  and it will not do it again." The cat had no idea that it was doing
  wrong. According to its way of life it was not doing wrong. It
  learned, however, from sensory experience that it must not do this
  sort of thing under special circumstances, and after the lesson has
  been once thoroughly learned there is no more trouble of this kind.

  Individuals who are of less mental stability than normal require,
  indeed, more careful discipline than average men. The rational may
  be managed by sweet reasonableness. The defective child must be made
  to realize that certain actions {743} will surely be followed by
  painful punishment, though, of course, the main purpose of modern
  care for such children is to watch over them so diligently as to
  prevent them getting into mischief. This is after all what we do
  with the animals, and we realize the necessity for it. Defective
  human beings approach the animal in their lessened power to resist
  impulses, and they must be treated in the same way. If we were to
  save the animals in an excess of tenderness toward them, because we
  held to the notion either that they did not know any better or else
  could not resist their impulses, and then permitted them to do
  things without punishment, we should either have to get rid of
  animals entirely, or else life would be one continuous readjustment
  of things to animal ways. Since defectives occur in the general
  population, it must be realized that far from being less rigid with
  them in the matter of meting out punishment for things they do that
  are harmful to others, we must be even more strict with them.
  Otherwise, we will have to take the bitter consequences of our own
  foolishness.

  It does not make so much difference if the thoroughly rational
  individual occasionally escapes punishment for something done, but
  whenever the subrational escapes, he is encouraged to do it again.
  More than that, the example of his punishment is needed for others.
  So far as possible, punishment must inevitably follow crime in the
  world, in order to impress the subrational and deter them from
  yielding to impulses. Far from being less deserving of punishment in
  every sense in which a modern penologist cares to inflict
  punishment, these individuals are more impressed by it, and, above
  all, need to be more impressed by it. When the subrational know that
  they can do things without being severely punished for them, they
  will always abuse that state of affairs. The thoroughly rational man
  may be depended on to do his duty as a rule without the need of
  punishment hanging over him. This is not true for the others, and
  hence the greater increase in crime, and above all in murder, which
  has made human life cheaper in this than in any other country in the
  world, as the direct consequence of recent abuses in our penal
  system.

  It has become very clear now that in recent years we have come to
  take entirely too lenient a view in these matters, and that many
  criminals who deserved to be punished, both because in this way they
  would be prevented from future crime and others deterred by the
  knowledge of their punishment, have been allowed to escape Justice.
  The tendency is toward too great mercifulness, which spoils the
  character of the nation, just as leniency to the developing child
  spoils individual character. Men may very well be insane, in the
  broad meaning of that term, in the sense that they have done
  irrational things, but then there is almost no one who has not. The
  responsibility of most men for a definite action is quite clear in
  the sense that if they are punished they will not do it again, or
  will be less likely to do it again, while if they are not punished
  their escape becomes a suggestion to themselves and to others to
  repeat such acts. It is for the subrational that we most need to
  insist on punishment. The cunning of the insane is proverbial, and
  this extends also to the subrational, and many of these folk realize
  that their difference from others, their queerness, as their folks
  call it, is quite enough to make a verdict of insanity in their case
  assured with the present lax enforcement of law. If the present
  state of affairs continues in this matter, we are simply allowing
  ourselves to be led by the nose by these cunning people into the
  perpetuation of a state of affairs in which they may do what they
  like because we have become foolishly oversensitive in the matter of
  inflicting punishment.

  On the principle that punishment deters, a man who has killed
  another man, even under conditions that seriously impaired his
  responsibility for the act and with evidence of previous lowered
  mentality, must never again be free to live the ordinary life of
  men. He must be under surveillance, and should be confined for life
  in an institution for the criminally insane. For the subrational
  such a sentence, if known to be inevitable, would usually be more
  deterrent than even imprisonment in an ordinary prison for life with
  all the possibilities for freedom which are presented by executive
  clemency, pardoning boards, and the like. It is absurd to say that a
  man may have such an attack of mental unsoundness as will lead him
  to do so serious an act as taking away human life, and then be
  expected to get over his mental condition so as not to be likely to
  do the same thing again. {744} Every alienist knows that this is not
  true. Such acts, when really due to mental instability, occur either
  in depressed or maniacal conditions, and these, as is now well known
  from carefully collected statistics, inevitably recur, or in
  weakened toxic conditions in susceptible subjects, and a return to
  the old mode of life may at any time bring recurrences.

It is in the treatment of disorders of the will of various kinds that
the physician is brought to realize how much harm is done by the
teaching that determinism and not free will rules life. It is true
that we often find cases in which men and women cannot use their wills
or at least seem not to be able to use them. They are lacking in some
essential quality of human mentality. We find many human beings,
however, doing things that are harmful for them and that are so
inveterated by habit that it is extremely difficult to get away from
them. In every case the sane person can conquer and break the habit,
no matter how much of a hold it may have obtained.

We have heard much of the born criminal and of the degenerate and his
inevitable tendencies, but most of the theories founded on this phase
of criminal anthropology have gradually been given up as a consequence
of more careful and, above all, more detailed observation. Many
criminals bear the stigmata of so-called degeneration. Many of them
have irregular heads, uneven ears, some fastened directly to the cheek
and some with the animal peak, many have misshapen mouths and noses,
but, on the other hand, many people having these physical qualities
are good men and women, perfectly capable of self-control, honest,
efficient members of society, and it is evident that the original
observations were founded too exclusively on the criminal classes,
instead of on the whole population. It is important, then, to get away
from the notion of irresponsibility in these cases.

While men are free, yet each in a different way and the freedom of
their wills is as individual as their countenances, it must not be
forgotten that the freedom of the will is a function of the human
being, and, like all other functions, can be increased or decreased by
exercise or the lack of it. The old idea of "breaking the will" was as
much of a mistake as that other old-fashioned notion contemporary with
it of "hardening" children by exposing them to inclement weather and
severe physical trials. The will may be strengthened, however, by the
exercise of it and if not exercised it may not be expected, by
analogy, at least, to be as weak and flabby as muscles would be under
similar circumstances. The training of the will by self-denial and
self-control is extremely important. When there is an hereditary
influence, a family trait and not merely an acquired character, by
which the will rather easily passes out of control, there is all the
more need for the training of it in early youth. Without such training
men may find it impossible to make up their minds to deny themselves
indulgence of many kinds, but this is not because they have not free
will, but because this function has never been exercised sufficiently
to enable them to use it properly. A man who attempts to do gymnastic
feats without training comes a cropper. A man who is placed in
circumstances requiring hard muscle exertion will fail if his muscles
have not been trained to bear it. The same thing will happen with the
will.

Unfortunately this training of the will has been neglected to a
considerable extent in modern education, and, above all, in modern
families, where the presence of but one or two children concentrates
attention on them, {745} over-stimulating them when young, leading to
self-centeredness and, above all, discouraging self-denial in any way
and preventing that development of thorough self-control which comes
in the well-regulated large family. Besides, unfortunately it is just
the neurotic individuals who most need thorough training in
self-control and whose parents suffer from the same nervous condition
(for, while disease is not inherited, defects are inherited), that are
deprived of such regular training in self-control because of the
inability of their parents to regulate either themselves or others
properly. Here is the secret of the more frequent development of
neurotic symptoms in recent years. It is not so much the strenuous
life as the lack of training of the will so that the faculty of free
will can be used properly. Lacking this, hysterical symptoms,
unethical tendencies, lack of self-control become easily manifest. The
training that would prevent these should come early in life, and when
it does not it is very difficult to make up for it later. Just as far
as possible, however, it is the duty of the psychotherapeutist to
supply by suggestions as to training and discipline for the education
of the will that has unfortunately been missed.


{746}

SECTION XX

_PSYCHOTHERAPY IN SURGERY_



CHAPTER I

PSYCHOTHERAPY IN OLD-TIME SURGERY


Surgery, a name derived from chirurgy--handwork--might seem to be
dependent almost entirely on mechanical and technical skill, yet there
has always been the conviction that the patient's attitude of mind
towards an operation is almost as important a factor in the success of
surgery as the surgeon's skill.


Astrology in Surgery.--From the earliest history of surgery we, find
that astrology was mainly employed in order to determine what days
were likely to be favorable, and what unfavorable, for the practice of
such surgical procedures as were in vogue at that time. Certain
conjunctions of the planets were declared to be particularly
unfavorable, and some of them, indeed, were declared almost absolutely
fatal; others were said to be especially favorable. As astronomical
and anatomical knowledge grew, more and more details were added in
this matter. Definite portions of the body were supposed to be under
the occult influence of certain constellations. It was only with
careful reference to these constellations then that surgical
procedures or, indeed, the application of remedies of any kind, might
be undertaken. All remember the picture in old almanacs of a man with
the signs of the zodiac around him, and the indications that referred
certain of these signs and the corresponding constellations to the
different parts of the body.


_Venesection and the Stars_.--When venesection became a frequently
used remedy, the question of the favorable and unfavorable influence
of the stars was an important element in it. In old Babylonia, noted
for its knowledge of astronomy, which was then called astrology
without any of our derogatory meaning in the word, certain positions
of the planets were absolute contraindications for the performance of
venesection. Indeed, astrology often furnished the best possible
excuses for the failure of what were thought to be absolutely specific
remedies. When the remedies did not succeed, their failure was
attributed to their being taken at unfavorable times and not to the
remedies themselves. These astrological ideas continued to influence
medicine, and, above all, surgery, down almost to our own time.
Galileo and Kepler made horoscopes, and Mesmer wrote a thesis on the
influence of the stars on human constitutions. In fact, very few
important patients of the seventeenth and even eighteenth centuries
were treated medically or surgically without due reference to the
stars at the time. All this had a profound influence on {747} the
patient's mind. He felt that every precaution was being taken to
preclude the possibility of failure and assure favorable results, and
he, therefore, submitted to the operation absolutely confident that so
far as human knowledge could go, everything was favorably disposed in
his regard.


Mental Influence in Old Hospitals.--It is rather interesting to
realize how much the history of medicine illustrates the profound
attention that was given in the old times to the question of the
occupation of patients' minds as an eminently helpful factor in the
treatment of disease and, above all, in convalescence. In the great
health resorts, the temple hospitals like that at Epidaurus, or even
the city hospital, the AEsculapeum at Athens, the question of
recreation of mind was evidently considered very important. At Athens,
the two city theaters, the larger one seating perhaps 50,000, and the
smaller, Odeon, were not far from the hospital. At Epidaurus, a
theater seating probably 12,000, in which the great Greek classic
plays were given; a Stadium, seating nearly 10,000, in which athletic
contests were conducted, and a Hippodrome, seating 6,000, in which
animal performances might be witnessed, were all in connection with
the temple hospital. Outdoor sleeping apartments were provided; that
is, the patients slept under a colonnade, and, in general, the mental
and physical hygiene of modern times was thoroughly anticipated. All
of this was considered particularly important for convalescents.
Patients were occupied, while in bed, with various interests. Just as
soon as they could be moved, their minds were occupied with all sorts
of interests external to themselves, and especially such as had the
readiest appeal to humanity. (See bird's-eye view, facing p. 9.)


Medieval Hospitals and the Mind.--It is not difficult to trace the
development of similar conditions in the hospitals of the Middle Ages.
While we are inclined to think of these older hospitals as surely
lacking in everything that we have developed in our modern hospitals,
they prove, on the contrary, to have anticipated most of our hospital
improvements. They were of single story construction, with large
windows high up in the wall so that there could be no drafts, with a
balcony on which patients could sit in the sun, with arrangements for
procuring privacy rather easily by means of sliding partitions, with
tiled floors, and, above all, with pictures on the walls, some of them
the products of the brush of the great artists of the old time and
which would serve to occupy patients' minds. Probably nothing is worse
for patients who are convalescing from illness or operation than to be
left to their own thoughts. Often they must not be talked to overmuch,
or permitted the exertion of conversation or of reading, yet they must
have some occupation of mind. The frescoes painted directly on the
walls of the old hospitals were eminently psychotherapeutic in this
respect, and we shall probably have to imitate them. Besides, the
patients had the opportunity every morning to hear Mass, which was
said at an altar at an end of the ward, and certain religious
exercises were conducted by the sister nurses each afternoon. How much
of consolation this was to believing patients at a time when all were
believers is rather easy to understand.


Medieval Surgeons and Mental Influence.--Some of the insistence on
this favorable state of mind for operations during the Middle Ages is
extremely interesting. One of the great surgeons of the fourteenth
century was Mondeville, whose text-book has recently been published in
both France and {748} Germany. I have translated in "Old-time Makers
of Medicine"   [Footnote 60] some of his emphatic expressions, which
show how important he deemed it to keep the patient in as favorable a
state of mind as possible before and after operations. He went so far
as to suggest that someone should be deliberately called in to tell
him jokes. He said, "Let the surgeon take care to regulate the whole
regimen of the patient's life for joy and happiness by promising that
he will soon be well, by allowing his relatives and special friends to
cheer him, and by having someone to tell him jokes, and let him be
solaced also by music on the viol or psaltery. The surgeon must forbid
anger, hatred, and sadness in the patient, and remind him that the
body grows fat from joy and thin from sadness. He must insist on the
patient obeying him faithfully in all things." He repeats with
approval the expression of Avicenna that "often the confidence of the
patient in his physician does more for the cure of his disease than
the physician with all his remedies."

  [Footnote 60: Fordham University Press, 1911.]

Mondeville was but one of the great surgeons of the medieval period
who dwelt on this. It would not be hard to find corresponding
expressions in the books of such men as Guy de Chauliac, Hugh of
Lucca, Theodoric, or even earlier among the great Arabian physicians
and surgeons. Rhazes, for instance, declared that "physicians ought to
console their patients even if the signs of impending death seem to be
present, for the bodies of men are dependent on their spirits." He
considered that the most valuable thing for the physician to do was to
increase the patient's natural vitality. Hence his advice: "In
treating a patient, let your first thought be to strengthen his
natural vitality. If you strengthen that, you remove ever so many ills
without more ado. If you weaken it, however, by the remedies that you
use, you always work harm." Another of his aphorisms seems worth while
quoting: "The patient who consults a great many physicians is likely
to have a very confused state of mind." For him a confused state of
mind evidently meant a lessened tendency to recovery.


Surgical Lesions Influenced.--The King's touch in England, which so
often proved beneficial for scrofulous patients, illustrates very well
how much strong mental influence may avail even in cases where surgery
seems surely indicated. Many cases of epilepsy were also greatly
benefited by the King's touch, and, indeed, in this matter there are
probably many more cases of the cure of epilepsy, or at least relief
of the worst symptoms of the affection, reported as following the
King's touch than after operation in the modern time. In both sets of
cases we are now confident that the good effects produced came through
the minds of the patients. When, during the eighteenth century,
Mesmerism began to attract attention, investigators and experimenters
on the subject were able to show that many pains and aches could be
greatly benefited by psychic treatment. The painful conditions
following fractures and sprains proved to be particularly amenable to
mental influence exerted in this special way. As we approach the
modern time, there comes to be a definite recognition of the fact that
the mind may produce many pains and aches which seem due to purely
physical conditions that might be expected to yield only to physical
treatment. A corresponding recognition of the power of the mind to
lessen and even suppress actual physical pain is almost a corrollary
of this.

{749}

Sir Benjamin Brodie declared, as I have quoted in the section on
"Diseases of the Muscular and Articular System" that a large
proportion of the painful joint conditions that he saw among his
better-to-do patients were of the hysterical or neurotic type. Sir
James Paget thought this expression of Brodie an exaggeration, but
acknowledged that one-fifth to one-fourth of all his cases in both
hospital and private practice were due to hysteria. In those days most
of the painful conditions were considered to belong rather to surgery
than to medicine, so that these opinions represent very well the
practice of medicine in these cases during the early nineteenth
century.

During the nineteenth century great practical surgeons, and especially
those who have taught us how to treat individual patients rather than
their diseases--for it is quite as true in surgery as in medicine that
the patient is more than his disease--have made distinct contributions
to the department of psychotherapy in surgery. Dr. Hilton's great book
on "Rest and Pain" is full of psychotherapy. His cases illustrate the
fact that when patients' minds and bodies are set at rest, all sorts
of serious conditions proceed to get better. The rest of mind, the
cessation of worry, the presence of a feeling of confidence in
recovery, is quite as important as the physical measures. Young
surgeons particularly probably could not do better than follow the
advice of the old Scotch surgical professor at Edinburgh who suggests
to his pupils that they should read Hilton's "Rest and Pain" at least
once a year.



CHAPTER II

MENTAL INFLUENCE BEFORE OPERATION


Much may be done during the preparation for operation to put the
patient in the most suitable condition for the manifestation of
healthy reaction of tissue and of normal convalescence. Many patients
do not come for operation until their health has been somewhat
impaired at least by the condition requiring operation. Not
infrequently a good proportion of this impairment of health is due not
so much to the lesion that is present as to the worry over it and the
anxiety and solicitude which its development has occasioned. If the
lesion is in connection with the digestive tract, this is particularly
likely to be true, and nutrition will often have been sadly interfered
with, not so much by direct influence of the pathological condition as
by the unfavorable mental influence developing in connection with it.
We know now that it is perfectly possible for an indigestion which is
entirely above the neck to make rather serious inroads upon the health
of the patient, by producing dislike for food or at least such loss of
appetite as leads to considerable reduction in weight. In such cases
there are often complications, such as tendencies to constipation,
that still further impair health or at least reduce vitality and
therefore hamper that healthy reaction which should occur after
operation in order to assure normal convalescence.


Accessory Neuroses.--In many of these cases, even where there is a
definite lesion present, the patient can be brought up to normal
weight, or at least his condition can be greatly improved by medical
treatment accompanied {750} by such attention to his state of mind as
will neutralize its unfavorable influence. If he can be made to
understand that a definite effort to increase weight and to bring back
his strength will be of assistance in recovery from the operation, and
that the reestablishment of certain habits of eating and caring for
himself will do much to help in this, very desirable changes for the
better in his general health may be brought about. This is illustrated
very well by what happens in certain incurable cancer cases. The
patients often have lost considerable weight, even thirty to forty
pounds, before an operation is decided on, and then when the operation
is performed their cancer is found to be inoperable. After the
exploration the patient is not told this, but is mercifully spared and
is assured that now he ought to get better, since an operation has
been performed. Such patients have been known to gain twenty, thirty,
and in one case I believe over forty pounds as the result of the
mental influence of this suggestion and the resumption of former
habits of life to some extent at least, consequent upon the
neutralization of the unfavorable state of mind into which they had
sunk before through over-solicitude about themselves. If even the
depressing effect of the toxins of cancer can thus be overcome, it is
easy to understand how much can be accomplished when there is no such
physical factor at work.


Dominant Ideas.--As a general rule, it must be recognized that
patients may be, and indeed frequently are, besides their definite
pathological conditions, under the influence of dominant ideas which
must be recognized and as far as possible neutralized. Some of them
have persuasions with regard to food and the amount that they can eat,
others have removed many important nutritious articles from their diet
and are quite sure that any attempt on their part to take such
articles is sure to be followed by indigestion, and still others have
habits with regard to the amount and the kind of fluids that they take
at meals and between meals and, above all, the lack of fluids in their
diet which need to be overcome. Unless such ideas are counteracted
there is difficulty even in convalescence, and very often they have
brought patients into physical conditions in which whatever
pathological condition is present is emphasized by that over-attention
which the nervous system is so prone to give to even slight sensations
when the organism is in a state of lowered nutrition.

In not a few of these cases the bringing of the patient up to the
normal condition of weight and health, and the removal of the
influence of dominant ideas, will perhaps also remove many of the
indications for operation. There are many patients, and especially
such as are reasonably educated and have some leisure, who get certain
of their organs on their minds and produce symptoms or emphasize such
symptoms as are present until it seems as though an operation is the
only thing that can lift their burden of discomfort and permit them to
go on again with their work. We have all known of physicians who felt
sure that they ought to be operated on for such conditions as gastric
ulcer or duodenal ulcer, though subsequent developments in the case,
when they were persuaded to put off operation and made to reform
certain ill-advised habits, proved that no such lesion as they
suspected had ever been present. Indeed, some of these physicians and
even surgeons have insisted so much that surgical friends occasionally
have operated on them and have found nothing to justify the operation.

{751}

Some of these states in connection with discomfort of various kinds in
the abdomen have been discussed in the chapter on Abdominal
Discomfort, and some illustrations of useless operations given. We
must not forget that there is a constant stream of pathological
suggestion in the air at the present time, not only in medical
journals, but even in the secular press, and that this concentrates
the attention of patients on comparatively slight discomforts and
leads to the exaggeration of them until even an operation seems a
welcome relief for them.


Operative Persuasions.--While surgical operations are in practically
all cases mutilations, they are absolutely necessary under certain
circumstances, are often, indeed, life-saving, and there is no doubt
that they have saved mankind a great deal of discomfort. Surgeons are
agreed, however, that they are not to be performed unless they hold
out a definite promise of physical relief. It is extremely important,
then, that patients must not become persuaded of the need of an
operation in their cases unless surgical intervention is really
necessary. This is as true for physicians and even surgeons
themselves, as I have said, as it is for the general public. Women are
much more susceptible than men to operation suggestions, and since it
has become fashionable to talk about _their_ operations, not only has
the deterrent idea of surgical mutilation been greatly lessened, but
there has actually developed in many of them a morbid fascination for
a similar experience with all its attraction of attention and promised
occupation of mind for the woman of leisure.

This phase of the necessity for favorable mental influence has been
especially emphasized in the chapters on Gynecology. Unless,
therefore, there are very definite indications, operations must not be
performed, for they will relieve, as a rule, only for the time being,
and further operations may have to be done to no purpose. Any
physician of reasonably large experience has seen such cases. Patients
get the idea of an operation as their one hope, and then nothing less
than that will produce such diversion of mind as will bring relief of
symptoms. It is important in these cases that such patients should not
have operations suggested to them. Once the suggestion takes hold,
they do not use their reserve energy in such a way as to help out
effectively other remedies that may be given. They distrust all
remedial measures, think that at most they can be only palliative, and
so do not add to other forms of therapeutics the power of
psychotherapy to cure them.

Besides the abdominal conditions, there are certain tuberculous
conditions with regard to which this seems to be particularly true. I
have seen enlarged cervical glands disappear without discharge when
patients have taken up the outdoor life, and, above all, when they
have gone out of the city and have lived the regime proper for those
in whom tubercle bacilli are growing. If such patients, however, once
become persuaded that their glands must be operated on, they are
likely to need, if not active intervention, at least the discharge of
material from their tuberculous lesions before they get well.
Operations of a radical character for tuberculosis used to be much
more popular than they are now, when we are likely to think that
nature can do more for tuberculous lesions in nearly all cases than
the most skillful surgery.


Fractures and the Mind.--In such surgical conditions as fractures and
dislocations, a change has come about in the mode of treatment, at
least in many hands, that seems entirely physical in its effect, yet
has undoubtedly {752} exerted important psychic influences favorable
to recovery which deserve to be noted. In dislocations and fractures,
and particularly the latter, it was the custom in the past to do the
fractured limb up in bandages and then leave it until knitting of the
bones, or, in dislocations, healing of the soft tissues, had taken
place. Apparently it was forgotten that this eminently artificial
condition was not conducive to that healthy reaction of tissues for
reparative purposes which must be expected in these cases. Circulation
was not so good because of the constrictive effect of the bandages;
vitality not so high because of failure of nervous activity in
absolute immobility; the return venous circulation was somewhat
hampered because there were no contractions of muscles; and all the
conditions were distinctly unfavorable, though nature was expected not
only to maintain the health of the part, but bring about the added
functions of repair. In spite of the more or less unfavorable
conditions, nature was able, as a rule, to do so. Prof. Lucas
Championére reintroduced the older method of treating fractures and
dislocations more openly and of even using certain manipulations,
passive movements, and massage in order to encourage the circulation
and the natural vitality of the limb.

There is another phase of the influence of this mode of treatment that
deserves to be recalled. When the fracture is hidden away for many
days and the patient is not absolutely sure whether it is getting on
well or not, solicitude or anxiety is awakened in some minds that
prevents, or at least delays, normal healthy repair. It is well known
by surgeons that fractures do not heal so well after accidents in
which there has been considerable shock, or in which the simultaneous
death of a friend seriously disturbs the patient's mind. Nor do
fractures heal so well if the patient is worried about business
affairs or seriously disturbed over family matters. Among sensitive
patients, a state of mind not unlike that produced by worry or shock
may develop as a consequence of the dread that the fracture may not
heal properly, or that there may be deformity, or that when the
surgeon removes the bandages he may find it necessary either to break
it again or do something that would involve considerable discomfort.
These patients need reassurance. If the surgeon sees the broken limb
occasionally, and, by manipulation and passive movements such as may
properly be used, assures himself as to its condition, the patient's
mind is much better satisfied and that inhibition of trophic processes
which otherwise sometimes occurs is prevented.


Incisions and Suggestion.--Something of this same psychotherapeutic
influence is noted with regard to the healing of incisions when these
are not left without inspection too long. The newer surgical customs
of comparatively few dressings, so that the wound may easily be
inspected and the patient may be completely assured with regard to it,
has undoubtedly had a good influence in bringing about more rapid
repair. Air is the best environment for a healing as well as a healthy
skin, and mental trust is best for the patient's power of repair. In
vigorous individuals such repair will occur anyhow. It is in those of
delicate health, neurotic disposition, and psychoneurotic tendencies,
that reassurances are needed. Often their physical condition is such
that they need every possible aid in bringing about complete repair.
Their state of mind, then, must be noted carefully, and any inhibitory
ideas that may be present because of over-anxiety as to how the
incision is getting on must be removed. This does not mean that
patients' whims should be yielded {753} to in the matter of
over-solicitude about their condition, but that proper care should be
taken to prevent inhibition of trophic influences through unfavorable
mental states just as far as is possible. Most surgeons of experience
do these things in the proper way by instinct from the beginning, or
by a tactful habit, which develops in their surgical experience of
adapting themselves to individual patients. It is well to realize,
however, that such mental attitudes are extremely important and must
be deliberately treated by the surgeon.


Pseudo-rabies.--Certain conditions usually treated of as surgical have
mental relations that are very interesting. There seems no doubt that
in a certain number of cases pseudo-rabies occurs; that is, persons
are bitten by a dog, become seriously disturbed over the possibility
of rabies developing, and after brooding over this for a time their
mind gives way and there is either a neurosis simulating many symptoms
of true rabies, or a state of collapse from fright in which even death
may take place. These cases are not frequent. Their occurrence is
taken by some of those who are opposed to animal experimentation as a
proof that rabies is always some such delusion, and that it is due to
the exaggeration of the significance of dog-bites by the medical
profession that the symptom complex known as rabies has come into
existence. This is, of course, nonsense, and many true cases of rabies
occur. Since, however, these other cases provide the opportunity for
argument in the matter, it is all the more necessary that they should
be recognized for what they are. When a patient has been bitten by a
dog that has not died from rabies within three weeks after the bite,
there is practical certainty that the animal did not have and could
not communicate rabies. The cases of hydrophobia with long incubation
periods are rather dubious, and the general impression now is that
there has been subsequent infection. Patients who are in the midst of
overwhelming dread of the development of rabies must be taken
seriously and their cases treated by mental influence. Suggestion,
instruction, and the neutralization of wrong ideas by reference to
authorities in the matter, must be used to overcome the unfortunate
state of mind which may, if allowed to continue and, above all, to
develop, prove serious for the individual.

Pseudo-rabies is but a type, though the most serious and perhaps most
frequent of what may be called surgical psycho-neuroses. There are
others. Imaginary syphilis is an affection that often causes worry and
trouble to patient and physician. _Herpes preputialis_ with mental
symptoms is almost as bad. These are mental infections of various
kinds. There are many neoplastic persuasions and toxic suggestions
that must be treated with tact and firmness.



CHAPTER III

MENTAL INFLUENCE IN ANESTHESIA


Nowhere in the domain of surgery is the influence of the mind more
important than in the production of anesthesia for surgical purposes.
It is well known that intense preoccupation of mind will make an
individual completely anesthetic even for very severe injuries. In
battle men frequently are severely wounded, yet do not know it, or at
least have no idea of the extent of the wound and of the pain that
ordinarily would be inflicted by it. In the {754} midst of panics, as
during fires, or when crowds are trying to get out of buildings
rapidly, people often suffer severe injuries and know nothing about
them. The story of the woman who lost her ear in the theater panic and
was quite unaware of it until her attention was called to it, is only
one of many striking examples. Men have been known to walk round even
with a broken leg, or with a dislocation with which it proved quite
impossible for them to move, once their mental preoccupation for
others ceased and they had time to think about themselves. Anesthetic
incidents under conditions in which great pain might well be expected
are not uncommon. It is evidently possible so completely to occupy the
mind that pain sensations cannot find their way into the
consciousness.


Pain and Diversion of Mind.--From very old times, attempts have been
made to use this power of the mind to prevent pain, and often with
some results. In preanesthetic surgery, minor operations were
performed rapidly, beginning just after the patient's attention had
been attracted to something else besides the thought of the operation.
Pain is, of course, much less tolerable and seems to the sufferer at
least to be much more severe whenever the attention is concentrated on
it. Specialists in nervous diseases, during the process of eliciting
complaints of pain or tenderness while employing movements or
manipulations, usually try to attract the patient's attention as much
as possible to something else, in order to determine just how much
genuine pain or tenderness is present. Often it is found that, while a
part of the body is complained of as exquisitely tender or it is
averred that a joint cannot, be touched or a limb moved without severe
pain, when the patient's attention is attracted strongly to something
else, deep palpations may be practiced and rather extensive
manipulations can be made without complaint. In these cases very often
the pain is not imaginary, but is slight, due to some physical basis,
and has been very much increased by the concentration of attention on
it. This part, at least of the pain, may be removed by an appeal to
the mind. The principle is valuable when there is question of minor
operations.

Surgeons have often taken advantage of this power of distraction of
attention to relieve pain in surgical manipulations. The story is told
of the French surgeon, Dupuytren, that he was called one day to see a
lady whom he knew very well in order to determine the form of injury
from which she was suffering. He found that she had a dislocation of
the shoulder, and during the manipulations, in order to make his
diagnosis, he almost inevitably inflicted considerable pain. She
complained very bitterly and told him that she understood that he was
very rough with his hospital patients, but he must not be rough with
her. He had hold of her hand at the moment, and, just before grasping
the arm in such a way as to make the manipulations necessary to reduce
the dislocation, he slapped her face and told her that she must not
talk to him while he was treating her. Needless to say, she was deeply
shocked. Before her shock had passed away, Dupuytren had completed the
reduction of the dislocation, and in her preoccupation of mind she
felt almost no pain. She remarked afterwards, however, that she had
suffered so much mental anguish from his unexpected roughness that she
was not sure whether, after all, she had been really spared in her
feelings.


Hypnotic Anesthesia.--When, in the first half of the nineteenth
century, {755} scientific attention was seriously attracted to
hypnotism, it was hoped that this would prove an effective means of
producing anesthesia during surgical operations or at least of greatly
lessening pain. The hope was not disappointed. There was a discussion
on the subject before the Medical Chirurgical Society of London in
1840, and in 1843 Dr. Eliotson wrote a work with the title, "Numerous
Cases of Surgical Operations Without Pain in the Mesmeric State." In
1846 Sir John Forbes wrote in his Review that "the testimony as to the
value of hypnotism as an anesthetic is now of so varied and extensive
a kind as to require an immediate and complete trial of the practice
in surgical cases." At the end of that same year, ether as an
anesthetic was introduced into England, and the first case was
reported under the caption "Animal Magnetism Superseded," which shows
how much attention the previous attempts at hypnotic anesthesia had
attracted. After this, hypnotism was given up for anesthetic purposes
except by a few enthusiastic students of it. These, however, succeeded
in accomplishing much with it. Dr. Esdaile, in India, succeeded in
doing all sorts of operations under hypnotism. Dr. Milne Bramwell, in
"Hypnotism, Its History, Practice and Theory" (London, 1906), lays
down the rules for hypnosis for anesthetic purposes. They are
eminently practical.

While hypnotism can be used to produce anesthesia, it has many
disadvantages. The length of the hypnosis cannot always be arranged so
as to assure anesthesia during the whole of an operation, while in
some cases it will continue after the operation for some time in spite
of every effort on the part of the hypnotist to bring the patient to
himself. Besides, the depth of the hypnosis cannot always be assured,
and sometimes some sensation remains. Patients will groan and wince
and move, though, of course, under ether or chloroform such
manifestations may take place, yet the patient afterwards will give
every assurance that not the slightest pain was felt. In some cases,
however, even where the pain sensation is not severe during an
operation under hypnosis, it may, nevertheless, prove sufficient, when
continued for some time, to bring the patient out of the hypnotic
state.

For short operations of minor character, undoubtedly hypnosis can be
employed successfully. As we explain in the chapter on Hypnotism,
anyone can produce hypnosis who has confidence in his own power and in
whom the patient has trust. There is no need of a special hypnotist,
and there is no special faculty required. There should be some
familiarity with procedures, but any man has just as much hypnotic
power as another. The influence does not pass from the operator to the
subject, but is due to the subject's concentration of his attention so
that there is a short circuiting of association tracts within the
brain very probably, which does not permit the entrance into
consciousness of sensations through any path except one or two,
usually that of hearing, and sometimes of sight, less frequently of
other sensations.


Concentration of Attention.--In a great many cases of minor
operations, such as the opening of a boil of a small abscess, the
pulling of a tooth, the lancing of a gum, or other such procedures, a
surgeon who is confident in his own mental power over his patient can
rather easily produce a state of mind in which the discomfort of the
surgical procedure is greatly minimized. There are certain physical
helps for this. For instance, if patients are asked to breathe rapidly
and deeply for a few minutes, there is a hyperoxygenation {756} of the
blood which seems to obtund sensibility. If patients are told of this,
and then made to breathe rapidly for a half a minute in order that
they may continue consciously their deep, rapid breathing even when
pain is noted, a state of mind is produced from concentration of
attention on their breathing in which painful sensations are greatly
obtunded. The effect is probably more mental than physical, and is
well worth while trying because of the amount of pain it often saves.


Waking Suggestion.--Without resort to hypnotism, much can be
accomplished by mental suggestion in the waking state to lessen the
pain of surgical operations and maneuvers. This is particularly true
as regards nervous persons, who will otherwise emphasize their
discomfort, and for those of lesser intelligence, children, and the
like. Esdaile's experiences in India show how much can be done in this
way. Often the hypnosis was so slight that the patients were perfectly
cognizant of everything that went on around them, yet under the
compelling influence of the assurance of Dr. Esdaile, whom they
trusted completely, they did not complain of pain nor wince even when
considerable surgical intervention was practiced, and they always
assured their friends afterwards that they had felt nothing. I know an
American physician who has an almost similar power over negroes.
Ordinarily it requires more of an anesthetic to produce
insensitiveness to pain in the negro than in a white person. By
personal assurance, by the absolute securing of their confidence, and
through their trust in him, this man is able to produce anesthesia
without the use of more than a minimum quantity of the anesthetic. He
is able to do the same thing with children, and, of course, it is well
known that mental influence over them is extremely important in
limiting the amount of anesthetic that will be necessary.


Personality of Anesthetist.--Some anesthetists by their personal
influence are able to bring patients under the influence of an
anesthetic with much less excitement and, as a consequence, with the
use of much less of the anesthetic than others. It is the same
question of personal influence that extends through all medicine. Some
men seem to have it naturally, and others not, though to some extent,
at least, it may be cultivated. Of course, it is now well understood
that, under no circumstances, should a patient be forced to take an
anesthetic. This is as true for a child as for any other patient. Only
a little management is required to secure the cooperation of even a
young child. Above all, there must be no struggling, and while there
may be a passing stage of excitement, which cannot be entirely
controlled, this can be eliminated by those who are skillful. It may
be necessary, especially in the case of children, for the little
patients to become familiar with the anesthetist. They should see him
on several occasions and should be made to feel that they know him.
The presence of a stranger is enough of itself to excite children and
make them suspicious and resentful of any manipulations. It may be
well for them to have breathed through the cone on several occasions
and to play a sort of game with it. In this way children will often go
under an anesthetic without any struggle or excitement.

It seems a little childish to suggest similar procedures with grown
patients, but even surgeons of long experience with the older methods
who have insisted on the trial being made on their patients have found
much benefit from it. Familiarity with the anesthetist and even with
the inhaler {757} and the breathing through it on several occasions
beforehand, when no anesthetic is being administered, helps many
patients not a little. This preliminary is particularly of help with
regard to nervous patients and especially women. It is very seldom
necessary to use nitrous oxide as a preliminary to ether if this mode
of procedure is practiced.


Mental Diversion.--It is well to concentrate the mind of the patient
on something else besides his sensations. One element that is
extremely important for anesthesia is deep breathing. The patient must
then have his attention called to the necessity for deep breathing and
should frequently have the suggestion to this effect repeated in his
ear as he comes under the anesthetic. There should be some practice in
deep breathing deliberately beforehand, with the idea of accustoming
the respiratory mechanism to take deep breaths by habit even when not
entirely under the control of the will. This may be done with the
inhaler on a few occasions at least. The occupation of attention
necessary for deep breathing during the taking of the anesthetic
lessens the concentration of mind on the feelings, and actually makes
the discomfort much less. Besides, deep breathing distributes the
anesthetic over the lungs, leads to its absorption more rapidly, and
makes the irritation of the anesthetic less by diffusing it over a
larger surface. On the contrary, short, rapid breaths lead to an
intensity of irritation and much slower absorption.

Skilled anesthetists have found it of decided advantage to keep the
patient's mind fixed on something else besides the breathing. Perhaps
the easiest recommendation is that of locking the hands over the
abdomen just above the umbilicus and asking the patient to hold tight.
This gives something very definite to think about and to occupy the
mind with. I have seen patients of rather nervous organizations go
under the influence of even a very small quantity of an anesthetic
when required to hold their hands thus and when the command was
constantly repeated, "Hold your hands tight," whenever there was the
slightest sign of struggle or excitement. Where this was done
tactfully and regularly, I have seen patient after patient go into
anaesthesia without struggle or excitement and usually without any
noise or even a loud word. I realize how much the personality of the
anaesthetist means in such cases, and I feel sure that anyone who is
confident in his own power in the matter will produce a corresponding
feeling of confidence in the patients.


Fright in Anesthesia.--There seems good reason to think that
occasionally the deaths reported from anesthesia have really occurred
from fright or at least have been greatly influenced by emotional
factors. It has often been noted that these deaths occurred
particularly at the beginning of the administration of an anesthetic
and before anything like a sufficient quantity to produce a toxic
effect had been administered. In other cases it has been noted that
patients were allowed to come out partially from under the anesthetic,
and as they recovered consciousness were disturbed by some incident.
Sometimes the pain seems to act as an inhibitory agent on the heart.
In more than one reported case the patient told afterwards of hearing
very distinctly some remark that seemed to be of bad omen. In one case
in my own experience the breathing and heart stopped (though the
patient fortunately was resuscitated) as a consequence of hearing a
series of rather loud goodbyes said at the door of the elevator
leading to the operating room during the {758} course of an operation
just at a moment when the anaesthetic influence was very much lessened
for a while. In some cases where there has been great fear of the
anesthetic which has been talked over beforehand by the patient, even
a few whiffs of the ether or chloroform have given rise to serious
symptoms from stoppage of the heart. It is evident that it is
extremely important properly to predispose such patients.

The well-known surgical warning not to make remarks during the course
of an operation that might prove disturbing to the patient, needs to
be emphasized. By a very curious psychological anomaly some patients,
though thoroughly anesthetic as regards pain, are able to hear and
understand very well remarks that are made near them. Fortunately,
such patients are few in number, but they are sometimes rather
seriously disturbed by chance observations that for the moment at
least seem to have an unfavorable bearing on their case. Besides,
certain patients sometimes have their special senses come out from
under the influence of the anesthetic before their sense of pain. They
may also hear and be disturbed. These cases illustrate very well the
place of mental influence and how much deliberate attention should be
given to this phase of the treatment of surgical cases coming out of
anesthesia, as well as while more or less under its influence.


Local Anesthesia.--In local anesthesia it has come to be generally
recognized in recent years that the personality of the operator is one
of the most important factors for success. A number of local
anesthetics have been introduced, and in some hands only comparatively
small quantities of them are needed in order to produce complete
absence of pain during operations. In other hands, however,
considerable and even toxic quantities may have to be employed and
sometimes without entire satisfaction. Infiltration anesthesia depends
for its success largely on the personal influence of the administrator
over the patient. It is extremely important that the patient should
have complete confidence and not have that confidence disturbed in any
way. For instance, he needs to be warned that he will feel the slight
prick of the needle when it is first introduced, for otherwise he will
be disturbed by even so slight a pain at the very beginning and will
magnify subsequent feelings until satisfactory local anesthesia
becomes impossible. Without thorough command over the patient and
complete trust, local anesthesia never succeeds except in very minor
operations. There are some men, however, who can do even severe and
extensive operations with comparatively small amounts of local
anesthesia. Others cannot perform satisfactorily even minor operations
with large amounts. It is the operator, his personality, and mental
influence over the patient that counts.


Vomiting After Anesthesia.--The vomiting that comes after anesthesia,
especially with ether, often constitutes not only an annoying but
sometimes a seriously disturbing complication. It must not be
forgotten that vomiting in neurotic individuals, and especially women,
may be largely due to a neurosis. In the section on Psychotherapy in
Obstetrics we discuss the vomiting that occurs in connection with
pregnancy and suggest that it is nearly always neurotic in character.
The best-known European obstetricians are now agreed in this. While
ether produces a tendency to vomit in everyone, in some the actual
vomiting is very slight or completely absent. If patients expect that
there is to be vomiting, if they are of the neurotic temperament that
not only {759} vomits easily but has a tendency to secure sympathy by
fostering this symptom unconsciously perhaps, then the vomiting may
become even a dangerous complication. If there is no expectancy in the
matter, however, but if, on the contrary, it is made clear to these
patients before the anesthetic is administered that, while there may
be some nausea, there need be no vomiting unless they yield too
readily to their feelings, much can be done to lessen the vomiting. A
single suggestion may not mean much in this matter, but a series of
suggestions properly given beforehand, especially if the patient has
seen others vomiting after operations and is worrying about it, may
prove of excellent contrary suggestive value.

If there is no expectancy, the physician must be careful not to arouse
it by over-solicitous anxiety in the matter. A plain statement should
be made on several occasions, however, so that the patient will have
in mind a good basis for contrary suggestion when coming out of the
anesthetic. Many remedies have been suggested for this post-anesthetic
vomiting, but, just as with regard to the vomiting of pregnancy, the
most important element in all the cures that have been reported has
been the influence upon the patient's mind. Whenever we have a number
of remedies for an affection, it is almost sure that it is not their
physical but their psychic effect that is of most importance.



CHAPTER IV

MENTAL INFLUENCE AFTER OPERATION


Every surgeon feels the necessity of having his patients as quiet and
restful as possible after operation. Any unfavorable mental influence
will surely hamper the curative reaction of tissues and delay
convalescence. We all know how fear blanches tissues, and anxiety
causes hyperemia, and how solicitude with regard to any part of the
body interferes with the normal control of the sympathetic nervous
system and sets up vasomotor disturbances. Either a lessening or
surplus of blood in a particular part interferes with the normal and
healthy curative reaction of tissues. The patient's mind should
therefore be as much as possible diverted from attention to the part
that has been operated on in order to leave nature to pursue its
purposes without disturbance. For this, of course, pain must be
relieved and every possible measure taken that will add to the comfort
of the patient. In spite of the fact that opium may interfere with
certain natural processes, it is always useful after severe
operations, because it represents the lesser of two evils. The pain of
itself would produce more detriment than does the opium which relieves
the pain. There are, of course, other anodynes which may be used and
that have less disturbing sequelae. In this matter, routine is
unfortunate, for individual patients react very differently to opium
and its derivatives, the disturbing effect upon the mind being greater
than the quieting effect on the body. Many patients stand the coal-tar
derivatives much better because of their lack of effect on the mind.


Removal of Worries.--Worries of all kinds not associated with the
operation must have been thoroughly removed beforehand and must not be
allowed {760} to obtrude themselves afterwards until convalescence is
well established. Business is quite another matter. Whenever it does
not imply worry but only means occupation of mind and distraction of
the attention of the patient from himself, it may very well be
permitted, after only a comparatively brief interval after operation.
Within a few days a business man may certainly be allowed to dictate
letters for an hour or so, and an author may even be allowed to
dictate notes of some of the fancies that came to him during
anesthesia. When a man has the opportunity to look forward to even a
short interval during the day when he can do something that is useful,
it serves as an excellent distraction for many hours beforehand and as
a satisfactory memory for hours afterwards.


Pleasant Visits.--It used to be the custom to keep visitors from
patients after operation much longer than is at present the custom.
There has come the realization, however, that short visits from
pleasant friends may mean much for the patient. It is hard to make the
selection, for certain friends and especially relatives disturb and
annoy rather than help the patient. Anyone who shows much solicitude
and, above all, fussy over-anxiety, must be excluded, no matter how
nearly related he or she may be.


Psychic Conditions of Hospitals.--The atmosphere of the hospital must
all conduce to peace and quiet of mind. It is surprising the
differences that may be noted in this respect. I have been in a
hospital where only a dozen of operations were done a week and have
scarcely ever been there without hearing complaints of pain and
discomfort that were surely disturbing to others. On the other hand, I
have been in a hospital where twenty capital operations a day were
done, and have heard no complaint, and at nine o'clock at night have
found in it the peace of a religious community. I knew that it was all
due to the personality of the surgeons and their lack of power in one
case to impress their patients' minds and a very marvelous power in
the other of impressing patients favorably. The success of many a
surgeon in a material way depends on this power to impress his
patients. It is they who send others to him, and in general there is a
feeling that if he cannot cure them no one can.

Of course, it is extremely important that circumspection should be
employed as regards chance remarks that may be seriously
misinterpreted and prove unfavorably suggestive. Patients should not,
as a rule, be allowed to see their own charts whenever there are
disturbing developments in pulse and temperature. During dressings the
conversation should be cheerful, distracting to the patient, and
should not contain remarks that may be disturbing. The surgeon and his
assistants must know how to control their expressions so as not to
reveal any solicitude that may be occasioned by the patient's progress
or by the state of his wound when these are not satisfactory.


Surgeon's Visits.--Practically every time that a surgeon visits a
patient after operation there is something that the patient has to ask
or have explained. A good deal depends, as far as regards the comfort
and peace of mind during the interval until the coming of the surgeon
again, on the satisfaction derived from the surgeon's explanation. He
should be prepared, therefore, to answer in such a way as will leave
no haunting doubts in the patient's mind. Some patients are very prone
to find unfavorable suggestions in even simple expressions of the
physician. He must be prepared for {761} this, therefore, and be sure
to say nothing that can possibly be misunderstood. In spite of this,
at times patients will draw unfavorable inferences and then the nurse
should have the confidence of the patient sufficiently to set the
matter right or at least to give reassurance that will keep the
patient's anxiety from disturbing until the next visit of the surgeon.
All of this seems trivial from a certain standpoint, but even surgery
is as yet an art and not a science. Art depends on personality and the
influence of it and the power to express itself. The personality of
the surgeon must be felt in the patient, and the more he can make it
felt the better the convalescence and the less discomfort even though
there should be more of pain. The amount of pain actually felt depends
on how much of it gets above the threshold of consciousness.

Almost any surgical patient, especially if he has gone through a
serious convalescence, will tell you how much good the visits of his
physician used to do him, though a glum and over-serious surgeon may
have exactly the opposite effect. Sometimes busy surgeons neglect to
visit their patients daily, and nearly always this has an unfortunate
effect. In serious cases, the seeing of the surgeon several times a
day, when it is well understood that his visits are not due to
over-anxiety with regard to the patient, may hasten convalescence
materially.


Comfort, Mental and Physical.--Everything must be done to make the
patients as physically comfortable as possible. It must be well
understood, however, that comfort lies much more in variety and
response to feeling than in any continuous condition. Patients will
have little complaints and there must be always something novel to do
for them. This does not necessarily imply medicine or even troublesome
external applications, but the rearranging of bed clothing, the use of
a hot-water bag or of an ice bag, the relief of pressure, sometimes
mild applications of pressure, the lifting of the head, slight
turning, even small changes of position and the like. Whenever a
patient can be relieved by some means so simple as these external
trifling remedial measures, confidence is awakened that the discomfort
they feel is not due to any serious condition, but is only such achy
tiredness as comes from confinement to bed. Without relief afforded in
this way, they are likely to let unfavorable suggestion accumulate
until their dread of something serious may inhibit convalescence or at
least interfere with sleep and greatly enhance their discomfort
generally. It is the state of mind that develops as a consequence of
continued trifling discomforts and not the physical results of those
discomforts that must be carefully looked to in post-operative
patients.


Nursing.--In the general management of patients after operations it
would be eminently helpful to the surgeon if surgical nurses were
supposed to read at least once a year, Florence Nightingale's "Notes
on Nursing,"   [Footnote 61] written half a century ago, and if the
surgeon himself should have read it through once at least and dip into
it occasionally afterwards. In her chapter on Noise there are many
remarks that I should like to quote, but the whole chapter is so
valuable that it is hard to know where it stops, and so only a few
expressions may be given here. For instance, "Never to allow a patient
to be waked intentionally or accidentally, is a _sine qua non_ of all
good nursing. If he is aroused out of his first sleep he is almost
certain to have no more sleep." "The more sleep patients get the
better will they be able to sleep." "I have often {762} been surprised
at the thoughtlessness (resulting in cruelty, quite unintentionally)
of friends or of doctors who will hold a long conversation just in the
room or passage adjoining the room of the patient, who is either every
moment expecting them to come in, or who has just seen them, and knows
they are talking about him." "Everything you do in a patient's room
after he is 'put up' for the night increases tenfold the risk of his
having a bad night. Remember, never to lean against, sit upon, or
unnecessarily shake or even touch the bed in which a patient lies."

  [Footnote 61: American edition, Appleton, N. Y.. 1860.]

Miss Nightingale, as might be expected, insists emphatically on the
state of the room, the arrangement of the furniture and the
cheerfulness of surroundings as important factors for the cure of
patients. One of the most important elements is, of course, the nurse.
She must be gentle, patient, quick to understand, often ready to
anticipate wishes, and always as noiseless as possible. Slowness may
be neither gentle nor noiseless. Patients, particularly men, often
grow impatient at the slowness with which things are done for them.


Chattering Hopes.--There is scarcely an element of mind in the
patient's environment that Miss Nightingale has not thought of and
touched with very practical wisdom. She deprecates, as does anyone who
knows anything about the care of patients, the "chattering hopes" of
those who try to cheer patients by simply telling them that they ought
to be more cheerful, that of course they will get well and that they
must not be anxious. She says: "I would appeal most seriously to all
friends, visitors, and attendants of the sick to leave off this
practice of attempting to 'cheer' the sick by making light of their
danger and by exaggerating their probabilities of recovery."
Cheerfulness and kindness towards the sick are one thing and foolish
attempts at encouragement not founded on good reasons quite another.


Variety of Thoughts.--From the chapter on Variety the following
quotations show the very practical character of Miss Nightingale's
persuasion as to the value of influencing the patient's mind:

  "To any but an old nurse or an old patient the degree would be quite
  inconceivable to which the nerves of the sick suffer from seeing the
  same walls, the same ceilings, the same surroundings, during a long
  confinement to one or two rooms." "The nervous frame really suffers
  as much from this lack of variety as the digestive organs from long
  monotony of diet." "The effect in sickness, of beautiful objects, of
  variety of objects, and especially of brilliancy of color is hardly
  at all appreciated."

As Miss Nightingale insists, flowers are remedies of great value for
the ailing and especially for those who are confined to their room for
a long period. She pleads for having the bed placed near a window in
order that they may see out into the fields and the scenery around
them, to which I would add with emphasis, and so that, if it is
possible, they may see the occupations of human beings. Miss
Nightingale adds: "Well people vary their own objects, their own
employments many times a day; and while nursing (!) some bedridden
sufferer then, they let him lie there staring at a dead wall without
any change of object to enable him to vary his thoughts." Quite
needless to say, variety is more important for the ailing than the
well.


Pain Psychic Conditions.--Pain after operation is an extremely common
symptom and often causes much disturbance. Every surgeon knows how
{763} individual are patients in this respect, and how much depends on
the personal reaction to pain. There are men and women who have very
serious lesions, from which much pain might be expected, who complain
very little. There are, on the other hand, many men as well as women
who complain exaggeratedly after even trifling surgical intervention.
We have probably had some of the most striking examples of the
influence of mind over body in these cases. Many a patient who
complained bitterly of torment that made it impossible to rest has,
after being given a preliminary dose of morphine hypodermically,
subsequently been given less and less of that drug, until finally,
after a few days, he was getting injections of only distilled water.
Without their injection he was in agony. After it he settled down to a
quiet, peaceful night. Very often it is noted that these pains are
worse at night and there is a tendency for such patients to attract
attention only at such times as may be productive of considerable
disturbance of the regular order and as may call special attention to
them. We used to call such conditions hysteria, though, of course,
they have nothing to do with the uterus and must be looked for in men
quite as well as women.


Psychoneuroses.--These neurotic conditions, to use a term that carries
no innuendo with it, may affect other functions besides that of
sensation. Occasionally a neurologist is asked to see a patient in
whom, following an operation, usually not very serious, some paralytic
symptoms have developed. There is an inability to use one or more
limbs, and the suspicion of thrombosis is raised. It is rather easy,
however, to differentiate thrombotic conditions from neurotic palsies.
The ordinary symptoms of the psychoneurosis are present. There is
likely to be considerable disturbance of sensation, with patches of
anesthesia and hyperesthesia, some narrowing of the fields of vision,
and anesthesia of the pharynx, sometimes even of the conjunctiva.
Often there is something in the history that points to the possible
occurrence of a neurotic condition. Sometimes it is extremely
difficult to get such patients over the mental persuasion that is the
basis of their palsy, but usually it can be accomplished by suggestion
in connection with certain physical means. Electricity is often of
excellent effect in demonstrating to these patients that their muscles
react properly under stimulus and that it is only a question of
inability to use them because of mental inhibition. Such conditions as
astasia-abasia may develop quite apart from surgery, but there is
always some "insult," as the Germans say, that is some physical basis
for them, and so they are often considered to be surgical.


Psychic Disturbance of Function.--Besides motion and pain, other
functions may be affected through the mind. After operations within
the abdomen it is sometimes difficult to move the bowels when it is
desired to do so. It must not be forgotten that not infrequently in
these cases the patient's mental attitude of extreme solicitude with
regard to his intestines is inhibiting peristalsis. Such constipation
will sometimes not yield to even rather strong purgatives, and yet
will promptly be bettered by something that alters the mental state.
It must not be forgotten that it is in cases of neurotic constipation
that _pittulae micarum panis_ have proven particularly useful. In the
chapter on Constipation there is a discussion of this subject that
will often prove suggestive to surgeons.

This same thing is true with regard to post-operative urination. In
women, {764} particularly, there may be difficulty of urination after
vaginal operations, which may be attributed to some lesion of the
urinary tract and yet only be due to failure of the patient properly
to control muscles in these cases. As in obstetrical cases, position,
the presence of others, and the mental disturbance, may inhibit
urination. The subject is discussed more fully in the section on
Psychotherapy in Obstetrics. Surgeons are not so inclined now to
insist on absolute post-operative immobility, and even a slight change
of position may enable patients to gain control over their bladders
without the necessity for the use of the catheter, which always
carries an element of danger with it.

The influence of the mental attitude with regard to both of these
functions--intestinal and vesical evacuation--must not be forgotten.
There are many persons who find it extremely difficult to bring about
such evacuations in the lying position. Everything is unusual, and
their exercise of the coordination of muscles necessary to accomplish
these functions is interfered with. It is somewhat like stuttering and
the incapacity of an individual who may be able to talk very well to
close friends and yet stammers just as soon as strangers are present
or he is placed in unusual conditions. It has even been suggested that
there should be some exercise of these functions in the lying position
before operation, in order to accustom patients to the conditions that
will obtain afterwards. They thus become used to their surroundings
and the newer methods required, and, above all, if there should be any
post-operative difficulty, they realize that it is not due directly to
the operation, but rather to the unaccustomed conditions. This proves
helpful in saving them from solicitude and consequent unrest and adds
to the rapidity of convalescence.


Food Craving.--When food is to be given in small quantities and there
is likely to be craving for it, much can be done to save the patient
disquietude and disturbance by giving small portions rather
frequently, rather than distributing it over three times a day, as the
routine of life sometimes suggests. When water has to be denied, small
pieces of ice may occasionally be used with excellent advantage.
Patients learn to look forward to breaks at the end of comparatively
short intervals in their craving, and the accumulative effect is
greatly lessened. It is well understood that whenever people are
absolutely denied anything, they are likely to let their minds dwell
on that fact and crave it much more than would otherwise be the case.
If they can look forward to having even the minutest quantities of
anything that they want, however, craving is much less likely to be
insistent, and the state of mind is much easier to manage. In all of
these cases the confidence of the patient and the lessening of
neurotic tendencies by suggestion means more than most of the physical
remedies that have been recommended. There are some patients who
respond almost in a hypnotic way to suggestion from a physician in
whom they have great confidence.


Position and Peace of Mind.--The patient's general comfort is very
important for the maintenance of a favorable state of mind. It used to
be the custom to keep patients rigidly in one position for days,
sometimes more than a week, after operation. We know now that this is
almost never necessary, and that, of course, it is most fatiguing to
the patient. Keep the ordinary well person absolutely in one position,
without the opportunity to change from side to side even during a
single night, and there will be justifiable {765} complaint of tired
and achy feelings as a consequence. To enforce such a state for
forty-eight hours in those who are well will produce a highly nervous
state, consequent upon the fatigue and soreness of muscles induced.
Hence, the importance of taking every possible means to provide even
slight changes of position for those who have been operated upon. A
number of regular-sized pillows should be provided so that the head
may be raised and lowered, and a number of smaller pillows should be
at hand which can be so placed as to relieve pressure at various parts
and permit the patient to make at least slight changes of position
during the first forty-eight hours. After this, usually definite
alterations of position may be allowed without danger. The surgeon
must think of these elements in the treatment and insist on them with
his nurses, or they will not be carried out. It is possible now to
permit patients to sit up much sooner than before, and, indeed, in
pelvic operations, this is said to be definitely beneficial by
preventing the spread of any infectious material that may be present
into the general peritoneal cavity, and in older people it prevents
the development or, at least, greatly facilitates the dispersion of
congestion or such beginning pneumonic areas from hypostatic
congestion as may be present.


{766}

APPENDIX I


ILLUSIONS


A physician who wishes to use psychotherapy effectively should know
something about physiological psychology, or analytical or
experimental psychology, as it is variously called, because of the
help that he will derive from it in understanding many of his
patients' symptoms. Fortunately this branch is now being taught in
some of the medical schools, and the greater requirements for
preliminary training bring to the medical school men who have already
had a course in this subject. The chapter on Illusions is particularly
important because it affords many illustrations of how easy it is to
be deceived by the senses and, therefore, how many precautions have to
be taken in order to be sure that impressions produced on patients'
minds that seriously disturb them may not merely be due to
exaggeration of the significance of information brought them by their
senses.

These illusions are of special interest because they represent not
only failures of the senses to convey truth, but because they
illustrate how easy it is for the mind to be led astray by the senses.
People often declare that they have seen things with their own eyes or
in some other way have definite sensory knowledge of them, yet these
illusions make it clear that it is perfectly possible for such sensory
phenomena to convey quite mistaken information. People who are
suffering from many symptoms are persuaded that they must pay
attention to their sensations. The main purpose of the
psychotherapeutist often is to have them neglect their sensations and
correct them by means of information gathered from other sources. We
do this with regard to our sensory illusions, why not also with regard
to many sensations which are probably quite as mistaken, in certain
individuals at least, as these universal illusions of mankind. The
argument from analogy holds very well and can be used to decided
advantage in many cases.

A startling illusion which makes it clear that care is needed in
interpreting our sensations, is the so-called tube illusion or
experiment. If a sheet of note paper be rolled into a tube of
something less than an inch in diameter and then held close to one
eye, both eyes being kept open, while the hand opposite to the eye
before which the tube is held is placed palm faceward against the side
of the tube about its middle, a hole will be seen, as it were, through
the palm of the hand. This false vision is as clear as can be and
persists after any number of repetitions of the experiment. It merely
illustrates two-eyed vision. We have a picture in each eye and we
combine them. When the pictures cannot be combined for any reason,
optical illusions result. There are many more optical illusions than
we think and there are many reasons besides two-eyed vision for them.

Other illusions of two-eyed vision may be illustrated rather easily.
If {767} two dots are made on a sheet of paper about two inches apart
and the eyes look at them in a dreamy way, looking far beyond the
paper, with vision more or less fixed between them, after a few
moments a number of things happen. Usually the two dots exhibit a
tendency to float together.

  [Illustration: Fig. 26 (two dots about two inches apart)]

After an interval four dots will be seen--each of the dots having a
picture in each eye. Then only one dot may be seen because the
pictures combine. Sometimes three dots will be seen. When the dots
swim toward one another, a curious feeling of insecurity comes over
the experimenter, showing how much our sense of stability is dependent
on vision and illustrating why vision from a height is so disturbing
because objects cannot be properly fixed on the distant background.

  [Illustration: Fig. 27 (from left to right--an empty bird cage, a
  vertical line, a bird)]

Just as the two dots may be made to come together, so, after a little
practice, a bird may be made to go into a cage (Fig, 27) or an apple
made to go onto a plate (Fig. 28),

  [Illustration: Fig. 28 (from left to right--an apple, a large plate)]

These illusions show how many things that people {768} "see with their
own eyes" are not so. All depends on the attention and the state of
mind at the time when the seeing is done. In day-dreams these
illusions often occur and may be the basis of delusions.

  [Illustration: Fig, 29 (Several complex line figures)]

There are, however, a number of optical illusions which illustrate
certain defects of our vision that cannot be corrected, no matter how
much we may desire to see correctly. We continue to see them not as
they are but as they seem, and we must correct our vision by
information from other sources. The Müller-Lyer lines are familiar and
are given here (Fig. 29) because {769} they show how easily the senses
may deceive us, even that most acute of our senses, vision, as to the
sizes of things.

  [Illustration: Fig. 30 ( Two identical figures, one above the other;
  each is like a funnel cut parallel to its axis and laid flat. )]

Figure 30 illustrates how easy it is to be deceived by the
juxtaposition of different portions of objects. I have had a woman who
had cut out high collars for children and who happened to put them in
the juxtaposition of the sketch here given think that she was either
losing her sight or her judgment was being affected by the nervous
condition in which she was. Nothing would persuade her that some
serious development was not taking place until I showed her this
illustration. In this illusion the juxtaposition of the short curved
line to the long curved line of the other figure produces all the
disturbance of judgment of size.

The illusions of filled and unfilled space are interesting and are
quite inevitable. They are due to physiological visual effects and are
very strikingly illustrated by what is known as the sun and moon
illusion. Both these luminaries seem larger at the horizon than they
are at the zenith. This is entirely an optical illusion. The horizon
seems farther away than the zenith because vision to it is
interrupted. The heavens appear not to be a half sphere, but more like
an old-fashioned watch glass.

  [Illustration: Fig. 31 (A--a square consisting of closely spaces
  vertical lines; B--a square consisting of closely spaces horizontal
  lines; C--a empty square with only its exterior boundaries.)]

Since the sun and moon occupying the same space on the retina are,
because of this apparent difference of distance, judged to be farther
away at the horizon than they are at the zenith, we are inevitably
forced to the conclusion that they are larger in size than when in the
other position. The over-estimation of filled space as compared with
{770} the unfilled is mainly due to the interrupted muscular action of
the eyes in traveling over the space requiring more effort. This makes
it seem longer. Probably physiological processes on the retina also
contribute to the illusion. A series of objects, even dots, will cause
a greater physiological excitation of the retina than an equal amount
of space, the boundaries of which alone are brought to our attention.

Illusions of size are even more startling than illusions of distance.
It is perfectly possible to take three spaces, each exactly a square
inch, and by drawing lines in two of them in different directions to
make the figures appear of {771} very different size. This is a rather
disturbing illusion, particularly for women who are apt to think that
perpendicular lines make them appear tall and thin, while horizontal
lines have the opposite effect. This is true if the lines are not
placed quite close together. The reason why women wear many ribbons,
however, whether they themselves recognize it or not, is that the
attraction of attention to these makes the space in which they are
seem longer. Hussars are dressed in uniforms with many rows of gilt
cord or braid running across their chests in order to increase their
apparent height. As a rule, a cavalry man must not weigh over 140
pounds or his horse will break down in long, forced marches. Such men
are often of small stature and their apparent height must be increased
by their uniform, so as to make them look formidable. Advantage is
taken of this optical illusion of filled space to produce this effect.

  [Illustration: Fig. 32 (several complex curved figures,)]

Other illusions of size are quite frequent. It is rather hard for the
ordinary observer to think that the half circles, _a_ and _a'_ (Fig.
32), are the same size, or that _b_ and _b'_ in the same chart are the
same curve. The interruption in the circles _c_ and _c'_ produce very
curious erroneous impressions which require a knowledge of this
illusion to correct.

Optical illusions with regard to directions of lines are extremely
common. Quite unconsciously we translate directions into special
meanings. This is what enables perspective to be effective in
drawings. It has many disturbing features, however. Some of these are
striking illustrations of the defects of our vision.

  [Illustration: Fig. 33 (tall, narrow rectangles covering diagonal
  lines passing under them.)]

  [Illustration: Fig, 34 (a large black square with several parallel
  diagonal white lines; each diagonal line has several intersecting
  lines; the upper left diagonal has horizontal intersecting lines,
  the next diagonal has vertical intersections; etc.)]

Poggendorf's illustration of the displacement of oblique lines (Figure
33) {772} and Zöllner's distortion of parallel lines as illustrated by
Figure 34, make it very clear that our judgment of direction must
depend on many factors besides our vision, if we are not to make
serious mistakes.

These optical illusions might seem to be of little significance, but
the Greeks thought them of so much importance and recognized so
thoroughly that they could not be corrected, and that the distortions
and displacements would inevitably take place, that they deliberately
put certain optical corrections into their great architectural
monuments in order to avoid these false appearances. These have been
traced very accurately in the Parthenon, for instance. In a word, the
Greeks, knowing of these optical illusions, in order to make the lines
of their buildings appear correct, deliberately made them wrong to a
sufficient degree to correct the optical illusion; This frank mode of
yielding to a limitation of human nature is a fine lesson for patients
to learn if they can only be made to learn it from these
illustrations.

It is with regard to colors, however, that we have the best examples
of optical illusions depending on the individual and his special
anatomy and physiology. Color-blind people are quite sure that they
see color, just as other people do, until their defect is demonstrated
to them. A man who is color blind for red thinks that he sees that
color as other people do, while all that he sees is a particular shade
of brightness which, because other people call it red, he has come to
call red. When asked to pick out red from a series of other colors he
may often succeed. When asked, however, to take a skein of red wool
selected for him to a basket containing a number of different colored
wools, and to bring back all those that are of the same color, he will
select grays and browns and sometimes greens as well as reds, and
present them as all matched colors. A man who is color blind for all
colors will still think that he sees colors as other people do. The
ingenious illustration of the American flag as it appears to people
suffering from different forms of color blindness, though they are all
persuaded that they see the same kind of flag, is an interesting
example of how different may be people's sensations, though their
conclusions are the same. It may be seen in many of the text books of
analytical or experimental psychology.

{773}

Dalton, to whom we owe the atomic theory, was himself color blind for
red and made the first investigations in that subject. He was of
Quaker origin and found that a great many of his brethren were
deficient in color vision. It becomes much easier from this to
understand why they resolved to wear nothing but gray. They did not
see colors as other people do and therefore could not understand nor
sympathize with the joy of other people in color. Dalton tells the
story of a Quaker prominent in his sect who once went to town to buy a
gray waistcoat and purchased instead one of bright red. When he
appeared at meeting in this he was promptly tried for heresy and
violation of church regulations.

There is an interesting tendency on the part of people who are
themselves defective in certain faculties of sensation, to conclude
that when other people are wrapt in admiration of something that they
cannot perceive, it is because these other people have some mental
defect that leads them to enthuse too easily over their sensations. A
story is told of a newspaper man who used to insist that all that was
said about the beauty of the song of birds was due to the vivid
imagination of the writers, for he could find nothing to admire about
the songs of birds. He was placed in a room with a number of fine song
birds all round him and it proved that he could not hear any of the
higher notes at all. It was easy, then, to understand his condemnation
of the enthusiasm of others as hysterical and imaginative. Nearly this
same thing is true of many quite intelligent people with regard to
music. They hear ordinary sounds, as did the newspaper man, very well.
They are tone-deaf however, that is, they are quite unable to hear and
appreciate combinations of sounds or even to catch melodious
successions of single notes. They cannot recognize one tune from
another and often do not know "Yankee Doodle" from the "Doxology," or,
at most, know only the most familiar tunes, but they set themselves up
very calmly as judges of the intellects of others and conclude that
music lovers are really a hysterical set of people who go into
ecstasies over certain quite insignificant sensations.

These interesting tendencies are helpful in enabling the physician to
understand his patients better. They often serve as texts from which
the physician can explain curious things to patients who are prone to
draw wrong conclusions from them and often suggestions unfavorable to
their health.

These illustrations and their discussion serve to make very clear the
distinction between illusions, delusions and hallucinations, which are
often confounded. Illusions are deceptions of the senses. If a man
walking along a country road where he fears the presence of snakes
sees in the gathering twilight a piece of rope coiled, he will almost
surely mistake it for a snake. This is an illusion produced by the
conditions in which the object is seen. If walking along the same road
the next day, more timorous than ever as to snakes, he should see in
broad daylight the same coil of rope, he might in his fright not stay
long enough to decide whether it was a snake or not, and his illusion
would continue, though it would partake somewhat of the nature of a
delusion due to fright disturbing his judgment. If, in spite of
careful examination, however, of it, such as would satisfy any
ordinary mind that it was a coil of rope and not a snake, he should
still insist in believing that it was a snake, this would be a
delusion. There is always a mental element in delusions. If, having
seen nothing, he should insist, owing to fright and {774} nervousness
or to some other cause, that he sees a snake where there is nothing at
all resembling a snake and where evidently whatever is the basis of
his idea of the presence of the snake, is within his own mind, then he
is suffering from an hallucination.

Illusions may be quite inevitable. Most of the optical illusions
continue to appeal to us as truths even when we know that they
represent errors of vision. In spite of the fact that we know that the
sun and moon are not larger at the horizon than they are at the
zenith, by optical illusion we continue to see them of larger size. It
is our duty to correct such illusions by information gathered from
other sources. To follow an illusion, that is, to give it credit, when
we should correct it, is a delusion. To think that because we cannot
see red that therefore there is no red, or because we do not hear the
sounds of notes of birds that they do not utter any notes, in spite of
the fact that we have the testimony of nearly the whole human race to
the contrary, is a delusion. When, using the verb in its broadest
sense, as "perceive," we seem to see things very differently from the
generality of people around us, there is every reason to suspect that
there is some specific or individual limitation of our senses which
makes us fail to perceive these things as others do. We have to
suspect our sources of information then and to correct them by what we
can learn from the experience of others. These are important
considerations for many of the ideas that patients cherish with regard
to themselves and their ills.

Hallucinations are entirely mental. But the phenomena that sometimes
appear to be hallucinations may be due to illusions of the senses
within the organism. For instance, those who indulge in cocaine often
have the feeling of having a veil over the face, or of having run into
a cobweb or something of that kind. The presence of the veil or the
cobweb on the face is probably not an hallucination, but is due to
certain disturbances in the circulation, or perhaps in the nerves
themselves, which affect the nerve endings of the face, causing them
to tingle in a particular way, and this sensation is translated as
coming from without in terms of something that has been felt before.
Some of the appearances of _muscae volitantes_, or of specks before
the eyes, or occasionally of wavy lines, are due to disturbances of
the circulation within the eyeball which cause corresponding
disturbances of the optic nerve, with consequent apparent visions.
When the eyeball is pressed upon, the sensation first produced is that
of light and not of pain, because whenever a nerve of special sense is
irritated, it produces its own specific sensation in the brain.

The chilly stage in malaria is a typical example of a physical
condition having an effect upon sensory nerves that more or less
necessarily produces a delusion. The patient is actually at the height
of his fever when the chilliness and shivering come on and when he
demands a larger amount of covers in order to protect himself from the
cold he will often have a temperature of 104 degrees Fahrenheit, or
even higher. What has happened is that the little blood vessels at the
surface of the body are shut up by the effect of the plasmodium upon
the system. Whenever we are cold these little blood vessels shut up in
order to protect the blood from being chilled by the external
atmosphere. The shutting up of the little blood vessels deprives, for
the time being, the terminal nerves in the neighborhood of some of
their nourishment. Their response is to set up a tremor or shivering,
which will mechanically tend {775} to open the blood vessels so that
they may have their nourishment once more. Whenever we have a set of
sensations that correspond to this connected set of events, we
translate them as feeling cold. The outer air does feel cold to the
body because the blood is not flowing through to the surface as it
would normally in order to warm it. Hence the chilliness. This is not
an hallucination; but an illusion with something of a delusion in it;
until we know how things are. Nervousness may set our teeth chattering
just as it may cause tremor through our sympathetic nervous system,
disturbing the flow of blood through muscles and so disturbing control
of them. Vehement emotion, anger, fright, and even those of less
violence may cause similar effects. All these phenomena illustrate the
close relation between mind and body.

{776}

APPENDIX II

RELIGION AND PSYCHOTHERAPY


Religion and psychotherapy have, of late, come to have many relations
to each other and many interests in common, at least in the minds of a
number of clergymen, and in popular estimation. There is no doubt but
that religion can do much to soothe troubled men and women, even when
their troubles are entirely physical in nature and origin. It at least
lessens the unfavorable effect of worry in exaggerating such
pathological processes as are at work. All diseases, functional and
organic, are rendered worse by solicitude, while many troublesome
symptoms become quite bearable if only the patient does not dwell on
them too much but takes them as they come, carefully refraining from
emphasizing them by over-attention. That is the very essence of
psychotherapy. Religion, in the sense of trust in divine wisdom, can
do much to originate and maintain this imperturbed frame of mind.
People who are without religion, that is, without the feeling that
somehow all their ills are a part of the great plan of the universe,
the mystery of which is insoluble, but the recognition of which is
demanded by reason, and who lack the assurance that somehow, in
Browning's phrase:

  "God's in His Heaven-
  All's right with the world!"

-- are more prone to give way to over-anxiety and consequently to make
themselves suffer more in all their ills, than is necessary or even
likely in the more favorable state of mind of those whose trust in
Providence is thorough and efficient.

In recent years there has been in the general population a distinct
loss of faith in the great religious truths that are so helpful in
engendering a peaceful state of mind in suffering. Many have come, if
not to doubt of the Providence of the Creator, at least to feel that
we do not know enough about it to place any such supreme dependence on
it in the trials of life as would make it a source of relief, or at
least consolation, in suffering. This same spirit of doubt has
paralyzed faith in the hereafter and in all that trust in it brings,
to sufferers, of consolation to come for their ills if these are borne
as becomes rational creatures whose suffering has a purpose, though we
may not comprehend it. Some people are destined by their physical
make-up or by accidental conditions to considerable suffering. There
are many ailments that are incurable and are definitely known to be
incurable. Some of these entail great suffering of body and even more
suffering of mind. Such suffering becomes quite unbearable unless the
patient is of a very stoic disposition, or unless the thought of a
hereafter in which the sufferings of this life will have a meaning is
present to console.

{777}

Great scientists in the midst of all our advance in science--one need
but mention here such men as Lord Kelvin, Clerk Maxwell, Johann
Müller, Laennec, Pasteur, Claude Bernard, though the number might
easily be multiplied--have insisted that the existence of a Creator is
absolutely demanded by what we know of the physical universe. "Science
demonstrates the existence of a Creator," is Lord Kelvin's expression.
The existence of a Creator implies, also, the existence of laws made
by Him, by which His universe is regulated in every detail, nothing
being left to chance. Chance is indeed only a term which indicates
that we do not know the causes at work. If somehow the Creator's power
has been sufficient to bring the manifold things of the universe into
existence according to a plan in which there is no such interference
with one another as would cause serious disturbance of the universal
order around us, then He can be trusted also to care for even the
minutest details of creation and of human life.

In the gradual disintegration of the religious sense which has come as
a consequence of certain materialistic tendencies in nineteenth
century education and science, these religious sources of consolation
have been shut off from a great many people. They have come to the
feeling of being portions of a machine that moves hopelessly on,
somehow, on the old principle, "The mills of the gods grind slow, but
they grind exceeding fine." The sufferings of humanity then, are, for
these people, only a portion of a great universe of suffering that is
constantly going on but for which they can see no reason and no
purpose. Lucretius's lines which make human sufferings the butt of the
jokes of the gods who look gleefully on from their Elysian happiness,
would represent the feelings of these doubters better than any
religious expression. We have come back in this age, when evolution
has so much influenced the thought of the time, after the curious
cyclic fashion in which human thought repeats itself from era to era,
to the attitude of mind of the old Roman poet who almost singly among
his contemporaries, had been deeply affected by the same doctrine of
evolution. The pessimism he was prone to as to the significance of
human life has become once more the fashion.

Such pessimistic thoughts do not come, as a rule, while people are in
good health, but they assert themselves with double emphasis in
moments of trial and suffering. Lucretius himself is said to have
committed suicide. The result of the diffusion of this materialistic
pessimism in our time has been a gradual preparation for a revulsion
of feeling in many minds. One manifestation of this reaction has been
seen in a form of religion which denies entirely the existence of
evil. God the Creator is good and therefore there can be no evil in
His world. Whatever of evil there is, is only due to man's failure to
see the entirety of things. Evil is an error of mortal mind--only that
and nothing more. In spite of the manifest absurdity of the underlying
principle, if people can only be brought to persuade themselves that
there is no such thing as evil or suffering, then many of their
discomforts disappear, all of their symptoms grow less and a sense of
well-being results. It is, indeed, surprising how many even physical
ills will be relieved by this state of mind if sincerely accepted. It
is the highest possible tribute to psychotherapy and the curative
influence of mind over body.

Another phase of this revulsion of feeling has been the institution of
a church movement that would make sufferers realize once more all the
{778} consolations there are in religion. The sufferer is brought to a
renewed lively sense of the presence of the Creator in the universe
and of His care for His creatures. The great purpose of suffering in
making people better and stripping them of their meanness and
selfishness is brought out. Anyone who has ever had called to his
attention the difference between two brothers, one of whom has been
chastened by suffering above which he has risen by character
development, and another who has enjoyed good health and prosperity
all his life, will realize how much of good suffering means in the
world. Pain is not in itself an evil, but a warning, and most of the
trials of life can rather readily be shown to partake of this
character. A man who can be made to submit himself, then, to the will
of the Creator and be persuaded to acknowledge that somehow we must
try to work out our part in the great scheme of things behind which
the Creator stands, is somewhat like the soldier ready even when tired
and worn out, to go in on a forlorn hope, because he has confidence
that he is executing a part of the plan of his general for his
country's welfare, though he does not know how, and he is quite well
aware that it is going to cost him much in pain and suffering, and
perhaps his life.

There is no doubt that an abiding sense of religion does much for
people in the midst of their ailments and, above all, keeps them from
developing those symptoms due to nervous worry and solicitude which so
often are more annoying to the patient than the actual sufferings he
or she may have to bear. While religion is often said to predispose to
certain mental troubles, it is now well appreciated by psychiatrists
that it is not religion that has the tendency to disturb the mind, but
a disequilibrated mind has a tendency to exaggerate out of all reason
its interests in anything that it takes up seriously. Whether the
object of the attention be business, or pleasure, or sexuality, or
religion, the unbalanced mind pays too much attention to it, becomes
too exclusively occupied with it, and this over-indulgence helps to
form a vicious circle of unfavorable influence. While many people in
their insanity, then, show exaggerated interest in religion, this is
only like other exaggerated interests of the disequilibrated, and
religion itself is not the cause but only a coincidence in the matter.

Clouston, in his book on "Unsoundness of Mind" (Methuen, London,
1911), put this very well when he said, "It is true that religion,
touching as it does, in the most intense way the emotional nature, and
the spiritual instincts of mankind, sometimes appears to cause and is
often mixed up with insanity. But in nearly all such cases the brain
of the individual was originally unstable, specially emotional,
over-sensitive, hyperconscientious, and often somewhat weak in the
intellectual and inhibitory faculties and, if looked for, other causes
will usually be found." He had said just before, "To talk of
'religious insanity' as if it were a definite and definable form is in
my judgment a mistake."

On the contrary, there is now a growing conviction that a deep
religious feeling, a sense of dependence on and trust in the Almighty,
will do more than anything else to keep people from those neurotic
manifestations which so often are seen in our day and are growing more
and more frequent as life becomes more strenuous and more attention is
paid to the material side of things, to the exclusion of the
spiritual. How true this is may be judged from expressions that have
been used in recent years by well-known specialists in {779} nervous
diseases and in psychology. These have included men who were often not
believers in religion themselves but who recognized its influence for
good for others. Such expressions are to be found in the writings of
men of every nationality. Not infrequently, in spite of their own
religious affiliation, they acknowledge what a profound influence
certain forms of religion have over people. These testimonies have
been multiplying in our medical literature in recent years, because
apparently physicians have come to appreciate much better by contrast
the influence for good of religion over some of their patients, since
so many of the sufferers from nervous diseases they see have not this
source of consolation to recur to.

In America we have a number of such testimonies. In his "Self Help for
Nervous Women" Dr. John K. Mitchell of Philadelphia, who may be taken
to represent in this matter the Philadelphia School of Neurologists,
to which his father has lent such distinction, said:

  It is certainly true that considering as examples two such widely
  separated forms of religious belief as the Orthodox Jews and the
  strict Roman Catholics, one does not see as many patients from them
  as from their numbers might be expected, especially when it is
  remembered that Jews as a whole are very nervous people and that the
  Roman Church includes in this country among its members numbers of
  the most emotional race in the world.

  Of only one sect can I recall no example. It is not in my memory
  that a professing Quaker ever came into my hands to be treated for
  nervousness. If the opinion I have already stated so often is
  correct, namely that want of control of the emotions and the
  over-expression of the feelings are prime causes of nervousness,
  then the fact that discipline of the emotions is a lesson early and
  constantly taught by the Friends, would help to account for the
  infrequency of this disorder among them and adds emphasis to the
  belief in such a causation.

Prof. Münsterberg, who may be fairly taken to represent the German
school, but whose long years of residence in America have made him a
cosmopolitan, is quite as positive in his declaration of the place
that religion may hold in making human suffering less. In his
"Psychotherapy" he devotes considerable attention to the subject. The
religious discipline, that is, the training of human beings from their
earliest years to recognize that there is a higher law than their own
feelings and that they must suppress many of their desires and take
evil as it comes as a portion of human life, is of itself, he insists,
an excellent preparation to enable the individual to bear up under the
physical and mental trials of life and to make many symptoms that
would otherwise be almost intolerable, quite bearable. It is from
earliest years that this training must make itself felt, and Prof.
Münsterberg insists that from early childhood the self-control has to
be strong and the child has to learn from the beginning to know the
limits to the gratification of his desires and to abstain from
reckless self-indulgence. A good conscience, he says, a congenial home
and a serious purpose, are, after all, the safest conditions for a
healthy man, and the community does effective work in preventive
psychotherapy whenever it facilitates the securing of these factors.

Self-denial has always been one of the main elements of religious
training, and indeed was declared a chief source of merit for the
hereafter. The modern psychotherapeutist, however, preaches
self-denial almost as strenuously as the religious minister of the
olden time, only now not for any religious {780} merit or reward, but
because it makes life more pleasant and by that much happier. When men
and women have learned to deny themselves in their younger years, it
is not hard to stand even pain when they grow older, and pain is
inevitable in every human life and the training to stand it is
therefore worth while. Pain borne with equanimity is lessened by
one-half if not in its intensity then at least in its power to
disturb, and since religion will do this it possesses an important
remedial value. Here is where religion is particularly valuable and
the passing of it from many minds has thrown them back on themselves
and left them without profound interests, so that they occupy
themselves overmuch with the trivial incidents of life within them and
disturb the course of many of their functions by giving exaggerated
thought to them. Religion adds a great purpose to life and such a
purpose keeps men and women to a great extent from being disturbed
about trifles.

Of course, it would be too bad if religion should do no more than
this. This, however, is the only phase of it with which we are
concerned here. We may think very strongly with Prof. Münsterberg,
that it would be quite wrong to assign to it only this place in life.
He says: "The meaning of religion in life is entirely too deep that it
should be employed merely for the purpose of lessening the pains and
aches of humanity and the dreads that are so often more imaginary than
real." He insists that "It cheapens religion by putting the accent of
its meaning in life on personal comfort and absence of pain." He adds,
"If there is one power in life which ought to develop in us a
conviction that pleasure is not the highest goal and that pain is not
the worst evil, then it ought to be philosophy and religion."
Present-day movements, however, tend to subordinate religion to
this-worldliness rather than to other-worldliness, and by just that
much they take out of religion its real significance. We are here on
trial for another world is the thought that in the past strengthened
men to bear all manner of ills, if not with equanimity, at least
without exaggerated reaction. It has still the power to do so for all
those who accept it simply and sincerely.

{781}

INDEX.


Abdominal discomfort, 302;
  from coffee, 306;
  from tea, 30;
  from tone factors, 306.
Abdominal viscera, 176.
Abernethy, 268.
Abortion, frequent, 457.
Abracadabra, 61.
Absence of occupation, 219.
Absent treatment, 141.
Abstraction, 129.
Academy, French, telepathy and, 147.
Accidents, telepathy and, 144.
Aches,
  filing, 397;
  occupation, 390;
  sawing, 397;
  sweeping, 397;
  writing, 396.
Acid, lactic, as a bactericide, 247.
Acquirements not transmitted, 628.
Action, integrative, 123.
Addictions, drug, 707.
_Adiposus panniculus_, 299.
Adjuvants, 163.
Advertising, psychology of, 690.
Aerophobia, 612.
AEsculapius, 7.
Affairs, knowledge of, 177.
"After dinner sit awhile," 180, 182.
Afternoon fever, 180.
After-treatment,
  of alcoholism, 705;
  of tuberculosis, drug habits, 705.
Agassiz's dream, 137.
Agate, 62.
Age, fasting and, 298.
Agoraphobia, 612.
Agrippa, Cornelius, 15.
Aichmophobia, 581, 612.
Ailurophobia, 612.
Air,
  appetite and, 268;
  fresh, comfort and, 356;
  in dyspepsia, 262;
  in intestinal rumbling, 284;
  in intestinal troubles, 284;
  rather than exercise, 203;
  swallowing, 284.
Alchemy, 40, 41, 56.
Alcohol, 3;

  in pneumonia, 31;
  in tuberculosis, 30;
  in vague affections, 31;
  milk and, 30;
  night workers and, 175;
  suggestive influence and, 31.

Alcoholism,
  after-treatment in, 705, 706;
  beginning of, 704;
  confidence in, 704;
  contagion in, 697;
  cures of, moral, 395;
  cures of, old and new, 694;
  frequent treatment in, 704;
  heredity in, 698;
  inherited resistance to, 698;
  mental influence in, 696;
  moral influences in, 704;
  national, 698;
  occupation pains and, 398;
  prophylaxis in, 701;
  real cures of, 395;
  religion and, 706;
  sanitarium question in, 702;
  supposed inheritance of, 697;
  "sure cures" of, 696;
  treatment of, 702;
  tuberculosis and, 703;
  warnings as suggestions in, 700;
  youth and, 701.
Alexander of Hohenlohe, Prince, 75.
Alexander of Tralles, 13, 61.
Alexandria, 11.
Alteratives, 100.
Ambrosia, 59.
Amenorrhea,
  ductless glands and, 439;
  dread and, 439;
  fright and, 437;
  home sickness and, 437;
  inanition and, 439;
  mental causes of, 437;
  mode of living and, 437;
  reputed remedies for, 440;
  suggestion in, 440;
  tuberculosis and, 437.
Amethyst, 60.
Amputation stump, pain in, 86.
Amulets, 15, 60.
Amusements,
  diversified, 9 182;
  mind and, 227.
Anatomy of melancholy, 61.
Anemia in Porto Rico, 106.
Anesthesia, 111;
  clasped hands in, 757;
  deep breathing in, 757;
  fright in, 757;
  from fixed attention, 755;
  game for children, 757;
  hearing during, 758;
  hypnotic, 754;
  local, 758;
  mental diversion in, 757;
  mind and, 733;
  occupation and, 754;
  rapid breathing: in, 755;
  suggestive, 756;
  vomiting after, 758.
Anesthetist,
  familiarity with, 756;
  personality of the, 756.
Anger, brief madness and, 741.
_Angina pectoris_, 27, 334;
  Broadbent on, 339;
  Charcot on, 337;
  coffee and, 336;
  false, 338;
  in woman, 339;
  neurotic, 338;
  psychotherapy and, 337;
  reflected pains in, 335;
  spurious, 336;
  tea and, 336;
  tobacco and, 336;
  true and false, 336, 339.
Anicetum, 59.
Animal emanations, 375;
  horse and dog, 244.
Animal hypnosis, 161.
Animal magnetism, 142;
  malicious, 142.
Animal risibile, 105.
Anise seed in lichen, 251.
Anthropology, criminal, 744.
Anodynes, useless, 219.
Antidotes, suggestion and, 33.
Antimony, 3;
  suggestions and, 26.
Antiochos, 12.
Antipathies, gastric, 245.
Apartment hotels, 183.
Apoplectic habitus, 518.
Apoplectics,
  examples encouraging, 521;
  new associations for, 521;
  new interests for, 521.
Apoplexy,
  Bacchus and, 517;
  cerebral, 513;
  change of occupation in, 519;
  complications in, 523;
  daughter as nurse in, 520;
  exciting occupation and, 517;
  heredity and, 517;
  hypochondriac, 514;
  lack of air and exercise in, 519;
  life-direction in, 519;
  mind before and after, 514;
  misplaced sympathy in, 522;
  neuroses and, 522;
  nurse, choice of, in, 520;
  outings and human interests and, 522;
  precocious, 510;
  preliminary motor symptoms in, 516;
  premonitory symptoms in, 514;
  prognosis in, 520;
  prophylaxis in, 517;
  pyramidal tracts and, 524;
  sympathetic cure of, 520;
  strokes, number of, in, 523;
  thinking and, 517;
  trained nurse in, 520;
  treatment of, 513;
  Venus and, 517;
  Vulcan and, 517.
Apparatus, brain,
  insulating, 123;
  switching, 123.
Apparitions, explanation of, 607.
Appearances, wraith-like, 608.
Appendicitis,
  chronic, 252;
  recurrent attacks of, 282;
  simulant, 587.
Appetite, 262, 592;
  air and, 268;
  emotion and, 264;
  feeling of, 264;
  food preparation and, 266;
  habit and, 265;
  increase in, 263;
  increasing, 301;
  indoor life and, 264;
  instinct and, 264;
  in the morning, 266;
  nervous loss of, 267;
  will and, 263, 592.
Appetizer, frequent eating as an, 267.
Appetizers, 264.
Application of psychotherapeutic principles, 104.
Arabian mental medicine, 13.
Arabian Nights, 12, 46.
Arch of the foot, yielding of the, 415, 417.
Areas of pain transfer, 252.
Argyria, 36.
Aristides, ancient hypochondriac, 73.
Aristotle, 10.
Arm,
  pitcher's, 397;
  motorman's, 397.
Armless men's foot powers, 419.
Arnold, Matthew, and number 13, 639.
Arrhythmia, 322;
  gastro-cardiac, 329;
  longevity and, 323.
Arterial sclerosis, diagnosis of, 514.
Arteries,
  calcification of, 512;
  longitudinal degeneration of, 515;
  premature degeneration of, 518;
  tortuous, 515.
Arterio-sclerosis, 512;
  dizziness in, 515;
  dread of, 516;
  over-eating and, 518;
  stimulants in, 518;
  tobacco and, 518;
  vertigo in, 515.
Artery of cerebral cortex, 125.
Arthritis,
  acute, 379;
  acute progressive, 423;
  "acute rheumatoid," 422;
  chronic, course of, 425.
Arthritis deformans, 421;
  climate and, 428;
  chronic, 424;
  diet and, 427;
  electricity and, 427;
  exercise and, 427;
  in old persons, 426;
  knitting and, 427;
  mechano-therapy and, 427;
  mental attitude and, 426;
  muscle disturbances in, 424;
  nerves and, 422;
  neurotic additions in, 425;
  occupation of mind in, 428;
  symmetrical, 422;
  treatment of, 426;
  usefulness in, 426;
  weather and, 428.
Arthritises, hysterical, 429.
Arthropathy, nervous, 422.
Asafetida, 69.
Association fibers, diversion of, 601.
Association of ideas, 123.
Astasia-abasia, 86.
Asthma,
  brothers and, 377;
  cardiac, 364;
  cat, 374;
  cigarettes and, 366;
  climatotherapy and suggestion in, 368;
  cubebs and, 366;
  cures for, 366;
  cyanosis in, 365;
  drugs and suggestion in, 368;
  dust and, 369;
  emphysema in, 365;
  essential, 364;
  eye strain and, 367;
  horse, 376;
  horse serum and, 377;
  horse sensitization and, 377;
  human emanations and, 377;
  lavage and, 367;
  mental influence and, 365;
  mental shock and, 366;
  mouth breathing and, 367;
  neurotic, 364;
  picture of hayfield and, 375;
  renal, 364;
  saltpeter paper and, 366;
  suggestion in, 366;
  symptomatic, 364;
  varied cures for, 367.
Astrology,
  Hippocrates on, 38;
  in surgery, 746;
  reassurance and, 40;
  suggestion and, 38;
  venesection and, 746.
Ataxia,
  accessory symptoms of, 526;
  back knee, 524;
  depression in, 525;
  emotional, 572;
  flat-foot and, 524;
  from emotion, 572;
  in talking, walking, etc., 571;
  locomotor, 524;
  loose joints and, 524;
  suggestions, favorable and unfavorable, in, 525.
Athens, psychotherapy in, 8.
Athletes,
  pneumonia and, 202;
  typhoid and, 202.
Attacks, auto-hypnotic, 541.
Attention,
  concentration of, 755;
  conscious, 129;
  memory and, 679;
  process of, 127;
  power of, 124;
  Ramon y Cajal's theory of, 126.
Attitude, mental, 100.
Attitudes,
  influence of, 100;
  of mind, 103.
Augustine, St., on warnings, 611.
Authorities on tuberculosis, American, 359.
Auto-hypnotism, 161.
Auto-intoxication,
  intestinal, 172, 270;
  supposed, 270.
Automatism, inhibition of, 601.
Auto-suggestion and the will, 148.
Avalanche in nerves, law of. 111.
Avalanche, law of, 585.
Aversion
  to cats, 617;
  to dead bodies, 617.
Avicenna on mental influence, 14.
Awake, lying, 667.
Awaking, mode of, 165.
Axis cylinders, 112.
Axon hillock, 114.


B

Babies, fat, 292.
Bacchae, 688.
Back ache, 174.
Bacon, as food, 249.
Bacteria, lactic, 247.
Ball for constipation, 278.
Balneo-therapy, 5.
Barometer, pains and, 382.
Baseball interest, 228.
Basedow's disease, 500.
Basil, Valentine, 9, 26.
Basophobia, 613.
Bath,
  cold, 166;
  hot, 166;
  morning, 166.
Bathing,
  abuse of, 166;
  overfrequent, 167.
Berkeley, Bishop, 57.
Bernard, St., 74.
Bernheim, hypnotism and, 159.
Biliary colic, pseudo, 588.
Billiards, 180, 182.
Binet, 153.
Biographic Clinics, 258.
Bishop, the mind-reader, 147, 194.
Bismarck's second eighty years, 724.
Bismuth, milk of, 285.
Bladder,
  emptying the, 470;
  evacuation of the, position in, 212.
Blanched fingers, 63.
Blanching, 190.
Bleeding, old-time, 381.
Blind and deaf training, 215.
Blind,
  color recognition in the, 214;
  training of feeling in the, 213.
Blood,
  child's not mother's, 462;
  turning of the, 64.
Blood letting, patient's mind and, 14.
Bloodstone, 60.
Blue glass, 44.
Blue light, 44.
"Blues, the," 641.
"Bluidy Jock," 357.
Blush, intestinal and vesical, 282.
Blushing, 190;
  obsession, 613.
Body, influence of, on mind, 100.
Boerhaave, 17, 71.
Bonaparte, 85.
Bouchard, 270.
Bovary, Madame, 243.
Bowels, over-attention to, 287.
Bowling, 182.
Boyle, Sir Robert, 35.
Bradycardia, 342;
  case of, 343.
Brain,
  anatomy of, 18;
  capillaries in the, 125;
  cells of, vital energy of, 131;
  cells of, number of, 132;
  cortex of, 109, 117;
  complexity of the, 109;
  intellect and, 549;
  machine, 132;
  number of cells in the, 110.
Brain workers, 601.
Brains, as food, 244.
Bramwell, Dr. Byron, 374.
Bramwell, Dr. J. Milne, 160.
Bread pills, 88.
Breakfast,
  a full, 299;
  before, 168;
  company at, 170;
  habits, 169;
  mail before, 170;
  newspaper at, 170.
Bridgeman, Laura, 214.
Bright's disease,
  insidious, 558;
  latent, 558;
  neurotic symptoms of, 558.
Bringer of Peace, 7.
Broadbent, Sir Wm., 319, 326;
  on angina, 339.
Brodie, Sir Benjamin, and hysterical joints, 386, 589, 749.
Bronchi, dilatation of, relief in, 210.
Bronchiectasis, position in, 210.
Brontophobia, 612.
Brown-Séquard, 48, 67.
Bunion,
  formation of, 417;
  gout and, 416.
Bunions and flatfoot, 416.
Bursa,
  housemaids', 399;
  miners', 399;
  organ grinders', 399;
  sitters', 399.
Bursae, discomforts of, 399.
Business,
  anxieties in, 184;
  habits of, 178;
  knowledge of, 177;
  light, air, and position in, 177;
  walk to, 171;
  worries in, 185.
Butter, microbes in, 95.
Buxom, etymology of, 297.


C

Cabanis, 84.
Cagliostro, 47.
_Calamus scriptorius_, 12.
Calculi, preputial, 485.
Calculus, biliary, simulation of, 282.
Calmady, Sir Richard, case of maternal impression in fiction, 221.
Calomel, 3;
  in pneumonia, 22;
  suggestion and, 27.
Campbell Thompson and cuneiform inscriptions, 38.
Canals, semi-circular, 97.
Cancer,
  abdominal, 303;
  heredity in, 631;
  latent indigestion and, 255;
  mind and, 750;
  nursing tonic in, 222.
Capillaries, congestion of, 126.
Card playing, 182.
Cardiac conditions, diagnosis of, 316.
Cardiac exercise, 325.
Cardiac inhibition, 313.
Cardiac neurosis and prognosis, 321, 322.
Cardiac palpitation, the intellectual life and, 323.
Cardiac stomach disturbance, 333.
Carlsbad, 278.
Carlyle's Miscellanies, 47, 685.
Carminatives, 285.
Carnelian, 62.
Cassius, lean and hungry, 297.
Casts, intestinal and tubular, 286.
Catalepsy, hypnotic, 159.
Catarrh, 39, 59;
  seasonal, 368.
"Catarrh spring," 369.
Cathay, cycle of, 517.
Catherine of Siena, 74.
Cato learning Greek, 680.
Cats,
  conjunctivitis and, 375;
  consciousness of presence of, 618;
  coryza and, 374;
  digestion disturbed by presence of, 254;
  dread of, 374, 617;
  dread from memory of killing, 375;
  fear of, and furs, 618;
  intolerance of, 374;
  odor of, 619;
  smell of, 374;
  urticaria and, 374.
Cautery,
  actual, 68;
  psychotherapeutics and, 408.
Cells,
  complexity of brain, 131;
  Golgi, 131;
  of the ventral horn, 133;
  perivascular, 121;
  pigment, 121;
  rest, 652;
  spindle, 112.
Cerebral artery, control of, 125.
Cerebration, unconscious, 128, 132, 134.
Cervical ribs, 400.
Chair, comfortable, 210.
Chamois garments, 168.
Champneys, on painful menstruation, 445.
Chance, 776.
Character,
  and suffering, 222;
  in therapeutics, 358;
  upbuilding of, 222.
Charcot, Dr., 71;
  on menstrual mental states, 434.
Charcot crystals, 364.
Charms for erysipelas, 22, 60.
Charmides (Plato), 11.
Cheese, habituation to, 246.
Chest protectors, 167.
Chesterfield, Lord, 225.
Chesterton, on suicide, 722.
Chestnuts, horse, for rheumatism, 385.
Chewing in tuberculosis, 355.
Cheyne, Dr., 314.
Child,
  diversion of the, 228;
  first years of the, 230;
  recreation of the, 228.
Childbirth,
  dangers of, 458;
  natural, 458;
  over-zeal to help in, 458.
Children,
  care of, 221;
  fat, 267;
  increase of suicide among, 721.
Chilliness, 773.
Chloral in hypnotism, 156.
Chorea,
  anemia and, 562;
  endocarditis and, 562;
  etiology of, 561;
  expectant treatment of, 563;
  colds and, 562;
  consciousness in, 562;
  cures of, 562;
  fright in, 562;
  growing pains and, 562;
  pathology of, 562;
  prophylaxis in, 563;
  pure neurosis and, 561;
  simple life and, 564;
  subsequent habit after, 563;
  treatment of, 562.
Cicero, 189.
Circle, vicious, 51, 251.
Circulation, favoring return of, 208.
Cirrhosis, alcoholic, 175.
Civil War, Reports of, 286.
Clairvoyant, 147.
Claude, Bernard, 20, 313.
Claudication, intermittent, 512.
Claustrophobia, 612, 616.
Clavus _hystericus_, 547.
Clergyman's knee, 411;
  sore throat, 411.
Clinics, biographic, 601.
Clitoris, removal of, 488.
Clothing, 167;
  warm, 356.
Clouston, 191;
  on religion, 777.
Coccydynia, 428.
Coccygodynia, 68;
  causes of, 428;
  hysterical, 429;
  labor and, 428;
  neurotic, 429;
  over-attention to, 429.
Coffee and abdominal distress, 307.
Cohnheim, 251.
Coincidences, 144;
  telepathy and, 146.
Colds,
  fat and, 298;
  fresh, 350;
  fresh air and, 350;
  more sleep and, 350;
  night air and, 350;
  quinine and whiskey for, 349;
  rational treatment of, 349;
  settled on lungs, 358;
  taking, 167.
Colitis,
  cures for, 288;
  excess of salt in, 284;
  in Civil War, 286;
  increase of, 287;
  muco-membranous, 286, 288;
  resorts, 289;
  suggestion in, 288;
  surgery for, 288.
Colles' Law, 630.
Color blindness, 771.
Columbus, 42.
Comedy, musical, 227.
Comfort, mental and physical, 761.
Compensation, 213.
Concussion of the brain, 118.
Conditions, mechanical, in pains, 174.
Confession in sex habits, 486.
Confidence, 15;
  of the patient, 14;
  of the physician, 4.
Conjunctivitis, cat, 375.
Constipation, 268;
  exercise in, 276;
  fats and sugars in, 276;
  in obesity, 296;
  in the stout, 278;
  oriental, 271;
  position in, 276;
  prophylaxis in, 269;
  reassurance in, 271;
  tolerance in, 272.
Contagion,
  coughing and, 688;
  expectoration and, 688;
  fashion and, 691;
  favorable mental, 692;
  giggling, 688;
  health, 692;
  laughing, 688;
  moving pictures and, 693;
  murder, 691;
  not heredity, 298;
  psychic, 688;
  sighing, 688;
  suicide, 691;
  yawning, 688.
Contagious trifles, 688.
Co-ordination in the organism, 132.
Copenhagen, Perkins in, 49.
Copremia, supposed, 270.
Cornelius Agrippa, 15.
Corns, soft, 418.
Corpulency, 290.
Cortex,
  diagram of, 113;
  pyramidal cell in the, 122;
  visual, 110.
Coryza,
  cat, 375;
  vaso-motoria periodica, 369;
  yearly, 372.
Cough,
  as tic, 348;
  habit, 347;
  hemorrhage and, 346;
  intestinal, 348;
  in tuberculosis, 348;
  irrational, 349;
  mental control of, 361;
  ordinary, 345;
  ovarian, 348;
  reflex, 347;
  remedies for, 345, 349;
  stomach, 348;
  stopping a, 210;
  suggestion and, 345;
  unproductive, 345;
  uterine, 348.
Coughing, control of, 361.
Counter irritation in nervous disease, 511.
Courting and telepathy, 143.
Coventry Patmore, Mrs., 144.
Coxalgia, hysterical, 429.
Cramp rings, 61, 80.
Cranberries in erysipelas, 22.
Creator, existence of, 776.
Crises,
  gastric, 526;
  intestinal, 526;
  tabetic, 526.
Critias, 11.
Cromwell, 81.
Crooke's theory of telepathy, 142.
Croup, nervous, 669.
Cure-alls, 3.
Cure
  houses, 10;
  magnetic, 55;
  relieve, console, 186;
  smiling and laughing, 104.
Cured cases as evidence, 52, 60.
Cures, 50;
  faith, 78;
  for colitis, 288;
  for tuberculosis, 351;
  hayfever, 373;
  supposed, 51, 387.
Curschmann's spirals, 364.
Cutten, on faith cures, 81.
Czermak, Prof., on inhibition, 313.


D

Dalton, color blind, 772.
Dangers of hypnotism, 161;
  Dr. J. K. Mitchell on, 161.
Darkness,
  dread of, 620, 668;
  Romilly and, 621;
  Rousseau and, 620.
Dawdling, 182.
Dead bodies, aversion to, 617.
Deaf, training of the, 215.
Death,
  AEschylus on, 622;
  After, What? 88;
  attitude toward, 730;
  captain of, 350;
  dread of, 621;
  fear of early, 622;
  impending, 336;
  life and, 89;
  mind and, 90;
  moment of, 147;
  premonition of, 636;
  put off, 91;
  socially, 731;
  Sophocles on, 622.
Defectives, sexual, 474.
Deformities,
  coincidences and, 464;
  etiology of, 466;
  falls and, 467;
  missteps and, 467.
Degeneration, stigmata of, 744.
Delusions, 603.
_Dementia praecox_ and paresis, 532.
Dendrites, 112.
Dentist's limp, 398.
Depression and disease, 641;
  and diversion, 643;
  and dyspepsia, 233;
  and hobbies, 646;
  and indigestion, 233;
  an incident, 650;
  benefits of, 650;
  care of ailing a cure for, 645;
  care of animals a cure for, 645:
  care of plants a cure for, 645;
  feminine, and children, 644;
  frequency of, 647;
  garden cures for, 646;
  heart disease and, 642;
  historical examples of, 647;
  insomnia and, 644;
  Lord Lytton and, 648
  Lowell, James Russell, and, 648
  nephritis and, 642;
  periodical, 641
  reading in, 646.
De Puysegur's instruction in hypnotism, 154.
Dermatotherapy, the mind in, 495.
Descartes, 41.
Desks, comfortable, standing, 176.
Determinism, 744.
Deterrent materials and suggestions, 34.
Deterrent taste and smell, 68.
Deterrent therapeutics, 63.
Diabetes
  acidosis, 500;
  air and exercise in, 499;
  causes of, 496;
  danger of over-treatment in, 497;
  eczema in, 496;
  frequent in obese, 294;
  general condition in, 497;
  incurable, 496;
  interval treatment of, 498;
  oatmeal and, 498;
  over-treatment of, 497;
  pancreatic changes in, 496;
  physician and patient's, 497;
  potatoes and, 498;
  rigid diet and solicitude in, 499;
  secondary symptoms of, 497;
  individual, the, and, 498;
  unfavorable suggestion, 496.
Diagnosis, announcing the, 354.
Diancecht, Irish physician, 58.
Diaphragm,
  excursions of the, 362;
  movements of the, 362.
Diarrhea,
  emotional, 283;
  fright and, 279;
  habitual, 280;
  nervous, 558;
  nervous, and urticaria, 281;
  neurotic, 279;
  worry and, 280.
Diathesis, uric acid, 380.
Diet,
  _do not_, 257;
  dyspepsia and, 256;
  fads, 171;
  limitation of, 275;
  mixed, 275;
  restrained, 298;
  rules, harmful, in, 256;
  tinkering, 380.
Diffusion, laws of, 132.
Digby, Sir Kenelm, 56.
Digestion,
  brain workers and, 258;
  chemistry and, 242;
  contrary suggestions and, 251;
  disgust and, 243;
  influence of mind upon, 242;
  mental changes and, 247;
  of cat, disturbed, 254;
  prejudices and, 242;
  study and, 253;
  worries and, 253.
Digitalis and mental influence, 313.
Directions to physicians, suggestion and, 197.
Disappearances, 608.
Disappointments, mental states of, 643.
Discipline, of mind, 196; of self, 223.
Discomfort,
  digestion and, 253;
  with eating, 301.
Discontinuity of the nervous system, 118.
Discoveries, scientific, 46.
Discovery, supposedly wonderful, 192.
Disease,
  American, 380;
  incurable, 186;
  individual, 224;
  patients and, 163;
  suggestion of, 94; thinking, 99.
Disease suggestions, 250.
Diseases of ductless glands, 496.
Dislocations, after-effects of, 388.
Disposition,
  suggestion and, 101;
  dual, 150.
Distension, 332.
Disuse, atrophy and pain, 394.
Diversion, 182;
  children's, 228;
  from pain, 225;
  of mind, 9;
  true, 224.
Divinity, medical, 7.
Doctor, "conjure," 64.
Dog and hog, 243.
Dominant ideas, 750.
Donne, Dr., 37.
Doubting, 732;
  daily review in, 738;
  habit, 733;
  marriage and, 735;
  opening letters and, 735;
  ordination and, 735;
  outdoor air and, 738;
  prophylaxis in, 737.
Doubts,
  Hamlet's, 735;
  program for day in, 738.
Dread, 2, 612, 613;
  habit of control of, 615;
  mental discipline in, 615:
  of arterio-sclerosis, 515;
  of death, 621;
  of dirt, 615;
  of heights, 614;
  of indigestion, 306;
  of insanity, 623;
  of small heights, 615;
  of the dark. 620;
  of water, 621;
  physical basis of, 614;
  subconscious, 625.
Dreads,
  heredity and, 626;
  men of genius and, 623.
Dreaming,
  "all the night long," 673;
  by day, 671;
  constant, Hazlitt, Mitchell and Owen, 672;
  Laughing, Blushing and, 607, 672.
Dreams, 8, 78, 669;
  and children, 678;
  and digestion, 100;
  and fright, 677;
  and reading, 678;
  and sensations, 575;
  art in, 136;
  children's, 677;
  erotic, 479;
  frequency of, 671;
  insufficient clothing in, 671;
  life and, 136;
  mathematical, 136;
  mercy's, 136;
  of falling, 670;
  out of breath, 671;
  poems and, 136;
  prophecy fails, 676;
  prophetic, 675;
  rearrangement in, 635;
  short duration of, 673;
  significance of, 674;
  suggestions and, 678;
  telepathic, 674;
  therapy and, 669.
Drug addictions, 707.
Drug habit,
  after-cures for, 712;
  confidence in, 711;
  cures for, 709;
  curiosity and, 708;
  early treatment in, 710;
  forming, 290;
  heredity and, 712;
  individual, 707;
  over-confidence in, 709;
  pleasant, 708;
  prophylaxis in, 708;
  relapses in, 709;
  sanitarium question and, 710.
Drugs, 8;
  effects of, imaginary, 88;
  in sufficient doses, 4.
Drunkenness, 117.
Dualism of disposition, 151.
Dumas, 47.
Dumb-bell, a parody of exercise, 204.
Dundrearyisms, 464.
Dupré, Giovanni, 136.
Dupuytren's slap for anesthesia, 754.
Dust and disease, 172.
Duval and neurons, 114.
Dwarf of French king, 314.
Dysmenorrhea,
  constipation in, 442
  cystic ovaries in, 446;
  extragenital 445;
  extrapelvic organs in, 442
  fisherwomen and, 444;
  individual 446;
  lack of occupation in, 443
  membranous, 445;
  minor lesions in, 446;
  moral fiber and, 443;
  operation idea and, 443;
  running down and, 442;
  spasmodic, 445;
  suggestion and, 445.
Dyspepsia, 301;
  abdominal muscles and, 261;
  air and, 262;
  American, 179;
  depression and, 233;
  from diet regulation, 256;
  mental work and, 253;
  sleep and, 262;
  state of mind in, 250.
Dyspeptics,
  exercise for, 261;
  longevity of, 259.


E

Eat, the will to, 263.
Eating,
  dread of, 264;
  enough, 299;
  more, 301;
  slow, 231;
  uncomfortable feelings after, 263.
Eddyism, 60, 386.
Edema, angio-neurotic, 283.
Education and discipline, 196.
Efficiency experts, 179.
Eggs,
  biliousness and, 246;
  idiosyncrasy for, 245;
  persuasion as to, 248;
  repugnance to, 246.
Egypt, psychotherapy in, 8.
Electric belts, 62.
Electric insoles, 63.
Electrical contrivances, 43.
Electricity, 5.
Electro-therapy, 5;
  suggestion and, 42, 43.
Elijah returned, 82.
Elixir of life, 44.
Embryo-complexity, 466.
Emissions,
  seminal, alcohol and, 478;
  constipation and, 478;
  full bladder and, 478;
  nocturnal, 477;
  prophylaxis in, 478;
  spices and, 478.
Emotion, heart and, 311.
Emotions as remedies, 17.
Encyclopedia Brittanica on mummifies, 64.
Energy, reserve, 108;
  law of, 92.
English, Dr. Thomas Dunn, on life, 724.
Environment, favorable, 188.
Epidaurus, 8.
Epidemic, suicidal, 691.
Epilepsy, 15;
  anise seed for, 25;
  attitude of mind in, 537;
  Byron and, 536;
  Caesar and, 536;
  colony system and, 535;
  cures for, 537;
  dread of insanity in, 535;
  emotion and, 535;
  fright and, 535;
  individual in, 536;
  influence of suggestion in, 535;
  mental "cures" of, 541;
  Mohamed, 536;
  Napoleon, 536;
  neurotic simulation of, 536;
  occupation in, 537;
  operations for, 505, 535;
  quiet life and, 537;
  rings in, 61;
  royal touch and, 79;
  suggestion in, 25.
Equilibrium,
  training in, 215;
  unstable intestinal, 286.
Erasistratos, 11.
Erotic, 480.
Erysipelas, 3, 21.
Erythrophobia, 613.
Esophageal stricture, 676;
  neurotic, 574.
Esophagus, constriction of the, 575.
Esquirol, on child suicide, 721.
Ether in telepathy, 142.
Euripides, 688.
Evacuation,
  habitual, 273;
  simulated, 285.
Evil, denial of, 776.
Evolution, Lucretius and, 776.
Excrement, goose and chicken, 34.
Excretions as remedies, 66.
Exercise, 198;
  air and, 203;
  for heart irregularity, 327;
  for sake of exercise, 204-7;
  fun and, 203;
  graduated, for heart, 328;
  in dyspepsia, 261;
  in early years--English and German customs, 199;
  interest and, 203;
  mental diversion and, 207;
  regulation of, 202;
  sport and, 203;
  sufficient, 199;
  treatment for heart and, 328.
Exhaustion, mental, 138.
Exhibitionism, 490.
Exosmosis, 132.
Expectancy, mental, 46.
Expectoration, difficulty in, 210.
Expert in health, 179.
Expression and feeling, 101.
Extensors and hate, 194.
Extra-systole,
  big beat and, 333;
  conscious, 333;
  long-pause, 333;
  prognosis in, 333.
Eye,
  oblique muscles of, 102;
  superior recti of, 102.


F

Fabricius Hildanus, 54.
Facial expression and feeling, 101.
Faddists, fruit, milk-product and nut, 258.
Fads,
  bathing, 167;
  harmful, 166;
  health and, 689.
Faith, 14, 15;
  cures by, 61;
  healing and, 196;
  power of, 196.
Familiarity with drugs, 4.
_Fascia dentata neuroglia_, 120.
Fashion contagion, 690.
Fasting ages, 298.
Fat,
  anemic, 298;
  in sick hogs, 303;
  lack of, 298;
  useless, 201.
Father John of Cronstadt, 75.
Fats in constipation, 276.
Fatty vicious circle, 292.
Fearing the worst, 98.
Feeling, expression and, 101;
  occupation and, 129.
Feelings, transferred, 251.
Feet above heart, 173.
Femero-coxalgia, 68.
Feré, 153.
Ferrier, Chancellor, 323.
Fever, afternoon, 180;
  typhoid, 3.
Filaments, terminal, 117.
Fish, coloration practice in, 494.
Fissure, calcarine, 110.
Flammarion, 607.
Flashes of heat, 773.
Flatfoot, 174, 383;
  circulation in, 419;
  prevention of, 419;
  relief for, 209;
  runs in families, 390;
  secondary consequences of, 420;
  sprains and, 420.
Flatulence, 332.
Flaubert, 243.
Fletcher, 231.
Flexors and liking, 194.
Flourens, 543.
Fluid,
  daily, 274;
  ingestion of, 274;
  in obesity, 296.
Folin, 231.
Food,
  amount of, 273;
  angle worms as, 244;
  brains, liver and spleen as, 244;
  caprice and, 266;
  chewing, 260;
  craving for, after operation, 763;
  custom and, 244;
  dislikes for, 245;
  dyspepsia and, 301;
  elimination of, 250;
  idiosyncrasies and, 282, 301;
  increase in, 273, 301;
  natural residue of, 275;
  preparation of, appetite and, 266;
  reduction of, 296;
  sleep and, 207;
  temptations to, 293;
  values and habits, 263.
Food faddists, 258.
Foot,
  exercise for the, 420;
  noises with the, 419.
Foot troubles,
  deformities in all classes, 413;
  mechanical factors in, 413;
  rarer, 418;
  significance of, 421;
  unfavorable suggestions and, 415.
Force, vital, 133.
Ford Robertson, 110.
Forel, Prof., 190, 706.
Foreskin, long, 484.
Forgetfulness, limits of normal, 683.
Formulas, word, 566.
Fox hunting, 205.
Fractures,
  after-effects of, 388;
  immobilized, 388;
  manipulation of, 388;
  massage of, 388;
  mind and, 751;
  of the clavicle, 89.
Francis of Assisi, St., 74.
Francis Xavier, St., 74.
Frankenstein, 626.
Free will, 148, 152, 739;
  argument for, 739;
  individual, 741.
Frenkel's method for tabes, 528.
Frenkel's treatment, origin of, 528.
Frere, Robert 36.
Freud, 595.
Friedländer on quackery at Rome, 58.
Fright,
  epilepsy and, 535;
  heart and, 315;
  in chorea, 562;
  in Graves' disease, 500;
  in paralysis agitans, 542;
  loss of bowel control and, 279;
  tremors from, 581;
  white hair and, 494.
Frights, forgotten, 625.
Fumigation, 60.
Fun and health, 203.


G

Galen, 12;
  on proprietaries, 59.
Galen's theriac, 20, 46, 51, 59, 71.
Gallstones, 80.
Galton, Sir Francis, 36, 601, 606.
Galvani, 43.
Gambling, 182.
Garments, chamois, 168.
Gas, 15.
Gassner, 15, 153.
Gastralgia, tabetic, 526.
Gastric crisis, 526, 586.
Gastric dilatation, 330.
Gastric fauna, 462.
Gastric motility, 176, 307.
Gastric muscular tone, 262.
Gastric reflexes, 251.
Gastric secretion neuroses, 586.
Gastric self digestion, 303.
Gastric sensations, 306.
Generalization of visceral pain, 252.
Genitalia, over-attention to the, 430.
Genius, De Musset, 624;
  Goethe, 624;
  idiosyncrasies and, 245;
  investigating, 130;
  Kingsley, 624;
  Montaigne, 624.
George Eliot, 135, 141.
Gerhardt, Prof., 317.
Ghosts, 605.
Gilbert, 42.
Gilles de la Tourette on tics, 564.
Ginseng, 35.
Giving up, 93.
Gladstone, 225.
Gladstone's chewing, 231.
Glands, intestinal, over-action of, 288.
Glycosuria,
  alimentary, 496;
  psychological, 291;
  neurotic, 496.
Goclenius, 55.
Gold, chloride of, 61.
Goldsmith, 223.
Golgi, 110, 131.
Gordon Holmes, 151.
Gordy, Prof. J. P., 230.
Gould, Dr. George, 258, 601.
Gout and flatfoot, 415, 416;
  rheumatic, 421.
Gowers, Sir William, 556.
Gowers' rule in writing, 396.
Grahamism, 256.
Grass scorpion, 35.
Grasset, 597.
Graves' disease,
  cures of, 504;
  diagnosis of, 502;
  diarrhea and, 501;
  diet and, 506;
  diversion and, 506;
  emaciation and, 501;
  emotion and, 500;
  etiology of, 500;
  _formes frustes_ 500, 502;
  fright and, 500;
  genital incidents and, 501;
  larval forms of, 341;
  menopause and, 502;
  mummy and, 504;
  operations for, 505;
  parathyroid and, 504;
  prognosis in, 502;
  responsibility and, 500;
  serums and, 504;
  sex incidents and, 501;
  sleep and, 506;
  snake skin and, 504;
  suggestion and, 504;
  sympathetic, 502;
  symptomatology of, 501;
  thyroid in, 469, 504;
  thymus in, 469, 503;
  touch of hanged in, 504;
  women and, 501.
Gravitation, 41.
Greatrakes, 81, 153, 386.
Greece, decadence in, 107.
Grief,
  Astley Cooper and, 731;
  consolation in, 729;
  Lord Lytton and, 731;
  melancholia and, 727;
  motives of consolation in, 728;
  pathological, 727;
  physical conditions in, 726;
  prophylaxis in, 728;
  Rossetti and, 732.
Grouch, perennial, 233.
Gymnasium director, 206.
Gymnastics, 181, 203.
Gynecology,
  dominant ideas in, 432;
  functional diseases in, 456;
  mental factors in, 433;
  mental healing in, 430;
  reputed remedies in, 431;
  self-control and, 433;
  suggested factors in, 431.


H

Habit, 125;
  appetite and, 265;
  business occupation and, 178;
  following chorea, 563;
  formation of, 229;
  in constipation, 273;
  is second nature, 229;
  non-inheritance of, 632;
  saves reflection, 235.
Habits,
  air and exercise, change of, 232;
  bolting, 231;
  law of, 230;
  mental, 233;
  physical, 231;
  sexual, 482.
Hack Tuke, Dr., 190;
  on warts, 493.
"Hacks," 361.
Hahnemann, 41.
Haldane, Prof., 132.
Hallucinations, 78, 141, 603, 773;
  auditory, 609, 773;
  cocaine, 773;
  disturbing, 611;
  dreams and, 606;
  explanation of, 607;
  frequency of, 604;
  insanity and, 609;
  significance of, 604;
  statistics of, 605;
  telepathic, 605;
  touch, 773;
  visual, 604.
Head,
  discomfort in, local, 552;
  over-attention to the, 547;
  raising the, 210.
Headache, 59;
  air and, 554;
  anemic, 553;
  at Epidaurus, 554;
  attention, 547;
  coffee and, 553;
  congestion, 549, 551;
  cures for, 546;
  direct mental treatment of, 553;
  distraction and, 548;
  drugs and, 553;
  exercise and, 554;
  extraneous, 550;
  eye strain and, 550;
  fear of brain lesion and, 549;
  frequency of, 546;
  lack of distraction and, 548;
  local conditions and, 550;
  loss of meal and, 551;
  mental treatment for, place of, 554;
  mental work and, 550;
  occipital, 552;
  occupation of mind and, 546;
  sense of pressure in, 547;
  source of pain in, 549;
  spirits and, 553;
  tea and, 553;
  tenderness and, 552;
  weight and, 553.
Head's studies in sensation, 252.
Healers of the nineteenth century, 81.
Healing, irregular mental, 209.
Health,
  central nervous system and, 191;
  good, and happiness, 234;
  muscle development and, 200;
  thinking, 99.
Health resort, 184.
Hearing, training of the, 686.
Heart,
  action of, after dancing, 324;
  action of, after Marathon, 324;
  action of, irregularity of, 322, 323;
  anxiety about the, 311;
  arrhythmia of the, 322;
  athletes', 324;
  coffee and the, 329;
  crowding of the, 323;
  cures, faith, and the, 312;
  defects of the, and quiet lives, 316;
  difficulties of the, 319;
  emotion and old physiology of, 311;
  fatty, and exercise, 326;
  fright and the, 315;
  functional affections of the, 321;
  gastric influence on the, 334;
  general condition and the, 318;
  German and Irish schools on the, 318;
  Indian fakirs and the, 311;
  in difficulties, 322;
  individual and the, 317;
  inhibition of action of the, 313;
  introspection and the, 327;
  irregularity of, not to be treated, 327;
  irritable, 324;
  limitation of  diet and the, 335;
  listening to the, 317;
  meat-eating and the, 335;
  mental influence on the, 310;
  missed beats of the, 322;
  muscular, 322;
  nervous, Morgagni and Lancisi on, 331;
  nervous system and the, 311;
  occupation of mind and the, 320;
  palpitation of the, 322;
  physiological work for the, 326;
  reassurance and the, 334;
  remedies and suggestion and the, 312;
  shock and the, 314;
  sorrow and the, 315;
  sounds, impure, in the, 324;
  stimulants and the, 326;
  stomach distension upward, effect of, upon the, 330;
  stomach gas and the, 329;
  suffering and the, 332;
  surveillance over the, 322;
  sympathetic, 319;
  taking, 312;
  tea and the, 329;
  therapy of the, psychic factors in, 315;
  tobacco and the, 329;
  training, 216, 326;
  trouble of the, consciousness of, 312;
  vaso-motors and the, 319;
  voluntary inhibition of action of the, 314.
Heart disease,
  consumption and, 321;
  declaration of, 321;
  diagnosis in latent, 316;
  exaggeration of seriousness in, 317;
  mental influence and, 311;
  prognosis in, 315, 316, 332;
  prophylaxis in, 315;
  symptoms of, in the young, 321;
  symptoms of, neglect of, 320;
  symptoms of, simulated, 319;
  symptoms of, subjective, 321.
Heart failure, 334, 341.
Heart murmurs,
  significance of, 317;
  uncertainty of, 318.

Heberden's nodes,
  causes of, 422;
  longevity and, 423;
  progress of, 423;
  solicitude over, 423.
Heels, high, 410.
Hell, Father, mental influence practised by, 153.
Hemorrhage,
  cough and, 346;
  mind and, 360.
Hen hypnotization, 160.
Herbal medicine and mental influence, 140.
Hereditary resistance, 712.
Hereditary syphilis, 629.
Hereditary tuberculosis, 629.
Heredity, alcoholism and, 629;
  disease and, 628;
  drug habits and, 712;
  false impressions concerning, 627;
  habits and, 632;
  Hapsburg lip, instance of, 632;
  mystery of, 633;
  resistance and, 352;
  principles of, 699;
  suggestion and, 251;
  tuberculosis and, 628;
  variation and, 633.
Hermaphrodites, partial, 489.
Hermaphroditism, mental, 490.
Herophilus, 11.
Herpes and mind, 492.
Hertz, Arthur, 270.
_Hexenschuss_, 391.
Hildanus, 54.
Hilprecht's sleep vision, 137.
Hilton on Rest and Pain, 52, 188.
Hippocrates, 10, 71;
  on astrology, 38.
Hives and diarrhea, 281.
Hobbies, 224;
  Virchow on, 226.
Hobby, 601.
Hog's meat, 243.
Holmes, Oliver Wendell, 4, 48, 50, 54, 56, 311.
Home work, 182.
Homo-sexuality, 490.
Hook-worm,
  in Egypt, 107;
  in Porto Rico, 107;
  in the South, 107.
Hope, renewal of, 91.
Horace, 223.
Horseback riding, 204.
Horse, outside of a, the, 204.
Hospitals,
  mind and, 747;
  psychic conditions of, 760.
Hours of diversion, 182.
Hudson, 251.
Humor, 105.
Hunger and sleep, 665.
Hunter, John, 17.
Hunyadi Janos, 278.
Hydrophobia, 613.
Hydrotherapy, 5.
Hygiene, personal, 178.
_Hyperemesis gravidarum_, 457;
  postanesthetic, 758.
Hypersecretion, gastric, 586.
Hypnoidal state, 198, 626.
Hypnosis, anesthetic, 755;
  animal, 160;
  of self, 161.
Hypnotism,
  accessories in, 155;
  Danger and Uses of, 162;
  drugs in, 156;
  effects of, 152;
  essence of, 152;
  explanation of, 118;
  for exhibitions, 162;
  influence of, 76, 111;
  in obstetrics, 458;
  lights in, 155;
  miracles of, 152;
  mystery of, 151;
  not mysterious, 158;
  practice of, 156;
  sensations of, 156;
  sound in, 156;
  stroking in, 156;
  susceptibility to, 159;
  three stages of, 158;
  valuation of, 152;
  uses of, 162.
Hypnotizers,
  Bernheim, 154;
  Braid, 154;
  De Puysegur, 154;
  Liebault, 154;
  Mesmer, 154.
Hypochondria, 287.
Hypochondriac, 94;
  sympathy with the, 335.
Hypochondriac organs, 335.
Hypochondriorum, _ex consensu_, 331.
Hypothesis,
  Duval's, for brain mechanism, 123;
  Ramon y Cajal's, for brain mechanism, 127;
  for sympathetic system, 127.
Hysteria, 80, 585, 590;
  dual personality and, 149;
  organic change and, 190;
  secondary personality and, 149.
Hysterical cutaneous conditions, 495.
Hystero-epilepsy, 538, 626.


I

Idea,
  single, 195;
  tends to action, 194.
Ideas,
  dominant, 97, 239;
  body and, 195.
Idiosyncrasies,
  food, 282;
  genuine food, 245;
  individual and heat, 329;
  intestinal, 282;
  physiological, 231.
I-Em-Hetep, 7, 71.
Ignatius Loyola, St., 102.
Ills,
  imaginary, 191;
  not fancied, 191.
Illusions, 603, 764;
  delusions, hallucinations and, 773;
  in connection with dots, 776;
  in connection with a tube, 764;
  of distance, 769;
  of  size, 769, 770;
  of the sun and moon, 768;
  optical, 770;
  universal, 764.
Image, wax, and distant effects, 141.
Imaginary ills, 191.
Imagination, 14, 15.
Immunity,
  acquired, 358;
  inborn, 358;
  lack of, 108;
  maternal, in syphilis, 629;
  of nursling, 461.
Impedimenta, 201.
Impotence,
  organic, 476;
  psychic, 475.
Impotency obsession, 476.
Impressions, mental, 346.
Incisions and suggestion, 752.
Incubation, 554, 669.
Incurable, care of the, 223.
Incurable disease, relieving, 510.
Incurability, so-called, 48.
Indigestion,
  above the neck, 257;
  auto-suggestive, 250;
  cancer, latent, and, 255;
  correction of, 259;
  depression and, 233;
  differentiation of, 254;
  diversion of mind and, 258;
  dread of, 305, 306;
  early tuberculosis and, 255;
  lack of sleep and, 254;
  neurotic, 169;
  prevention of, 259;
  unfavorable states of mind and, 250.
Individuality, 133.
Individuals, human, 224.
Infections, mental, 753.
Influence,
  malign, 141;
  of the mind, 2, 84;
  of the stars, 39;
  telepathic, 141.
Inheritance of defects, 632.
Inhibition, 46;
  cardiac, 313;
  menstrual, lack of, 434;
  nervous, 87.
Injuries,
  old and painful, 387;
  unconscious, 85.
Insane, cunning of the, 743.
Insanity,
  dread of, 623;
  genius and, 536;
  hallucinations in, 609;
  Perkinean, 49;
  plea of, 742;
  religious, 777;
  self abuse and, 484.
Insomnia, 125;
  coffee and, 659;
  cold and, 656;
  cold bath and, 658;
  cold feet and, 656;
  diet and, 659;
  direct suggestions and, 660;
  dread of, 651;
  drugs and, 654;
  encyclopedia reading and, 662;
  evening hours and, 660;
  food before retiring and, 659;
  hot foot bath and, 657;
  Jacinth and, 37;
  lack of air and, 657;
  lack of occupation and, 644;
  not serious, 651;
  persuasion of, 651;
  pillow and, 655, 656;
  sea voyage and, 658;
  solicitude about, 654;
  suggestion and, 654;
  tea and, 659.
Inspiration, 135.
Instinct,
  appetite and, 264;
  disturbed, 267;
  not theory, 256.
Interest,
  human, 206;
  in others, 221.
Intestinal control, 280.
Intestinal tolerance, 271.
Intestinal unrest, 255.
Intestine, 269.
Introspection, morbid, 302.
Invalids by profession, 184.
Irish school on heart, 318.
Irregularity,
  functional, of the heart, 327;
  myocardial, 327.
Irresponsibility, 744.


J

Jacinth for sleep, 37.
James, Prof., 16, 92.
Janet, 597.
Jew's ear, 35.
John of Cronstadt, 75.
Johnson, Samuel, 80.
Joint affections, position in, 212.
Joint conditions,
  differentiation of, 381;
  hysterical, 239;
  hysterical, frequency of, 387;
  neurotic, frequency of, 386;
  old, injured, and dampness, 387;
  painful, 379.
Joy and pleasure, 104.


K

Ka (Egyptian soul), 9.
Kaltenbach, 456.
Keller, Helen, 214, 234.
Kepler and astrology, 39, 41.
Khou (Egyptian mind), 9.
Kidney,
  abnormal fixity of, 307;
  backache and, 308;
  calculus of, 80;
  floating, operation for, 308;
  loose, 302;
  movable, 307;
  movable, mechanical treatment for, 308;
  movable, weight, and, 297, 308;
  of pregnancy, 307;
  position of calculus in, 209.
Kidneywort, 35.
King, Prof., on natural obstetrics, 459.
King's evil, 79, 81.
King's touch, 748.
Kircher, S. J., Father, 42, 160.
Knee,
  after loose cartilage, 412;
  foot troubles and the, 410;
  high heels and the, 410;
  hip and the, 410;
  housemaid's, 39;
  lumbar discomfort and the, 411;
  muscle disuse and the, 412;
  unusual occupations affecting the, 410.
Knee jerk, 556.
Kneipp, Father, on hydrotherapy and psychotherapy, 72.
Kneipp societies, 73.
Know, I do not, 466.
Kocher, 505.
Korsakoff's psychosis, 687.
Krafft-Ebing, 631.
Kronecker, 269.
Kronig, 456.


L

Labor,
  at the ninth month, 454;
  delayed, suggestion and, 454;
  natural, 459;
  patient helps, 459;
  postures after, 459.
Labouchère, 147.
Lachesis, snake venom, 66.
Laennec pearls in asthma, 364.
Lancisi, 17, 331.
Lapax, Indian chorea, 688.
Larrey, Baron, 68.
Lauder Brunton, on inhibition, 313.
Laugh and grow fat, 297.
Laughing, diaphragm and, 105.
Laughing cure, 104.
Laughter, hearty, effect of, 297.
Law of avalanche, 111.
Laxatives, abuse of, 287.
Layer, plexiform cerebral, 126.
Lead in muscle aches, 398;
  poisoning from, 172.
Learn,
  by heart, 223;
  failure to, 129.
Leg exercises in constipation, 277.
Legs, inequality of, 410
Leisure, use of, 181.
Leisure classes, 184.
Letters, cross, 140.
Leyden jar, 42;
  "cures" by the, 42;
  effects of the, 42;
  suggestion and the, 42.
Lichen,
  anise seed in, 25;
  snakes in, 25.
Liebault on hypnotism, 407.
Life,
  aimless, 220;
  and death, 89;
  dangerous, 512;
  intellectual, 125, 134, 302;
  interests in, 169;
  natural, 267;
  out-of-door, 358;
  persuasion of short, 636;
  principle of, 191;
  regulation of, 220;
  worth living, 722.
Light,
  and psychotherapy, 44;
  in hypnotism, 155;
  lack of, 173.
Lightning, fear of, 612.
Lincoln's steamboat, 253.
Liniments, suggestion with, 29, 393.
Liquor problem, scientific solution of the, 701.
Literature and life, 648.
Lithemia, 380.
Litton's diaphragm phenomenon, 361.
Liver,
  business and the, 253;
  gastric symptoms from the, 177.
Liverwort, 35.
Lloyd Tuckey on mental influence, 156.
Lobe, occipital, 116.
Local anaesthesia, personality of operator and, 758.
Locomotor ataxia, 524.
Lombroso, 88, 130.
Longevity and delicate health, 202.
Looking forward, 183.
Looking up, 102.
Lord Bacon, 54.
Lord Kelvin on the Creator, 730.
Louis', grief, 732.
Love, Greek, 482.
Lowell, James Russell, 649.
Lucas Malet on maternal impressions, 221.
Lucian on warts, 493.
Lucretius' pessimism, 776;
  evolution and, 776.
Lumbago, 402;
  adhesive plaster for, 407;
  cautery and, 408;
  electric equilibrium in, 408;
  etiology of, 404;
  hypnotism in, 407;
  paper on loins and, 407;
  piles and, 403;
  seminal vesicles and, 403.
Lunar caustic, 36.
Lunch,
  hurried, 171;
  women's, 180.
Luncheon, in Vienna, 179.
Luncheon clubs, 180.
Lung at rest, 361.
Lungs not laboratories, 132.
Lytton, Sir Robert Bulwer, 648;
  grief and, 731.


M

McDougal, 123.
McGuire, John Francis, on Father Mathew, 75.
Machines, electrical, 43.
Mackenzie on the heart, 323.
Magnan, Prof., on sex perverts, 480.
Magnetics, 15;
  application of, 42.
Magnetism,
  human, 41;
  malignant, 142;
  personal, 14, 70;
  suggestion and, 41.
Magnets, 15.
Malaria,
  degeneration and, 107;
  mental, 93.
Man,
  of one idea, 195;
  without habits, 230.
Manners and disposition, 234.
Manzoni and memory, 685.
Martyrs, 112.
Massage and exercise, 206.
Mastication,
  stomach and, 261;
  wearying, 355.
Maternal impressions,
  in old literature, 461;
  superstition and, 465;
  supposed examples of, 463;
  time of, 463.
Mathematical medicine and suggestion, 41.
Mathew, Father, and alcoholism, 75.
Meal,
  midday, 180;
  principal, 180.
Meat, dog, 244.
Mechanism,
  of influence of mind on body, 107;
  of mental influence, 108;
  peripheral ganglionic, 190.
Mechano-therapy, 5.
Médecine, La, des Âmes, 90.
Medication, 2.
Medicine man, 78.
Medicine,
  minus mental influence, 192;
  plus mental influence, 192.
Medieval mind healing, 14.
Melancholia,
  neurasthenia and, 556;
  suicide and, 556.
Memories,
  individual, 684;
  vertigo and, 516.
Memory,
  age and, 679;
  attention and, 679;
  auditory, 682;
  brain cells in, 128;
  Carlyle's, 685;
  committing to, 223;
  cultivating looseness of, 683;
  definite location of, 128;
  diseases of, 682;
  disorders of, 678;
  disturbance of, 124;
  exercise of, 687;
  fatigue and, 682;
  genius and, 684;
  Goldsmith's, 684;
  groping, 127;
  hallucinations of, 635;
  improvement of, 687;
  in defectives, 686;
  intellect and, 684;
  intimate mechanism of, 128;
  laxative and, 270;
  low grade intelligence and, 685;
  Manzoni's, 685;
  name, 681;
  newspapers and, 684;
  Newton's, 684;
  of animals, 127;
  of words, 127;
  pauses and lapses of, 681;
  peculiarities of, 680;
  process underlying, 133;
  psychotherapy of, 679;
  public speakers and, 127;
  Scott's, 684;
  sensations and, 682;
  sense defects and, 682;
  solicitude and, 680;
  supposed loss of, 679;
  tone deafness and, 682;
  training the, 686;
  tricks of, 685;
  visual, 682.
Menière's disease, 516;
  vertigo and, 516.
Menopause,
  air and, 452;
  benefits of, 452;
  definite prescriptions for, 451;
  diversion of mind and, 452;
  exercise and, 452;
  family cares and, 451;
  Graves' disease and, 502;
  lack of occupation and, 451;
  old-fashioned attitude toward, 451;
  pseudo-epilepsy and, 540;
  unfavorable suggestions and, 450.

Menorrhagia,
  favorable disposition in, 449;
  fibroid and, 448;
  individual and, 449;
  menopausal, 448;
  mental factors in, 447.
"Men's diseases," 474.
Menstrual condition, 59;
  disturbance through brain in, 190;
  hyperemia and, 436;
  irritability and, 441;
  over-attention to, 441;
  over-reaction in, 436;
  psycho-physical factors in, 436.
Menstruation,
  air and, 436;
  dreads and, 434;
  emotion and, 438;
  lack of inhibition in, 434;
  misophobia in, 434;
  psychic states of, 434;
  sensitiveness in, 435.
Mental attitude, 4.
Mental energy, law of, 16.
Mental exhaustion, 599.
Mental healing, 386;
  in the Renaissance, 14;
  3,000 years of, 81.
Mental incapacity, 597, 598;
  functional, 599.
Mental influence,
  anesthesia and, 753;
  before operation, 749;
  distant, 140;
  in surgery, 747;
  medieval, 747;
  on organs, 87;
  post-operative, 759;
  therapeutics and, 196;
  with digitalis, 312.
Mental medicine, law of, 99, 251.
Mental short circuit, 5, 601.
Mentality, physical basis of, 133.
_Meralgia paresthetica_, 405.
Mesmer, 51, 153;
  methods of, 154, 386.
Mesmerism,
  "Christian Science" and, 55;
  surgery and, 748.
Message, telepathic, 145.
Metabolism, fatty, 291.
Meyer, 105.
Michelangelo on trifles, 164.
Microbophobia, 612.
Milk,
  asses', 246;
  bovine, humanity and, 461;
  dislike of, 246;
  goats', 246;
  mares', 246;
  maternal supply of, mind and, 460;
  more than food, 461:
  sour, 96, 247.
Mind,
  absorption of, 130;
  abstraction of, 129;
  body and, 233;
  brain and, 549;
  concentration of,  124, 130, 197;
  diversion of, 182, 224, 225;
  fractures and, 751;
  heart and, 311;
  herpes and, 492;
  making up, 737;
  menstrual, Charcot and Möbius on, 434;
  mortal, evil of, 776;
  motility and, 86;
  preoccupation of, 130, 136;
  relaxation of, 228;
  urticaria and, 491;
  vacant and distressed, 219.
Mind healing,
  in Greece, 10;
  novelties in, 5.
Mind reading, 141.
Miner's elbow, 399.
Mirabeau, 27.
Misophobia, 615.
Mitchell, Dr. John K., 161.
Mitchell, Dr. S. Weir, 136, 572.
Möbius on menstrual mental states, 434.
Mommsen, 130.
Monastic work intervals, 226.
Mondeville, mental influence and, 747.
Monotony in diet, 296.
Moodiness, 233.
Moral, influence of the, on the physical, 84.
Morgagni, 16, 331;
  and venesection, 27;
  on nervous heart, 331.
Morning,
  dawdling in the, 165;
  walks in the, 169.
Mother and child, distinct beings, 462.
Mothers of syphilitic children immune, 680.
Motility, gastric, 261.
Motion and will, 109.
Mouth breathing, 105.
Movements,
  habitual, 173;
  pain and, 396.
Movements, passive, 207.
Moxa and suggestion, 68.
Müller, Johann, 18, 607, 678.
Müller-Lyer lines, 767.
Müller, Max, 243.
Mummies in therapy, 64.
Münsterberg, Prof.;
  on Pastor Gassner, 778;
  on psychotherapy, 75.
Murmurs,
  heart, 318;
  extraneous sounds and, 318;
  significance of, 318.
Muscle reading, 195.
Muscles,
  exercise of the, heart stimulation and, 328;
  gastric, 261;
  health and, 200;
  internal secretions in, 328;
  overtiredness of, 392;
  relaxation of, 197;
  thought and, 194;
  unconscious regulation of, 230;
  useless, 201.
Muscular exertion, unaccustomed, 392.
Muscular pains and aches,
  atrophy and, 394;
  causes of, 391;
  counter-irritation for, 393;
  habits and, 392;
  lead and, 398;
  local conditions in, 389;
  treatment of, 406.
Music as recreation, 139.
Musk, 69.
Mutism, hysterical, 574.
Myotatic, 556.
Mysteriea, natural, 109.


N

Names, euphonious, 59.
Nancy, hypnotism at, 154, 159.
Napoleon, 85.
Narcosis, nervous mechanism in, 123.
Narcotism, 111.
Nature, human, 359.
Natures, two in man, 148.
Nature's compensations, 508.
Nauheim,
  baths at, 328;
  exercise at, 328;
  suggestion at, 216.
Nectarium, proprietary medicine, 59.
Nephritis, insidious, 642.
Nerve currents, 123.
Nerve explosions, 564.
Nerve fibers, plexuses, systems, 109.
Nerve impulses and electricity, 110.
Nerve pressure, anesthetic for, 401.
Nerves and tissues, 88.
Nervous diseases, organic, 508.
Nervous weakness, 555.
Nervousness, Jews, Quakers, Roman Catholics and, 778.
Neuralgia, 59.
Neurasthenia,
  an American disease, 559;
  arteriosclerosis and, 557;
  Bright's disease and, 557;
  concentration of mind and, 560;
  diabetes and, 559;
  due to over-attention, 559;
  hysterical, 561;
  in the old, 557;
  melancholia and, 556;
  nervous weakness and, 555;
  paresis and, 532;
  rheumatism and, 555;
  significance of, 555, 556;
  simulation of, 557;
  splanchnic, 36, 297;
  substitution of symptoms and, 561;
  too satisfying, 555.
Neuritis,
  deltoid, 397;
  ulnar, 398.
Neuroglia cells,
  perivascular, 122;
  plexiform, 126;
  pseudopods of, 122;
  spinal, 122;
  subcortical, 122;
  superficial, 126.
Neuroglia theory, 86, 119.
Neurokym, 111.
Neurons,
  from optic lobe, 117;
  in psychic states, 117;
  movement of, 114, 119;
  motor, lower, 114;
  peripheral, 118.
Neuroses,
  accessory, 749;
  biliary, 586;
  intestinal weight in, 285;
  motor, 589;
  secretory, 586;
  sexual, 472.
Neurosis,
  cardiac, 321;
  exercise and, 326;
  muscular, 393;
  neuritis and. 398.
Neurotic joints, 589.
Neurotic simulation, forms of, 585.
Neurotic tendencies, 480.
New Englanders, religious, 82.
News, bad, 85.
Newspapers at breakfast, 170.
Newton, 130.
Night air, 450.
Night duty, 175.
Night terrors,
  ghost stories and, 668;
  melodrama and, 668.
Night workers and alcohol, 175.
Nightmare, 339.
Nihilism, therapeutic, 5.
Nissl bodies, 114.
Nitrate of silver, 36.
Nitrous oxide, 18.
Nodes, Heberden's, 422.
Nomenclature of disease, 556.
_Non nocere_, 187.
Norman, 42.
Nosology, preputial, 475.
Nostrum promoters, 56.
Nostrum venders, 3, 59.
Nothing to do, 184, 218.
Nursing,
  cheery, 760;
  suggestions and, 460.
Nurslings' immunity, 460.
Nutrition, intrauterine, 465.
Nux vomica, 5.


O

Obese, 290.
Obesity,
  alimentary, 293;
  constipation and, 296;
  early treatment of, 292;
  essential, 293;
  examples and, 293;
  exercise and, 294, 296;
  frequency of, with diabetes, 294;
  heredity and, 293, 295;
  pathological, with diabetes, 290;
  prophylaxis in, 293;
  sleep and, 294.
Obsession,
  sexual, 476;
  subconscious, 476.
Obsessions, 624.
Obstacle sense, 214.
Obstetrics,
  posture in, 459;
  suggestion in, 452;
  sympathy harmful in, 452.
Occupation,
  alcohol and, 398;
  diversion of, 226;
  dual mental, 139;
  dusty, 172;
  feminine, 183;
  finding mental, 223;
  lack of, 219;
  mental condition in, 177;
  pleasant, 84;
  position during, 176;
  sedentary, 302;
  standing, sitting, intervals of rest in, 173.
Occupation pains, 396.
Ointment,
  expensive, 59;
  weapon, 54.
Old-maid, psychasthenic, 221.
Olfactory acuity, 619.
Operation,
  idea of, 751;
  mental influence after, 759;
  suggestive, 306, 431;
  visits after, 760;
  work after, 760.
Operations on the abdomen, 303;
  series of, 304.
Opium,
  in hypnotism, 156;
  mind and, 192.
Oppenheim, Prof., 323, 511, 512, 527, 660.
Optic thalamus and dual dispositions, 151.
Orchitis and epigastric reflex, 252.
Ordure in therapy, 34.
Organic disease, mental influence and, 190.
Organic nervous diseases, 508;
  adventitious symptoms of, 509;
  compensation and, 508;
  incurable, 509;
  prophylaxis in, 509;
  unfavorable influence and, 508.
Organs, feminine, out of pelvis, 430.
Osler, Sir William, 11, 323.
Osteoarthritis, 424.
Osteopath, 52, 381.
Osteopathy, success of, 207, 385, 386.
Overcautiousness, 189.
Overeating, habit of, 266, 291, 297.
Oversensitiveness, neurotic, 239.
Overseriousness, 218.
Overweight,
  prevention of, 295;
  short life and, 294.
Ozena, 98.


P

Paget, Sir James, 589;
  on hysterical joint, 749;
  on neurotic joints, 386.
Pain,
  after operation, 761;
  a stimulus, 240;
  bearing, reconstructive, 235;
  character and, 238;
  consciousness of, 236;
  conservative, 240;
  contraindication to treatment, 394;
  deterrent, 68;
  differentiation of, 241;
  diffusion of, 238;
  discipline for, 238;
  dispelling, 130;
  distraction and, 754;
  diversion and, 225, 754;
  equanimity in, 779;
  in life, 237;
  location of, difficult, 251;
  memory of, pleasant, 238; 724;
  neurotic and organic, 240;
  on motion, 241;
  over healthy lung, 362;
  overattention and, 236;
  power to bear, and the individual, 441;
  preoccupation and, 235;
  psyche in, 761;
  radiation of, 240;
  relief of, in gynecology, 431.
Pains,
  barometer and, 382;
  company in, 10;
  in rainy weather, 382;
  muscular aches and, 389;
  occupation of  mind in, 395.
Paladino, Eusapia, 88.
Palpitation from over-attention, 324.
Palsies,
  musculo-spiral, 401;
  neurotic, 589.
Palsy, infantile, training for, 216.
Panniculus, 299.
Paracelsus, 15, 688.
Parallels, distortion of, 770.
Paralysis agitans, 579;
  cord stretching in, 544;
  cures of, 544;
  drugs in, 544;
  Frenkel's method in, 544;
  mental control in, 542;
  mental influence and, 543;
  organo-therapeutics and, 544;
  psychic factors in, 542;
  psychotherapy and, 545;
  suspension and, 544;
  vibration and, 544.
Paranoia and paresis, 532.
Paraplegia, mimicry of, 590.
Paresis,
  alcohol and, 530, 532;
  consoling hesitancy in diagnosis of, 533;
  difficulty of diagnosis of, 534;
  exciting life and, 530;
  hereditary factors in, 532;
  low grade nervous system and, 530;
  paranoia and, 532;
  parasyphilitic, 530;
  psychic influence in, 533;
  simulants of, 534;
  sparing relatives in, 533;
  syphilis and, 631;
  worry over syphilis in, 530.
Paris, Dr., 16.
Parry, old Dr., of Bath, 163.
Parthenon, optical corrections, 772.
Pâtés de foie gras, 291.
Pathology, humoral, 57.
Pathophobia, 612.
Patient,
  individual, 10;
  his disease and, 163.
Patients,
  objective and subjective history of, 164;
  no incurable, 184.
Paul of AEgina, 13.
Paul, St., 148.
Pawlow on digestion, 269.
Payot, M. Jules, on will, 220.
Pelvic discomfort and attention, 430.

Peristalsis,
  attention and, 270;
  experiments upon, 269;
  psychic influence and, 269.
Perkins' tractors, 5, 48, 51, 386.
Perversions, sexual, 489.
Personal influence, 69;
  place of, 77;
  relationship and, 77.
Personality,
  deeper levels in, 150;
  dual, hypnotism and, 150;
  dual, hysteria and, 149;
  human, 607;
  impressive, 70, 147;
  in therapeutics, 69;
  other. 135;
  primary, 148;
  secondary, 149;
  supernumerary, 149.
Pessimism, 233.
Pets, fat, 291.
Pettigrew, 61.
Phantasms of the dying, 147.
Pharmaceutics, father of modern, 15.
Pharmocopeia, 1.
Phenomena,
  healing, 78;
  hysterical, 149.
Philip Neri, St., 74.
Phobophobia, 612.
Phthisiophobia, 612.
Phthisis, exaltation in, 642.
Physicians,
  abdominal discomfort and, 302;
  as patients, 191;
  family and, 729;
  old family, 714;
  personality of, 191.
Physiognomy, 106.
Pictet, 18.
Pieta, 36.
Pigmentation,
  neurotic, 493;
  psyche and, 494.
Pills,
  bread, 88, 281;
  ground biscuit. 281.
Pinel, 8.
Planes, intermuscular, 393.
Plasters,
  medicinal, 63;
  suggestion of, 34.
Plato, 10, 94, 99.
Play and exercise, 204.
Pleasure,
  joy and, 104;
  pain ingredient in, 240.
Pleural adhesion, 401.
Plexuses of nerve fibers, 109.
Pliny,
  on proprietaries, 59;
  the elder, 59.
Plombières, 287.
Plutarch on suicide, 719.
Pneumogastric pressure, 315.
Pneumonia, 3, 22;
  depression in, 23:
  heart failure in, 23;
  hereditary, 383;
  in athletes, 202;
  nursing in, 23;
  suggestion in, 23.
Podmore, 55, 605, 607, 635.
Polypharmacy, 41.
Pomponatius, 14.
Ponto, 68.
Pope, 223.
Pope Leo XIII, 223.
Pork and cabbage, 249.
Position,
  after meals, 176;
  changes of, 210;
  in constipation, 276;
  in emptying the bladder, 472;
  in therapy, 207;
  post-operative, 763;
  relief and suggestion and, 213.
Pott's disease, 68.
Poultices,
  of crushed lice, 34;
  of deterrent materials, 34;
  of insects, 34;
  of moss from mummy skull, 34;
  ordure, 34;
  signatures and, 34.
Powder, sympathetic, 56.
Power to choose, 149;
  will, 740;
  will, responsibility and, 738.
Practice, metallic, 50.
Precious stones,
  signatures and, 36;
  suggestions and, 36.
Precordia, pain in, 339.
Predisposition to tuberculosis, 354.
Pregnancy, 453;
  abortion for vomiting in, 455;
  air in, 453;
  exercise in, 453;
  habits of life in, 454;
  natural life in, 454;
  obesity in, 454;
  termination of, natural, 454;
  vomiting in, 455;
  vomiting of, remedies for, 455.
Premonition, 78, 634, 675;
  fulfilled, 637;
  memory hallucinations and, 635;
  paralyzing, 611;
  suggestion and, 635;
  superstitions and, 638;
  unfulfilled, 637.
Premonitions,
  coincidence and, 638;
  telepathy and, 640.
Prepuce, long, pathology in, 475.
Preputial cleanliness, 485.
Prescriptions,
  earliest, 60;
  favorite, 3;
  Latin, 191;
  many ingrediented, 41;
  secret, 192.
Pressure discomfort, abdominal, 252.
Principles,
  chemical and physical, 132;
  vitalistic, 132.
Prognosis in Graves' Disease, 503.
Prophylactic psychotherapeutics, 237.
Prostate and self-abuse, 484.
Prostatism, 468;
  castration and, 468;
  individual, 471;
  organotherapy and, 468;
  palliative treatment for, 471;
  position in, 471;
  seminal vesicle tissue for, 468;
  suggestion and, 270;
  vasectomy and, 469.
Prostatitis and epigastric reflex, 252.
Proteus, daughter of, 688.
Providence, trust in, 775.
Pruritus,
  air bath and, 494;
  diversion of mind in, 495;
  mental factors in, 494;
  occupation and, 495.
Pseudo-angina, 338.
Pseudo-cyesis, 438.
Pseudo-epilepsy, 538;
  auto suggestion and, 539;
  dread and, 539;
  menopause and, 540;
  mental cures of, 541;
  neuronic disturbance and, 539, 597, 693.
Pseudo-Messiahs, 81.
Pseudo-paresis,
  memory disturbance in, 531;
  tremor in, 531.
Pseudopods of neuroglia cells, 127.
Pseudo-pregnancy, 438.
Pseudo-presentiments, 635.
Pseudo-rabies, 753.
Pseudo-rheumatism, 379.
Pseudo-science, 43, 61, 81, 35;
  mental healing and, 38.
Psychasthenia,
  heredity and, 603;
  natural and acquired, 598;
  post-critical, 602;
  retirement and, 602.
Psychic research, 144.
Psychic states, neurons in, 117.
Psycho-analysis, 77, 595, 625;
  dreams and, 595;
  hysteria and, 595;
  instruction in, 596;
  mesmerism, etc., and, 595;
  reversion and, 595;
  sex and, 595.
Psychology
  of advertising, 690;
  of the mob, 690, 692;
  of patent medicines, 690;
  old and new, 58;
  principles of, 201.
Psycho-neuroses, 239, 281;
  after-treatment for, 591;
  appetite and, 592;
  asafetida and, 593;
  bread pills and, 593;
  business worries and, 593;
  children in, 592;
  disappointments and, 593;
  diversion and, 592;
  dominant ideas in, 593;
  drugs and, 593;
  love and, 593;
  lumbar, sciatica and, 406;
  mental impression and, 591;
  motor, 589;
  occupation and, 592;
  painful, 589;
  post-operative, 762;
  quinine and pepper for, 593;
  sorrow and, 594;
  subconsciousness and, 594.
Psychotherapeutics, unconscious, 19.
Psychotherapy,
  abuse of, 6;
  Alexandrian, 11;
  at Rome, 12;
  concealed, 192;
  frank use of, 192;
  general principles of, 185;
  history of, 2;
  indeliberate, 3;
  individual patient and, 163;
  Münsterberg, Prof., on, 778;
  religion and, 775;
  skin diseases and, 491;
  surgical, 746;
  systematized, 192;
  tact and, 191.
Pulse, intermission of the, 339;
  morning, 343.
Pulse, rapid, hereditary, 340;
  paroxysmal, 340;
  persistent, 340;
  prognosis in, 340.
Pulse, slow, athletes and, 344;
  congenital, 344;
  Napoleon and, 344.
Punishment,
  deters, 743;
  of sub-rational, 743;
  responsibility and, 740.
Purgatives, abuse of, 287.
Purgings, old time, 381.
Purifiers, blood, 57.
Pyramid, 7, 112.
Pythagoras, 26.


Q

Quack, 3.
Quackery,
  history of, 53;
  mind cures and, 46.
Quakers,
  color blindness in, 772;
  nervousness among, lack of, 778.
Quinine,
  as a febrifuge, 28;
  as prophylactic, 28;
  in fever, 28;
  suggestion and, 28.


R

Radiation of pain, 241.
Radium, 5, 45.
Rainy weather pains, 382.
Ramon y Cajal, 110;
  on attention, 126.
Rattlesnake bite, 65.
Raynaud's disease, 63, 492.
Rays,
  actinic, 44;
  ultra-violet, 45.
Razor, dread of, 195.
Reaction, exaggerated, 360.
Reading,
  for insomnia, 139;
  in bed, 139;
  mind quiescent during, 139;
  muscles during, 195;
  of newspapers, 138.
Recreations, 9;
  mental, 13;
  music and, 139;
  social, 139;
  theater and, 139.
Re-creation, 124, 138.
Reduction in weight,
  alcoholism and, 293;
  a life task, 293;
  without effort, 293.
Reflexes, cardiac, 330.
Regulation, monastic, 104.
Reid, Dr. Archdall, on heredity, 230, 699.
Reil, Island of, 18.
Relationship, personal, of physician and patient, 164.
Relaxation,
  abdominal, 209;
  mental, 140;
  of mind, 138;
  sessions of, 198.
Relief,
  in severe injuries, 85;
  natural, 188.
Religion,
  cheapening, 779;
  insanity and, 777;
  meaning of, 779;
  psychotherapy and, 775.
Religious sense, disintegration of, 776.
Remedies,
  new, 19;
  plus suggestion, 19, 197;
  proprietary, 59;
  repugnant, 66;
  secret, 53;
  secret, origin of, 53;
  specific, 186;
  various, 1, 349.
Reserve energy, law of, 18, 92, 93, 310.
Reservoir of energy, 93.
Residue, intestinal, 274.
Responsibility, 738;
  differing, 741;
  of  defectives, 743;
  personal, 148;
  punishment and; 740;
  will power and, 742.
Rest,
  genuine, 224, 237;
  pain and, 52, 188;
  wear and, 602.
Restlessness, conservative, 211.
Retention, mental, 143.
Reutergehem, 159.
Rhazes, 13.
Rheumatism, 44, 98;
  acute, 382;
  anodynes for, 406;
  classic symptoms of, 406;
  derivation and relationship of, 380;
  foot troubles and, 414;
  heredity of, 382;
  muscular, 391;
  no lasting effects in, 379;
  old injuries and so-called, 387;
  recurrence of, 384;
  sequelae of, 384;
  so-called, 385;
  so-called chronic, 383;
  subacute, 384;
  treatment, abuse of, in, 381;
  unfavorable suggestion and, 385.
Rhinitis _sympathetica_, 369.
Rhythm, nodal, 342.
Ribot, 138.
Richardson, Benjamin Ward, 16.
Riding, horseback, 204.
Ring-worm, 61.
Robert Boyle, 61.
Roberti, S. J., Father, 65.
Robertson, Dr., 16.
Roger Bacon, 466.
Roman life and manners, 58.
Rome, 8;
  patent medicine men in, 58.
Röntgen, 44.
Rose, catarrh suggested by, 372.
Rose cold, 369, 375.
Rose fever, artificial, 372.
Rossetti's grief, 732.
Routine, weekly, 183.
Royal Society, 50.
Royal touch,
  Charles I and II and, 79;
  Edward the Confessor and, 79;
  James I and, 79;
  Queen Anne and, 79;
  Queen Elizabeth and, 79;
  William III and, 79.
Royce on premonitions, 635.
Rubber, 52.
Rules, dietetic, 256.
Rumbling, intestinal, 284.


S

St. Ives, R. L. Stevenson, 357.
St. John Long's liniment, 29, 381, 402.
St. Moritz, 357.
St. Vitus' dance, 688.
Sacrocoxalgia, 68.
Sacro-iliac joint, tuberculosis of, 403.
"Safe cure," 58.
Saleeby on gymnastics, 203.
Salicylates,
  as specifics, 387;
  in old and young, elimination of, 387.
Salivation, pregnancy and, 457.
Salmon, not tortoise, 338.
Salpêtrière, 154, 159.
Salt,
  excess of, 283;
  mucous colitis and, 284.
Sanatoria, modern and ancient, 10.
Sardonyx and suggestion, 62.
Sarsaparilla, 5;
  suggestive value of, 57.
Sauerkraut, 248.
Sausage, blood, 77.
Scheidemantel on psychotherapy, 17.
Schools, teaching of pathology and physiology in, 95.
Schopenhauer, 648.
Schrenk-Notzing and hypnotism, 159.
Schurz, Carl, and failed premonition, 637.
Sciatica, 402;
  acupuncture for, 408;
  etiology of, 404;
  hot needles for, 408;
  intra-pelvic causes of, 405;
  position at work and, 405;
  pressure and, 404;
  stretching and, 408;
  treatment for, 405.
Science and a Creator, 776.
Seasickness, 97;
  remedies and suggestion, 97.
Secretions as remedies, 66.
Sedentary life, preparation for, 200.
Self,
  over-attention to, 600;
  subliminal, 148;
  the other, 148.
Self-abuse,
  after-cure of, 487;
  air and, 487;
  breaking off the habit of, 486;
  cleanliness and, 488;
  confession and, 486;
  confidence and, 486;
  effect of, on prostate, 484;
  exaggerated effects of, 483;
  female, 488;
  habit of, 482;
  insanity and, 484;
  occupations and, 488;
  preputial concretions and, 485;
  reading and, 488;
  relapse into, 486;
  sleep and, 487;
  times of danger and relapses into, 487.
Self-consciousness,
  in clergymen, 582;
  in teachers, 582.
Self-control, 148;
  for obesity, 294.
Self-denial, 240.
Self-discipline, 146.
Self-hypnosis, 161.
Self-indulgence, 148.
Self-watching, 600.
Sensations,
  ideas and, 109;
  manifold, 560;
  missed, 129;
  over-attention to, 560;
  simple painful, 131;
  transfer of, 252;
  uncomfortable, 218.
Sense of pressure, 262.
Sepsis and alcohol in suggestion, 30.
Serpents in therapeutics, 65.
Sex,
  cultivation of, 481;
  curiosity concerning, 489;
  exaggerated significance of, 479;
  expectorating, the, 346;
  in the background, 481;
  "mad," 480;
  on the mind, 479;
  perversion of, bathing and, 489;
  ugly habits and, 481.
Sexual afflictions trivial, 473.
Sexual neuroses, 472.
Sexual perversions, 489.
Sexual solicitude, 477.
Sexual symptoms, exaggerated, 472.
Sherrington on nerve mechanism, 123.
Shilling, live on a, and earn it, 268.
Shivering, 773.
Shock,
  anesthesia and, 754;
  the heart and, 314.
Shoe-maker,
  magic, 414;
  present day, 418.
Shoes,
  old-fashioned, 418;
  sloppy weather, 414.
Short circuit, mental, 223, 225.
Shoulders and feelings, 103.
Sidis, Boris, on psycho-analysis, 270.
Sight, lapse of, 129.
Signature, tremor in, 584.
Signatures,
  doctrine of, 21, 34, 35;
  psychotherapy and, 35.
Simpson, Sir James, 147.
Simulation, psycho-neurotic, 588.
Sitophobia, 264, 612.
Sitting on foot, 405.
Skin lesions,
  artefact, 495;
  mind and, 493.
Sleep, 111, 122, 123;
  amount of, 165;
  at sea, 658;
  communications during, 136;
  encroachment on, 183;
  habits and, 660;
  how much necessary, 653;
  Humboldt on, 653;
  hypnotic, 152;
  hypnotism and, 159;
  loss of, longevity and, 661;
  mental diversion and, 661;
  monastic rule and, 295;
  not dreamless, 672;
  noise and, 666;
  on trains, 666;
  prevention of, 653;
  solicitude over, 652;
  starting in, 664;
  troubles of, 663;
  troubles of, hunger and, 665;
  vibration and, 566.
Sleeping in the light, 669.
Sleeplessness, 651.
Smaragdum and suggestion, 62.
Snake, bite of, suggestion for,
  prostration and, 32;
  in stomach, 13;
  skin of, in lichen, 25.
Society,
  Perkinean, 49;
  Psychic Research, 146.
Socrates, 11;
  diversion and, 610;
  headache cures and, 554.
Solicitude and prognosis, 237.
Somnambulism, 138;
  hypnotic, 161.
Somnambulistic, 137.
Sound in hypnotism, 156.
Sound reproduction, 610.
Space, filled, illusion of, 768.
Spasm,
  expiratory, 364;
  inspiratory, 364.
Specialist, advertising, 476, 482.
Spectacles properly fitted, 258.
Speech, tricks of, 566.
_Spes pthisica_, 642.
Spinal cell, 133.
Spine, typhoid, 403.
Spirit rapping through foot tendons, 419.
Spiritualism, 78.
Spitting, unnecessary, 346.
Spleen as food, 244.
Sport, 228;
  for its own sake, 229;
  indoor, 204;
  winning, 229.
Sprain and fractures, 387.
Sputum as a remedy, 67.
Station, tremor in, 581.
Steak, camel and elephant, 245.
Steppes, 23.
Stereoscopic vision, 766.
Stevenson, Robert Louis, 356.
Stew,
  cat, 245;
  dog, 245;
  lion, 245;
  rat, 245.
Stigmata, hysterical, 590.
Stomach,
  attention and the, 306;
  dilatation of the, 330;
  mental states and the, 243;
  motility of the, 261;
  not test tubes, 132, 242;
  resonance in, fifth interspace, 332;
  snake in the, 13.
Stout people, constipated, 278.
Stroke, "third fatal," 523.
Stroking the forehead, 156;
  hypnotic, 153.
Students,
  medical, 99;
  symptoms in, 93.
Study, 125.
Stupidity, bodily conditions and, 106.
Stuttering, 570;
  attention to, 577;
  breathing and, 578;
  correction of respiratory defects in, 573;
  cures of, 576;
  distraction of mind in, 79;
  forms of, 570;
  hindrances to speech and, 577;
  inserted letters in treatment for, 578;
  in the young, 573;
  in women, 573;
  Itard's fork and, 578;
  Kingsley's cork and, 578;
  Leigh methods and, 578;
  mental influence and, 572;
  practice in self-control for, 573;
  regulation of respiration in, 577;
  singing in treatment for, 577;
  state of mind in, 57;
  suggestion for, 579;
  tongue against teeth in, 578;
  tongue lowered in, 578;
  treatment for, 576;
  type of loss of control in, 570;
  walking and, 571;
  writing and, 571.
Subconscious self, 145, 148.
Südhoff, 38.
Suffering,
  a tonic, 723;
  real, 222.
Sugars in constipation, 276.
Suggestion, 2;
  antimony and, 25;
  as to symptoms, 360;
  coincidence and, 20;
  death and, 91;
  for colitis, 288;
  for surgical lesions, 748;
  in cold, 21;
  influence of, 76;
  in rheumatism, so-called, 385;
  in tuberculosis, 362;
  mechanism of, 109;
  neutralizing contrary, 186;
  not heredity, 251;
  pathological, 93;
  physiological, 260;
  seasickness and, 97;
  unfavorable, 186.
Suggestions, optimistic, 511.
Suggestive operation, 306.
Suicide, 713;
  among children, 720;
  bureau of, 714;
  burial in disgrace and, 719;
  cataclysm and, 718;
  Chesterton on, 722;
  confession and, 714;
  contagious, 691, 720;
  cowardice of, 721;
  disgrace and, 719;
  dread of, 714, 726;
  earthquakes and, 718;
  epidemic of, 691;
  functional irrationality and, 714;
  Hamlet and, 722;
  headache and, 715;
  insomnia and, 715;
  justification of, 9;
  melancholia and, 556;
  mental factors in, 716;
  most frequent in June, 717;
  pain and, 723;
  prevention of, 713;
  problems of, 718;
  physician and, 726;
  prosperity and, 713;
  rarest in December, 717;
  reassurance and, 725;
  religion and, 718;
  social factors in, 717;
  suggestion and, 713;
  underweight and, 297;
  unexplained, 195;
  war reduces, 717;
  weather and, 715;
  women of Milesia and, 719.
Supernatural, naturalizing the, 607.
Superstition concerning "13," 639.
Superstitions connected with medicine and surgery, 62.
Suppression of reaction, 86.
Supreme Being, 78.
Surgery,
  astrology in, 746;
  suggestion and, 748.
Surveillance,
  heart, 323;
  inhibitory, 600;
  insistent, 269;
  of function, 269;
  self, 600.
Swallowing, 575.
Sydenham, 16, 71.
Symonds, J. Addington, and consumption, 357.
Sympathetic powder, 66.
Sympathy, 188;
  as a remedy, 222;
  heart and, 319.
Symptoms, hysterical, 590.
Synapse theory of fatigue, 123, 124.
Syncope, neurotic, 540.
Syphilis,
  curability of, 630;
  congenital contagion and, 630;
  heredity and, 629, 631;
  imaginary, 753;
  maternal immunity from, 630;
  paresis and, 631;
  worry and, 509.
System, sympathetic, 127.
Systems of nerve fibers, 109.
Systoles, extra, 333.


T

Tabes,
  complications in, 527;
  "cures" of, 529;
  diphtheria serum in, 529;
  drugs in, 530;
  magic shoes and, 529;
  mental attitude and, 527;
  mild course in, 527;
  muscle control in, 528;
  normal lifetime and, 527;
  over-stretching the spinal cord in, 530;
  reassurance in, 528;
  relearning muscular movements in, 528;
  suspension in, 530;
  urethral treatment for, 529.
Tabetic neuroses, 527.
Table, leaving the, hungry, 299.
Tachycardia, 340;
  essential, 342;
  Mackenzie on, 342;
  paroxysmal, 341;
  Wood's case of, 341.
Tails, expressions in, 141.
Talismans, 60.
Talking, co-ordination and, 230.
Tar water, 56.
Taste, cloying, 131.
Tea and abdominal distress, 307.
Teaching, disease, 95.
Tears, 66;
  grief and, 103;
  joy and, 103;
  relief of, 103.
Telegraphy, wireless, telepathy and, 142.
Telepathic premonition, 640.
Telepathy,
  accidents and, 145;
  in trade, in ordinary life, and in juries, 143;
  investigation of, by French Academy, 147;
  negation of, 144;
  negative tests of, 147;
  on the stage, 144;
  social life and, 143;
  supposed examples of, 144;
  twins and, 147;
  wireless telegraphy and, 142.
Temper,
  bad, 739;
  uncontrollable, 739.
Temperature, variations of, 203, 354.
Tennyson, 35.
Tension, relaxation of, 197.
Tenting in tuberculosis, 369.
Thackeray, 35.
Theater fires, 85.
Theory, Duval, 123.
Therapeutic persuasions, 26.
Therapeutics of position, 208;
  popular, 186.
Theriac, 20;
  Bernard's, 20;
  Galen's, 3.
Thick lips, meaning of, 106.
Thinness, physical disadvantage of, 298.
Thompson, Francis, 357.
Thompson, Prof. J. J., 139.
Thompson, Sir Henry, 494, 657.
Thomson, Dr. Wm. H., 505.
Thoreau, 357.
Thought,
  for others, 221;
  New, 209;
  original, 135;
  pale cast of, 737;
  transference of, 141.
Thunder, fear of, 612.
Tics, 230, 564;
  as types of nerve explosions, 564;
  children's, 568
  drumming with the fingers, 567
  emotional, 565;
  expletives and, 565
  facial, 565;
  familiar expressions and; 565;
  gestures and, 565;
  heredity and, 569;
  in games, 567;
  jerking, 565;
  mental treatment for, 569
  motor, 569;
  prophylaxis in, 569;
  shrugging, 565;
  speech, 565, 566
  squinting, 565;
  swearing, 568
  teachers' habits and; 566;
  winking, 565;
  writers', 567.
Time is money, 179.
Tissues, nervous, changes of, 89.
Toes,
  claw, 418;
  hammer, 418.
Tolerance, intestinal, 217.
"Tommyrotic" and erotic, 480.
Torcular Herophili, 12.
Torticollis, 393.
Tortoise and salmon, lives of, 338.
Touch and sight, 214.
Tozzi twins, 229.
Tractoration, 48.
Tractors,
  Perkins', 49;
  in yellow fever, 51.
Training, 213;
  appetite, 216;
  equilibrium and, 215;
  facial muscles, 101;
  feeling and, 215;
  for pain, 217;
  for weight, 217;
  hearing, 215, 636;
  heart, 216;
  infantile palsy and, 216;
  in self-control, 745;
  intellectual, 218;
  memory, 686;
  movement, 686;
  muscles, 215;
  of defectives, 743;
  sight, 215;
  touch, 215.
Trains and intestinal disturbances, 280.
Treatment, absent, 5, 141.
Tremor,
  senile, longevity and, 580;
  premature, 580;
  prognosis of, 580;
  significance of, 580.
Tremors, 579;
  actors and, 582;
  clergy and, 582;
  dread and, 581;
  fright and, 581;
  hypnotism and, 584;
  in intention, 581, 583;
  mental control and, 583;
  self-discipline and, 584;
  shaving, dread of, 581;
  standing, 581;
  suggestion waking, 584;
  teachers', 582;
  types of, 579;
  writing, 584.
Treves, Sir Frederick, on alcohol, 30.
Trifles,
  fascination of, 651;
  in health, 164.
Troubles that do not happen, 233, 612.
Troy, 62.
Trudeau, 359.
Tuberculosis,
  classes of, 188;
  contagion and, 353, 628;
  courage in, 356;
  "cures" for, 351;
  early diagnosis in, 354;
  early stage in, 353;
  heredity and, 352;
  heroes of, 356;
  immunity from, 629;
  incipient, 348;
  incurable, 352;
  predisposition to, 354;
  prevalence of, 351;
  protective, 629;
  pulse and, 354;
  quitters and, 355;
  remedies for, 351;
  slow, 352;
  stimulating, 356;
  suggestion and, 362;
  temperature range in, 354;
  unfavorable prognosis in, 352;
  vital resistance and, 351;
  whooping cough and, 346.
Tumors, pelvic, sciatica and, 405.
Twain, Mark, disappearance story of, 608.
Types of expression, 102.
Typewriters' fingers, 89.
Typhoid fever,
  antisepsis in, 24;
  in athletes, 202;
  mental symptoms in, 93;
  nurses in, 24;
  spine in, 403;
  suggestion in, 24.


U

Unconscious cerebration, 128.
Unconsciousness, 119, 123.
Underclothing, variety in, 167.
Undereating, 297.
Underweight, correction of, 300.
Unguentum _Armarium_, 54.
Unknown, the, 189, 607.
Urbantschitsch, hearing training, 686.
Uric acid diathesis, 270.
Urinary worries, 470.
Urination, position in, 459, 472.
Urticaria,
  diarrhea and, 281, 282;
  mind and, 491.
Use and abuse, 196.


V

Vacuum cleaning, 174.
Valerian, 68.
Valerianate ammonium, 68.
Van Eeden and hypnotism, 159.
Van Helmont, 15, 55, 64.
Van Swieten, 17, 71.
Variation, 633.
Varicocele, 473;
  depression, mental, and, 474.
Varicose veins, 208.
Varicosities,
  feet elevated in, 208;
  occupations and, 208.
Vascular pedicles, 126.
Vaso-motor disturbance, 492.
Vegetarianism, 256.
Venesection,
  for eye diseases, 28;
  for migrane, 28;
  mental influence and, 28;
  mind and, 14;
  suggestiveness of, 28.
Version,
  by heel in perineum, 459;
  natural, 459.
Vertigo,
  Menière's, 516;
  over-attention and, 512;
  significance of, 512.
Vest, 168.
Vibrations of cells, moments of, 142.
Viper venom, 66.
Virchow, 62, 226, 618, 647;
  on hobbies, 226.
Virility, The Ages of Mental, 624.
Viscera, sensitive nerves and, 560.
Vision,
  illusion of two-eyed, 764;
  stereoscopic, 766.
Vitalism, 191.
Vitality, resistive, and muscle, 108, 201.
Volta, 48.
Voltaic pile, 43.
Vomiting,
  abortion and, 456;
  after anaesthesia, 758;
  distraction of mind and, 456;
  frequency of, 456;
  neurotic, 455;
  non-suggestion of abortion and, 456;
  of live mice, 462;
  of snakes, 462;
  pernicious, 455;
  pregnancy and, 456.
Von Bülow's case of headache, 550.
Von Leyden crystals, 364.
Von Moltke, 647.
Von Monakow, 115.
Von Retzius, 121.


W

Wakefulness,
  matutinal, 662;
  persistent, 652.
Waking, suggestion method for, 197.
Walking, 205;
  complexity of, 229;
  coordination in, 3.
Walks, morning, 169.
Warming up, 92.
Warning, coincidences and, 611
Warts,
  counting of, 493;
  Lord Bacon and, 493;
  mental influence and, 493.
Wash water of little babies, 67.
Water,
  dread of, 62;
  drinking, 232;
  hypodermic, 88.
Waters, mineral, 45.
Waves of nervous energy, 110.
Weak foot, 391.
Weakness and discomfort, 299.
Weapon ointment, 54.
Weapon salve, 55.
Weight,
  abdominal distress and, 309;
  for height, 299;
  gain in, 301;
  good feeling and, 297;
  in intestinal neuroses, 285.
Weir Mitchell's disease, 492.
Wessex Tales, mental influence, instance of, 64.
Whewell, 14.
Which? (dream poem), 136.
Whiskey,
  in hypnotism, 156;
  in snake bites, 32.
White hair and fright, 494.
Whoop, habit, 25.
Whooping cough, 24;
  diphtheria serum in, 25;
  mine air in, 25;
  more air in, 25;
  sea water in, 25;
  tuberculosis and, 25.
Wiggs, Mrs., of the Cabbage Patch, 234.
Will,
  appetite and, 592;
  breaking the, 744;
  disorders of the, 694;
  education of the, 220;
  motion and the, 109;
  over the heart, 313;
  re-education of the, 737;
  to live, 90;
  training the, by punishment, 742, 744.
Wimshurst machine, 43.
Wind,
  second, 92;
  third and fourth, 92.
Wine and the doctrine of signatures, 36.
Winkel on vomiting at pregnancy, 457.
Witchcraft, 141.
Woman, average normal, 433.
Women,
  feed hearts of, 221;
  home-keeping, 169;
  working, 169.
Woodward, 286.
Wordsworth, 135.
Work,
  at home, 182;
  latent intellectual, 134;
  monastic division of, 227;
  night, 175;
  six hours of, 182;
  social, 221;
  the day's, 165, 171;
  two-hour periods of, 227.
Workers, night, 175.
Working woman, 183.
Worldliness,
  this, 779;
  other, 779.
Wraiths, 608.
Writers' cramp, 396, 572.
Writing rule, Gower's, 174, 396.


X

X-rays, 5, 44.


Y

Yawning, contagious, 688.


Z

Zöllner's distortion of parallels, 771,
Zoöphobia, 612.