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.

Muensterberg, 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 confrere, 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 seances 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 seances 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 deg. F. or--10 deg., 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 deg., 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.