nothing but a cheap counterfeit of what is needed. Voluntary effort
is needed, and this is the field where the psychotherapist must put
in his most intelligent effort. There is no one for whom there is
not a chance for work in our social fabric. The prescription of work
has not only to be adjusted to the abilities, the knowledge, and
social conditions, but has to be chosen in such a way that it is
full of associations and ultimately of joyful emotions. Useless work
can never confer the greatest benefits; mere physical exercises are
therefore psychophysically not as valuable as real sport, while
physically, of course, the regulated exercises may be far superior
to the haphazard work in sport. To solve picture puzzles, even if
they absorb the attention for a week, can never have the same effect
as a real interest in a human puzzle. There is a chance for social
work for every woman and every man, work which can well be chosen in
full adjustment to the personal preference and likings. Not
everybody is fit for charity work, and those who are may be entirely
unfitted for work in the interest of the beautification of the town.
Only it has to be work; mere automobiling to charity places or
talking in meetings on problems which have not been studied will, of
course, be merely another form of the disorganizing superficiality.
The hysterical lady on Fifth Avenue and the psychasthenic old maid
in the New England country town both simply have to learn to do
useful work with a concentrated effort and a high purpose. From a
long experience I have to confess that I have seen that this
unsentimental remedy is the safest and most important prescription
in the prescription book of the psychotherapist.
_Care of Children_.--Probably the most important therapeutic factor in
the cure of the ills which come to unoccupied women is the finding of
some occupation that will absorb their hearts as well as their
intellects, that is, satisfy their feelings as well as appeal to their
intelligence. That very acute observer and kenner of her sex, Mrs. St.
Leger Harrison, who is Charles Kingsley's daughter and writes under
the pseudonym of "Lucas Malet," said in "Sir Richard Calmady": "Feed
their hearts and the rest of the mechanism runs easy. I have known
disease to develop in a perfectly healthy woman simply because the
heart was starved." For most women the only thing that will entirely
satisfy the heart or keep it from hunger is children. Fortunately an
interest in other people's children can, under certain circumstances,
be almost as satisfying as in one's own.
_Interest in Others_.--Probably the best possible occupation that a
childless woman can have is the care of others. Charity in one form or
another satisfies the emotions as well as creates interest and gives
varied occupations. Even the frequent disillusions that are
encountered in charity work only add variety {222} to the experience,
and do not discourage those who have the real charity instinct. For
women particularly, as we have said, some charity that brings them
much in contact with children is the surest preventive of
over-occupation with themselves and over-emphasis on their feelings
and sufferings. Many a woman in our large cities owes her freedom from
the neurotic symptoms to which her sisters are subject, to her
interest in tuberculous children. There is just enough of suffering to
arouse all the pity of the visitor, without so much of anguish as
would deter the more delicate from being interested in the work.
_Touch with Real Suffering_,--For patients who think they have much to
suffer, yet whose complaints are all of subjective feelings of
oppression and depression, there is no better remedy than to come in
touch with real suffering. I have known not a few neurotic young
women, who were preparing for themselves years of suffering by
over-attention to little pains and aches, saved to a life of
usefulness and even happiness by having to nurse near relatives
through the last stages of fatal cancer. When these neurotic persons
are brought intimately in touch with real suffering, have their
sympathies aroused, and see how well human nature can bear pain when
it has to, and yet not be impatient, nor wish to end it all, then a
renewed life comes over them and they cease to be preoccupied with
themselves.
_Sympathy as a Remedy_.--In former days, when hospitals were not so
well provided and trained nurses non-existent, all forms of suffering
had a wider appeal and aroused more active sympathy than at present.
It is true that patients, in both hospitals and homes, suffered from
the lack of trained nursing, and that was an even greater
disadvantage. But it is, nevertheless, too bad that more actual touch
with suffering does not come to people now, for nothing is so sure to
make little ills disappear as the sympathy aroused by the sight of
real suffering. Certainly, our cancer cases might well be a strong
therapeutic factor for many of the neurotic ills of the world. They
are, of course, deterrent to many people. It would seem to add
needlessly to human suffering for some of the delicate to have to be
in contact with what is one of the most awful afflictions that flesh
is heir to. If death and suffering were not inevitable, we might try
to save people from the suffering which sympathy entails. But there is
no avoiding them; soon or late they are sure to come to everyone. The
upbuilding of character, consequent upon intimacy with them, is of
great value, and really brings so much of contentment to people who
are over-worried about little things that it is worth while to recall
how valuable this sympathy for suffering is in psychotherapy.
I have spoken of this phase of occupation as if it referred only to
women. There are many men of whom one may well say that they need more
human sympathy in their lives and that if they had it their supposed
ills would drop from them, or seem so slight as to be quite
negligible. Over and over again, I have seen men who had become too
occupied with themselves lose their pains and aches in an interest in
some real charity. Charity, however, not philanthropy, is the secret.
The sitting on a board of trustees of a charitable institution may
mean little though even this usually has its good effect; but close
contact with the poor, intimate personal relations with other human
beings who are in suffering, are quite as necessary for men
over-occupied with themselves as for women.
{223}
_Care of the Incurable_.--Mother Lathrop (Hawthorne's daughter) in her
cancer work prefers not to take patients suffering from incurable
cancer into the homes that she has for them, if they can in any way be
cared for reasonably at their own home. Of course, the main reason is
because there is so much of cancer in the community (one in thirty of
the population now die of it), that it is impossible to take care of
all the cases that apply for admission. Another excellent reason is
that it would be too bad to take out of a home the opportunity for
self-discipline that is afforded by the care of one of these patients,
when it does not inflict an intolerable burden on someone already
overworked. As a rule, the effect of attendance on such a patient does
so much for character upbuilding, and for a proper realization of
values in life, that trivial things fall into their right places.
Anyone who has seen the development of character, And the growth in
amenity of disposition of those who bear such a burden with patience,
will realize just what is meant by the expressions used.
Finding Mental Occupation.--For many of his patients the physician
simply must find occupation of mind. Not a little racking of brain is
needed for this, until experience helps. One form of occupation of
mind that seemed quite unpromising at first, but that has in a number
of cases proved of value, is the committing to memory of passages in
verse. A generation ago it was quite common for people to have their
memories stored with fine passages from authors which they could
repeat literally. Latin verse particularly was learned by the school
boys of fifty years ago. Frenchmen know their classical poets, and
some of the Italians also know theirs with wonderful fidelity. It is
said that, even in his advanced years, Pope Leo XIII could repeat long
passages of Dante and often found a relief from pressing cares of
state in the ponderings of the great thoughts recalled by the verses.
I have known half a dozen Italian clergymen who could from memory
follow up a line of Dante, taken anywhere in the poet's writings, with
the rest of the passage.
Such well-stored memories furnished much more abundant food for
thought to their possessors than do those of the modern time. Our
modern system of education has done away, to a great extent, with
learning by heart, but as one of those educated under the older system
and who is still able to recall many passages from Pope, or
Goldsmith's "Deserted Village," or "The Traveler," or from Virgil or
Horace, I feel sure that this is a serious mistake. In some cases I
have deliberately tried to make up for it by having people, even well
on in years, settle down to memory lessons again. Under disorders of
memory I suggest the use of this practice as a valuable training which
serves first to dispel the idea that memory is failing when it is only
lack of attention and of concentration of mind that is at fault, and
secondly, because after a time there can be observed an actual
improvement of the memory faculty. Here I would insist on its value as
an occupation of mind for those who lack some serious interests. I
have found it to be ever so much better as a diversion than reading or
the theater. If the interest in it can be awakened, it represents a
valuable adjunct in the treatment of some rather difficult cases of
mental short-circuiting. Lord Chesterfield, in one of his letters,
suggested to his son that even very brief periods during the
day--those that are ordinarily used for the fulfillment of bodily
necessities--might be employed to store the memory with valuable
quotations, great thoughts {224} greatly expressed, and this should be
recalled. After a little practice not near so much time is required
for memory work as might be imagined, and the effects are excellent.
Much of this may seem too trivial for the physician to occupy himself
with and quite apart from his duties as a practitioner of medical
science. But it must not be forgotten that medical science is as yet
quite imperfect and the practice of medicine is an art. What we have
to do, is to treat individual patients rather than cure cases, for
that is why medicine is a profession. Each affected individual who
comes to us is quite different from any other. In spite of our
grouping them under certain heads, the diseases of the race are as
distinct from one another as the features of the individuals affected.
CHAPTER VI
DIVERSION OF MIND--HOBBIES
There are two classes for whom diversion is of the utmost value. The
first are over-occupied with themselves; and the second group are so
occupied with some one interest in life, or with one narrow set of
interests, that it becomes an obsession, never leaving them. Constancy
of mental occupation with one set of thoughts proves seriously
disturbing after a time, especially if the only amusements available
are so superficial that they do not really act as a diversion. Many of
the so-called neurasthenic or psychasthenic states (I would prefer to
call them conditions of nervous weakness and of psychic impotency,
because the simpler names carry with them no suggestion of a definite
ailment) are really the consequence of this lack of any true
diversion. The patients do not get any genuine rest.
The typical example of such lack of diversion is the business man who,
contrary to the wisdom of the ages, takes his business home with him.
If we accept Ramon y Cajal's theory of attention, by which whenever a
particular portion of the brain is occupied with a subject the
capillary blood vessels in that particular part are pulled wide open
by the contraction of the neuroglia cells, certain of the brain
tissues in these cases are constantly in a state of congestion. It is
not surprising that such men suffer from insomnia. It is scarcely less
to be wondered at if their digestion suffers, since that function is
so important that it requires most of the nervous energy that a man
can provide at certain times. Besides his brain cells are never really
resting. If a man goes to sleep with a thought and wakes with it, even
though he may not be quite conscious of the fact, his mind has been
occupied with it. Brain cells need definite periods of rest. These
cells are not getting such rest--hence the development of many
pathological conditions.
I have described the extreme case, but it is not exaggerated. Writers,
editors, scientific investigators and generally those whose work does
not bring them much in contact with others, are likely to thus suffer.
Contact with others, even on business matters, seems to have a
relaxing effect. Social amenities and personal interests prevent
absolute concentration of mind over long periods. In some people even
milder degrees of preoccupation with a {225} single subject may work
harm. Some people are able to stand concentration of mind for many
hours a day for years. Others cannot. We have come to recognize that
more than eight hours a day is a mistake, but there are many people
who cannot work more than a four-hour day. The sooner this is
recognized and diversion of mind provided, the better for them. This
is one of the most important benefits that psychotherapy can confer on
many of the so-called neurasthenics.
Possibility of Diversion of Attention from Ills.--The necessity for
diversion of attention from one's ills is best realized by considering
what happens in the opposite direction. Headache, toothache, and many
other uncomfortable feelings, especially discomfort associated with
abdominal disturbances, can be entirely banished from the mind by
pleasant association with friends, by an interesting play, by a game
of cards, or, indeed, by almost anything that takes up the attention
completely. It is well understood that the severer forms of pains can
not be thus banished, but discomforts that make life miserable for the
patient may be entirely relieved for the time being. If this power of
mind to divert attention from the ills of the body means so much, it
is not hard to understand that if this mental influence be directed in
the other way, that is, to emphasize the ailment by attention to it,
it will not be long before symptoms become quite unbearable.
Hobbies.--A hobby is the physical salvation for a man who wants to
work hard, yet not become so absorbed in his work that it becomes an
obsession. Unfortunately, it is not possible to create a hobby for a
man or a woman in a short time. It must be a growth for many years
until it has become a portion of one's life. It must, as far as
possible, be something to which one turns with as much interest as to
one's regular occupation, so that the time taken from it, even for the
necessary vocation of life, is more or less resented. If a man has two
occupations that are intensely interesting, then he gets the best
possible rest. Otherwise it will be necessary in many cases for the
physician to help him in the choice of another interest in life. It is
not enough that there should be a vacation once a year, or a
conventional day off on Sunday. There must be much more than this,
deliberately planned and faithfully carried out.
_Gladstone_.--Men with hobbies have done some of the best of the
world's work; busy for many hours every day, they have yet lived to be
eighty and even ninety years of age, and have been industrious to the
end. A typical example in our generation was Gladstone, the great
English statesman. Few men had their minds occupied with more serious
problems than he for nearly forty years of a busy existence. In spite
of this, he found time to make a study of Greek literature and of
ecclesiastical writers; He acquired even more authority perhaps in
these subjects than in political science, doing the work of several
men, yet he lived to be an extremely old man. He welcomed the
opportunity to get away from one kind of work in order to devote
himself to another, but this occupation of an entirely different set
of brain cells gave those that had been previously at work opportunity
for complete rest. Very probably, except at times of special crisis or
stress of anxiety, his political problems did not disturb his studies
of Greek literature, not because he insisted on keeping them away, but
because this other interest was so absorbing that it required no
special effort to occupy his mind completely with it.
{226}
_Virchow_.--For more than a year I lived close to the great German
pathologist, Virchow, and found that his varied interests were
probably the secret of his power to devote himself to work for many
hours a day, take only a small amount of sleep and yet live healthily
and happily for over eighty years. Frequently he did not leave the
Prussian legislature until 1 a. m., or even later, and yet he seldom
failed to be at his laboratory before 7:30 o'clock in the morning,
though it was several miles from his home and took over half an hour
to get there. Besides pathology, he was deeply interested in
anthropology and in most of the biological sciences, and his favorite
hobby was the practical care of the health of the city of Berlin. From
the time when Berlin, just after the Franco-Prussian war, began to
grow out of the half-million provincial town that it was, into the
great world capital that it became, a transformation that took less
than twenty years, Virchow had charge of the health of the men engaged
on the sewer farms of the city. Berlin, unlike other great capitals,
is not situated on a large stream that will carry off its excreta, and
consequently a new problem in sewage disposal had to be met. The
sewage was spread over fields outside the city and proved, as might be
expected, a magnificent fertilizer. The whole cost of sewage disposal
was recouped from the sale of the farm products.
Prophecies of dire disaster of many kinds were made when this system
was first proposed. It was said that the men engaged on the farms
would suffer from all sorts of disease, especially respiratory and
intestinal diseases, that the farm products would be insanitary, and
the whole plant would be such a disease producer for the city as to
become a nuisance. Virchow was put in charge of the sanitary side of
the project, and how well he fulfilled his obligations is shown by the
statistics. The people who worked on the farms were healthier than the
average inhabitants of Berlin, and were especially free from
intestinal disease. Every phase of disease that occurred among the
workers on the farms, and there were many thousands of them with their
families, was reported to Virchow. Every night, the last thing before
he went to bed, he looked over this report and if there were any
suspicious cases, made arrangements for the prevention of the spread
of disease.
This of itself might seem work enough for one man, but it was only a
diversion for Virchow, turning his mind away from his other
intellectual work completely during certain hours of the day. His
visits to the farms, his planning for the prevention of the spread of
disease, his deep interest in the reports and the constant improvement
of conditions, instead of hampering his other intellectual activity by
wasting brain force, probably proved restful by diverting the blood
stream away to the cells that occupied themselves with this other and
very different problem, and so proved a benefit, not an evil. Perhaps
other men might not have had the store of nervous energy to enable
them to carry on work in this way, but for those who have, this is the
ideal arrangement. There are many others whose names might be
mentioned here. John Bigelow and Pope Leo XIII are typical recent
examples. Great workers are usually long livers, barring accident, and
all of them have had variety of occupation.
Necessity for Diversity of Occupation.--Even for those of lesser
intellectual capacity, it is advisable to have, in a lower order of
intellectual occupation, two very different things in which there is
intense interest. The blase {227} attitude in which the individual
finds no interest in anything and nothing worth doing, makes it
impossible to secure such relaxation as will give relief from worry.
So long as nothing happens to call for special resistive vitality,
such people may go on nursing their unhappiness. It is from this
class, however, that the suicides come. The mind becomes occupied with
the worries that it cannot get away from, sleep is interfered with;
the worries become an obsession, and brain exhaustion results. It is
usually said that suicides are insane, and to this extent certainly
the expression is true. Certain brain cells have so long been occupied
with a particular subject, because the mind has no other interest to
divert attention and blood supply to other portions, that these cells
are overborne and become utterly beyond the control of reason and
will.
Intervals in Work.--The old university rule of long ago was that no
one should do more than two hours of intellectual work continuously at
the same subject. Certain of the monastic orders required scholars and
students to take a break from an intellectual occupation for a
measured interval at least every two hours. The modern business man,
and even the literary man or reporter, would think this preposterous.
The rule is, however, founded on good common sense, for it relieves
the tension and keeps conditions of strain from inveterating
themselves in such a way as to do harm.
As a matter of fact, better work is accomplished if it is done in
two-hour intervals, with a break of fifteen minutes to a half-hour
between, than if the attempt is made to work longer. This may not be
true for certain forms of creative literary work, where, when the mood
is on, it is easier to finish things than if a break occurs, but these
are exceptional cases, and even here there may be serious abuse. Many
of the men who work late at night eventually get into habits that
seriously impair their sleep. This system of rest prevents such a
strain from being put upon the physical organs underlying attention as
will prevent them from promptly relaxing when the call upon them has
ceased.
There are, of course, men for whom no such rules as these seem to be
needed, because they apparently thrive on work. These are exceptions,
however, that prove the rule. They will usually be found on
investigation to have been men who lived very simply and permitted
themselves very little excitement. There is great danger in imitating
them because most of them had a superabundant vitality which expressed
itself in longevity as well as in a noteworthy capacity for work. They
had superabundant brain power to run their business (even though it
was deeply intellectual), but then, too, these men were careful not to
throw extra burdens upon their digestive organs, nor to abuse
stimulants, nor to permit a regular routine of work to be disturbed.
When symptoms of nerve weakness begin to show themselves, even the
exceptional men must be warned of the danger. The causes of the
exhaustion of nervous vitality should be pointed out, and an
improvement of habits insisted upon.
Amusement and the Mind.--The theater, as it is at the present time,
affords very little opportunity for mental relaxation. Most of our
theatricals are mere show that occupies the eye but does not seriously
catch the attention, especially after a certain number of types of
these performances have been attended. The humor of the comedians of
our musical comedy may, for {228} a certain number of people, mean
something as a diversion of mind, but it does not last. Unfortunately,
practically all their humor runs along the same line, most of it is
extremely superficial, much of it is borrowed and wears signs of its
origin, not a little of it is mere horse-play, which may divert
children but not grown men, and so the theater as a mental relaxation
has lost nearly all of its effect. Other diversions are sometimes more
hopeful. For baseball enthusiasts, attendance at a game may be such a
complete occupation of mind as to furnish thorough relaxation.
The kind of work that provides mental relaxation for others often
proves exhausting to those who do it. Humorists, especially those who
have to grind out paragraphs or columns of humor every day or every
week, are usually melancholy men. The story of Grimaldi illustrates
how serious may be the effect of work that seems mere play if pursued
too singly. This humorist on one occasion consulted a specialist in
mental diseases, for certain symptoms of nervous breakdown and
depression that were causing him much annoyance and even more
solicitude. The specialist believed in diversion of mind, and, having
been to see Grimaldi the night before and enjoyed him hugely, though
he did not recognize him off the stage, counseled him to go and see
that humorist and have his "blue devils" banished for good. "If
Grimaldi won't cure you of your depression," he added, "I don't know
anything that will." "My God!" the humorist said, "then don't leave
me in despair. Man, I am Grimaldi!"
Sports.--Unfortunately in our modern life we have to a great extent
lost the idea of sport. The conventional make-shifts of life in a camp
that is really a luxurious country house, or on a luxurious yacht, do
not replace the complete diversions that came with real camping,
hunting, fishing, sailing and the like. People now go to the country,
but take the city with them. They live in country hotels and make five
changes of clothing in the day, if not more. If men are interested in
hunting and fishing and can go into the forest (unfortunately even the
Adirondacks can scarcely be so designated now and we have to go into
the Canadian wilderness to get away from the pall of regular life and
civilization), complete recreation is secured. This makes a real
vacation which does not mean absolute freedom of mind, but freedom
from other cares so that one may with complete absorption apply
himself to something different. During the year sports for grown-ups
are difficult to obtain. Some men continue well on in middle life to
play tennis, hand-ball, and certain other games, _O fortunati nimium_,
that make the best kind of diversion. Fortunately, in recent years
golf has become a favorite and for many makes a genuine diversion.
Children's Diversions.--In recent years we have so interfered with the
normal natural development of the child that there is need to
emphasize certain details in this matter. The modern child is apt to
be precociously occupied with books and adult interests, because he is
brought so much into the foreground of family interests. True play for
some city-bred children is almost an anomaly. Exercise and air they
get. They are conducted solemnly to the park by a nursemaid, who is
instructed to see that they do not play with other children unless
quite as well dressed as they are themselves, and their dress is often
so elaborate that it is quite impossible for them to think of any real
play. There is absolutely no recreation for the child in this
procedure: on {229} the contrary, a new effort of will is required to
walk with the stately propriety that is expected of it. Then the child
is preoccupied with the thought of its clothes. Relaxation of mind is
often quite out of the question, and yet we wonder why children are
nervous and do not sleep well, why they have night terrors and do not
digest their food properly, while all the time they are living
unnatural lives that give no proper outlet for their energies and
little diversion for their mind.
Games are important, but their true spirit has gone out in recent
years. There are still a few young people who play for the sake of the
sport, but everything now seems to be a preparation for some sort of
contest. Only those are engaged in these contests and the preparation
for them whose muscular development is such as to suggest that they
will help to win. Winning, and not sport, has become the purpose of
our games. This makes the participants worry about the games and
associate them with dread of errors and ill chances. It is true that
the interest for the contestants during the game is sufficient to make
up for this and make the game valuable as relaxation; but those who
need such relaxation most--the boys and girls who are underdeveloped
muscularly--must sit and watch the contests, and this, after one has
become accustomed to it, like newspaper reading and the theater,
constitutes a poor apology for the complete relaxation of mind and
diversion of brain-cell energy that used to come with sports when they
were freely indulged, for the sake of the sport and not for the sake
of winning.
CHAPTER VII
HABIT
Few people realize how powerful a factor for physical, as well as
moral, good and evil is habit. The old expression that habit is second
nature is amply illustrated in the most familiar experiences. The
child, unable at the beginning to make any but the most ill-directed
movements, learns during its first two years to make the most complex
co-ordinated movements--first with difficulty, then with ease, and
finally with such facility that there is no need for it to pay any but
the most perfunctory attention to their execution. Walking requires
the co-ordination of a large number of muscles so that the absolute
position of every muscle in both the legs and in the trunk, at least
as far as the shoulders, must be definitely known and their activity
properly directed. Perhaps nothing brings out more clearly the
difficulty of walking, though it depends on only one factor, the
co-ordination of the two sides of the body, than the story of the
Italian Tozzi twins. They were born with two heads and shoulders and
with only one pair of legs. It was found that each head ruled the leg
on its own side of the body. It was impossible for the creatures to
walk. They lived to adolescent life, yet never succeeded in walking.
The intimate association of the lower parts of their trunk and the
long years of companionship of their brains, did not enable them to
accomplish what seems to us so commonplace a co-ordination of movement
as walking.
Formation of Habits.--The co-ordination of the two limbs is after all
only a small portion of walking. The body must be held erect, the
curve of {230} the spine must be managed so that the center of gravity
is kept well within the base, and gluteal and femoral and calf muscles
must all be co-ordinated with one another. In a few months a child
learns to do all this, and in a couple of years it executes all the
co-ordinate motions with such certainty that walking becomes not only
an easy matter but an absolutely unconscious accomplishment that can
be carried on while the mind is occupied with something else or while
it becomes so abstracted that surrounding objects are not noticed.
A far more difficult co-ordination is required for talking. It is only
when we analyze how nicely adjusted must be every movement, in order
to pronounce consonants and vowels properly and to combine them in
various ways, that we realize how complex is the mechanism of talking.
A difference of a hundredth of an inch in the movement of the tongue,
or less than that in the movements of various muscles of the larynx,
makes all the differences between clear articulation and a defect of
speech. In the course of the years up to seven, the child learns this
wonderful co-ordination apparently without difficulty, but really at
the cost of constant well-directed effort. There is no time in human
existence when the child really learns so much as during the first
four years of its existence, even if it learns nothing else except to
walk and to talk. The foolishness of obtruding other things,
information and study of various kinds, on the child's attention at
this time should be manifest.
_Unconscious Regulation of Muscles_.--What is thus prefigured in early
life invades every activity in later years. The boy who learns to ride
a bicycle must at first devote all his attention to it, but after a
while rides it quite unconsciously, his muscles having learned by
habit to accommodate themselves automatically to all the varying
positions of his machine. Anything well learned by habit is never
forgotten. How hard it is to learn to swim, yet, after years away from
the practice of it, the art comes back at once. The same is true of
skating, and of the nice adjustments of muscles required in various
games. Such is the influence of habit in forming a second nature. It
is no wonder that Reid, the Scotch philosopher, should have written:
As without instinct the infant could not live to become a man, so
without habit man would remain an infant through life, and would be
as helpless, as unhandy, as speechless, and as much a child in
understanding at threescore as at three.
Commenting on this Prof. J. P. Gordy, in his
"New Psychology," [Footnote 26] says:
[Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.]
Strong as this statement seems, it is probably an understatement of
the truth. Without habit, we should rather say, a man would be as
helpless, as speechless, as unhandy at three-score as at birth.
Habit is the architect that builds the feeble rudimentary powers of
the child into the strong, developed powers of the full-grown man.
If a child's vague, purposeless movements give place to definite
movements performed for definite purposes, if his sensations become
more definite, if his perceptions become clearer, if his memory
becomes more accurate, if he reasons more and more correctly and
logically, it is because of habit.
Law of Habit.--The law of habit is that every time we perform any
action, mental or physical, or allow ourselves to be affected in any
way, we have more proneness to, and greater facility in the
performance of that action or in {231} experiencing that affection
under similar circumstances, than we had before. In the chapter on
Tics, I call attention to the fact that all the curious gestures by
which we are individualized, are due to the law of habit. It is
infinitely amusing to watch a group of people and note the endlessly
different habits of which they have become the victims. There are
tricks of speech and tricks of gesture eminently characteristic and
often quite laughably individualistic. We imitate, especially those of
whom we think much. Sometimes it is only when a father's attention is
called to them in his sons that he realizes the ludicrousness, or at
least laughableness, of some of the things he does, and he proceeds to
correct both generations of their faults.
PHYSICAL HABITS
Habit and Food.--Most of our likes and dislikes for food are neither
physical nor physiological, but simply habitual. We have become
accustomed to certain things, and so we like them. We are unaccustomed
to them, and do not care for them. It is amusing when people put
forward these lacks of habituation as if they were physiological
idiosyncracies. Many thin people do not like butter and milk. The real
reason for this is not any peculiarity of digestion, or any gastric
incompatibility, at least in 99 cases out of every 100, but the mere
fact that they are not habituated to their use. That is one of the
reasons why they are thin. Our tastes for curious foreign foods are
nearly all deliberately acquired. Not one in ten ordinary Americans
likes olives or caviar when first tasted. Nearly every curious article
of food is "caviar to the general" at first trial. Later it becomes
impossible to understand how we could have had any objection to them.
At times, even an actual craving for them asserts itself as a
consequence of the habitual use, and then deprivation means positive
discomfort.
Slow Eating.--One of the most valuable habits that a man can
cultivate, but one of the most difficult to acquire in our time, is
that of eating slowly. Most Americans bolt their food to a degree that
would be quite appalling to them if they realized what they were
doing. Pieces of potatoe as large as the end of the thumb are
swallowed. Bread and milk may be eaten so hurriedly as to be as potent
a source of digestive disturbance as fried onions. There seems no
doubt from what we know of Fletcher's experience and Chittendan and
Follin's studies that a man derives more nutrition from food that is
masticated properly, that he can get along and do his work on less
material and that, above all, there is not the same tendency for him
to put on weight that is so common among people after reaching middle
age.
Sir Andrew Clarke used to have his patients chew a definite number ol
times on each bite--say thirty times. Even so great a man as Gladstone
submitted to this rule and gradually learned to accustom himself to
eating very slowly. Fletcher's system of chewing the food until it
passes down the esophagus of itself without any swallowing effort is a
better rule. It is a surprise to most people how unconsciously
swallowing can be accomplished in this way and how little liquid is
needed in order to prepare food to be swallowed. The formation of the
habit, however, is not an easy one. Persistence and frequent reminders
are needed, or else the beginnings of the habit are soon dissipated
and old bolting habits reassert themselves.
{232}
Water Drinking.--In drinking, habit is as supreme as in eating. The
majority of people who work outside and perform muscular labor crave
and take an abundance of water. Many of those who live indoors,
especially in steam-heated houses, may need it quite as much if not
more, but get out of the habit of drinking water. As we need about
three quarts of water per day for use in our economy, this no water
habit often becomes a serious factor in the production of
physiological disturbances. We have replaced water drinking and the
milk drinking of the olden times by tea and coffee, and as these are
stimulants, habits form very readily with regard to them. I have known
people who were sure they would be miserable without their half-dozen
cups of tea or coffee each day, and who actually would be miserable
for a few days, when deprived of it. They were seriously impairing the
efficiency of their nervous system by so much stimulation.
Unfortunately, it is just those whose nervous systems have least
stability, and are already the subjects of more stimulation by
conscious introspection than is good for them, that are most likely to
form the tea and coffee habits, and who are most harmed by them,
though they find it hard to understand the reason therefor.
Air and Exercise Habits.--Habits with regard to exercise and fresh air
are particularly important. In this matter it is only habit that can
be really helpful. To work at high pressure indoors for several days,
and then, when one is quite on edge, to take a lot of severe physical
exercise is not good. Every human being should go out between meals. I
am not one of those who believe much in exercise for exercise's
sake--what is needed is fresh air. Our sanatorium patients who sit
out-doors all day have fine appetites. The advice to a busy man that
he must form the habit of being out between every two meals for from
half an hour to an hour would usually evoke a strenuous protest, but
all he needs to do is to get up half an hour earlier and walk down to
his office, and if he will walk back in the evening he will have
plenty of air and exercise between his meals.
Change of Habits.--Patients do not want to change their habits. They
come to a doctor to be treated. They want some medicine that will,
without further inconvenience, rid them of certain discomforting
symptoms. At the beginning, at least, patients resent interference
with their habits. They are quite satisfied, and to modify them
requires an effort that must be continued for some time. The changing
of old habits and the formation of new habits are most important for
the ordinary ills to which mankind is prone. Modifications of habit
constitute real hygiene and are not mere corrections of symptoms,
permitting the habits that have led up to them to go on.
Patients may conclude that it is too much trouble to change their
habits. We all know persons who feel that they can not give up their
coffee. As to whether or not the modification of a habit is worth the
trouble it involves, the patient must be the judge after the case is
put properly before him. It is possible that he may learn to endure
the inconvenience given him by his symptoms rather than to stand the
inconvenience of changing a nicely settled habit, and forming a new
one. The reward should be put very plainly before him, however, and
besides, the consequences of his habit in the future should be
suggested so that he may realize just what it will lead to.
{233}
MENTAL HABITS
It is evident from the foregoing that physical habits have much to do
with making life easier and saving expenditure of nervous energy, but
just this same thing holds good for mental states. With care, a proper
habit of mind and of the mental attitude towards difficulties in life,
can be so cultivated as to ward off many of the discouragements, and
most of the causes of depression that weigh heavily on some people.
The natural disposition can not be entirely overcome, but habit, as a
second nature, can modify the personality so as to make conditions
much better than before.
With this wonderful power in habit, it is too bad that its force for
good is not used. It is especially important that its force for evil
shall not allowed to dominate human actions so as to make them harder
of accomplishment. Many people, who are greatly troubled by the
inconveniences and discomforts necessarily associated with human life,
worry over it to such a degree as to make themselves sick. The
expression I have quoted elsewhere of the old man who said, "I have
had many troubles but most of them never happened," is a typical
example of what the habit of looking at things from a wrong standpoint
means to many people. They are confirmed pessimists. Their one
consolation, when a small evil happens to them, is that perhaps this
may be sufficient to ward off the greater evil that fate surely has in
store.
Pessimism.--Pessimism has been defined as sticking one's nose in a
dungheap and then asking, "How is it that it smells bad around here?"
Some people are always nursing a grievance. No matter how many times
they may happen to have been undeceived, still the next time the
opportunity occurs they are sure that fate or friends or someone has
it in for them and that the worst may happen at any time. In the
expressive words of a recent slang phrase, they have a "perennial
grouch." This state of mind toward the environment not only prevents
the physical and mental good that cheerfulness brings with it, but it
unfavorably influences physical conditions within the body. People
suffering from indigestion are usually morbid, petulant, and hard to
get along with. Many a dyspeptic makes this an excuse for his bad
temper. Anyone who has had to study these cases much soon comes to the
conclusion that the beginning of the digestive disturbance was the
gloomy outlook on life, which flowed inward to disturb the digestion
and all the other animal functions.
Depression of Mind and Body.--Patients suffering from melancholia
nearly always lose in weight. As a result of their lowered vitality,
there is a suppression of the nervous impulses which rule over
nutrition, with a consequent loss of weight. In cases where there are
only tendencies to depression and gloom, the effect upon the digestive
system is not so marked but there is no doubt that there is some
effect, and that the indigestion in these cases is more often than not
a result of the depressed state of mind, rather than the depression of
mind the result of the indigestion.
Moodiness.--The habit of looking at the gloomy side of things is
easily formed and, once acquired, it becomes very forceful. Many a man
who was quite cheerful when young, becomes moody as he grows older.
Nearly everyone permits moods more than is good for him. The attitude
of mind that should be cultivated is one in which it is realized that,
though there may be {234} many sources of evil in the world there is a
preponderance of good even in the worst environment, and that
opportunities for making the best of things will be found by any
cheerful disposition. _Mrs. Wiggs of the Cabbage Patch_ is a typical
example in fiction of the optimism that counts. Miss Helen Keller in
real life is a typical example of how the most untoward circumstances
can not crush the spirit of man if he only wishes to be cheerful--if
he only tries to lift himself above his surroundings, no matter how
discouraging they may seem to be. No one is without discouragement and
causes for unhappiness. "Happy he who has least," the Greek dramatist
said.
The difference between the optimistic and the pessimistic point of
view is much more a matter of habit than is usually thought to be the
case. Indeed, there is good reason for assuming that it is so largely
a matter of habit, that other factors count for little. We all know
individuals who, after having, been cheery, bright, hopeful and
helpful, have had some incident sour them and then they have been just
the opposite. This did not come all at once; it was a growth. They
felt hurt and aggrieved, and then began to look at things through dark
glasses, and after a time could see nothing on its brighter side. Not
infrequently, as doctors well know, the growth of such a moody
disposition has been the signal for the development of a series of
complaints, if not of actual symptoms, and men and women who have not
been in the doctor's hands before now become valetudinarians. This new
physical condition is often attributed by their friends, by
themselves, and even by complacent physicians, to the effect upon them
of the trial or disappointment that struck them. Only too often it is
wholly due to the cultivation of a habit of pessimism consequent upon
a shock that for the moment pushed their cheerfulness into the
background. Strong characters will not be thus easily affected, but
weaker characters need not suffer such a change of disposition and
with it a deterioration of health or well-being unless they so will
it.
MANNERS AND DISPOSITION
Habit can modify nature so much as to make what is practically another
man. We all know how the dancing master can transform a country gawk
into a refined, courteous society man (not gentleman, for that is
something else) of graceful carriage and even handsome bearing. He
cannot do this for all the pupils that come to him, for it is
impossible to make a silk purse out of a sow's ear, but for anyone
that comes with good will the revolution in manners is often a
revelation to those who have known the man before. When the exterior
can be changed so much, the interior attitude toward other people
certainly can be greatly modified.
Persons of a melancholic disposition may be surprisingly cheerful, and
even gay, with comparative strangers when they make the effort to be
so. For many people, meeting with strangers is an excellent remedial
measure. It stirs them up to present the best side, and it occupies
attention to the exclusion of themselves in a way that is extremely
beneficial. If people would only form the habit of being as courteous
to their own folks as they are to others, the disposition involved in
this would often save them from certain symptoms, and save their
physicians from many complaints.
{235}
Happiness is the basis of good health. The phrase is often put the
other way: Good health is the basis of happiness. Without health there
is no happiness. But every physician knows that many a patient
suffering from real organic ills, and having much physical pain to
bear, still has many hours of happiness in working for others. This
happiness reflected back upon his physical life is not able to cure
his ailments, but does so lessen the significance of the symptoms as
to make the ailment more bearable.
THERAPEUTIC IMPORTANCE OF HABIT
The most important therapeutic element in the formation of good
habits, mental and physical, is that habit does away with the
necessity for conscious regulation of many details of life. Without
habits of doing things, we have to make numerous decisions and keep on
making them under conditions that require special effort and waste of
energy. When habit asserts itself, there is little or no difficulty.
Habits of living in airy rooms, of taking exercise, of food regulation
as to quantity and quality, of methods of taking food as regards
mastication, the quantity of fluid ingested, the hours of meals and
the like, can all be formed and then followed without effort. Just
inasmuch as life can be ruled by habit, nerve force is conserved. This
is as true for our attitude towards life, our disposition and
consequently our satisfaction with life, as for anything else that we
do. Habitual cheerfulness, habitual readiness to make allowance for
others and to be helpful to them, habitual self-control--all of these
things can be cultivated. Properly cultivated, they save much of the
wear and tear of life, and make for contentment and happiness much
more than many of the things for which men strive so anxiously because
they seem to promise happiness.
CHAPTER VIII
PAIN
Pain, while always a dreaded symptom of disease, seems, with the
increase of comfort and the gradual abolition that has come in our
time of many of the trials of existence, to have had its terrors
increased. Even a slight pain or ache is dreaded, and if continuous or
frequently repeated, becomes for many people a trial that is almost
impossible to bear. This is all the more to be deplored because
ability to stand a certain amount of pain, with reasonable equanimity,
is almost a necessary condition of rapid recovery from disease or
injury. Placidity of mind favors the flow of nerve impulses for
reconstructive purposes, while over-reaction to pain inhibits the
natural processes of repair. According to Shakespeare's heroine:
"There was never yet philosopher that could endure the toothache
patiently." Pain is usually supposed to be an essentially physical
phenomena for which mental influence can be of little, if any,
benefit. As a matter of fact, however, the mental attitude towards
pain modifies it to a considerable degree. I have quoted Hippocrates'
declaration that a greater pain drives out a lesser pain. Any strong
preoccupation of mind will greatly lessen pain at any time.
{236}
Pain is not, after all, in the nerves, nor in the central nervous
system, but in the consciousness. Just as there is no sound unless the
waves in the air arouse recognition in the consciousness, so there is
no pain unless the disturbance of nerves finds its way above the
threshold of consciousness. Nerves may be racked, yet no sensation may
be felt. There may be pain in the mind apart from the nerves, and
slight nervous affections may produce severe pains. The whole question
of the treatment of pain involves the individual much more than it
does the affliction which causes the pain. What seems unbearable pain
to many may be little more than a passing annoyance to others. What
would be, under ordinary circumstances, intolerable torture,
especially to sensitive people, may, because of intense preoccupation
of mind, remain absolutely unnoticed. Maniacal patients sometimes
inflict what would normally be extremely severe pain on themselves by
burning or mutilation without any manifestation of pain. In the
excitement of a panic men may suffer what would, under other
circumstances, be excruciating agony, and yet not know that they are
hurt.
To a mind that is without serious interest, even slight pain, if
continuous, soon becomes unbearable. The course of pain, where there
is no diversion of mind, is an interesting study. While suffering, we
seem always able to bear the pain of the present moment, and it is
only the cumulative effect of the pain that is past and the
anticipation of the discomfort to come, that make the pain unbearable.
Nearly, always it is much more the dread of what the pain may mean,
and the lack of power to endure which gradually develops as a
consequence of suffering, that constitute the worst features of pain.
At the beginning of a period of pain we stand it well, as a rule, but
its continual nagging debilitates us and heightens our susceptibility
until we cannot nerve ourselves to further endurance. If our power of
endurance were not thus gradually lessened the pain would not seem
severe. There are many neurotic people whose susceptibility to pain
has been so much increased by their lack of self-control and their
tendency to react easily to pain, that even slight pain becomes a
torment. Psychotherapy should gradually train these people to a power
of endurance.
Pain from Over-Attention.--Much of what is called pain is really due
to such concentration of mind on a particular portion of the body that
the ordinary sensations of that part, usually accomplished quite
unconsciously, become first a source of uneasy discomfort and then an
ache or pain. There may be some slight physical disturbance which
calls attention to the part, but there is no really serious
pathological condition. While such pains are spoken of as imaginary it
must be remembered that this does not mean that they are non-existent.
On the contrary they may be much more real to the patient than
physical ailments. A pain in the mind is a much more serious condition
than having it in the body.
While pain may be thus created by concentration of attention, it must
not be forgotten that what the mind can do in increasing pain is even
more important than in originating it. Slight discomforts by
concentration of attention on them may be made insupportable. It is
this element in pain, above all, that the physician requires skill to
alleviate. Habits of introspection and the lack of serious occupation
of mind of many people leave them the victims of over attention to
themselves. In trying to relieve their pain it may be {237}
comparatively easy to alleviate their physical condition, but the
mental condition, once aroused, may remain, and may easily tempt to
the use of habit-forming drugs or others that may do serious harm. The
story of the evil effects of headache powders in recent years, and of
the opium habits formed in olden times, are a significant commentary
on this fact. It is probable that in most of these cases, the
discomfort for which remedies were frequently taken was of a kind that
should have been treated only partly, if at all, by drugs. It is more
important to lessen susceptibility than to try to cure the pain.
The relation of the mind to what is often considered severe physical
pain, has come to be generally recognized in recent years. Neuralgias,
for instance, have often been reported as recurring after fright, or
strong emotion, or worry. It is at moments when patients are much run
down in health that pains are particularly likely to be unrelievable,
and during periods of emotional strain that anodyne drugs are most
called for and are most likely to be abused.
Rest and Pain.--In any study of pain and its relief, one must always
recur to that classical contribution to medicine, now in the fiftieth
year of its publication and still as important as when it was written,
Hilton's "Rest and Pain." He calls attention to the fact that what he
wrote was only a development of what many practical physicians had
thought long before his time. He quotes a prize essay of the French
surgeon, David, written in 1778. Hilton's development of the idea that
pain is usually a signal on the part of nature for rest, and that rest
will usually enable her to overcome the pathological condition and so
relieve the pain without recourse to drugs, is, and ever must be, the
basic element in the therapeutics of pain. How many forms rest may
take can only be judged by a careful reading of Hilton's book. The
oftener one reads it, the better one realizes how much of precious
common sense and acute clinical observation there is in it. It is
essentially a book of psychotherapy. It treats the patient's mind
first and then through that changes his habits, persuades him of the
need of rest, directs how that rest should be taken and so leads up to
his natural cure.
Every treatment of pain must include rest of mind as well as body.
Hilton has particularly dwelt on the rest of body. Rest of mind is
just as important. Many pains could be easily borne were it not for
the worry that accompanies them. A slight pain becomes greatly
annoying because the patient's general condition makes it impossible
to stand discomfort with equanimity, and there has been no training in
self-control. In spite of all our advance in medicine, we are not
likely ever to make life so free from pain that people can go through
it without needing self-control. Training in self-control is an
important psychotherapeutic prophylactic. If, with a certain amount of
capacity to bear discomfort, there goes such rest of mind as does not
exaggerate or emphasize the condition, then many of the pains of life
lose their power to annoy, all of them are distinctly lessened and the
relief of them by accessory physical methods becomes easier.
Pain in Its Relation to Life.--There is an unfortunate tendency to
exaggerate the significance of pain. We have cultivated irritability
in the physical sense, rather than the power of endurance. Patients
should, as far as possible, be lifted out of this condition of
over-delicate sensitiveness and put into a state where the idea of
pain is not so serious. Only in this way can {238} the more or less
inevitable discomforts of life be borne without such reactions as
seriously interfere with health. It may be said to be other than the
physician's business to secure this magnanimity, but as magnanimity is
needed in our patients, and there is no one else to respond,
physicians must start its cultivation. The necessity for learning to
bear minor discomforts, at least without exaggerated reaction, need
not be presented to the patient directly, but can be gradually made a
part of the system of treatment. By absorption in other interests, the
consciousness of these discomforts disappears without the necessity
for recourse to drugs.
Self-Denial.--Many thoughtful people are sure that what is needed to
make a large number of our generation more happy, or at least less
miserable, is training in self-denial and in self-control. The word
self-denial has come to have a very distant sound for most of our
generation. From early childhood anything that is unpleasant is
shunned and anything that is difficult is likely to be shirked. The
head-master of Eton College has recently insisted that too much is
being done to please young folks and too little to stimulate them to
activity. He declares that, as a rule, any undertaking begins to be
useful just where it ceases to be simply pleasant. Unpleasantness is
avoided to such a degree that the habit of thinking that it has no
part in life comes to be a second nature. As a consequence, the
reaction to any continued unpleasantness is likely to be exaggerated
and make the subject very miserable, and sometimes disturbs and
discourages, whereas it should have the effect of stimulating to
reactive efforts, to bring out the best that is in us.
Hinton emphasizes the fact that an ingredient of pain is necessary to
all health or pleasure. The fatigue and the hardship associated with
mountain climbing is a portion of the essence of the pleasure in it.
All healthy, pleasant exercise has an accompaniment of fatigue and
some aches and pains. What is needed, then, in our time is the
training to do things for the sake of doing them. We should be
neglectful of the discomfort that may be associated with them, or we
should even consciously rejoice in the fact that this very discomfort
is of itself a sign that functions are being used to such an extent,
that their limits are being expanded, their limitations overcome.
It may well be said that it is not the physician who, as a rule,
should do this; it should be accomplished in the early years by the
teachers and trainers of the young. True enough. But physicians can at
least help in reforming the tradition in this matter so as to
neutralize the present state of mind which seems to look upon pain as
an evil. Pain is always either a conservative sensation or an actual
stimulus to function. Besides, many of the present generation who come
to us, having had no training in the precious qualities of self-denial
and self-control under difficulties and discomforts, must have this
knowledge supplied for them as far as possible by suggestions of
various kinds. It is more difficult to accomplish much in this matter
for the adult, but even in apparently hopeless cases of over-attention
to self and incapacity to bear discomfort, much can be accomplished by
patience and persistence.
The common dread of suffering is quite unwarranted by what we know
about the effect of pain. There are many motives that may be adduced
to make it seem less terrifying than it now is to many people. The
effect of pain upon character is always excellent. The difference
between two brothers, as we have said, one of whom has had the
discipline of pain or suffering and {239} the development of sympathy
that comes with it, and the other who has not had the advantage of
this great human experience, is likely to be marked. In the one there
is a depth of human nature that enables him to appreciate and even to
express the meaning of life better than his apparently more fortunate
brother. Practically all the men who have ever got close to the heart
of the mystery of life, and expressed it in poetry or other form of
literature or art, have gone through suffering as a portion of their
training. Even the suffering that comes from ill health is never
wasted. Men have gone through it who have thought that the ecstasy of
relief following it made the experience worth while.
Men are not deterred from action by the prospect of even severe pain.
Probably no greater physical suffering can possibly be invited than is
sure to come to those who go on Arctic expeditions, or who undertake
prospecting in Alaska. Of course, many of the prospectors find
themselves in the bitter cold of the North without having realized
what they would have to stand. But Arctic explorers, as a rule, know
exactly what they have to expect. Most of of them have been through it
all before, yet they deliberately choose to go again for rewards that,
to an average man's eyes, seem trivial. The memory of past pain is
rather pleasant. Virgil's "Perhaps it will be pleasant to recall these
trials at some future time" is not poetic exaggeration.
_The Discipline of Pain_.--There is only one way to learn how to bear
pain, and that is by practice in it. There might be no necessity for
this in case life were arranged differently. But all men must die, and
death inevitably involves a painful process. Suffering is practically
unavoidable for the majority of men. Even in the midst of every
possible material comfort, cancer may come with all its hideous
connotations. It is important, then, that everyone should be prepared
to stand some pain. Certain suggestions help in bearing special pains.
Pain Diffusion.--Pain along one nerve may readily become diffused.
This diffusion will sometimes cause discomfort, and even tenderness,
at a distance from the original seat of the pain. Such diffusion tends
to produce in the patient's mind the idea that the underlying
pathological condition is spreading, though it is only a sign that the
nervous system is becoming irritable and easily responding to sensory
disturbance. Dr. Head's investigations ("Brain," 1893), should be
known to physicians, and the conclusions that flow from them should be
presented to patients who are sometimes suffering quite as much from
their apprehension of the spread of pain, and its significance, as
from the discomfort itself. Dr. Head says:
If I have an aching tooth, the pain is at first localized to the
tooth affected. The longer the toothache continues the more I become
worn out, and the pain is rapidly accentuated by a "neuralgia," that
is, a pain in the face. The neuralgia is soon accompanied by
distinct cutaneous tenderness over a definite area on the face
corresponding to the tooth affected. If I am anemic, or if the pain
remains untreated until my bodily health is affected, I no longer
have a localized area of tenderness, but the pain, and with it the
tenderness, spreads until the whole of one-half of the head and even
the neck may be intensely tender. Thus at last the pain of an aching
tooth has produced tenderness over areas which bear no relation to
the affected organ.
As pain can be suppressed by diversion of mind, or concentration of
thought on something that creates great preoccupation, it must not be
{240} forgotten that pain may almost be created by concentration of
attention on certain areas of the body, or certain nerve tracts.
Over-attention will actually make sensations intolerable that are at
first quite indifferent, or at least very easy to bear. Sensitive
people, in the ordinary meaning of that term, are those who are much
given to paying attention to their sensations, and who therefore have
much to complain of them. There is much in modern life that has the
tendency to produce this sybaritic condition in which even slight
discomforts become the sources of almost unbearable annoyance.
Even where there is no good physical reason for the occurrence of
pain, thinking may produce discomfort. The one thing that Freud's work
has made clear is that in neurotic persons the memory of a mental
shock or strain may be transferred to some portion of the body related
in some way to the shock, and then prove to be the source of
hysterical pains and also of hysterical palsy. The case told by him in
which the young woman massaging her father's limbs allows them always
to rest on her own lap during the process, and after his death suffers
from an hysterical, painful condition in this region, is a typical
illustration. Her sympathy for her father, accentuated by his
subsequent death, and her sorrow at a time when her nursing efforts
made her particularly susceptible, led to an explosion of nervous
energy along those nerves which had always felt the impress of his
legs. The hysterical condition resulted. This is an extreme case. In
milder forms it would be possible to explain many otherwise
inexplicable pains and aches in sensitive young people along these
same lines.
More than once I have seen young women, who had been asked to rub
father or mother with liniment, complain of tingling pains in their
fingers which were followed by some redness so that one would be
tempted to think of Weir Mitchell's disease, though evidently the
pathological cause at work was the slight disturbance of the vasomotor
system due to the liniment and the rubbing, emphasized by the
sympathetic feelings, and by the over-attention which this brought
about. Whenever women have, for a prolonged period, to nurse others in
whom they are deeply interested, and have to perform some habitual
action that is somewhat fatiguing for them, after the death of the
patient there will not infrequently be the development of hysterical
or neurotic over-sensitiveness in the parts employed. This may give
rise even to an hysterical joint, or to severe neurotic pains. Once
these cases are recognized, the attention can be diverted from
themselves and they can be made to understand that their grief and
sympathy are being concentrated on the part and by transfer are
producing physical manifestations. The pain is not imaginary, but the
condition will improve as soon as the mind is diverted from it.
Neurotic and Organic Pain.--The distinction between pain due to a
neurosis and to a definite lesion is often difficult to make. If there
is a definite localization of pain, it is almost surely not neurotic,
but organic. If there are certain positions in which pain is felt
while it disappears in others, there is some local inflammatory or
congestive condition and not mere hypersensitiveness of nerves at the
bottom of it. These positions of maximum pain are important. When pain
radiates a great deal, even though there may be complaint of a
particular region, it is usually neurotic. If patients are asked to
tell exactly where their pain is, and they indicate its location by a
wave of the hand, it is probable that the condition is neurotic. When
there is a definite {241} localized point of tenderness with the pain,
even though there may be radiations, usually the condition is based
upon some organic trouble. It must not be forgotten, however, that
slight local troubles may by concentration of mind on them, become
exaggerated and that, in spite of the fact that there is or was at the
beginning a definite localization of pain with some tenderness, the
neurotic elements may, after a time, become manifest and prove to be
much more important than the others.
Pain that is definitely influenced by motion, as by the jarring effect
of walking, or by bending and stooping, is practically always organic.
The best differential diagnosis between neurotic abdominal conditions
and organic trouble can be made by the help of information obtained in
this way. If the appendix is inflamed, or the gall bladder infected,
or contains a calculus, or if the kidney has a calculus, these are all
made worse by movements, by jarring, by stooping as in tying the
shoes, by riding on rough roads, and the like. If patients who suffer
from obscure abdominal conditions associated with pain of which they
complain much, can, at certain times, indulge with impunity in these
exercises and motions, it is probable that their attacks are neurotic
in character. Especially is this true if the indulgence in these rides
and motions is without effect when they are in pleasant, agreeable
company, though there may be some complaints when they have to ride
alone, or under conditions that are less pleasant. If a hint of this
distinction by which the physician differentiates one form of pain
from another is given a neurotic patient, the suggestion will serve
the purpose of producing complaints whenever the opportunity presents
itself. Such patients take such suggestions, as a rule, without
wishing to deceive, but they become persuaded that their sufferings
are of the character asked for.
{242}
SPECIAL PSYCHOTHERAPY
SECTION VI
_THE DIGESTIVE TRACT_
CHAPTER I
INFLUENCE OF MIND ON FOOD DIGESTION
With the progress of biological chemistry, digestion came to be
considered a purely chemical process. Now we realize that even more
important than the chemical factors of digestion is the individual
liking for particular kinds of food, and the mental attitude of the
patient toward digestion.
Not only may mental factors interrupt or hamper digestive processes
generally but, as the investigations of Pawlow at the Imperial
Institute of St. Petersburg show, they may modify very materially the
chemical processes within the stomach. If, for investigation purposes,
a stomach pouch be experimentally segregated in a dog from the rest of
the stomach, and the dog be fed food that he has a particular liking
for, the gastric juice manufactured will be especially strong and
effective. If the food given be less to the dog's liking, the gastric
juice is not nearly so efficient in its activity. Finally, if food be
consumed for which the dog does not care, but which he takes because
hunger compels him, the gastric juice manufactured for its digestion
is quite weak and the process of digestion is slow. If this is true
for an animal like the dog, whose psyche is comparatively of much less
importance than that of human beings, the corresponding influences in
men and women will be even more emphasized. This is only what common
experience has always shown us. The human stomach is not a test-tube
in which mere chemical processes are carried on, but its vital
activity is of great importance. That vital activity depends to a
large extent on the state of mind, on the relish with which food is
eaten, on the individual likes and dislikes, and on the emotional
condition during digestion.
Prejudices and Digestion.--Perfectly good food materials may become
difficult or impossible of digestion as the result of learning
something about their mode of preparation. In the country this is
often noted, with regard to butter, milk, and even eggs. The story of
the farmer's wife who wanted to trade her own butter for an equivalent
amount made by someone else illustrates the influence of mind over
relish for food. She was candid enough to say that the reason she
wanted to exchange the butter was that a mouse had been seen in the
cream, and her children could not, therefore, eat it. She took {243}
back home with her exactly the same butter in another crock, and there
was no further difficulty, though before this the children would have
been actually sick if compelled to eat the butter. I once saw a family
of three women who had vomited because they heard that the dishes had
been washed in a slop pan, though this proved to be a mistake. Such
occurrences emphasize the necessity for properly predisposing the
mind, and for removing unfavorable suggestion, if digestion is to
proceed properly.
Mental States and the Stomach.--The typical example of the influence
of the mind on the digestive tract is to be found in the experiences
of Flaubert, the French novelist, while writing "Madame Bovary." When
he was writing the scene in which he describes the effects of the
arsenic which Madame Bovary takes, he himself suffered from
practically all the symptoms due to the drug. In order to describe it
faithfully he had studied it carefully. He had the pains, the
vomiting, the burning feeling and even the garlicky, metallic taste in
his mouth. Such an incident is extremely exceptional, yet its
possibility is recognized, and it illustrates how sensitive some
people are to the action of mental states upon the body, and how large
a role a strongly excited imagination can play in producing definite
physical symptoms. There are many more such realistic imaginations
than we have, perhaps, been inclined to suspect. It is over these
particularly that the psychotherapeutist can exert his influence by
helping to modify the cause of their symptoms, the mental attitude
which exists, rather than by trying to change the symptoms which are
only effects, for diseases must, as far as possible, be treated in
their causes.
_Disgust and Disturbance of Digestion_.--Max Mueller's story, told in
his book on "Language," to show how language might have been a human
invention from imitation of natural sounds, illustrates the influence
of an unfavorable state of mind in disturbing digestion. An
Englishman, traveling in China, fearful lest he should not be able to
obtain food that he cared for, because of his lack of knowledge of the
language of the country, was rather surprised on his first day's
journey into the interior, to be served with a stew made of some kind
of dark meat that tasted very well indeed and with which he was so
much pleased that he asked for a second helping. Just as he was about
to eat the second portion, he thought it well to ask the waiter what
sort of meat it was, as he wished to be able to obtain the same kind
at other places. Calling the waiter to him, he said, pointing to the
dish of meat with a questioning tone, "Quack, quack?" The waiter at
once shook his head and said, "Ugh! bow wow!" The Englishman pushed
the second portion away and got up from the table.
Tinder the same circumstances nearly everybody would feel the same
qualmishness--at least all who had been brought up according to our
Western notions. Reason has little or nothing to do with it. It is a
question of feeling. The dog is much more cleanly in its habits than
the hog, but we in the West are used to the idea of eating hog-meat
just as they in the East are used to eating dog-meat. The objection,
of course, might be urged that the difference between the hog and the
dog is that we do not eat carnivorous but only herbivorous animals.
But the slop-fed hogs from the neighborhood of our large cities,
constituting a goodly portion of those brought to market, eat meat
quite ravenously. They certainly are not exclusively herbivorous.
There is no {244} principle behind our objection to dog meal
then--only the unfamiliarity of the idea of eating it.
The treatment of patients with digestive disturbances requires a
careful analysis of the conditions of mind towards foods. If prejudice
exists with regard to certain foods, there will be no relish for them,
and unless these prejudices can be removed, the foods either will not
be taken, though they represent important nutritional elements, or
else they must be taken in such small quantities and digested with so
much consciousness of their presence and such difficulty as to be a
disturbing factor for health. Persuasion, the custom of the country,
habit, training, mean much for this modification of mental attitude.
_Custom and Food_.--In recent years many parts of animals, not
generally eaten before, have come to be consumed with a relish because
of the removal of prejudices against them. It might be thought that
organs like the kidney, the essential function of which is excretory,
and through which so much of the offensive waste products of the body
pass, could not be a relished article of food. But it has become quite
a dainty. The liver, owing to the peculiar nature of its function, its
very special flavor, and the staining with bile, might be expected to
be objectionable. It is not, but, strange to say, a third organ of the
abdominal cavity, the spleen, which has none of the external
objectionable features of kidney or liver, is not yet eaten, and most
people would probably find it rather difficult to eat it. This
difficulty would result, not because of anything in the organic
substance itself, but because of the lack of accustomedness to it.
There are a number of people who now have trained themselves to eat
it. Such apparently impossible portions of the animal as the
intestines, even those of the hog, are eaten with relish by a great
many people, though there are others who have never been able to get
used to them. The dainties of some peoples are utterly repulsive to
others. The French like brains and other special portions of animals
that are not much eaten by Anglo-Saxons. Fried brains in black butter
sauce are enough to turn the stomach of some people by the very
thought of it, though it is a highly prized dish in the south of
France.
In Italy most visitors eat snail soup with relish before they know
what it is. It seems to be a special kind of gumbo soup. Down at
Marseilles, gourmets occasionally eat angle-worms and find them to be
a very appetizing dish. In all of these things the question of relish
and peaceful, happy digestion depends entirely on the attitude of
mind. The first men who ate eels must have been looked upon with
considerable suspicion by their neighbors as viper eaters, and
probably they themselves were not comfortable over the feat. It has
been said that the first man who ever swallowed an oyster performed as
great a feat as any of our important inventors or discoverers.
_Gastric Antipathies_.--To the great majority of mankind the idea of
eating horseflesh is repulsive. Numbers of people in various parts of
Europe have found, however, that after the initial repugnance is
conquered, it is quite as pleasant to eat as cow's meat. To my taste,
at least, it is much more palatable than venison or bear meat. At the
beginning, its sweetish taste has a curious reflex effect. Taken in
connection with the thought that this is horse meat, the taste is apt
to produce a sensation of nausea. This is readily overcome, though the
first time it is necessary to keep constantly inhibiting {245} the
mind from acting unfavorably upon the stomach during the course of
eating and digestion. Custom, I learned from many, soon made it quite
as savory as beef.
_Food Varieties and the Mind_.--How easy it may be to overcome many
prejudices in the matter of food digestion under the stress of
necessity and the influence of example, was well illustrated during
the siege of Paris. The Parisians, though a most delicate people in
the matter of eating, were able to accommodate themselves to the
conditions, and practically every kind of animal was eaten with a
relish. Before the siege, to most of them it would have seemed quite
impossible, that they should sit down with complacency to the dishes
which afterwards were so appetizing. At the beginning there was a
definite attempt to conceal the eating of rats, mice, cats and dogs
under various names, and by various modes of preparation. But it was
not long before there was an end of this pretense. The animals in the
zoological garden proved a veritable life-saving store of meat. Every
one of them was eaten, people were glad to get them, and paid high
prices for them. Camel steaks, elephant cutlets, lion and tiger stews,
appeared under their own names, even at the banquets of the wealthy.
What is true of the mental attitude for meats influencing not only the
relish for them, but their digestion, is also true for many
vegetables. There are unfavorable suggestions in the minds of many
with regard to the supposed indigestibility of potatoes, turnips,
carrots, beans and occasionally with regard to tomatoes, lettuce, or
the like. A few definite physiological idiosyncrasies against these
vegetables, or certain of them, do actually exist. The attitude of
mind, however, is largely responsible for the discomfort that occurs
after the consumption of most of them. Patients who ought to consume
more starchy substances, or whose bowels need the residual materials
that are contained in these vegetables, for the sake of their effect
upon peristalsis, should be persuaded to take these vegetables, first
in small quantities and then in gradually increasing amounts. Many of
them can thus be brought to a diet at once more nutritious and more
likely to help out intestinal function. Their objection to them is
usually but a fancy.
Genuine Food Idiosyncrasies.--There are certain genuine idiosyncrasies
with a physiological basis which prevent the taking of certain kinds
of food, or cause disturbance if they are taken, but these are rare.
Their presence should never be considered as demonstrated by
subjective signs alone for these are eminently fallacious. In certain
cases, however, so rare as to be almost always curiosities in medical
practice, there are definite objective symptoms of the idiosyncrasy.
These consist of urticarial rashes, tendencies to vomiting, or
diarrhea, or both. Sometimes these result from the most bland and
nutritious of foods. I have notes of the cases of two children--whose
father could not eat eggs without vomiting--and to whom fresh eggs fed
at the age of two and three years, always produced this same effect.
Even small portions of egg would cause it. It mattered not how the egg
was prepared, nor even whether it was carefully concealed in custard
or in cake provided there was a certain amount of it, the food eaten
with it would be vomited. There are many such idiosyncrasies for shell
fish, cheese, and such fruits as strawberries, pineapples,
pomegranates and the like, but they are demonstrated by objective
signs. But by far the greater number of food dislikes are entirely
{246} subjective and the subjective feelings can probably always be
overcome by habit and training.
Food Dislikes.--_Milk_.--Nothing makes more clear the absolute
dominion of the mind over the stomach than the likes and dislikes of
people for various kinds of milk. Most Americans can take cow's milk
with good relish, though there are a few to whom it is distasteful. In
this country we have not had much experience with the milk of other
animals. Even goat's milk is not commonly used. The very thought of
taking it disturbs many people, and to take it with other food would
almost surely produce disturbance of digestion. I have seen people
while traveling quite upset over the discovery that goat's milk had
been put into their tea or coffee. Mare's milk is commonly used in
some parts of Europe and in many parts of Asia, but it would be quite
impossible to most of our people. Sheep's milk is used in some places.
Ass's milk is commonly used in parts of Asia and may be obtained in
Spain and is said to be less likely to disagree with children in
summer than cow's milk. Most American mothers would rather not hear of
it.
The same thing is true of the milk products. Some people find certain
kinds of cheese quite out of the question though other people relish
them. It requires special training, not of stomach but of mind, to
enable one to eat certain cheese, though once the habit has been
acquired such articles are delicious. It is only in recent years that
some forms of cheese with greenish tints have become popular in
America. To serve them at a dinner a generation ago disgusted many
people. Now a dinner does not seem complete without them.
The beverages of various countries illustrate this same principle. The
wines the Spaniards care for are not palatable to the Italians, and
_vice versa_. Beer, as the result of familiarity, is now drunk
everywhere in Europe, but when it was first introduced into Italy from
Germany, it was considered impossible to understand how anybody could
take it and pretend that its taste was pleasant. The question is said
to have been once asked of one of the Congregations at Rome whether it
was permissible to take beer on fast days. The Cardinals who tasted it
declared that not only did it seem to them permissible but that it was
a mortification to drink it and therefore it was proper Lenten
exercise.
_Eggs_.--Many people have a supposed natural repugnance for eggs which
they are sure indicates that these are not good for them. As a result,
the physician gets all sorts of stories with regard to the supposed
effects of eggs. One person tells you that more than two eggs a day
makes him bilious. Another will tell you that they are too heavy for
him. A third will tell you that they are distinctly constipating. A
fourth will tell you that they produce a tendency to diarrhea. Here,
as with regard to milk, the experience of the tuberculosis sanatoria
has shown that there are but few people who cannot, when properly
persuaded and when eggs are given in various forms, take from four to
six eggs in the day without injury, and even without inconvenience. In
these cases, it is largely a matter of mental attitude towards the
food. In many instances, it will be found that the disinclination
began in some experience in childhood when an egg was not very good,
or when it was served insufficiently cooked, or when, perhaps, eggs
always cooked one way were made a staple of the diet for a
considerable period. There are over one hundred {247} ways of cooking
eggs and this variety of preparation will often make them palatable,
and nearly always digestible.
Over and over again I have seen people who had thought that eggs made
them bilious, and who accordingly had for long refused to eat them,
put in circumstances (from tuberculosis, diabetes, or obesity) where
eggs had to form a considerable portion of the diet. Then there was no
difficulty about eating and digesting eggs. In three cases in my
experience patients with an objection they thought constitutional,
developed glycosuria, and then nearly all their desserts were
custards, and eggs became a standing dish in their daily diet. In
every case not only was there no trouble, but they got to like the
eggs and wondered why they should ever have had any prejudice against
them. Two of the patients were women, the third a man who had not
touched eggs for many years. His wife's comment was: "Eggs always made
him bilious when he did not take them, but now that he is taking them
freely they no longer make him bilious."
Mental Changes and Digestion.--The change that has come over the
public mind with regard to sour milk is a typical illustration of how
much a difference in the mental attitude towards a food product may
mean for its satisfactory consumption by many people. Sour milk,
though many farmers and working people thought it a pleasant acid
beverage, was for long looked upon as a product fit at most to be fed
to the pigs, if, indeed, there might not be question even of the
advisability of this. Only the very poor who craved the nutritious
value there was in it, continued to take it to any extent. Even if the
milk still tasted sweet, but broke when it went into the tea, that was
enough to make it quite impossible for many sensitive stomachs.
_Lactic Acid as a Bactericide_.--Then came Metchnikoff's announcement
that his studies showed sour milk to be an extremely valuable food
material, but much more than that, an important auxiliary for the
lessening of microbic life in the intestines. He seemed to be able to
demonstrate that a great many bacteria, whose products, absorbed from
the intestines, hastened that process of deterioration in the tissues
that we call old age, were inhibited when sour milk or lactic acid
bacteria were present. The general health of the person who took sour
milk was, as a consequence, much better. Not only this, but processes
of deterioration being lessened, prolonged life and even old age could
be promised to those who drank sour milk in sufficient quantities.
Metchnikoff had been brought to the study of this question by what he
had seen on the Steppes of Russia. Among the nomad tribes a principal
part of whose diet consists of soured mare's milk, he found a large
proportion of very old people. In looking for the reason for this
disproportionate longevity, he came to the conclusion that the sour
milk had something to do with it. Then laboratory observations and
experiments as to the influence of the bacillus, that causes the
souring of the milk, on the growth of other bacteria, and especially
such bacteria as are usually found in the human digestive tract,
seemed to show that the lactic bacteria had a strong inhibitory effect
on nearly all the pathologic flora of the intestines.
As the result of these studies, all the world is now quite willing to
take its share of sour milk. We no longer hear the complaint that
uncomfortable feelings in the digestive tract are the result of taking
milk that was a little sour.
{248}
Since this doctrine of Metchnikoff's has come to be popularly known,
fewer patients have insisted that they could not take milk in such
quantities as the physician thought desirable for them. Before that, a
persuasion with regard to the ease with which milk becomes
contaminated with microbes, and the dread that it might thus be a
source of disease, or at least of disturbance of digestion, made it
very difficult of digestion for many people. Now that they have a good
authority who insists that, even if it should become somewhat soured
in the ordinary way, this, far from making it a pathological article
of diet, rather adds to its value from a therapeutic standpoint, has
changed the attitude of mind of these people.
We need a similar feeling with regard to eggs in order that they may
be eaten by many people who now refuse them because they fear the
possible evil results of taking even a slightly tainted egg. Our
recent pure food investigations have shown that the bakers in our
large cities have been for many years using canned eggs, and that
these would be quite impossible of consumption except disguised as
they are in the midst of baker's products. Sometimes these eggs have
been kept for several months before being canned. All the cold storage
eggs that cannot be disposed of otherwise are thus treated. In spite
of the common use of these canned eggs by a large proportion of the
city population no serious results have come from them. The change
that comes over eggs in time does not apparently spoil their nutritive
quality, but only disturbs their taste. The main element in the change
is the production of hydrogen sulphide. This gas has a very unpleasing
odor, but its presence is not of pathological significance. This gas
is a common ingredient in those mineral waters that are known as
sulphur waters, and that have a reputation for curing many forms of
digestive disturbance, especially chronic cases of nervous
indigestion. What is true of sour milk, then, would seem to be true of
eggs that have been, to some degree, spoiled, and at least no serious
results may be expected from them. If serious results were to be
expected, we should have had many evil reports of them in recent
years. Whether considerations of this kind will help patients, who
need to get over qualminess with regard to eggs, because they are
always suspicious lest they should not be fresh, will depend a good
deal on the suggestive value of such information as presented by the
physician.
_Another Organic Acid_.--Sauerkraut has shared the fate of sour milk,
and because of its acid bacteria has been accepted by Metchnikoff as
an ally. Yet sauerkraut used to be thought quite out of the question
for invalids, especially those suffering from digestive disturbances.
I recall the case of an old German shoemaker who had lived very much
on sauerkraut when he was a young man and then, having made money in
the manufacture of shoes, had not had much of it for thirty years,
pleading with me, when he was old and it was rather hard to get
anything to stay on his stomach, that he should be allowed to have
sauerkraut. On the principle that what a man craves is usually what
does him good, I allowed it. The physician with whom I was in
consultation was perfectly sure there would be trouble, and the family
were confident that his physicians evidently had given up all hope and
were quite ready to yield to his caprices and let him take anything
that he cared for. He not only took the sauerkraut without any
trouble, though I must confess to some misgivings myself (for I am of
those who unfortunately do not care for it and, therefore, {249} was
prejudiced), but after having eaten a large plateful of sauerkraut
twice a day for several days, he began to crave other things that
would not stay down before, retained them well, digested them without
difficulty, and got over that attack of indigestion and lived for
several years afterwards. His own mental attitude was a better index
than our supposed knowledge, though science has now come to confirm
his state of mind.
_Bacon and a Change in Suggestion_,--Another food material with regard
to which there has been a complete change of view in recent years, is
bacon and hog products generally. Pork in all forms used to be
considered quite indigestible, and was one of the first things that
people suffering from indigestion--or the fear of it--eliminated from
their diet. Now we know how valuable a food product it is, especially
for those inclined to suffer from constipation, or who are under
weight. Many people still look surprised when advised to eat it
regularly. Here we have a typical example of the change in the mental
attitude toward a particular article of food bringing about a
corresponding difference as regards not only the appetite for it, but
also its digestibility. Many persons, who used to have no appetite for
breakfast, now find that after eating a crisp piece or two of bacon,
they develop an appetite for other foods. Bacon has become a fetish
for some people and is considered a help, not a detriment to
digestion.
I recall a case in which I had very nearly the same experience with
bacon as I related with regard to sauerkraut. The patient was an
elderly woman, probably nearly ninety years of age, who, because of a
crippling deformity, had not been able to get outside of the house for
many years. She sat in a wheel chair, transported herself from one end
of an apartment to another, spent most of her time by the window, but
was very helpful in many little things about the house and occupied
her hands with knitting and sewing. In spite of her condition, she was
cheerful, pleasant, happy, and all her life had had a good digestion,
her only trouble being a tendency to asthma as she grew old. I came
back to the city after a summer vacation to find that she was not
expected to live because nothing would stay on her stomach. She was
sinking, and the end seemed not far off. I was asked to see her more
because I had been her regular physician for some years, and it was
thought that it would console her to see me than with any real hope of
betterment. It had been extremely hot weather and this seemed to be an
unfortunate circumstance. At my visit, I asked her if there was
anything that she cared for. She shook her head and yet there seemed a
hesitancy. I urged her to tell me if there was anything that she
wanted, but only after considerable urging did she venture to say that
there was something, only that she knew that she could not have it.
Putting her thumb on the top of her little finger, she said, "Oh, I
would like so much to have just a teenie-weenie bit of bacon." I said
that she should certainly have it. Then taking courage, she asked if
she could not have a little cabbage with it. I said, "Certainly." Her
friends thought that it was just a yielding to one of the last wishes
of an invalid with the idea that nothing could much harm her, since
she was so near the end. She had eaten cabbage and bacon all her life;
she ate it again with a relish, and in spite of the heat kept it down
and digested it well. She had bacon and cabbage next day, and for
several days; she gradually got strong and lived several more years of
her happy contented life.
{250}
CHAPTER II
INDIGESTION AND UNFAVORABLE STATES OF MIND
Indigestion is the characteristic disease of our time. There are few
men or women over thirty who have not suffered from it. The working
classes are spared the most, but with the frequent suggestions in the
newspapers and the introspection which has become so common,
indigestion is often complained of even among them. Sedentary
occupations, involving mental work and little physical effort, seem
especially to predispose to some form of indigestion. Few of those who
live what is called the intellectual life escape suffering from some
of its symptoms. Not infrequently men have been hale and hearty
specimens of muscular manhood when they took up some profession which
compels them to be indoors, yet before long, they begin to complain of
discomfort after eating, of tendencies to constipation, of headaches,
of depression, of incapacity for mental effort after meals, and all
these symptoms are attributed to the almost universal disease,
indigestion.
It is possible for the general attitude of mind to have a great effect
on digestive processes, and the symptom-complex which is called
indigestion, or dyspepsia, is probably much more dependent on the mind
than on any other factor. In many cases it is primarily due to
over-concentration of attention on digestion. In others it is due to
over-occupation with business, worry, or serious thought at times when
the digestive processes need all the energy. In many cases so-called
dyspepsia is due to an unfavorable state of mind toward digestive
processes in general, because of unfavorable auto-suggestion.
Normally, stomachic sensations reach our consciousness only under
special circumstances. When, however, much attention is paid to them,
even the slight sensations that occur with normal digestion may rise
above the threshold of consciousness and become subjects of
solicitude. If they do so, then the increased attention likely to be
paid to them surely interferes with function and changes what may be
merely physiological into pathological processes.
Disease Suggestions.--An unfortunate state of the public mind with
regard to indigestion in general has been cultivated by many
publications on the subject. People dread its occurrence, and fear
that the first sign of discomfort in their gastric region is a signal
of the beginning of a progressive affection. They fear the worst, and
the consequence is a reaction quite out of proportion to the gravity
of the ailment. So much has been said particularly of mistakes in diet
that just as soon as they feel, or often rather think they feel, the
first symptom of beginning dyspepsia they begin to study how to modify
their diet so as to prevent its progress. They begin to eliminate
various supposedly indigestible foods. Usually among the first things
that are greatly reduced in quantity, or are entirely eliminated, are
the fats and certain of the starchy vegetables. Because of expressions
heard and read as to its harmfulness, the fearful ones also are
usually timorous about taking fluid at meal times. As this is about
the only time when they are likely to take fluid, unless it be summer,
they soon suffer for lack of it. Eating only food that {251} leaves
little residue and taking insufficient fluid leads to constipation.
This reacts still further to disturb digestion, and to interfere with
appetite.
This leads to further reduction in the amount and variety of food,
with the consequence that insufficient nutrition to supply energy for
bodily needs is taken. The digestive system gives up to the body as
much as it possibly can, not only of the food materials to be
consumed, but of its own substance. Thus it weakens its own vitality,
with a lessening of appetite and of digestive power. Hence, a vicious
circle of change is instituted, the consequences of which are easy to
see. After a time the patient is taking only the blandest foods,
constipation has become an important element in the case, and the mind
is constantly occupied with solicitude over the digestion and the
choice of materials at meals.
Contrary Suggestion and Digestion.--Hudson, in "The Law of Mental
Medicine," insisted on the necessity for not suggesting to children
the possibility of indigestion of various substances, for that is
almost sure to disturb digestive functions. Children sometimes hear
the remark that father or mother cannot take a certain article of food
because it disagrees with them. The imitative faculty of the child is
sure to be aroused, with the consequence that this particular food is
not eaten with relish nor given a fair show for digestion, and will be
the source of some stomach disturbance. Not infrequently substances
thus spoken of are among those that are especially likely to do
children good, such as milk or eggs, or occasionally butter. The harm
done by the remark may, therefore, even be serious, for these foods
should constitute a large proportion of the child's diet. Indeed, an
excellent prophylactic in the matter of indigestion is to prevent as
far as possible all conversation at table about the indigestibility of
food. Unfortunately, this has, in late years particularly, become a
favorite subject of table conversation.
Transferred Feelings.--Professor Cohnheim called attention to the fact
that many uncomfortable feelings are likely to be mistranslated
because they are referred to organs with which there is nothing wrong.
Whenever this function is hampered in any way, there are many
uncomfortable feelings associated with the digestion of food. The
custom has been to refer the origin of all these to the stomach.
Cohnheim thinks that it is much more likely that they really originate
in the intestines, though the rule has been to take the patient's
feelings as an indication and to treat the stomach. It is not an
unreasonable thing for patients to be deceived as to the exact
location of discomfort. Even in so acute a process as toothache it is
possible to mistake the particular tooth that is giving trouble, and,
as dentists know, a perfectly quiescent tooth is sometimes blamed for
pain that is coming from another. Fillings have been removed, teeth
have been treated, good teeth have been extracted, because patients
insisted on the significance of their feelings in such cases. The
stomach must not always be blamed. Sometimes the only source of
supposed gastric discomfort is the constipation present which is
usually easy to relieve.
_Gastric Reflexes_.--While the mind may serve to disturb digestion and
produce gastric discomfort by over-attention, there are many reflexes
that center in the digestive tract, the origin of which may be in
distant organs. Fright often produces a sensation as of cold at the
pit of the stomach. Looking down from a height has the same effect in
some persons. Discordant noises {252} have the same effect on people
of sensitive hearing and certain reactions to touch may be similarly
reflected. There are a number of affections which produce
uncomfortable reflex sensations in the gastric region. This is the
hypochondrium of the olden time. Whenever feelings were complained of,
for which there was no actual basis in the hypochondriac region, it
came to be spoken of as hypochondriasis, a word that has an innuendo
of imaginativeness about it. Dr. Head's studies with regard to the
transfer of sensations from one portion of the body to the other, show
us that there is a good physical reason in reflexes for many of these
complaints. An explanation of this to patients will often relieve
their minds greatly and make their discomfort seem much less serious.
Dr. Head said:
With orchitis or prostatitis, we also occasionally find that the
patient complains of a pain at the epigastrium, representing the
stomach area. This is put down to hypochondriasis and if it occurs
in a woman as a consequence of ovaritis, she is said to be
hysterical. But this phenomena is no more "hysterical," whatever
that may mean, than is the reference of the pain and the tenderness
of an aching tooth to the back of the head or the shoulder.
[Transfers which have been observed actually to take place.]
This is the phenomenon I have been accustomed to call
"generalization" of visceral pain and tenderness, and is of such
common occurrence as to form a very important factor in the clinical
picture of many diseases.
The order in which generalization takes place, leads one to speak of
the relative "specific resistance" of the centers for the sensory
impulses from various organs. No very definite rule can be laid down
to govern every case, but each case must be considered on its
merits. However, the area which appears most easily on a woman, as a
secondary affection, is the tenth dorsal; then, perhaps the sixth
dorsal, or inframammary, and then the various gastric areas,
beginning first with the ensiform or seventh dorsal. In a man the
tenth dorsal appears rather less readily while the ensiform appears
with great ease.
Affections of other organs within the abdomen may produce like
reflexes. A chronic appendicitis, for instance, will often be
reflected in the stomach area. So will the presence of gallstones, or
of disturbances of the biliary mucosa. Loose kidney often produces
stomach reflexes. Any disturbance of the intestinal function will
produce gastric irritation and inhibition of digestion. Most of the
other primary conditions are more serious. Often the patient is aware
of their existence, and it is a relief to him to find that the stomach
symptoms are not the index of further pathological development, but
only reflex conditions. This of itself does much to make the condition
more bearable.
Patients who are suffering from symptoms of indigestion often have
areas of their skin surface that are at least very sensitive, if not
actually tender. They feel the pressure of their clothing over a
particular portion of the body, usually on the left side of the
abdomen somewhat above, though at times also below the umbilicus.
Though not painful, as a rule, it is decidedly uncomfortable and
produces a constant desire to loosen the clothing, or lift it from the
part. Mere loosening, it is soon found, does no good, because the
clothing continues to touch the skin and it is not the constriction or
pressure but the contact that produces the discomfort. Sometimes there
is a distinct lesion of the stomach. This cutaneous hyperasthesia may,
indeed, rise to the height of extreme tenderness in cases of gastric
ulcer, or the like. But there is no {253} doubt that a certain amount
of this sensation is present with all functional disturbances of the
stomach and that the reflex sensitiveness of superficial nerves is
only what might be expected from what we now know of this subject.
_Discomfort and Digestion_.--Just as certain food materials disagree
because of the state of mind, so certain feelings in the gastric
region, even in the skin surface, sometimes disturb digestion and lead
to changes of the diet unwarranted by the condition. Patients conclude
that, if the skin is so tender, then the underlying organs, the
disturbance of which causes this tenderness, must be in a serious
condition. For these patients the explanation of the present state of
our knowledge as to reflex disturbance of sensory nerves will be of
therapeutic value. They must be taught that pain is reflected from one
nerve branch to another, and is not communicated by continuity of
tissue, or by sympathetic affection from the stomach mucous membrane
through the stomach wall, and then from the abdominal wall to the skin
surface. This knowledge will prove reassuring.
Division of Energy.--After this mental occupation with digestion
itself, which by consuming nervous energy lessens the amount available
for digestive purposes, probably the most common factor in the
production of indigestion is the concentration of mind on serious
subjects, while digestion is proceeding. An old English maxim is that
some people have not enough brains to run their liver and their
business. The liver in old-time pathology was considered the most
important of the abdominal organs and was taken by metathesis for them
all. Most of us have only a limited amount of vital energy and,
usually, we can accomplish only one thing well at a time. If we try to
do intellectual work while digestion is going on, both the
intellectual work and the digestion suffer. If we persist in
attempting to do both, we will surely disturb the digestive organs and
we may bring about grave neurotic disturbances in the central nervous
system. We may be able for a time to accomplish the two things at the
same time, but it will not be long before evil results will be seen.
Nervous, high-strung people should be reminded of Lincoln's anecdote
of the little steamboat on the Mississippi which had not steam enough
to blow its whistle and run its paddle wheels at the same time, so
that whenever the engineer wanted to blow the whistle he stopped the
boat.
Indeed, much of the indigestion that we see is due to this dissipation
of energy through the attempt to do two things at the same time. Those
who live the intellectual life are the most frequent sufferers.
Worries and anxieties that are allowed to trouble the mind during
digestion time are sure to disturb digestion eventually because they
use up energy that is needed for physical purposes.
A change of environment that takes us away from the ordinary cares of
life, is often sufficient to make all the difference between ease of
digestion and extremely uncomfortable dyspepsia. By worry the mind
apparently becomes short-circuited on itself and uses up a large
amount of the available energy in nervous impulses that do not find
their way outside the central nervous system at all, but are used in
disturbing associated nerve cells. Just as soon as a change of scene
and occupation calls for a different set of thoughts and other
feelings, energy is released for work outside the central nervous
system itself, digestion begins to improve, and in a comparatively
short time what seemed to be a serious gastric disturbance, disappears
almost completely.
{254}
_Lack of Sleep Repair_.--In my own experience one of the most
characteristic stigmata of these cases of indigestion which are due to
exhaustion through other channels of vital energy, is that they feel
much better in the evening than in the morning. They are, therefore,
tempted to stay up late and so do not get the necessary rest. Their
excuse for late hours is that they need recreation. To that excuse I
have no objection. They do need more recreation; they need more hours
during which their minds are absolutely free from business cares; but
these hours must not be taken from their sleep, for they need rest
even more than recreation.
_Worries and Irritations During Meals_.--The presence of worries or
irritation during meals or shortly after, as well as unfavorable
states of mind towards digestion itself, and occupation of mind with
serious affairs during digestion, are likely to be sources of serious
disturbance of digestion. A fright, a fit of anger, nagging,
irritation, or any disturbing emotions, may hamper digestion. An
experiment that is sometimes performed in the physiological laboratory
on the cat nicely illustrates this. If the laboratory cat is fed some
dainty that it likes, mixed with bismuth in order that its stomach and
intestines may be made opaque to the x-rays, and then be examined by
means of the fluoroscope, the peristaltic processes of digestion by
which food is mixed in the stomach, passed out into the intestines,
and by which intestinal digestion is stimulated, may be seen to go on
very interestingly. If, now, the cat is made to arch its back, and
manifest the usual signs of extreme irritation, the process of
digestion is interrupted, and will not be resumed till some time after
the cat quiets down. The lesson is obvious.
CHAPTER III
PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS
If discouragement and solicitude make a healthy stomach digest
imperfectly, the same mental factors will play an even more serious
role with a diseased stomach. Certainly without the mind's aid, there
can be little hope of such a reactive vital resistance as will enable
the organ to recover from the organic ailment.
So many cases of indigestion are due to mental persuasion alone, that
after a time there is danger that the physician may be over-confident
in his diagnosis, and may occasionally overlook serious organic
lesions. Before attempting psychotherapy in these cases, the physician
must assure himself that no organic lesion is present. This is
particularly true for cancer in the middle-aged and ulcer in young
women. At times these lesions are latent except for certain vague
digestive symptoms. After careful consideration it is generally
possible to make a definite decision, and then the indications are
clear. Even when an organic lesion is present, a modification of the
mental attitude will often be of great service to the patient.
Suggestion will even make a cancer patient gain in weight, though one
must be careful of that very fact because the apparent improvement may
occasion delay until the case becomes inoperable.
Once the presence of these serious organic lesions of the stomach can
be {255} excluded, the bringing of influence to bear on the patient's
mind for the improvement of his digestion is indicated. It is true
that there are certain reflex disturbances of the digestive tract
consequent upon affections of other abdominal organs. Chronic lesions
of the appendix may produce stomach symptoms as will also pathological
conditions of the biliary tract. A floating kidney, various affections
of the pelvic organs, especially in women, and of the urinary organs
in men are sometimes said to produce seriously depressing effects upon
the stomach. Where this occurs, the first indications undoubtedly are
to put the patient into as good condition as possible before making
any decision. Where a lesion of the stomach itself exists suggestions
with regard to the increase of diet may do harm. They will not do harm
in the reflex conditions, and so patients can be brought into better
physical condition. As a consequence of this, their symptoms in other
organs will often disappear. In case the symptoms do not disappear the
patients are in better condition to stand and react from operative
intervention.
Before concluding as to the character of the stomach symptoms we must
make sure that other important organs are not affected. Most cases of
tuberculosis begin with stomach symptoms, which often make their
appearance before there is cough or any definite localizing symptom of
the disease. Often there is only a disturbance of pulse, and perhaps a
slightly increased range of temperature. If the patient has been
exposed to tuberculosis, a careful investigation of the lungs should
be made. Any disturbance of the liver or pancreas (especially cancer)
will almost surely give rise to stomach symptoms. Latent cancer in any
part of the body, however, will, by its depressing toxemia, produce
loss of appetite, consequent loss of weight, and a number of symptoms
that are sure to be referred to the stomach. I have seen cancer of the
prostate, without disturbing urination, produce such symptoms for
months before it was recognized. I have seen cancer of the rectum in a
comparatively young woman treated as piles, without an examination,
the development of the piles being attributed to the gastro-intestinal
symptoms which were consequent upon the presence of the cancer.
MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION
It is often said that this teaching as to the effect of the mind on
digestion and its eminent usefulness for the treatment of dyspeptic
conditions, is due to the attention that has been attracted to this
subject as a consequence of the prominence of Eddyism, New Thought,
Mental Healing, and the like. There are absolutely no good grounds for
any such assertion. Here in America, more than twenty-five years ago,
before there was any question of the modern mental healing movements,
our greatest medical clinician, Dr. Austin Flint, expressed himself
very emphatically with regard to mental influence over digestion, and
to solicitude of mind as one of the most frequent etiological factors
in dyspepsia.
Dr. Flint was thoroughly scientific in his medical observations, was
no seeker after notoriety, and he was reading his paper before the
older physicians of the period, and all of those who took part in that
first meeting of the New York Medical Association strove to make their
papers of scientific value. His words, then, must carry great weight:
{256}
Dyspepsia formerly prevailed chiefly among those who adopted, to a
greater or less extent, the foregoing maxims [the finicky rules of
dyspeptics which he deprecates and corrects as quoted later in this
chapter]. It was comparatively rare among those who did not live in
accordance with dietetic rules. The affection is much less prevalent
now than heretofore, because these maxims are much less in vogue.
The dyspeptics of the present day are chiefly those who undertake to
exemplify more or less of these maxims. It seems to me, therefore, a
fair inference, that dyspepsia may result from an attempt to
regulate diet by rules which have for their object the prevention of
the affection which they actually produce. It is to be added that an
important causative element involved in the practical adoption of
these rules is the attention thereby given to digestion. It is by
introspection and constant watchfulness of the functions of the
stomach, that the mind exerts a direct influence in the causation of
this affection.
Dietetic Rules of a Former Day.--In order to make definite just what
were the views of the olden times which he deprecates, he stated them
briefly and forcibly:
The views generally entertained, at the time to which I have
referred, largely by physicians and almost universally by
non-medical sanitarians, may be summed up in a few maxims as
follows: Eat only at stated periods, twice or thrice daily, and
never between meals, no matter how great may be the desire for food.
Never eat late in the evening or shortly before bedtime. In the
choice of articles of diet, carefully select those which reason and
personal experience have shown to be best digested; and never yield
to the weakness of eating any article of food simply because it is
acceptable to the palate. In order to avoid the temptation of
overeating, let the articles of food be coarse rather than
attractive, and eschew all the devices of the cuisine. Always leave
the table hungry. Study personal idiosyncrasies, and never indulge
in kinds of food which, although wholesome for most persons, are
injurious to a few who are peculiarly organized. With reference to
this last maxim, bear in mind that "what is one man's meat is
another man's poison." In order to secure, as effectually as
possible, a proper restriction in the quantity of food, it was
recommended by some physicians and to some extent practiced, that
every article be carefully weighed at meal times, and that a certain
quantity by weight be never exceeded. Vegetarianism or Grahamism was
advocated and practiced by many. Total abstinence from drink was
considered by a few as a good sanitary measure, compelling the body
to derive the needed fluids exclusively from fruits, vegetables, and
other solid articles of diet. Restriction in the amount of drink, as
far as practicable with regard to the power of endurance, was very
generally deemed important, so as not to dilute the gastric juice.
When to his question, "Do you regulate your diet," the patient
answered promptly and often emphatically in the affirmative, Dr. Flint
insisted always: "This is a good reason for your having dyspepsia; I
never knew a dyspeptic get well who undertook to regulate his diet."
When the patient asks then, "How am I to be guided," the reply is,
"Not by theoretical views of alimentation and indigestion, no matter
how much they appear to be in accord with physiological and
pathological doctrines, but by the appetite, the palate and common
sense." He then goes on to answer certain other objections that
patients are wont to urge, and says:
But the patient will be likely to say, "Am I not to be guided by my
own experience and avoid articles of food which I have found to
disagree with my digestion?" The answer is, that personal experience
in dietetics is extremely fallacious. An article of diet which may
cause inconvenience of indigestion to-day may be followed by a sense
of comfort and will be readily digested to-morrow. A variety of
circumstances may render the digestion of any article of food taken
at a {257} particular meal labored or imperfect. As a rule articles
which agree with most persons do not disagree with any, except from
casual or accidental circumstances, and from the expectation, in the
mind of the patient, that they will disagree. Without denying that
there are dietetic idiosyncrasies, they are vastly fewer than is
generally supposed; and, in general, it is fair to regard supposed
idiosyncrasies as purely fanciful. Patients not infrequently cherish
supposed idiosyncrasies with gratification. The idea is gratifying
to egotism, as evidence that Providence has distinguished them from
the common herd by certain peculiarities of constitution.
Dietetic Instructions.--Finally Dr. Flint has a series of instructions
for those suffering from indigestion: