Do not adopt the rule of eating only at stated periods, twice or

thrice daily. Be governed in this respect by appetite; and eat

whenever there is a desire for food. Eat in the evenings or at

bedtime, if food be desired. _Insomnia is often attributable to

hunger_ [italics ours]. In the choice of articles of diet, be

distrustful of past personal experience, and consider it to be a

trustworthy rule that those articles will be most likely to be

digested without inconvenience which are most acceptable to the

palate. As far as practicable, let the articles of diet be made

acceptable by good cooking. As a rule, the better articles of food

are cooked, the greater the comfort during digestion. Never leave

the table with an unsatisfied appetite. Be in no haste to suppose

that you are separated from the rest of mankind by dietetic

idiosyncrasies, and be distrustful of the dogma that another man's

meat is a poison to you. Do not undertake to estimate the amount of

food which you take. In this respect different persons differ very

widely, and there is no fixed standard of quantity, which is not to

be exceeded. Take animal and vegetable articles of diet in relative

proportions as indicated by instinct. In the quantity of drink,

follow nature's indication; namely, thirst. Experience shows

abundantly that, with a view of comfortable digestion, there need be

no restriction in the ingestion of liquids.

Removal of Solicitude as a Remedial Measure.--Many dyspeptics have no

subject that they occupy themselves with more seriously than their

digestion, and they thus divert blood needed for digestive purposes as

well as nervous energy that would help in it from the stomach to the

brain, in order to exercise surveillance over the process. As has been

well said, "Probably much more than half of the indigestion is really

above the neck." This does not mean that there are not cases that need

definite stomachic treatment, or even that patients who have succeeded

in functionally disturbing their digestion by thinking over much about

it, will not need gastric remedies.

The explanation of the many fads and remedies that _cure_ indigestion,

real or supposed, is exactly this tendency of the suggestive influence

of such remedial measures to lessen the patient's solicitude about

digestion. Any change in diet that carries with it the persuasion that

for any reason digestion ought to be better, will, because of this,

make digestion better. Any habit of taking warm or cold water before

meals, or of chewing in a particular way, or of taking a particular

kind of food different from what is usually taken--exclusively cereal,

uncooked, largely fruit, vegetarian, etc.--will lift the concentration

of attention on the digestive process, and so give the stomach a

chance to do its work without interference from the brain.

Du Bois has quoted some striking testimony in this matter from Baras,

who wrote on the "Gastralgias and Nervous Affections of the Stomach

and the Intestines" as early as 1820. Baras had himself been a

sufferer from {258} gastric discomfort, fullness after eating,

eructations of gas, constipation, and general depression. He consulted

most of the distinguished medical practitioners of his time. With one

exception they were convinced that he was a sufferer from chronic

gastro-enteritis. They added more and more to his concern about his

stomach, and furnished him with numerous sources of autosuggestion. In

spite of all that they did for him, his condition grew worse and

worse, he lost in weight, and was sure that his case was hopeless. He

was cured in a single day. His daughter was attacked with consumption,

and "in the moment my attention," says Baras, "was centered entirely

upon my child, I thought no more of myself, and I was cured."

Brain Workers and Indigestion.--Perhaps the best proof of how

necessary it is that people should not continue to occupy their

intellect seriously during the time when digestion is going on, is to

be found in the frequency with which complaints of indigestion occur

in literary folk. The complaints are heard most from literary folk

because they are more likely to tell their stories. They have their

work, and thoughts of it, always with them. So there is a constant

call for nervous and mental activity and for much blood in the brain

tissues. This subtracts from the nervous energy necessary for

digestion, and makes it impossible to conduct it with that perfection

which comes naturally to people who banish all other thoughts and keep

their minds free for the pleasures of the table and social intercourse

at meal time.

Nervous indigestion is so common among literary folk, teachers and

scientific workers, that various causes have been suggested for it.

Dr. George Gould, in his "Biographic Clinics," calls attention to it

and suggests that the cause is probably the need of properly fitted

spectacles. In our own time, when we are much more careful in the

matter of eyeglasses, and when most writers and professors wear

scientifically adapted glasses, the complaints still continue. The

reason is evidently something associated with the almost continuous

work that they do. Such people, too, are much more self-conscious than

others. They think more about their digestion and what they eat. They

often think that they differ from other people and have special

idiosyncrasies for food. These thoughts are sure to culminate in

nervous indigestion.

Food Faddists.--Literary folk and people who live the intellectual

life are very prone to take up with fads of various kinds and find

surcease from their sorrows in all sorts of out of the way dietaries,

modes of eating, food limitations and specializations. They constitute

a majority of the food faddists. Some of them--sure that they should

not eat meat--are strenuous vegetarians. Others confine themselves

entirely to food the life of which has not been completely destroyed

by cooking. They are fruit faddists, nut faddists, milk-product

faddists, and the like. Some of them try to persuade the world that it

eats too much; others that it eats too frequently. Some of them take

but a single real meal a day and have apologies for the other meals.

All want to lead people to their particular mode of life, as if all

the world had been wrong until they came to set it right. Some want

the rest of the world to chew seventy-times-seven before they swallow

and to adopt other exaggerations of attention to eating that are quite

contrary to instinct, the most precious guide that we have in the

matter of food choice and food consumption.

These intellectuals are always improved by their fads, no matter what

they {259} may be. The reason is apparent. Their original digestive

disturbance was due to over-occupation with intellectual work. Then

they began to worry about their digestion and feared that nearly

everything they ate would disagree with them. This fear and solicitude

still further interfered with digestion. Next they acquired the new

fad. They became persuaded that they could eat certain things in

certain ways. They no longer disturb their digestion by anxiety about

it, but, on the contrary, help it by favorable suggestion. Now under

the new regime everything will surely go on well. Besides, they

usually learn the lesson of not doing intellectual work close to their

meals, and of spacing their work better. They learn to do a daily

stint of work and no more. One of the fads that goes with most food

fashions is abundant outdoor air. This always does good. Between the

favorable mental influence, the lessened work, especially just after

meals, and the increased outdoor air they get better and then they

attribute it all to their special fad about food. The _"cure"_ is due

to psychotherapy and common sense, and not in any way to the special

fad.

Worry.--Worry of any kind will have the same effect as the

over-attention of the literary man or teacher to his work. Anyone who

brings his business home with him is likely to suffer and, unless he

has a superabundant supply of energy, will impair his digestive

function as a consequence of attempting to do business after dinner,

perhaps also stealing some of it in before and during breakfast.

PREVENTION AND CORRECTION

The important rule with regard to the mental attitude of the patient

toward uncomfortable feelings due to digestion must be, first to

correct all other possible sources of the trouble, and only after

these have been proved not to be factors in the case, should there be

any question of modification of diet. This is just the opposite rule

from that which obtains, and by which patients begin to meddle with

their diet at the slightest symptom, or supposed symptom, of

indigestion. My custom is to tell patients at once that there is

probably something else besides their diet at fault. It is not that

they eat too much, nor too great a variety, but that perhaps they eat

too rapidly. Without reducing their diet, and above all without

eliminating supposedly indigestible things from it, there should be

formed a habit of eating more slowly. This will usually result in the

reduction of the quantity eaten, but the variety of food should be the

same, and the patient should not be permitted to limit his diet to a

few supposedly bland, unirritating materials. In that event,

constipation will assert itself, particularly if there is limitation

of the amount of fluid taken.

Longevity of Dyspeptics.--There is one consolation that may be given

to nervous dyspeptics, though in the midst of their worst symptoms

they may not be sure whether it is a genuine consolation or not. It

has been noted that many of those who live to extreme age tell the

story of having suffered from nervous dyspepsia in middle-life. Their

solicitude about themselves makes them safe against over-indulgences

of many kinds in food or drink that might prove hurtful to them. Much

of their discomfort is indeed due to the fact that they do not eat

quite enough. If they succeed in avoiding the {260} pitfalls of the

infectious diseases, and especially tuberculosis during their earlier

years, and most of them are likely to because of the great care they

take of themselves, they often live to old age. Certainly of two men,

one of whom eats very heartily and the other very sparingly, the

latter is much the more likely to attain old age. There are those who

declare that the valetudinarian life, "half dead and alive," which

even Plato satirized nearly 2,500 years ago, ever renews the question

as to whether life is worth living or not. It is particularly

dyspeptics who seriously discuss this question--yet with all their

complaints, they actually do live longer lives.

Pharmaceutic Remedies.--This insistence on the importance of mind in

the treatment of indigestion does not imply that tonic remedies, and

especially such substances as strychnin, which stimulate appetite and

add tone to the muscles of the stomach, should not be used when duly

indicated. They are always helpful. Alone, these remedies give but

temporary relief and after a short time the system becomes accustomed

to them. If prescribed in connection with changes in the patient's

habits, and especially such as divert his attention from his digestive

tract, and from wrong persuasions as to food taking, the good they

accomplish will be lasting. Nervous people usually have an increase of

acidity. They are liable to overdo everything, and even the stomach

overdoes its acid forming function. For this, alkaline remedies such

as rhubarb and soda will do good. But, just as with strychnin, the

benefit is but temporary unless the patient's habits and attitude of

mind are modified so as to eliminate their solicitude as a constantly

disturbing factor.

Circumstantial Suggestions.--There are many changes of habits that are

of great value in the treatment of nervous and allied forms of

indigestion. These changes often make a great difference in the

general health of the patient and thus help to improve digestion.

Besides their influence as alteratives, they are valuable from the

mental influence which they exercise. It requires a definite exertion

of will many times, perhaps, each day to bring about the omission or

performance of certain actions, and this act of the will is

accompanied by the repeated suggestion that this will cause

improvement in the digestion. Many of the cures effected by special

diet. Habits of exercise, health resort regimes and the like, owe

their efficacy to this accompanying repeated suggestion of acts for

the formation of new habits or the breaking of old ones.

Physiological Measures.--There are, of course, certain details with

regard to digestion in which the patient's mental attitude needs to be

changed by instruction rather than persuasion, by knowledge of

physiology rather than by psychology. In the taking of food itself,

chewing is, of course, the most important consideration after its good

preparation by the cook. If patients are told to chew their food

carefully, however, without further directions than this, it will

usually be found that they begin to chew their meat a great deal and

their vegetables scarcely more than before. It is, however, vegetables

that must be chewed particularly. The meat-eating animals bolt their

food. They have only cutting and tearing teeth. Their instinct is

correct, for the saliva has nothing to do with the digestion of meat,

and therefore no chewing is necessary. On the other hand, the

vegetable-eating, and especially the grain-eating animals, chew

carefully. Most of them are ruminants, that is, after a preliminary

thorough chewing of their food, they swallow it, and then {261}

afterwards at their leisure bring it up once more into the mouth and

chew it again.

_Mastication and the Stomach_.--If food is not chewed well, and occurs

in large masses in the stomach, not only is it not dissolved easily,

but the work of passing it out to the intestine is delayed. The reflex

which brings about the opening of the stomach and the ejection of food

into the intestine is best brought about by the liquefaction of the

stomach contents. During the mixing process all the food, as far as

possible, becomes fluid and then is passed on. Large pieces of any

kind are delayed, however, hamper the emptying of the stomach and

interfere with stomach motility. The stomach is only a thin-walled

membranous viscus which finds difficulty in dealing with food in

lumps. It is different from the stomach of the hen, which, having no

teeth, swallows grains of all kinds without chewing, but also by

instinct swallows small stones which, in its thick-walled, muscular

gizzard, are used for grinding up the food.

_Exercise_.--The taking of exercise is an important habit that needs

to be changed in the case of dyspeptics. Many of those who live a

sedentary life, and are much occupied with intellectual or business

matters, are almost sure to take little or no exercise. If earlier in

life they were accustomed to take much, the lack of it leads to

serious disturbances of nutrition. They have formed certain habits as

to the amount of food they eat, and these continue, so that they

consume more heat-making material than they can use. In the process of

dissipating it, there is likely to be much nervous energy wasted,

usually to the discomfort of the patient. This is likely to be

eventually reflected back to the stomach, with disturbance of appetite

and digestion.

We now know that the motor function of the stomach is much more

important than its secretory function. Its main purpose is to mix the

food and pass it on in small quantities, at intervals, to the

intestines. When patients have a sense of uncomfortable fullness in

the gastric region after a hearty meal, or of discomfort after the

taking of food, especially if much liquid is taken with it, they are

prone to attribute these feelings to imperfect secretion not

completing digestion as it should, and permitting fermentation with a

production of gas and consequent stomach distention. The real reason

for their discomfort is not secretory, but motor. It is due to a delay

in passing on the food and to stomach distention because the gastric

muscle is not in good tone.

People who have been used to taking exercises have their muscular

system in good tonic condition. This includes the involuntary muscles,

as well as the voluntary, and if they are neglecting air and exercise,

the whole muscular system becomes flabby. Hence the uncomfortable

sense of distention, because the stomach walls do not contract readily

for the expulsion of food. A second important factor is also

present--the muscles of the abdomen. Ordinarily they support the

abdominal organs without any sense of effort. If by lack of exercise

they have diminished in tone, however, when a hearty meal is eaten,

the abdominal muscles have to support this additional weight since the

stomach itself sags, and the consequence is a feeling of pressure on

the left side of the abdomen about the level of the umbilicus. To

relieve this feeling the tendency of the patient is almost always to

lessen the amount eaten. If he is not distinctly overweight this will

do harm rather than good. Instead he {262} needs to take sufficient

exercise to tone abdominal muscles and reflexly also tone even

involuntary muscles, and with them the gastric muscularis.

_Air_.--Almost more important than exercise is an abundance of fresh

air, and without this muscles soon fail to respond to voluntary or

involuntary impulses. If people do not spend two or three hours in the

air every day, they are likely to develop an over-sensitive condition

in which all nervous sensations are exaggerated. The reason men and

women differ so markedly in their reaction to pains, aches and

discomforts, is mainly that their habits of being out in the air

differ correspondingly. Men are out much and, as a rule, stand

discomfort better. Women are out little and are more sensitive to

pains and aches. The more a man is out, the less is he likely to

notice discomforts and aches that he would otherwise complain about.

_Sleep_.--Another important factor is the amount of sleep. Over and

over again I have found that patients who were beginning to complain

of discomfort, which they associated with the word indigestion, were

taking too little sleep, and as soon as I persuaded them to add an

hour or more to their sleep their gastric symptoms began to improve.

It is easy in our large cities to acquire the habit of shortening the

hours of rest. This is sometimes done so gradually that the individual

scarcely realizes how much he has cut into his sleeping period. Some

people who have to get up at seven or half-past seven in the morning

go to bed about twelve, but really do not get settled for sleep until

nearly one o'clock. Sometimes people read interesting books just

before going to bed, or while in bed, and it is nearly two o'clock

when they get to sleep.

Many people have the habit of reading themselves to sleep. This may be

an excellent way to get rid of bothersome thoughts, provided the

reading selected is not of too absorbing a character, and provided

also as soon as sleepiness comes its call is heeded. Some write

letters late at night. Writing always keeps one awake, though reading

may be helpful for sleep. If this abbreviation of sleep becomes

habitual, the first organs in the body to set up an objection is the

digestive tract. It is one of the hardest worked systems in the body,

having to dispose of its quantum of food three times every day, and if

the organism does not receive due rest, the digestive tract suffers

first. People who get insufficient sleep often have no appetite in the

morning, and suffer from uncomfortable feelings in the gastric region.

What they are too prone to do is to meddle with their diet, and this

practice always does harm.

CHAPTER IV

APPETITE

Two classes of patients come to the physician complaining of lack of

appetite. The first and more important class consists of those who are

eating too little, who are consequently under weight, and who must be

made to eat more. The other class consists of those who eat enough but

complain that they do not relish their food. Careful questioning

usually elicits sufficient information to enable one to decide that

most of these latter are eating too {263} much, or unsuitable food,

and at too frequent intervals. They are usually overweight, and there

is need to reduce the amount they eat. In both of these classes the

physician is tempted to conclude that medicines should form the

principal part of the treatment. We have a number of tonics and

stimulants that undoubtedly initiate a desire for food, or at least so

increase the circulation in the stomach that patients feel much more

inclined to eat than they otherwise would. There are a number of

remedies, also, the so-called anti-fat group, which produce a

disinclination for food.

Power of Mind Over Appetite.--Appetite, whether in deficiency or in

excess, is best regulated through the patient's mind. Patients

frequently state that they cannot eat more than they do, that they

have no inclination for food, and yet, after a little persuasion, they

can be made to increase the amount they have been eating, and then

that can be gradually raised until they are taking what is for them a

normal quantity. There are many things that we swallow without caring

for them. Most medicines we not only do not like, but positively

dislike. We put them down, they accomplish their purpose, and food

will act nearly in the same way. There are few cases where food is

positively rejected. Patients can be persuaded to eat more, and after

a time will be surprised to find that their desire for food increases

with the habit of taking it. On the other hand, patients can be made

to see that they are taking too much food really to enjoy its

consumption. Their appetites are perpetually cloyed, and to them food

has none of the pleasant flavor that exists when it is taken in

moderation.

_The Will to Eat_.--In various parts of this book there is emphasized

the necessity for the exercise of the human will in order to aid in

the accomplishment of even physical functions. The basis of many

nervous symptoms is a lack of sufficient nutrition to steady the

nervous system. Some people not only lack will power, but also

judgment in the matter of eating; they prefer to err on the side of

insufficiency lest they should over-eat. For these people the

important remedial measure is to dictate the amount that they shall

eat, and gradually to increase it until they are eating enough for

their nutritional purposes.

When this advice is given to patients, they are willing to agree that

a gain in weight would be good for them, but they cannot understand

how they can eat more since they are now eating all they can, or

certainly all they care to. Appetite grows by what it feeds on, and

increase in appetite is a function of the habit of eating.

But some patients, after having tried the prescription of eating more,

are still in the same condition, and find that they cannot put on

weight. What is needed in such cases is an inquiry into all the

conditions of the daily life, their habits of eating and the amount of

time that they take for their meals. They are probably eating one good

meal a day, their dinner in the evening--but they confess that the

other meals are not satisfactory. If their habits are rearranged, the

will to eat does the rest. Sometimes they complain of uncomfortable

feelings after eating and this makes them eat less at the next meal.

There are various mental elements that disturb the efficacy of the

will to eat, consequently these patients do not get on. What they need

is emphatic insistence on the necessity for persistent effort in

regular eating day after day, meal after meal, and it is not long

before improvement comes not {264} only in weight, but also in

appetite. I have known patients to gain five or six pounds a week

after having tried weeks in vain to gain a single pound.

_Sitophobia_.--Many people read much of the possibilities of evil in

overeating, and they conclude that a limitation of diet would be

better for them. After a time some of these people of nervous

constitution acquire an actual dread of over-eating and develop what

has been called sitophobia, or dread of food. Before anything can be

done with them, this dread must be removed. The problem is discussed

more fully in the chapter on Weight and Good Feeling, but here it

seems necessary to emphasize that it is often quite impossible by

ordinary medical means to produce an appetite in these patients. Their

mental persuasion with regard to food must first be removed. If it

cannot be removed, improvement is usually out of the question. No

medicines are sufficiently powerful to overcome a fixed unfavorable

idea with regard to food. The same is true as to sleep, or any other

natural function--it comes and must go through the mind.

Disturbance of Mind and Its Influence on Appetite.--The basis of the

psychotherapy of the digestive tract is the fact that appetite is a

function of the state of mind rather than of the state of body. We all

know how easy it is to lose the appetite by emotional disturbance. We

may come into the house after a brisk walk, when we know that dinner

is going to be better than usual, quite ready to anticipate the

pleasure we are to have in eating it and with appetite craving that

dinner shall not be delayed, we find a telegram announcing the death

of a friend or the illness of a relative or some other bad news, and

in an instant our appetite has disappeared. It makes no difference to

us for hours whether we eat or not. What we eat gives us no

satisfaction. It will be taken entirely from a sense of duty and

without pleasure and will digest slowly, even if it does not produce

discomfort.

_Feelings and Appetite_.--There is no need for a serious stomach

condition to develop, to diminish, or eliminate appetite. The sight of

an accident on the street, especially if blood is shed, will entirely

take away the appetite of many persons. Now that suicide beneath the

wheels of subway trains has become a rather frequent way of going out

of life, physicians note that nervous patients who happen to see these

sad affairs have no appetite, not alone for the next meal, but

sometimes for several days. Some people have no appetite at all if

there is a dead body in the house where they live. I have known people

who felt it almost a desecration to eat under such circumstances. Even

much less than this may serve to diminish appetite. An offensive odor

of almost any kind is quite sufficient to take away the appetite of

many people. For some the odor of cooking food, if they have been in

it for some time, is almost sure to cloy any desire for food.

Cooks suffer from loss of appetite for this reason. The sight of a

disagreeable stain on a tablecloth, or of a waiter's thumb in the

soup, or of some unpleasant characteristic of the waiter, may be quite

enough seriously to disturb the appetite of sensitive people.

We know all this very well, and yet we are prone to think of appetite

as something regulated by instinct, and representing the real needs of

the organism in its cravings and the limitations of the necessity of

food by its satisfaction. In our sophisticated modern life instinct

will often fail entirely to fulfill these purposes. Appetite for those

who live much indoors is a question of {265} habit and regulation

rather than of instinct. It has to be voluntary to a large extent, not

only as regards the quality but also the quantity of food. We eat the

things that we care for, but how much of them we shall eat is another

matter. That depends on how we happen to be disposed at the moment,

and whether there is any good reason for eating more or less at the

given time.

Appetizers.--There is a whole group of substances recommended as

appetizers, most of which are effective, but their effect is likely to

be temporary, and to fail particularly in those cases where an

appetite is most needed. Anything that will increase the circulation

in the stomach will usually add to appetite; consequently warm drinks,

alcoholic liquors and spices of various kinds have this effect. In

vigorous people, a dash of cold on any portion of the body, is

followed by a strong reaction of the circulation. Cold drinks,

therefore, will sometimes serve as an appetizer, especially in hot

weather. Almost anything that has a certain peculiarity of taste, and

that is taken with the definite suggestion that it will produce an

appetite, will almost surely have that effect. All sorts of articles

of diet have in various countries acquired a reputation as appetizers.

Fermented mare's milk is effective in central Europe; a glass of

buttermilk in Ireland; some very hot soup with one of the strong

spiced sauces in it in England; and various curious combinations of

fruit and other materials in the shape of what are called cocktails,

in America. Anything that stimulates the stomach a little unusually,

and is accompanied by the idea that it is likely to increase the taste

for food, almost surely adds to appetite.

This question of appetizers is as yet a mystery to us. It is eminently

individual and yet much depends on racial customs, the habits, the

environments and the family training. It is surprising what curious

materials serve to excite the appetite. Caviar, in spite of the

distaste of "the general," is undoubtedly a good appetizer for many

people. Bismarck herring, or kippered herring, acts in the same way.

In the old days men used to take what were called red herrings and

undoubtedly found in the eating of them a renewal of desire for food,

when there had been absence of appetite. There are some people in whom

a little taste of cheese serves the same purpose. Bitter tastes

usually increase appetite. Salt under certain circumstances has a

similar effect. Acid fruits sometimes stimulate a jaded desire for

food. Nearly always the effect of these various appetizers is

increased by the attitude of expectancy. They have the reputation of

being appetizers and so, though often at first somewhat disagreeable,

they eventually prove to be helpful stimulants.

Appetite and Habit.--For those who live an indoor life, and have that

nervous disposition that disturbs instinct, the only safeguard for

nutrition is a definite formula for eating which must be followed

strictly, especially by those who are below the normal in nutrition.

In the chapter on Weight and Good Feeling I discuss the failure of

appetite following a diminution of the amount of food. The stomach may

be described as unselfish, and in times of scarcity it gives up to

other organs more of the nutrition that comes to it than it should. As

a consequence, it is not so well able to fulfill its functions of

digestion and of craving for food, which is part of its function, as

it would otherwise be. It is the people who are eating a proper amount

and have been eating it, whose digestive tracts are in a condition to

crave the proper {266} amount of food. Those whose habits have

unfortunately led them into eating amounts too small, also suffer in

not having the proper desire for food.

Nervous people particularly are likely to lack appetite in the early

morning. Those who are under weight will almost invariably confess

that they take little breakfast. Their reason for so doing is that

they have no appetite. For most of them what is really true is that in

the early hours of the day their will has not yet taken properly hold

of their economies and everything is in a depressed state. These

patients usually confess that they wake feeling not rested but tired,

fearing the day, and wondering now they will be able to get through

it. Only toward the middle of the day do they feel like themselves,

while towards evening they wonder how they could have been so

depressed in the morning. What these people need is the rousing into

activity of their functions. Occasionally, especially in summer, a

cold sponge on rising in a room into which an abundance of air is

admitted will do much for them. Often a walk of even ten minutes

before breakfast will make all the difference between appetite and

lack of it. Above all, however, they should be made to feel that if

they want to eat they can eat--if they want to they can reestablish

the habit of taking breakfast, and then it will be a pleasure instead

of a burden.

_Food and Caprice_.--Those complaining of lack of appetite should

learn not to let caprice rule them in the matter of eating. There are

people who by habit eat too much. What they must do, as pointed out in

the chapter on Obesity, is to unlearn the habit of overeating, and

that is almost as hard to break as the habit of taking stimulants.

Most nervous people undereat, but they must take themselves in hand,

eat three meals a day, and reestablish the habit of taking as much at

these meals as they ought. What each one should consume is eminently

individual, depending altogether on the sort of heat engine that each

one is. Family traits mean much in this. Some must eat much more than

others to keep up their weight and strength, because they are wasteful

heat engines. As a rule, tall, thin people must eat more in proportion

to their weight than shorter individuals of stout build. They expose

more surface for heat dissipation. In this each person must learn for

himself his own necessities. When there is a question of regulating

eating by reason, the rule must be remembered that there is a tendency

in people living indoors to take too little rather than too much.

_Appetite and Food Preparation_.--There are many curious things with

regard to the formation of the habit of eating that show how easily

the appetite or instinct is vitiated. Women, for instance, are nearly

always prone not to eat enough if they have to prepare their own

meals. When a mother and daughter or two sisters live together, they

usually prepare one good meal, but the other two meals are likely to

be picked up any way. The presence of a man in the household makes all

the difference in the world. Meals are prepared regularly for men.

Even for a boy of five to fifteen, meals are regularly prepared, and,

as a rule, the presence of a child makes for regularity in eating.

_Habit of Overeating_.--On the other hand, it is easy to form habits

of eating that go quite beyond appetite and vitiate the desire for

food quite as seriously in the opposite direction. Many stout people

take snacks between meals; women, already too heavy, indulge in the

afternoon tea habit with a surprising amount of substantial food taken

with the tea; many a stout man {267} takes a glass of beer

occasionally and never fails to take something to eat at the same

time, mainly with the idea, as he says to himself, that by taking

something to eat the beer will be less likely to do him harm. Stout

children are likely to form the habit of eating too frequently. When

they come home from school they have a piece of something; before they

go to bed they have a glass of milk, and a piece of cake, and

sometimes are encouraged in these bad habits by their parents. Any

child who is more than ten per cent. above weight, should be kept

strictly to its regular meal times, and should not be allowed to put

on additional weight, for this will be very hard to get off in adult

life. To carry more than ten per cent. of over-weight is a burden, and

not a benefit.

Frequent Eating as an Appetizer.--Thin people should be encouraged to

indulge in some of these between-meal privileges. Very often a thin

person who has been accustomed to take comparatively small amounts at

meal times, will find it easier to gain in weight by indulging in

luncheons between meals than by increasing the amount of each meal.

Large meals on stomachs unaccustomed to them, and somewhat less

vigorous than they ought to be because of lack of nutrition, may be

the cause of considerable discomfort if abundant meals are taken where

small ones have been habitual. In this case, multiple feeding at

shorter intervals will gradually increase tissue strength. After the

patient has come up to normal weight, regular intervals between meals

may be determined and sufficient quantities taken at each meal. Nearly

all thin people sleep better, and are more comfortable if they take

something shortly before going to bed. Most people will eat their

breakfast better after such an indulgence than if fourteen hours

elapse between the evening and the morning meal.

Nervous Loss of Appetite.--Nervous patients often say they have no

appetite, that, even though they eat, their food has no taste. Such

people have often lost their eating instinct to a certain degree. They

eat merely from routine, or because food is placed before them. They

would usually just as soon not eat and they have no instinctive

directions as to quantity. If a number of courses are presented to

them, they eat such as they care for and take a conventional amount of

each kind of food presented, but they have no particular feeling to

guide them in the matter of quantity. There are moods in which these

patients care to eat. There are others in which eating seems a hard

task. If they are in reasonably poor circumstances and have not to

prepare a meal for others they are likely to neglect the preparation

of one for themselves, take almost anything that happens to be at

hand, and then consider that they have eaten.

Instinct and Natural Life.--If one expects the natural guidance of

one's instincts then one must give these instincts a proper

opportunity. Instinct is a part of our animal nature, and unless other

portions of our animal nature are given rather free play, or at least

the opportunities for their natural life, we cannot depend on any

single one of the instincts to be a safe guide. Man was meant to live

much outside. He was meant to take considerable exercise and to have

to get his food by severe exertion. We have changed this. We live

indoors to a great extent in an equable temperature, we very seldom

tire ourselves by exercise, and it is not to be wondered at if we have

not that craving for food that comes to the man who lives a more

animal existence. The {268} Scotch surgeon, Abernethy, once said that

the best possible tonic for the appetite was "to live on a shilling a

day and earn it"--of course, he meant by manual labor. He talked at a

time when the English workmen got but three shillings a day for

fourteen hours of work.

Application of Principles.--What is needed for the mental treatment of

patients with defective appetite, is that they should be made to

realize that appetite is a function of habit, rather than of absolute

natural craving in the conditions in which men and women live at the

present time. The most important physical factor for appetite is not

exercise, as has often been thought, because this, by consuming

material, is naturally supposed to increase the craving for material

to renew the tissue, but air, for it is oxidation processes that

stimulate metabolism and make the call for a fresh supply of

tissue-building material. People without an appetite must be made to

understand that they should spend a considerable portion of the time

between meals in the open air. Sitting in the open air is often even

more effective than exercise under similar conditions, especially in

weak people. The reason is exercise exhausts energy, and sometimes

does not leave enough vitality for digestion, or even for the craving

for food. Exercise is, of course, excellent for those of stronger

constitution, and especially those who have been accustomed to it.

Those who need to eat more, must keep constantly before their minds

the suggestion that if they want to eat they can, and that if they

actually do eat more, satisfaction with eating grows, and appetite is

restored to its normal place of influence. This is as true for those

who are convalescing from some ailment, or who are in the midst of

some progressive disease such as tuberculosis, as it is for the merely

nervous persons whose lack of will and inefficiency of judgment have

disturbed their eating habits. The will to eat is the most important

appetizer that we have. The old Scotch physician's rule that if food

stayed down it would do good, and that if the residue of it passed

through the intestinal tract there was nothing very serious the matter

with the patient, applies to the majority of patients who come to be

treated for obscure ailments, especially of a chronic character,

whenever they are associated with or developed on a basis of lack of

normal weight.

CHAPTER V

CONSTIPATION

To judge by the frequency of advertisements for laxatives of various

kinds, constipation must be an extremely common affection. At least

one out of every three city dwellers suffers, it is said, from

constipation. Proper regard for the taking of food calculated to help

this important function, the formation of appropriate habits, and the

proper disposition of the mind so as to relieve worry and anxiety,

will cure the majority of these patients. There are some who need

additional treatment, pharmacal or mechanical, but these are few.

Undoubtedly the mind plays the most important role in the therapeutics

of the affection. It is influenced partly through instruction, {269}

partly by the modification of unfortunate auto-suggestion, and partly

through auxiliary favorable suggestions of one kind or another.

Prophylaxis.--What is needed in most cases is such instruction as will

lead to a better observance of certain common-sense laws of health,

rather than the addition of remedies which eventually only complicate

conditions.

Many people believe that unless they have an ample movement of the

bowels every day all sorts of serious results are likely to follow. If

they do not have the expected movement before noon, they suffer during

the afternoon from headache that is probably due more to worry than to

any physical cause. Ordinarily it is quite out of the question that

the retention of the contents of the lower bowel for a few hours

should produce any such serious effects as these patients immediately

begin to feel. Especially is this true when on the day previous there

has been, as is often the case, a sufficient movement of the bowels,

due to the use of medicine. Some people have become so anxious in the

matter that they foster the development of feelings of discomfort both

in their abdominal and intracranial regions.

This over-anxiety is all the more important because recent

observations have made it clear that over-occupation of mind actually

hampers peristaltic movements of the intestines, and thus prevents the

muscular action which would gradually pass the excrementitious

material on to the lower bowel, to be evacuated in the normal way. _It

cannot be too often repeated that nature resents too close

surveillance of her functions and operations_. Just as soon as the

over-anxiety is relieved, and patients are made to appreciate that if

they do not have a movement to-day they may wait without serious

solicitude till they have one to-morrow, the amount of medicine

required to bring about movements of the bowels is at once reduced.

The Mind and Peristalsis.--Analogous to Pawlow's ingenious

experiments, with regard to digestive secretion in the stomach, are

Kronecker's experiments at Berne upon the motor function of the

intestinal tract. Pawlow showed that the appetite depended, not on

physical conditions so much as on the mental state of the animal and

its desire for a particular kind of food. Kronecker, by isolating a

loop of intestine in which a metal ball was placed, showed that it was

possible to modify peristalsis very materially by affecting the

psychic condition of the animal. There was a distinct difference in

the movements of the intestine, in the passage of a metal ball, when

the animal was called and expected to go for a walk with its master,

than when it was threatened with punishment or rendered depressed for

some other reason. In animals, the psyche plays a very subordinate

role in inhibition and stimulation compared to that exercised by man's

higher nervous system, since in him this portion of the organism is so

much better developed than in the animal. The condition of the human

mind in its possibilities of unfavorable influence over the intestinal

function, is, therefore, extremely important.

The more one knows about the curious power of the mind even over so

material a function as intestinal peristalsis and movement, the more

is one convinced of the necessity for a properly disposed mind toward

intestinal function, if it is to be accomplished with regularity and

without disturbance. Many persons thoroughly under hypnotic influence,

who are told that they will have a movement of the bowels at a certain

hour the next day will have it. Indeed, this constitutes one way of

treating certain forms of constipation in nervous, {270} preoccupied

people. There are many stories that illustrate the influence of

auto-suggestion upon the bowels. We have already mentioned Flaubert's

suffering as a consequence of realistic absorption in "Madame

Bovary's" poisoning by arsenic when he was writing that scene in the

book. Boris Sidis has told the story of a man who used to have a

disturbance of the bowels at every new moon, as the result of his

memory, acting unconsciously, reminding him of his mother's habit of

giving him a purgative about that time. These may be and doubtless are

exceptional cases, yet they illustrate the influence of mind and show

how much it must be the effort of the physician to use this effective

adjuvant just as much as possible in this very common and often

obstinate affection in which drugs so often fail, or are

unsatisfactory.

So-called Intestinal Auto-intoxication.--Those who are anxiously

interested in the subject are likely to have read so much of

intestinal auto-intoxications, of which a great deal has been written

in recent years, that they will be quite sure the slightest delay in

intestinal evacuation may be serious, or at least may profoundly

disturb their economy. As a consequence, just as soon as the hour at

which they should have a movement passes, they begin to worry about

it. In a couple of hours they feel tingly all over, and they know that

there most be poisonous substances in their circulation. After two or

three more hours, they begin to have a headache. Then they have to

give up work, and still more devote themselves to concentration of

attention on the disturbed condition. Their sleep will be disturbed,

perhaps will be delayed; they wake unrested and fearful of the awful

effects of intestinal auto-intoxication. In most people this state of

feeling is entirely due to suggestion.

So much has been said in recent medical literature of the influence of

absorption of poisonous substances from the intestinal tract--the

so-called intestinal auto-intoxication--that it is a surprise to learn

how little we know, definitely and absolutely, about this subject, and

how many theories have come and gone. Arthur Hertz, in his

"Constipation and Allied Intestinal Disorders" (Oxford Medical

Publications, 1909), reviews the whole subject very interestingly but

shows that we are entirely without any definite conclusive evidence

for what has been talked about so much. The idea had often occurred,

and been expressed vaguely, in medical literature in the old time, but

began to have its great vogue when the high-sounding Greek term

copremia (literally "excrementitious-substances-in-the-blood") was

invented, toward the end of the first quarter of the nineteenth

century. Naturally this had a strong suggestive effect. Bouchard took

it up a generation later, and then intestinal auto-intoxication,

another mouth-filling term, came to occupy much attention as an

explanation for various vague conditions, and especially nervous

discomforts of many kinds. Bouchard's method of proving his theory by

showing how much toxic material was reabsorbed from the intestines,

using the urine for injection into animals, was open to many

objections. Now it has been quite discredited.

Bouchard's disciples exaggerated and theorized even beyond their

master, until intestinal auto-intoxication became the same sort of a

refuge for the puzzled physicians of our time--like rheumatism or the

uric acid diathesis, for those of a score of years ago. Various

methods of demonstrating the toxicity of substances absorbed had a

vogue for a time, but they have now lost their significance. There are

only a limited number of people who seem to suffer {271} from the

symptoms attributed to such reabsorption. Some people who are quite

constipated have none of the symptoms at all, while a delay of an hour

or two in the evacuation seems to affect other people very much. These

latter are especially nervous persons. It now seems very clear that

the liver acts as a safeguard against the absorption of poisonous

materials from the intestinal tract, and that neither degenerate

proteid materials, nor bacterial toxins, are allowed to affect the

system to any serious degree. After all our study, as Dr. Hertz

insists, we have as yet no evidence that poisons are absorbed.

Reassurance as an Element in Treatment.--The most important element in

the rational treatment of constipation is to make patients understand

that under ordinary circumstances the symptoms of auto-intoxication,

of which so much is said, do not develop until there has been

long-continued accumulation of excrementitious material and under

conditions favoring absorption. Even then nature learns to protect

herself against untoward conditions. We have some very striking

examples of good health in spite of even very rare movements of the

bowels.

_Examples of Intestinal Tolerance_.--There is the famous case of the

French army officer who, from his earliest years, did not have regular

movements of the bowels, but secured evacuations of them by artificial

aid once every two months or more. He lived to the age of past fifty,

and then died from an intercurrent disease not connected with his

intestinal condition, having in the meantime enjoyed good health. He

was able to accomplish his duties as an officer without any special

allowances, and he was on the sick list much less than many brother

officers whose intestinal condition left nothing to be desired. This

remarkable man succeeded in doing his life work without his condition

being known by others to any extent, and it was only inconvenience,

and not serious illness, that he suffered from. After his death, it

was found that certain folds of the lower bowel were so large as to

meet across the lumen of the bowel, making shelves and pouches in

which fecal material gathered, preventing the movement of all material

above.

In the Orient, it is said that many people, especially of the better

class, do not expect to have movements of their bowels every day. Some

of them, indeed, do not encourage intestinal evacuations oftener than

once a week, sometimes even more seldom. As their diet is more largely

vegetable than ours, this is all the more surprising. This custom does

not contribute to their good odor, but this they compensate for by

using various Eastern perfumes. The average length of life of such

people is not much below the Occidentals and the difference is

probably accounted for to a great extent by other unhygienic

practices, rather than this failure to have regular movements of their

bowels. In the meantime, they do not suffer any particular

inconvenience, and live life quite as free from the ordinary pains and

aches as do the people of the West. Of course, in such cases the

custom has been established early, and nature has grown accustomed to

it. Nature seems to be able to stand almost anything, if she can only

survive it long enough to neutralize its effects by some of her

marvelous means of compensation.

A case under my observation some years ago deeply impressed upon me

how thoroughly the human system can learn to get along in spite of

extremely unfavorable conditions in the matter of intestinal

evacuation. The case was that of a young woman suffering from some

internal trouble and there was {272} a possibility of the growth of a

tumor. Some charitable people had been interested in her case, and the

question had arisen whether the tumor might not be physiological. Her

story was a very curious one. She and her sister worked in a mill.

They came from a family that had been reduced in circumstances, and

were much more sensitive, as regards the decencies of life, than were

their fellow workers. In order to get to the toilet, the working girls

had to pass a window of an office where a number of men were at work.

The other girls did not seem to mind it, but these two girls were so

sensitive that they preferred not to use the toilet room at the

factory. They had to leave home shortly after six o'clock in the

morning. They did not get home until nearly seven. For a time, they

succeeded in accomplishing their intestinal functions during the hours

of their stay at home. Gradually, however, this habit was broken, and

at first they went two or three days without an evacuation, then four

or five days, and finally a week. It then became their custom to take

a large dose of epsom salts on Saturday night and spend most of the

day on Sunday getting rid of the accumulated excrementitious material

of the whole week.

They taught Sunday School in the afternoons, and as the elimination of

the accumulation of week-long material interfered with this, they

gradually acquired the habit of doing their Sunday School work on

alternate Sundays, each taking the other Sunday for evacuation

purposes. It might be expected that this serious abuse of function

would soon lead delicate girls, compelled to work full eleven hours a

day, into rapid serious breakdown. But it did not. This state of

affairs continued for more than a year. Then finally one Sunday, the

more delicate of the two girls found it impossible to open her bowels

at the end of two weeks, and though she stayed at home the next Sunday

found it likewise impossible. Had not the directress of the Sunday

School, who had become interested in them, succeeded in gaining their

confidence, it is possible that they would not have consulted

physicians even for some time longer, though about three weeks had

passed without an evacuation.

Probably every physician in active practice has women patients who

have been constipated for successive periods of three or four days at

a time, for several months, without much disturbance of the general

condition. While, then, there are many nervous persons who are quite

sure that they begin to notice definite symptoms within a few hours

from the failure to have a motion of the bowels at the time when they

had been expecting it, it seems certain that this is generally rather

the result of anxiety and nervous worry than consequent upon any

actual absorption of toxic materials--intestinal auto-intoxication--as

these patients, with a naive liking for nice long names, find such

satisfaction in describing their condition. A simple explanation of

the complete lack of inconvenience that is found in so many cases of

constipation, will neutralize the unfavorable auto-suggestion that

exists, and make these people much less likely to suffer.

_Individual Variation_.--Another suggestive item of information that

should be given those who are over-sensitive and anxious in the

matter, is that different individuals vary very much in the need for

intestinal evacuation. Perfectly healthy people have lived long and

happy lives, having an intestinal evacuation only once every two days.

Whether it may not in exceptional cases be rarer than this without

serious injury, immediate or remote, {273} experience has not

definitely settled. Many of these people with infrequent intestinal

movements, have gone on utterly unconscious of the frequency or

infrequency of the calls of nature, paying no attention at all to the

matter until by some chance remark or a newspaper health item, it is

brought forcibly to their notice. They have not had a symptom before

of any kind, but now they begin to note all sorts of symptoms because

they try to order their lives after the supposed rule that they have

heard or read.

_Anatomical Peculiarities_.--On the other hand, some people normally

have two evacuations a day, and seem to require them if they are to

remain in the best physical condition. While daily evacuation is to be

considered normal, individual departures from it in either direction

must be respected as quite within the bounds of good health. Sometimes

there are anatomical reasons, as the capacity of the large intestine.

Sometimes there are physiological factors, as the amount of food

taken, or the fullness or rapidity of function in the digestive tract.

Amount of Food as a Causative Factor.--Frequency, or infrequency, of

bowel movements seems to depend to a great degree on the amount eaten.

It is well known that two men of the same weight and doing the same

work often seem to require quite different amounts of food to enable

them to accomplish their tasks. This is what might be expected, since

it holds true also for the consumption of fuel in heat machines.

Engines built in exactly the same way often require quite different

amounts of fuel in order to release the same amount of energy. Where

men are large eaters, the amount of excrementitious material left will

usually provoke, if not actually demand, more frequent evacuation than

where the amount eaten is small. Variety of food also has an important

bearing. Men who live largely on beef, milk, eggs and food materials

that do not leave much residue, do not require, indeed they cannot

have, frequent evacuations. Those who live almost exclusively on

vegetables, with large amounts of residue, will require more frequent

evacuation of the bowels. Certain other dietetic habits, as the amount

of fluid taken with the meal, or whether food is eaten in the solid

state or cooked into purees, stews and the like, make a decided

difference, the reasons for which are obvious.

Habit in Treatment.--For the regulation of the bowels and the proper

treatment of constipation in nearly all cases, more weight must be

given to the directions laid down for the patient's attitude of mind

and habits of life than to drug treatment. The patient must be made to

realize that the directions given to him are much more important for

the effective relief of his condition, than is the medicine

prescribed. As a rule, medicine is meant only to afford relief from

immediate inconvenience, in the hope that after a short time new

habits will be formed which will remove the habitual constipation by

correcting certain hampering conditions that have unfortunately become

established.

_Habitual Evacuations_.--By far the most important element in the

treatment is to make the patient realize that habit plays the largest

role in the regular evacuation of the bowels. A child, even under two

years, can, by tempting it at certain times to evacuate its bowels, be

gradually brought to establish a habit that will save much

inconvenience for nurses and the family. This has actually been done

for most human beings now alive, and this same thing can be done at

all stages of life. If a particular time be chosen, and the {274}

individual habitually goes to the toilet at that time, results may be

confidently expected. It is rather important that the time chosen be

one when there is not much hurry nor anxiety, and when it is

reasonably certain that the same time can be taken every day. It is

surprising how much so simple a bit of advice as this will do for many

people who have considered that they have been suffering great

discomfort from habitual constipation. Between the persuasion that an

occasional failure to have a movement is not serious and the definite

habit of journeying to the toilet room at a particular time, whether

the desire is felt or not, many cases of habitual constipation will

disappear with, perhaps, only the necessity for the administration of

such drugs as will prove laxative to a slight degree during the first

two or three weeks.

Ingestion of Fluids an Important Influence.--After the suggestion of a

habit and its extremely efficient influence, the most important idea

that a patient suffering from constipation must be made to grasp, is

the necessity for fluids. That there shall be easy movement of

excrementitious material in the digestive tract, there must be fluid

enough ingested to keep the residue, after digestion, thoroughly

moist, so as not to allow it to become dry and compact. To secure

this, a reasonable amount of liquids must be taken. So much has been

said in recent years about the actual and possible harm of taking much

fluid with meals, because of the danger of diluting the gastric juice,

dilating the stomach and the like, that many persons who eat under the

control of their reasons rather than their instincts, have very

materially lessened the amount of liquids taken at meal time. This is

undoubtedly one of the reasons why constipation has become more common

in the last half century. In the olden time considerable quantities of

fluid were taken at meals. With people in our time deliberately

diminishing the quantity, there is often not enough fluid ingested to

keep the human economy in proper working order. Prof. Hawk's work

shows how utterly wrong was this limitation.

The ordinary excretion of water through the kidneys should be at least

three pints, another pint is exhaled from the lungs--the quantity is

even more than this in steam-heated houses where no provision for

moistening inhaled air is made--and probably still another pint is

needed for other purposes, perspiration, nasal and ocular secretion,

and the like. Two quarts and a half to three quarts of liquid must be

daily ingested then, and unless special care is taken to see that this

amount is consumed the system may have to get on with much less, but

as can readily be understood, not without difficulty. The ordinary

glass of water does not contain half a pint; the ordinary tea cup

probably holds not more than from four to six ounces. A glass of water

and a cup of tea or coffee is about the limit of consumption of fluids

at meals for ordinary people, and some take even less. Except in hot

weather, comparatively few regularly take any fluids between meals. At

the most, then, three or four pints of liquid is taken, instead of

five or six, and the consequence is that the intestinal contents are

deprived of their fluids by the call of the system for more liquids.

Peristalsis has, therefore, to overcome the sluggish movement of the

excrementitious material, which usually does not contain as much

liquid as would make its movement easy and normal.

Residual Material.--The next most important consideration after the

amount of fluid in the intestines, is the amount of the residuum which

the lower bowel has to move. Evacuation of the intestines is to a

great degree {275} a mechanical arrangement. When sufficient material

is contained in the lower bowel, it pushes on ahead of it the matter

that has been gathered there during the immediately preceding time,

and so leads to an accumulation in the rectum that brings about reflex

evacuation. It is only indigestible material that is thus excreted. If

sufficient indigestible material is not taken with the food, there

will not be sufficient residue left after digestion to call for the

exercise of the evacuant function of the intestines, and the

consequence will be sluggishness and failure to bring about daily

movements. Originally nature provided food materials so arranged that

the amount of indigestible material was sufficient for the exercise of

peristaltic function; or rather perhaps, the regularity of peristaltic

movement is of itself a development from the habits that were

gradually formed in moving the residue that is normally left from food

materials in the state in which they are produced by nature.

Food materials are no longer taken to any great extent in the form in

which they are provided by nature. We have learned to eliminate the

coarser indigestible portions. Bread used to be made of the whole

wheat, and of rather coarse flour, leaving a large residue for

peristalsis to exercise itself on. Now only fine white flour is used,

leaving a minimum undigested. Vegetables used to be taken with much

more waste material attached to them than is the case now. After being

baked, potatoes were often eaten with the skins on, apples and other

fruits were eaten unpared and many of the coarser vegetables, turnips,

carrots, beets, and greens of various kinds that leave large

proportions of waste were much more commonly used. Movements of the

bowels depend on this residue. If it is not present the bowel

movements will not take place with the regularity observed when food

with more residue is consumed.

Diet--Prof. Otto Cohnheim, in his lecture before The Harvey Society in

New York, December, 1909, emphasized the necessity for a mixed diet.

The less vegetables are taken, the less cellulose remains undigested

to stimulate peristalsis. Liquids find their way through the

intestines by a system of percolation, and do not excite peristaltic

movements. Meat, if well digested, is almost entirely dissolved in the

stomach and becomes a fluid. Vegetables are passed on to the

intestines as a rather thick paste. Occasionally, in the midst of this

paste there are portions of food of good size. Those excite

peristalsis; hence the necessity for vegetables in the diet, if

peristaltic movements and regular evacuations are to take place. This

physiological law is poorly understood. Patients have heard so much

about the indigestibility of starches, that whenever they have any

uncomfortable feelings in their abdominal region, supposed to be due

to indigestion, they commonly eliminate vegetables from their dietary

with the consequence that their disturbed condition is likely to be

emphasized rather than improved.

_Limitation of Diet_.--Just as soon as a patient's attention is

attracted forcibly to any tendency to constipation, he is almost sure

to conclude that this is a symptom of indigestion and he proceeds to

put into practice all the rules which he has heard and read for the

treatment of indigestion. The first of these is elimination from the

diet of all indigestible food products, including most of the

vegetables. The result is a vicious circle of cause and effect by

which constipation is rendered worse than before. This needs {276} to

be explained to intelligent patients in order to make them understand

that some of the new habits which they have been forming and which

they are prone to think highly hygienic, of cutting off all food

containing indigestible material, are really important factors in the

causation of further intestinal disturbance. It will often be found

that the real reason for patients' inability to have daily evacuations

of the bowels, is that they have become persuaded that various forms

of food are either indigestible on general principles, or else are

indigestible for them. For this reason they have eliminated from their

diet most of nature's ordinary and quite natural provocations to

intestinal evacuation, only to have to substitute artificial means to

the same end in the form of the various laxatives.

It is important to talk this matter over with patients; otherwise the

true cause of their constipation may be missed. For instance, from the

very beginning of human life an excess of fat acts as a lubricant of

the intestine, and as a material by means of which other and more

concentrated objectionable matter that needs to be eliminated is

carried out with as little friction as possible. Mother's milk

contains from one-fourth to one-third more fat than the baby can use

in its economy. This is meant to furnish a lubricant for the large

intestine. It is a residue that will aid in securing movements of the

bowels at regular intervals.

_Fats_.--Many people who come to their physicians complaining of

habitual constipation have been told, or have read, that fat is rather

indigestible, and, as a consequence, they have eliminated from their

dietary all fatty materials. Even butter they use but sparingly, and

they exchange the cream in their tea or coffee for plain milk; they

carefully remove as much as possible of the fat of meat and they

abstain from all sauces in which fat is employed. Such practices make

normal, natural, regular evacuations of the bowels extremely

difficult.

_Sugars_.--Another food material that is a valuable aid to nature for

the stimulation of peristalsis is sugar. In its digestion, a certain

amount of fermentation takes place, and the gas from this stimulates

peristalsis. Of course, there may be excessive fermentation, and then

harm rather than good, is done. Ordinarily a certain amount of sugar

is demanded by nature and practically all the food materials, even the

meats, contain it. All the starches from vegetables have, as the end

products of their digestion, various forms of sugary material. These

are just the classes of foods that many nervous persons, suffering

from constipation and anxious about their digestion, eliminate from

their diet under the mistaken notion that they are indigestible, or

are productive of undesirable fermentations. When they do so, it is

not surprising that their constipation should be emphasized and that

they should have to ingest other irritant materials, laxatives, to

replace the sugars. It is probable that where constipation exists in

the bottle-fed infant, the addition of a little brown sugar to the

water with which the milk is diluted, is the safest and most natural

way of correcting the sluggishness of the intestines.

_Supposed Idiosyncrasies_.--The physician will in many cases meet with

the objection that some of these materials that he is recommending

disagree with his patient. Most of the presumed idiosyncrasies in the

matter of food are founded on extremely insufficient evidence.

Not infrequently young persons who are thin and inclined to be {277}

constipated, and who need to take fats plentifully, do not care at all

for butter. Sometimes this is founded on nothing more than the fact

that at some time or other the butter provided for them was rather

poor, and they got out of the habit of eating it. Now they assume that

their disinclination is physiological. In this regard, as with milk, a

little careful persistence will usually convince the person that there

is no natural obstacle and no good reason why they should not partake,

in moderate quantities at least, of this extremely valuable article of

food.

Often the supposed idiosyncrasy against a food is due to no better

reason than that on a single occasion it disagreed, owing to its

preparation, the circumstances under which it was eaten, or the

materials with which it was associated. An aversion, for instance, to

so nutritious and so valuable a food-stuff as hog-meat will be

acquired for no better reason than that fried ham or bacon disagreed

with the patient on one or more occasions. Such people when told that

ham, boiled so thoroughly that it crumbles in the fingers, is a

favorite mode of giving meat to convalescents in European hospitals

and that it agrees very well with them, will often be tempted to try

it. Then they find they have been harboring an illusion as to their

supposed idiosyncrasy for hog-meat. Nearly the same thing is true of

bacon. A trial or two of crisp bacon, with the fat so thoroughly

cooked out of it that it may be eaten out of the fingers without

soiling them, will often convince those who doubt of their ability to

eat it, how tasty a nutriment it is. Bacon is one of the most precious

dietetic adjuvants in the treatment of constipation.

Exercise.--There is always a serious difficulty in the treatment of

constipation in stout people. To counsel fats and starches and liquids

in the quantities necessary to bring about regular natural movements

of the bowels, through the mechanical presence of a sufficient amount

of residue, will often add greatly to their weight. For them,

exercises are needed. Not exercise in general, for many a man who

takes abundant exercise may be constipated. I have patients with this

complaint who are letter carriers, expressmen, even stevedores, and

the like. The mere absence of a sedentary occupation will not

guarantee against constipation. Motormen and conductors not

infrequently suffer from it. What is needed particularly is exercise

directed to the strengthening of the abdominal muscles, and the

increase of peristalsis.

For this certain leg exercises that can be readily and easily done in

less than five minutes each day will be found useful. A patient may be

directed to lie on his back, lift up the leg as high as possible in

the extended position, and do that with each leg an increasing number

of times every day. At the end of a month he is able to lift each leg

up forty or fifty times at each trial. This exercise twice a day,

morning and evening, just before and after sleep, will usually relieve

the constipation. The bringing up of the thigh on the abdomen as far

as possible, not only acts as a sort of massage upon the abdomen

itself, but the bellying of the large muscles within the pelvic and

abdominal regions mechanically helps the movement of the intestinal

contents. If, in addition to this, the patient gradually accustoms

himself to rise to a sitting from a lying position, the constipation

will almost invariably yield. In stout people, the presence of fat in

the abdominal wall seems to weaken the muscles so that the intestines

are not compressed as they should be in ordinary conditions, and

peristalsis seems to be thus interfered with.

{278}

A heavy wooden (bowling) ball rolled on the surface of the abdomen,

beginning low down in the right lower quadrant up towards the liver,

across just above the umbilicus, and then down on the left is often

advised. It is a good remedy but not better than the simple exercises

of the leg and abdominal muscles suggested. The use of the ball has

the advantage of novelty, and of distinctly adding to the suggestive

value of the exercise treatment. It is particularly valuable for

women. All of these exercises have a distinct value from their

suggestive side. If thus twice a day for three minutes people are made

to recall while doing the exercises the necessity for taking an

abundance of fluid, forming a habit with regard to movements of the

bowels and eating so as to encourage peristalsis, a definite good

effect will be produced. In the treatment of stout people

particularly, it is important to remember that the use of sufficient

salt, and then of certain of the natural salts, as Carlsbad or Hunyadi

Janos, may be of distinct advantage for their obesity. If taken

regularly in small amounts, that is, just enough to help to a movement

of the bowels, and if varied from time to time and occasionally

interrupted while some other form of laxative is taken, much good may

be done. It is as well to take simple irritants of this kind as some

of the irritant foods that will have a tendency to add to their

accumulation of fat, though they may increase peristalsis.

Influence of Position.--Little things may mean much in the matter of

the regular movements of the bowels. In my student days in France, our

little hotel in the Quartier had the old-fashioned water-closets

consisting of a hole in the floor in one corner, and a place to put

one's feet properly beside it, thus reverting to the old-fashioned

natural method of bowel evacuation. Some of the American students

found it an uncomfortable proceeding at the beginning, but, on the

other hand, some of them who had suffered from constipation in America

were no longer troubled that way. I have found in quite a few cases of

younger men that the suggestion to revert to this natural mode of

evacuation helped in the formation of the habit of having bowel

movements at a regular time. How much of the effect was physical and

how much was mental seemed hard to decide. The suggestion was

particularly valuable in my experience with patients of the better

educated classes.

CHAPTER VI

NEUROTIC INTESTINAL AFFECTIONS

There is a whole series of intestinal affections dependent on nerve

influence that get worse and better under stress of emotion or relief

from it. Probably the commonest of these is constipation, which is

dealt with in a separate chapter. Often these nervous intestinal

conditions are associated with other neurotic manifestations. On the

other hand, patients are seen who are absolutely without any other

sign of the neurotic habit, and have nothing like hysteria, yet who

suffer severely and rather frequently from intestinal neuroses. Most

of the people who react symptomatically to the eating of strawberries,

or of shellfish, or of pork in any form, or cheese or other milk

products, also have a definite tendency to certain skin neuroses and

to suffer from intestinal troubles as a consequence of emotional

states. It is hard to trace {279} real causation in many of these

cases, because it is so easy to accept the patient's expressions that

they must have taken cold, or they must have eaten something that

disagreed with them.

Neurotic Diarrhea.--But it must not be forgotten that nervousness

alone, without any additional factor, may produce a disturbance of the

functions of the intestines, and may even increase peristalsis and

bring about severe diarrhea. Anyone who has observed students going to

examinations has surely seen many examples of this. There are some

individuals--fortunately they are rather rare--who always suffer from

diarrhea when they have to take a serious examination. Some of these

cases are pitiable because the effects are quite beyond control, and

make it almost impossible for them to do justice to themselves.

_Fright and Loss of Bowel Control_.--Severe disturbance, such as

fright, may bring on this paralysis of proper regulation of

peristalsis, with consequent imperative intestinal evacuation. A

classical case in history is that of James II, for whom the Irish

soldiers invented a special name because of the tradition that he

suffered from an intestinal accident in one of the battles with

William of Orange. The imputation of cowardice on the last of the

unfortunate Stuarts has been completely wiped out by the investigation

of recent historians, and James' character for bravery has been

thoroughly vindicated. The fact that the story should have gained

credence shows that there is a general persuasion and popular

tradition that such intestinal incidents do occur from fright. An

incident told of the Franco-German War illustrates this, though I do

not vouch for the facts. Wishing to test the bravery of some soldiers

whom he was to send on a very dangerous expedition, and above all to

try how they would bear up even before the threat of instant death, an

officer of the French troops is said to have asked that half a dozen

brave men be sent to him. Without a word, he announced that there had

been treason in the ranks, and that the army needed an example. They

were condemned to be shot. A platoon of soldiers was drawn up, the men

were placed with their backs to a wall and they were asked whether

they wished to be blindfolded. They refused though they protested that

they did not know why they were being put to death. Then the word fire

was given. All of the men, excepting one, fell down, though the guns

of the firing party had been loaded with blank cartridges. The one who

remained standing was told that he was the man who would be selected

to go on the expedition, which, though perilous, was also of great

glory for himself and profit for his country. He said that he was

ready to go, but he asked permission to be allowed to change his

clothing, as he had not been able to keep as good control over his

intestinal muscles, as he had over his muscles of station.

Fright often has this effect in children. These stories and traditions

illustrate the influence of the mind and of deep emotions over the

intestines, and while only profound mental disturbance will produce

the most serious effects, there seems no doubt that lesser emotions do

interfere with normal function. This phase of the subject serves to

strengthen the contention that over-attention to the bowels may bring

about constipation by causing increased inhibition of peristalsis,

just as severe emotional disturbance may paralyze inhibition and so

bring about increased peristalsis with consequent diarrheal symptoms.

{280}

Habitual Diarrhea.--There are certain forms of chronic diarrhea,

usually considered most intractable, that owe their origin and

continuance to neurotic conditions of the intestine, rather than to

any gross organic lesion. In these cases the bowels acquire the habit

of emptying themselves two or three or more times a day, and the

stools are seldom formed. All sorts of physical treatment are employed

for these conditions, usually without avail, but whenever the

patient's mind can be set at rest, and his attention distracted from

his bowels by thorough occupation with some interesting work, the

intestinal disturbance gradually becomes less annoying. Ordinarily,

when stools have been frequent for a prolonged period, the case is

considered more or less unamenable to treatment. So far as ordinary

drug remedies go, this is true. What is needed is attention to the

patient's mind, to his habits of life, and to his worries, and the way

that he takes them. The illustrations given of the influence of the

mind over the bowels should make it clear that this therapeutic

principle can be of far-reaching significance and must be applied

deliberately and with confidence in the results.

_Worry as a Factor_.--Very often it will be found that the diarrhea is

particularly bothersome on days when the patient is worried. In a

clergyman friend and patient who was building a church, the approach

of days on which bills and notes became due, was always the signal for

a diminished control over his bowels, and there were frequently three

or four stools in the day. On his vacations, when eating unusual

things, drinking unaccustomed water, exposed to changes of

temperature, all the factors that give many people diarrhea, he was

perfectly regular because the worries had been lifted from his mind.

In another case, where for fifteen or twenty years a writer living

much indoors had had tendencies to diarrhea, always made worse by

worries, self-discipline and the refusal to let troubles occupy him by

always turning to something else, did him so much good that he

considered himself cured. In his case the return of a manuscript from

a magazine would always affect his bowels unfavorably. If, as

sometimes happened, he found that the manuscript had been returned

only for some corrections, there would be an immediate relief of his

condition.

Change of Mode of life and Intestinal Control.--An interesting phase

of the neurotic or mechanical disturbance of peristalsis is found in

the interference with regular movements of the bowels when persons are

aboard trains for long distances, or for more than twenty-four hours.

There are very few people who are not bothered in some way by such a

journey. Those of a nervous temperament are likely to suffer from

diarrhea. This is usually attributed to catching cold because of

drafts, but in recent years, when well guarded Pullmans eliminate

drafts to a great extent, the bowel disturbance continues. For the

majority of people, however, constipation results. The cause of it

seems to be due to a disturbance of peristalsis in the line of

inhibition because of the vibration and jolting of the train. The more

or less conscious assumption of definite positions of the muscles of

the abdominal region in order to save the body from the action of the

unsteady movement of the train, seems to be reflected in the sphere of

peristalsis with consequent constipation. There are other features,

such as a lessened consumption of food and water and absence of

exercise, that seem also to have an influence. If the journey is for

several days patients should be advised to walk out during the longer

stops.

{281}

Mental Influence and Indifferent Remedies.--The best evidence that we

have of the influence of mind upon the intestinal tract, and the

importance of employing that factor for therapeutic purposes, is found

in the number of cases of various intestinal disturbances, often

apparently chronic in character, which have been cured by the

administration of quite indifferent remedies. Dr. Hack Tuke in his

"Influence of the Mind on the Body" reports a number of cases in which

bread pills were used with good effect. _Pillulae micarum panis_ were

not an infrequent prescription in preceding generations. They are

usually supposed to have been effective only against the curious

symptoms that develop in hysterical women, but it must not be

forgotten that neurotic manifestations connected with the abdominal

region may occur very freely in men, and that treatment by suggestion

in connection with some remedy, real or supposed, is the most

efficient cure. The "British and Foreign Medical Review" for January,

1847, has a series of cases among naval officers which were reported

by a surgeon of long standing and wide experience. These cases include

painful intestinal psycho-neuroses, occasionally accompanied by

diarrhea, and sometimes by constipation and sometimes even by

dysenteric movements, all cured by bread pills when these were

administered in certain definite ways, and the patient's attention

concentrated on their expected effects. Bismuth lost its effect in one

case of repeated colic, opium was beginning to lose its effect. The

patient was then told that on the next attack he would be put under a

medicine which was generally believed to be most effective, but which

was rarely used on account of its dangerous qualities, and that would

not be used unless he gave his consent. At the first sign of his next

attack, a powder containing four grains of ground biscuit was

administered every seven minutes while within the hearing of the

patient the greatest anxiety was expressed lest too much should be

given. The fourth dose caused an entire cessation of pain. On four

other occasions, the same remedy was employed with equal success for

the same sort of attack. In a seaman who was suffering from obstinate

constipation which resisted even the strongest purgatives, including

Croton oil, pills consisting of two grains of bread were administered

every seven minutes, and the patient watched with very apparent

anxiety lest an overdose should be given. Within two hours he began to

have nausea at his stomach, which had been foretold as one of the

symptoms to be expected, and his bowels were freely open almost

immediately after. Apparently the administration of the bread pills

eventually cured his constipation.

Skin and Intestinal Sympathy.--Curious intestinal conditions are, as I

have said, often associated with neurotic manifestations of other

kinds. Attacks of hives and other neurotic skin disturbances are

common in association with nervous diarrhea. Sometimes the attack of

hives precedes the intestinal disturbance; sometimes it accompanies

it. Soon after eating the offending material, the skin manifestations

may begin and other symptoms follow. Only a few minutes elapse, even

when the patient does not know that the offending material has been

eaten, because it is concealed in some combination, yet the reaction

takes place evidently not from digestive absorption, but from

intestinal reflex. Very often there is vomiting, as well as diarrhea.

It is not hard to understand that in these cases there is produced an

irritation of the intestinal mucosa, corresponding to that seen in the

skin. Whenever {282} this occurs, it is not surprising that there

should be evacuation of the contents of the digestive tract in every

way that nature has provided for removing irritating material. The

simple nervous diarrhea is often spoken of as an "intestinal blush,"

as the neurotic disturbance of the bladder which causes frequent

urination is spoken of as a "vesical blush." Blushing is certainly the

external manifestation that corresponds most closely to the

disturbance that is probably the basis of these curious

manifestations.

_Urticaria and Diarrhea_.--Patients who suffer from urticaria readily

are almost sure to have other neurotic disturbances, and their

intestines seldom escape. On the other hand, those who have an

idiosyncrasy for certain kinds of food are almost sure to have other

nervous neurotic disturbances, which emphasize the fact that these

curious idiosyncrasies are of reflex nervous origin, rather than due

to any chemical irritation.

Some of these lesions of the intestinal tract related to urticaria may

affect, either primarily or secondarily, the biliary structures. Under

these circumstances there may be symptoms resembling true biliary

colic with some jaundice and pain that radiates toward the right

shoulder. Whether these bile symptoms are due to the occurrence of

actual urticarial lesions in the bile duct, or so close to the papilla

of entrance of the gall passages into the intestine as to occlude it,

is doubtful. Practically all the symptoms of the presence of biliary

calculus may be thus simulated. The differential diagnosis can only be

made by the rapid clearing up of the symptoms, and by the history of

the case. As a rule, where there is the story of repeated attacks of

neurotic intestinal disturbance, the physician and especially the

surgeon, should be slow to conclude as to the presence of a serious

pathological condition anywhere in the intestinal tract, unless the

symptoms are absolute. This is all the more necessary because now, in

patients' minds, the words appendicitis or biliary calculus are

associated with the thought of operation. This thought sometimes gives

rise to so much dread as to seriously disturb the appetite and still

further predispose the patient to the repetition of neurotic

intestinal trouble.

In the chapter on Abdominal Discomfort, the necessity for absolute

assurance of some definite lesion before there is any question of

operation, is insisted on. Here the disturbing mental influence of

suggestion, with regard to certain serious abdominal conditions, may

be emphasized. Many painful conditions in the abdomen are either

primarily or secondarily due to appendicitis. Most of these are quite

acute, and practically all amenable to definite diagnosis. There is,

however, a tendency to exaggerate the place that this organ holds in

the pathology of chronic cases. Many women who suffer from nothing

more than hysterical abdominal conditions are told by someone that

they have recurrent attacks of appendicitis, though there is nothing

except their suggestive complaints of pain on which to found such a

diagnosis, and then it becomes extremely difficult to remove this idea

from their minds, and contrary suggestion applied over a long period

is the only therapeutics that favorably affects them.

Intestinal Idiosyncrasies.--I have had the opportunity to see a series

of cases of intestinal idiosyncrasy in a family that has been an

interesting study for many years. One of the members has the most

exquisite case of susceptibility to various articles of food that I

think I have ever seen or heard of. {283} Even the eating of a little

unrecognized pork in sausage will give rise to a diarrhea so intense

that there is no peace for hours, and slight movements take place

every few minutes. Towards the end of the attack, there is always

considerable blood in the stools. Often the attack is preceded by

vomiting. While in most people the idiosyncrasy is limited to one

article of food, this patient has it for all of the articles that are

usually the subjects of idiosyncrasy. Besides pork, shell-fish will

produce vomiting and diarrhea within a few minutes, strawberries act

detrimentally at once, and cheese produces an almost immediate

reaction.

The most interesting feature of this case is that occasionally an

attack of diarrhea that is extremely severe, will occur merely as a

consequence of a strong emotional stress. Any great anxiety will have

this effect. The knowledge that someone has a telegram for her whose

contents she can not ascertain for a time, will act as a cathartic.

She also has other neurotic manifestations, especially of an

urticarial character, that are equally interesting. On a number of

occasions, when she has particularly prepared for some special event

such as a wedding or reception, for which a new gown has been provided

and preparations made with considerable solicitude to the end that she

shall appear at her best, she has suffered from a severe attack of

angio-neurotic edema affecting either her lips or her eye-lids so that

it was absolutely impossible for her to be present at the social

engagement. This has happened to her over and over again. On the first

two occasions, one eye was closed completely by the edema. In each

case she attributed it to the sting of an insect. There was no sign of

any sting, there was no itching or inflammation, the condition

presented all the signs of angio-neurotic edema, had come without

warning, and disappeared in from 36 to 48 hours without leaving any

mark or trace of its origin.

There is absolutely not a sign of hysteria in this individual, nor is

there any tendency to what would be called an emotional neurotic

condition. On the contrary, she is lively and sensible, the life of

her friends when they are ill, their consolation when they are in

trouble, and she herself has shown the power to bear trials and

difficulties. It is only the peripheral circulation in the intestinal

mucosa, and in the skin, that passes from under her control. She

neither laughs nor cries without reason and she has no other

exaggerated nerve reactions. Even more interesting is the fact that

the angio-neurotic condition can be traced in the preceding

generation, while the tendency to an intestinal neurosis complicated

by diarrhea exists in a sister in this generation. Examinations are

always a source of grave distress to the sister. Although she is a

bright intelligent woman she does not do justice to herself because of

her nervousness. Usually she has a vomiting spell in the morning

before the examination, and rather serious intestinal disturbance

during the day. That this is entirely neurotic is clear from its

constant disappearance immediately afterwards, and its constant

reappearance whenever there is this form of emotional stress.

In certain of these cases of supposed neurotic, intestinal troubles,

one cause of the condition sometimes fails of recognition. Many of

these people are found on inquiry to be taking much more salt than

usual. It is hard to understand how this occurs, but I have seen it in

a number of cases, sometimes in men, but much more frequently in

women. Some sort of a vicious {284} circle has been formed: probably

their original tendency to diarrhea led to a craving for salt, because

of the excessive serous evacuations. Somehow, then, the habit of

taking more salt was formed and its presence reacted to produce

irritative conditions in the patient, which, combined with neurotic

tendencies, produced the intestinal disturbance. I have seen chronic

diarrhea, mucous diarrhea, and even mucous colitis, associated with

the over-free taking of salt. When salt was eliminated from the diet

the cases at once improved. We now realize the value of a salt-free

diet for many conditions disturbing osmosis, and the presence of serum

where it should not be. It is probable that most people take more salt

than is good for them.

Intestinal Troubles Due to Air.--One of the most annoying intestinal

troubles due to a neurosis is the passage of air from the intestines,

or in some people a rumbling through them, which is distinctly of

neurotic origin. It is increased under emotional stress or whenever

there is anxiety with regard to it. This is much more common in the

old than in the young, as if relaxation of tissues had much to do with

it. Old men seldom complain of it to their physicians, but for obvious

conventional reasons, we are rather often asked to control it in older

women, and are occasionally asked to treat poignant cases of it in

young women. The older women are often stout, of flabby constitution,

and one has almost to accept the conclusion that the real trouble is

such a relaxation of the intestinal walls that the empty intestines do

not fall together as they used to, but rather tend to lie apart from

one another with the production of spaces into which gases, perhaps by

diffusion from the blood, find their way and are expelled. Usually

these patients were stouter than they now are.

Often after these patients have walked outside for some time,

especially if they have become quite tired, and then sit down inside

and become warm, the expansion of the air in the intestines leads to

some rumbling and the production of flatus. This experience is so

common with elderly people, when they come in in cold weather, that

they do not feel quite right unless it actually happens. The odor of

the flatus is seldom offensive.

_Air Swallowing_.--There seems to be no doubt that a certain amount of

air is swallowed, that it finds its way along the intestines, and

then, with the change of temperature on coming into the house,

expansion takes place and the air finds its way out. In certain

patients the habit of swallowing air may grow, and the necessity for

its evacuation, either by eructation or flatus, may be a source of

great discomfort. The latter form of relief may be impossible owing to

conditions, though it is quite as natural as other forms of the

evacuation of the bowels, and it must not be considered pathological

unless it becomes too frequent. People of other civilizations than

ours are not so sensitive in this matter. A late distinguished Chinese

Ambassador to this country relieved himself of an accumulation of gas

in his lower bowel quite as indifferently as he would have of gas in

his stomach--but without so much as "by your leave" and evidently

without a thought of anything unseemly in the act--apparently to his

own great satisfaction, though sometimes to the consternation of the

bystanders. Utterly failing to understand why he should not permit

himself this satisfaction, he peremptorily refused to conform to our

Western refinements in this matter.

In many of these cases habit may add to the necessity for relief of

this {285} kind, and habit may require considerable self-discipline

and training of organs to overcome it. To attempt to control this form

of intestinal trouble by ordinary intestinal remedies, and especially

by carminatives, is almost sure to increase it rather than do any

good. It is the patient's mental attitude toward the affection that

must be modified, and the intestinal bad habit must be brought under

control.

_Intestinal Uneasiness_.--In young women the cases are much more

serious, for the presence of gas in the intestines sometimes leads to

such dread of physical events over which they fear they may have no

control, that it makes it impossible for them to carry on their

ordinary occupations, hinders their conformance with social usages, or

even their association with any but very near friends. The cases are

not frequent, but are poignant when they occur. Many young women

suffer from rumblings in the intestines whenever more than four hours

have passed since their last meal. This phenomenon is not likely to

manifest itself unless they are nervous, excited and worried over

something, but is particularly likely to be troublesome when they are

with persons whom they are most solicitous to impress favorably. The

manifestation is undoubtedly associated with emptiness of the

intestines and relief will usually be afforded by taking something to

eat, even something so simple as a glass of milk and some crackers,

shortly before the time when the rumblings are usually heard. Dread of

this annoyance plays a large role in it, and it is due to an

exaggeration of peristalsis with the consequent crowding into larger

masses of small quantities of air that ordinarily would find their way

much more slowly along the intestinal tract. Milk of bismuth will do

more than anything else, though the presence of a certain quantity of

food is probably the best prophylactic and remedy.

Besides these cases, there are some that are even more annoying. These

occur in young women who have all the symptoms of an approaching

intestinal evacuation, and then find when they have excused themselves

that there is nothing but gas to be passed. This gas is nearly always

quite inoffensive, and is evidently air that has been present in the

intestines for some time, and has in the midst of the excitement of

peristalsis been forced on into the rectum and gives the sensation of

an approaching stool. These cases are coming into notice much more

commonly since young women have taken up business occupations. The

symptoms are worse in those who are constipated, though sometimes in

these cases there are recurring attacks of diarrhea showing that the

normal function of the intestine is disturbed. It is more annoying

just before and during menstruation than at any other time.

_Physical Basis_.--Whenever the patients are run down in weight there

is a distinct exaggeration of the condition. Whether the loss of

weight, by removing fat from within the abdomen, does not tend to make

the intestines more ready to take up air and to produce these

manifestations is a question worth considering. The most annoying

cases that I have seen were in people who had lost considerable weight

and though there had been some tendency to the condition before they

lost weight, it was doubtful whether the symptoms were greater than

those often seen and which are not productive of special annoyance

except in very sensitive people. In three of these cases that have

been under my observation in recent years, improvement came promptly

when weight was put on. The presence of an abundance of fat in {286}

the abdominal cavity seemed properly to balance the intestines and to

dampen peristalsis.

Reassurance, absence of worry, occupation of mind with interests that

keep it from putting such surveillance on the intestinal tract as will

surely be resented, must be the chief care of the physician. Without

these any relief afforded will be only temporary. With psychotherapy

relapses will occur, for these individuals are in a state of unstable

intestinal equilibrium, but practically all the successful remedies of

the past have been founded on it and its effect may be renewed over

and over again under various forms.

CHAPTER VII

MUCO-MEMBRANOUS COLITIS

Probably the severest, certainly the most interesting of the neurotic

conditions of the intestines, is muco-membranous colitis. The only

lesions discovered are those which point to a functionally increased

secretion of tenacious mucus from the lower bowel. No definite

pathological changes are known. The colic seems to be due to nothing

more than the effort of the large intestine to push off the thick

mucus which has been secreted, and which in many cases clings to the

bowel walls. This may be of such consistency that it is passed from

the bowel in the shape of tubular casts. These casts have often been

seen in place in the lower bowel. While the word membranous used in

connection with the disease has produced the impression that this

might be a form of diphtheritic affection, it is now known that it is

only due to an abnormally increased function, and not to any

structural pathological condition or infection of the lower bowel. The

membranous material is often gelatinous, and so the casts may hang

together in long pieces.

Neurotic Etiology.--It might be thought that such a cast could not be

formed, remain in situ in the lower bowel for a considerable period,

and then be passed as a whole, or in quite long portions, without

causing serious tissue disturbance in the mucous membrane. As Sir

William Osier says, in spite of the apparent improbability, the

separation may and usually does take place without any lesion even of

the surface of the mucous membrane. The epithelium seems to be left

intact. Owing to the curious nature of the stools, the disease has

been recognized for a long time and the descriptions of this disease

by the older authors are very interesting. Muco-membranous colitis

occurs mainly in nervous individuals, and is much more frequent in

women than in men, but it is not limited to women. Some of the

severest cases have occurred in men, and Woodward, in the second

volume of "The Medical and Surgical Reports of the Civil War," has an

exhaustive description of the disease as it occurred among soldiers.

It is particularly those who are worried and run down from overwork

and excitement who are likely to suffer from it, but it occurs

typically in people who, _faute de mieux_, worry about themselves.

Most of its victims are self-centered, though not hysterical.

Recent Increase in Number of Cases.--According to all the authorities,

there has been a considerable increase in the number of cases in

recent years. {287} At one watering place in France, Plombieres, which

has acquired the reputation for relieving, or even curing the disease,

about 400 cases had been under treatment during the course of about

two years. This increase was attributed by Boas of Berlin to two

causes. First the struggle for life has become much more intense in

our day, and the nervous conditions which are practically always the

basis of muco-membranous colitis, have as a consequence become more

frequent. Not only this, but mild cases that were not called to the

attention of physicians in the past, have become so emphasized by the

nervous worries of the strenuous life that now they seldom escape the

physician's attention. Besides our generation is getting away from the

old-fashioned idea of patiently standing many pains and aches, and

refusing to call in a physician unless the condition persists or seems

to be producing serious results. There are more cases of the disease,

but physicians also see more of the cases than formerly because

patients come for treatment for slighter causes.

Dr. Boas considered that, besides the strenuous life, there was

another prominent factor in the increase of the disease. This is the

abuse of laxatives and purgatives. Many of these have their principal

effect on the lower bowel. In consequence the nervous mechanism of

this structure has been irritated to a point where occasionally

explosions of nerve force take place. This causes an increase of the

secretion, and a tendency to cramp-like contractions. While there is

undoubtedly much of truth in this, there is no doubt that the most

important factor in the disease is the patient's nervous condition.

Only those who are inclined to be introspective, to worry much about

themselves, and who are constantly examining their stools for the

presence of mucus, suffer severely from the affection.

Very few cases have been seen among the working classes. Most of the

cases have hypochondriacal symptoms that sometimes go to the extent of

real melancholia and the full persuasion that they have an incurable

disease, a visitation on them for some real or fancied lapse from the

laws of health in earlier years. The affection usually lasts a long

time, or has been in existence for some years when the physician is

asked to see it, and patients are made most miserable by it.

Unfavorable Suggestion and Over-attention.--The pathological

physiology of this disease, for, as has been said, it has no pathology

in the proper sense of the word, is in many cases a problem of mental

influence. For some reason, the patient gets his or her lower bowel on

his or her mind. There is so much talk of constipation and its evil

effects in the newspapers, in advertisements and by suggestion from

bill-boards and in the magazines as well as, sad to relate, in

parlors, drawing-rooms and even dining-rooms, that it is easy for

those who are introspective and nervous about themselves, and who have

some little tendency to constipation already, to become much worried

about it. If, then, as was suggested by Boas, they take laxatives in

profusion, the irritation set up further fixes the attention on this

portion of the body. After a while, in these people, a goodly portion

of the waking hours are spent in thoughts with regard to the lower

bowel. The morning thought is the possibility of a stool to-day,

followed by conjecture as to its character. After the stool has taken

place, if there seems anything abnormal about it, comes a morbid dread

of the consequences of having such stools.

{288}

This constant attention sends down a lot of impulses to the lower

bowel. Anyone who has studied the psychology of attention knows how

much influence can be exerted on the skin, or on the mucous surface by

mental influence. Hyperemia is produced, and this leads to over-action

of the glands of the large intestine. These glands secrete a glairy

mucus which is necessary to protect the bowel from the offensive

material that is always present, and from the hardened material that

is so often there when there is a tendency to constipation. This mucus

is secreted in large quantities, while at the same time a hyperemia of

the colon tends to interfere with peristalsis and consequently to

delay the passage of contents and to keep the mucus in place. An

accumulation goes on for some time, until irritation is set up by the

presence of such a large quantity of material in the intestine, and

then colicky efforts for its removal are occasioned. All of this

process is accompanied by suggestive reactions upon the mind that

further complicate the case. This story of the affection points out

the indications for treatment. Unless the patient's mind can be

diverted from its constant attention to the lower bowel, the

possibility of cure is distant, and even after such diversion any

return of attention is likely to bring on a relapse.

Treatment.--The treatment of this affection emphasizes its neurotic

origin. We have had any number of cures for it and each one has

actually relieved many patients. The more trouble the cure involves,

and the greater the impression produced on the patient's mind the more

likely is there to be a relief of symptoms. All sorts of drugs have

been employed. Many of them have for a time been heralded as more or

less specific. The important thing, however, was that the patients

should come predisposed to believe that they were going to be

improved, and then that suggestion should be made at frequent

intervals--a combination of auto-suggestion through the administration

at regular intervals for a long period of simple remedies with the

confident suggestion of the physician that the patient will get

better. Local treatment of various kinds has been reported to bring

about improvement. The more difficult this is, and the longer it

takes, as well as the more bother it involves for the patient and the

attendant, the better the response to it is likely to be. Long rectal

tubes were found beneficial in many cases, though they failed in many

others, and most physicians have seen relapses occur in spite of the

continuance of the treatment that at first did much good. High

injections of water containing various drugs, and of olive oil

sometimes bring improvement though they afford no guarantee against a

relapse. Mineral waters do good only in the suggestive environment of

the spring.

_Surgery and Suggestion_.--The symptoms have sometimes been so severe

and the complaints of the patients have been so great that even

surgery of serious character has been recommended and tried in some of

these cases. The making of an artificial anus in the right inguinal

region, so that for a time the feces are not allowed to pass over the

colon mucous membrane has been tried. This gives decided relief from

the symptoms, but when the artificial anus is allowed to close,

recurrences often take place. It has been suggested, therefore, that

the artificial anus should be allowed to stay open for months, but

even this seems to afford no guarantee against a relapse. In recent

years the appendix has been taken out through the opening in the right

inguinal region, and a portion of it allowed to remain through which,

when {289} fastened to the abdominal wall, injections might be made

into the colon. In these cases ice-water has been found probably of

more effect than any drug solutions. This rather serious surgical

procedure is, however, as yet on trial, and we do not know enough

about the after-course of the cases to be sure that it has any

permanent effect.

A strong suggestion is involved in the removal of the appendix, and

the use of the stump of it as an irrigating tube. When the treatment

consists of something that is so strongly excitant of feeling as

ice-water, applied directly to the colon, it is easy to understand

that suggestion reaches the limit of its possibilities. No wonder

these cases improve, though we are not sure as yet what happens after

the appendix opening is allowed to close, or is deliberately sutured.

I should expect a recurrence of symptoms, if ever a time came when the

patient was run down in weight and worried by external conditions,

introspection, and above all by concentration of attention on the

intestines.

_Direct Suggestion_.--The question is whether suggestion can be used

to advantage in these cases without employing any of the radical

measures that have been suggested. There is no doubt that at certain

watering places where a specialty is made of this disease, and to

which patients go, sure that they are going to be much better than

before, and where they see patients all round them who are improving,

they often get complete relief. This is only what might be expected.

Whether a similar effect can be produced by simple suggestion when the

patient is thoroughly convinced that the physician understands the

case, and that if they will respond he can cure it, remains to be

seen. I know that mild cases improve rapidly under simple hygienic

measures, with a renewal of confidence in the possibility of relief,

and with the diversion of the patient's mind from the intestinal

difficulty. This is the most important factor in the treatment, as it

is the most important factor in pathology. If the patient's nerve

centers can be kept from sending down impulses causing exaggerated

action of the glands, then there is some hope of relief. A habit has

been formed in the matter, and a habit can only be broken by a series

of acts, just as it was formed. It is not effort for a few days nor a

week that counts in these cases, but diversion of mind for long

periods, until normal function is restored. It is usually quite

impossible to keep up this improvement constantly in nervous patients.

There are setbacks, but then this is true in every form of nervous

affection. It is, then, that the renewed suggestion of the physician

is needed.

_Resort Cures and Suggestion_.--Physicians often tell patients that

muco-membranous colitis is incurable, or at least emphasize strongly

that it is very refractory to treatment, and that it is prone to

relapse even after improvement. After a certain number of physicians

have insisted on these points, it is inevitable that patients should

not respond readily to treatment, and that they should be solicitous

about themselves, even when improvement does come.

It is most important then to bring about the neutralization of these

unfavorable suggestions. This is what is particularly accomplished at

the health resorts where muco-membranous colitis is successfully

treated. At these the patients see other sufferers from the disease

who proclaim how much better they are and some at least who are

entirely cured. The waters {290} used at these health resorts are not

nearly so efficient when used at a distance because of this lack of

additional suggestion.

The most efficacious treatment of muco-membranous colitis then is to

bring the patient up to normal weight, for they are often thin people,

quiet their solicitude about themselves, give them a bland and

irritating diet and get them away from worries or anxieties about

themselves or others. I know cases in physicians where the effect of

worry of any kind can be traced very clearly in the increased symptoms

of their colitis and the greater frequency of attacks. It is

particularly important not to give habit-forming drugs in these cases

for they always do harm. Where the pain is much complained of the

coal-tar anodynes are useful, but ice in the rectum or even

suppositories of gluten, or of cocoa butter without any medication

often prove useful. Most of these patients watch prescriptions that

are given them rather carefully and make up their mind beforehand

whether they are likely to do them good or not and the event usually

follows their premonition. They often have habits of self-drugging

which must be stopped and always carefully inquired into for they will

sometimes continue to take things for themselves in spite of being

under the doctor's care. If they have heard of surgical treatment for

their affection they are likely to think that they will have to come

to it eventually and this prevents a favorable attitude of mind

towards their affection. Unless this is secured no treatment will

prove efficient. With it almost anything that keeps up the suggestion

will greatly relieve and often will actually cure the condition.

CHAPTER VIII

OBESITY

Obesity, popularly considered to be an over-accumulation of fat, is

sometimes thought to exist only when there is the large development of

abdomen which is more properly designated corpulency. In its strictly

scientific sense it represents excessive over-weight, that is, above

twenty per cent. more of weight than is normal for the height of the

particular individual. (See table of weight for height in chapter

Weight and Good Feeling.) The Latin derivation of the word gives also

its etiology. Ob-ese means having eaten too much. It is a question of

failure of due proportion between the taking of nutrition and the

oxidation processes within the body. More food being taken than is

needed, there is an accumulation of it in the form of fat, and this is

deposited by natural preference in certain places, such as the

abdomen, the breasts and in the _panniculus adiposus_ beneath the

skin. The fats and starches are most readily converted into this fat,

but under certain circumstances proteid material may be turned into

fat, and then a true pathological condition develops resembling

diabetes in certain ways.

The metabolism of fat is rather simple, but this may be disturbed by

bad habits. When such large quantities of sugar-making materials are

taken that they are beyond the power of the normal metabolism to

dispose of, they are excreted in the urine with the production of what

is known as physiological {291} glycosuria. In the same way, the

eating of a superabundance of fat-forming food leads to the deposition

of fat in the tissues where, when in excess, it is just as much wasted

as if it were excreted. Physiological glycosuria is, however, usually

considered to be dangerous, inasmuch as its frequent occurrence may

disturb the normal metabolism of sugar, and lead to diabetes. In the

same way, the over-consumption of fat-forming materials may disturb

the fatty metabolism, and lead even to the changing of proteid

materials into fat. This represents a real disease requiring careful

management, while ordinary obesity needs only the exercise of the

patient's will to secure such proportion between the amount of food

taken, and the amount of exercise and fresh air, as will not only

prevent accumulation of fat but will lead to the reduction of any

accumulation that may, through neglect of this care, already have

taken place.

Over-eating.--The putting on of weight depends on the individual's

craving for food, and his satisfaction of his appetite. While it is

not ordinarily looked at from this standpoint, this craving for food

and the habit of satisfying it which is developed, is not very

different from the craving for stimulants and the habit that forms

with regard to them. People insist that they can not eat less--that

their appetite simply requires them to eat. We have all heard this

story over and over again from the man who craves alcoholic

stimulation. Usually the obese can be persuaded more easily than the

inebriate to break off their habit, but they relapse into it even more

easily than he does. It is comparatively easy to limit the appetite,

or rather to forego the satisfaction of eating abundantly, for a week

or two weeks or even a month, but the effort finally becomes appalling

and the consequence is a relapse. If the patient really wants to lose

weight, in nine cases out of ten it is a comparatively simple matter.

The trouble is that they want to lose in weight without giving up the

satisfaction of eating.

Under Exercise.--The second factor in obesity--lack of sufficient

exercise, is even more important than the habit of over-eating. This

is illustrated very well by the cases of certain animals who, without

any tendency to fat accumulation by nature, but rather the contrary,

acquire fat to a marked degree, owing to the habits that are forced on

them by their relations to human beings. A typical example is the pet

dog. Dogs living their natural active lives, have little tendency to

put on superfluous flesh. Kept in the house in cities, they

practically always put on weight until, after some years, many of them

are quite incapable of moving except in an awkward waddle, often

comically symbolizing their mistresses in this respect. Besides the

inactivity, the dog is subject to the influence of the other cause of

obesity, the over-eating of fat producing material. Another typical

example, and one that provides evidence of the pathological tendency

to fat accumulation, is found in the Strasburg geese from whom the

fatty goose livers for _pates de foie gras_ are obtained. Geese are

placed in a warm underground room, in a mass of cement that gradually

hardens round their feet keeping them almost completely inactive, and

then they are fed abundantly with fat-forming materials. The absence

of light and air, and the immobility, leads to the production of the

fatty changes, eventually producing the enlarged fatty livers, which

delight the gourmet's palate.

What is true of the dog and the goose is exemplified in the lives of

all other {292} animals. The fattening process is well understood by

butchers--keep the animal inactive and supply an abundance of

fattening food. The inactivity is even more important than the food.

Prophylaxsis.--Of course, if obesity is to be successfully treated,

cases must be seen early and before there has been a large

accumulation of fat. When people are more than 10 per cent. over

weight they are in the danger zone, and with 20 per cent. above the

normal, decrease must come or the condition becomes inveterate. It is

between these two points and not when they are forty or fifty pounds

over weight that they need the advice of a physician and the careful

institution of regular life to prevent further fat accumulation. After

the body has carried thirty or forty pounds over weight for some time,

it has acquired the habit of accumulating fat, rather than using it,

and this, once acquired, is hard to break. Every additional pound

tempts to the formation of lazy or sluggish habits because of the

additional weight that has to be carried around. Everyone knows how

hard it is to walk a few blocks a little briskly carrying a suit case

that weighs thirty pounds. Even twenty pounds soon proves to be a

burden. Fat in the tissues, though it seems to be a portion of the

individual, is really quite outside of him and consists of extra food

material that the body is carrying round, having accumulated it for

the purpose, apparently, of using it at some time when it should be

necessary. While carrying this burden, people have little inclination

to an active life. Inactivity lowers oxidation processes and leaves

them with an additional tendency to fat accumulation because of lack

of oxidation. In a word, a vicious circle of cause and effect is

formed. Accumulation of fat prevents the taking of proper exercise,

and lack of exercise leads to further accumulation of fat!

Not only should the treatment of obesity begin early in a particular

case, but, in families where there is a recognized tendency to take on

fat, it should begin early in life.

Children should not be so fed that they become mere specimens,

illustrative of how early fat accumulation may occur, and to what a

degree it may go. Just as soon as baby shows signs of an accumulation

of fat above its normal weight for age and size, there should be just

such a regulation of its diet as would be considered necessary if it

were an older person, and showed the same unfortunate tendency. This

is particularly important if the parental relatives on either or both

sides of the house show tendencies to fat accumulation. We are sure

that in diabetes the over-eating of starchy and sugary substances

produces what is, at the beginning, an alimentary or so-called

physiological glycosuria, though it is doubtful whether any glycosuria

is ever absolutely physiological. This may lead to a pathological

glycosuria and the production of a true diabetes. So, also, the

tendency to accumulation of fat, as the result of what might be called

alimentary obesity, may lead eventually to the production of an

essential obesity in which even the proteid materials of the food may

be changed into fats, just as in the case of diabetes they are changed

to sugar. This fat is then stored up in the tissues though there is no

need at all for such an accumulation, and the food stuff is wasted

quite as much as in diabetes.