The Will in Treatment.--The important element in the treatment of

obesity is the readiness of the patient to follow directions. Nine out

of every {293} ten stout people are thoroughly able to control the

accumulation of fat and even to bring themselves down to about normal

weight, if only they _will_ to do so. This is no easy matter. It is

not an affair of a few weeks, or even a few months. Just as in the

case of over-indulgence in alcohol, it will probably be a life

struggle. It is well worth the while, however, for life is longer and

is larger without the accumulation of fat, which is not only so

uncosmetic, but is so preventive of real enjoyment of life.

Unfortunately, the cosmetic side of it, that is, the absurdity of

going round among one's friends with a very prominent abdomen, or with

noticeable protuberances, is the particular motive that appeals to

most people. While women may be quite ready to stand many discomforts

for cosmetic effect when dictated by fashion, they are not ordinarily

persistent enough in their efforts to prevent fat accumulation to be

successful in this much more important purpose.

Such patients make the rounds from physician to physician, and from

quack to quack, and go from patent medicine to patent medicine, to

find something that will enable them to lose weight without the

necessity for their taking any trouble. It is the old, old story that

the nerve specialist who is known occasionally to treat his patients

by hypnotism has so often presented to him. Patients who are sufferers

from alcoholism, or drug addiction, or some other vicious habit,

present themselves and ask if they cannot be hypnotized and then lose

their tendency to fall back into the old habit. There is no

possibility of this. If they are willing to cooperate, all of these

habits may be overcome, but a constant effort will be required and,

even after the habit is broken, there always remains a distinct danger

of relapse. Patients suffering from obesity want to transfer the

burden of working it off to someone else's shoulders, or they want

some specific remedy that will bring about reduction in weight yet

permit them to indulge in all the pleasures of their artificially

excited appetite. They follow directions for a few weeks, often

half-heartedly, and then give up the struggle.

_Food Temptations_.--With obesity, as with indulgence in alcohol, the

main difficulty is the occasion. Most of these fat people are placed

in circumstances in which tempting food passes them three times a day,

and it is hard to refuse it. If a hot punch or a fragrant cocktail

were several times every day passed under the nose of a man with a

tendency to inebriety it would be beyond the bounds of reason to hope

that he should withstand his craving. Just as soon as those who want

to reduce in weight are put in conditions in which only simple food,

though there may be a reasonably good variety of it, is presented to

them, the difficulty of limiting the amount they eat is comparatively

easy. This necessitates, as a rule, refusing invitations to dinner at

friends' houses, especially at the beginning of a reduction cure,

avoiding hotel _menus_ and giving up various social functions. It may

even involve changing home customs from those of luxury back to

simplicity. The question is whether this is worth while or not. When a

husband is likely to indulge over much in alcoholic liquors a wife is

apt to consider it easy to deny herself the privilege of such liquors

on her table and of avoiding places where he is likely to be tempted.

The rest of the family are usually quite satisfied to stand some

self-denial so that unfortunate results may not follow.

Where father or mother are suffering from obesity this same thing may

be necessary with regard to rich and highly seasoned foods. This would

be a {294} hardship to inflict on the family were it not for the fact

that the health of all the members will be distinctly benefited and a

return to simple food, nutritious and with a variety that makes it

eminently wholesome, will be good for them as a prophylactic measure.

_Motives for Self-Control_.--The task of keeping the weight down is so

difficult that very few people with a tendency to over-weight are

equal to it. They need the help of every motive possible for

encouragement. It is well to make these persons realize that

over-weight, according to the statistics carefully gathered and

collated by the large insurance companies in recent years, is a

serious bar to great expectancy of life. In a large series of cases it

was found that not a single individual recorded as being more than

twenty per cent. over the normal weight that he should have for

height, died of old age. Furthermore no one of over-weight attained

the age of eighty years, though 44 under-weights passed this age, and

two of them even reached the age of ninety. Death from nearly every

known cause is more frequent among the over-weights than in the normal

population, except in the single instance of tuberculosis.

What was thus demonstrated from statistics, carefully gathered in

modern times, has been a commonplace in medicine since the earliest

days. Hippocrates summed up Greek experience in the aphorism "persons

who are naturally very fat are apt to die earlier than those who are

slender." Practically all the commentators since his time have agreed

with him. In early years thinness may be quite as dangerous.

If there were no other reason but the greater frequency of _diabetes_

among the obese, this of itself would be sufficient to act as a strong

deterrent motive. It may well be used as such, especially in families

where a tendency to diabetes has been manifest. Diabetes figures as a

cause of death in life insurance statistics five times more frequently

among those who are over-weight than in the general population. Those

who are under-weight suffer from the disease in fatal form less than

one-half as frequently as the average. Hence, obesity and diabetes are

evidently closely related. As we have suggested, the disturbance of

metabolism due to the failure to use sugar properly in the system and

to its consequent elimination, corresponds in some, as yet not well

understood, way to the other metabolic disturbance by which

unnecessary fat is accumulated in the system. It is probable that the

over-eating of starchy foods and fats which leads to obesity, causes

in some people a breakdown of metabolism in the matter of the proper

disposal of sugar, and this initiates diabetes which becomes a

pathological condition, after a time quite beyond control.

Sleep and Exercise.--After the reduction of diet, the most important

feature of any successful treatment of obesity must consist of an

increase in the amount of exercise. Both of these can be accomplished

only through the patient's will, and by frequently repeated

suggestion, and auto-suggestion, of the necessity for constant

surveillance in both these matters. Any form of exercise that is

pursued faithfully is beneficial. Exercise in the open air, because it

encourages oxidation, is preferable to gymnastic exercises, but the

care of a trained instructor, the influence of example, the habit of

taking it at regular hours, make gymnastic exercise of value in this

condition. A regular walk every day is invaluable if it can be

secured. Women can be tempted {295} to walk even three or four miles,

if the habit is gradually formed, and if they realize the necessity

for it. It is important that too much sleep should not be indulged in.

One of the difficulties with pet animals is that they sleep so much

more in domesticity than in the state of nature. Sleep must be

absolutely regulated for the obese. The old monastic rule "seven hours

for a man, eight hours for a woman and nine hours for a hog" must be

emphasized.

Heredity.--There always remains in these cases the influence of

heredity. Many people are sure that because they come from families

with the tendency to obesity, it is impossible for them to overcome

this assumed heredity, and that the only thing for them is to bear the

affliction with equanimity. They usually do this while indulging their

taste for the luxuries of the table rather freely. This question of

heredity, however, has come in recent years to occupy a very different

position in the minds of biologists from that which it held a

generation ago. We know now that the evidence for acquired characters

being transmitted is so trivial as to be quite negligible.

The children of stout parents are likely to acquire their parents'

habits as to the consumption of food, in such quantity and quality as

will almost inevitably put fat on them. It is this habit much more

than any hereditary element, which is the underlying cause of the

obesity. There may be some influence of heredity, but it is much less

than has been thought, and even where it exists, it is not so

inevitable as has been considered. There are cases in every

physician's experience where the children of stout parents who, for

some reason, have been brought to habits of spare eating, have been

thin all their lives. On the other hand, anyone who has seen the

change that has come over the sons of spare, lanky farmers, in whom

both father and mother were of the thin type, yet who in the midst of

the luxury of city life have taken on weight, will be convinced that

personal habits mean much more than any influence of heredity in the

production of obesity.

Where there is normal occupation of mind and body with strict

regulation of the hours of sleep, and simple though abundant food,

there is little tendency for people to become obese, even though there

may seem to be hereditary tendencies. In a considerable experience

with religious communities I have often noted that the member of a

family who enters a religious order often goes but slightly above

normal weight, even though other members of the family may become

distinctly fat. This is not because of rigid self-denial in the matter

of food, that is to such an extent as to take less food than is

necessary, for most members of the religious communities work too hard

for this to be possible, but because they live the regular active life

and have the simple food of the community. This is true in spite of

the fact that their indoor life would seem to predispose them to the

accumulation of fat. After fifty most of them put on weight because

this is the physiological accompaniment of that period of life, but it

is not this form of fat accumulation that the physician is called upon

to treat as a rule, but that in people between the ages of twenty and

forty.

If the prevention of over-weight is taken up in time, if habits are

broken before they become tyrannous, if proper self-control is

cultivated early in life, there are very few people that need fear the

oncoming of obesity. There are some pathologically obese families in

which this will not be true, but they are as rare as diabetic

families. The most important element in any {296} treatment is the

rousing of the patient's mind and his will to take up seriously the

task of unlearning habits of overeating and not allowing sluggishness

of life to gain control. This can be done best, not by removing all

sorts of articles for which there is special taste from the diet, but

by a general reduction in the quantity of food eaten, by the

introduction of food material that does not put on weight yet

satisfies the craving, by the replacing of many of the starchy

vegetables by greens of various kinds, by replacing many of the

desserts by gelatine products and cheese, and by additions to the

exercise. But there must be no extremes in the reduction of food or

the taking up of exercise. Patients should not be permitted to lose

five pounds a week--at most two or three pounds--and they should be

made to understand that it is a life work and the formation of lasting

habits that they have before them. They should be made to understand,

also, after a time the satisfaction that comes from a more active life

will give them even more pleasure than the satisfaction of their

appetite did before.

Principles of Treatment.--Many systems of treatment of obesity have

been invented. All of them are supported by cured cases. Some of them

are founded on a reduction in the amount of fluids, some on a

reduction of the amount of vegetables eaten, in some cases going to

the extreme of an almost exclusively meat diet. Most of them modify

the diet very extensively. It is doubtful, however, whether any of

these systems, when successful, have owed their success so much to the

physical effect as to the suggestive influence exercised on the

patient's mind, that he must at the same time limit his eating and

increase his exercise. In the matter of fluids particularly, some of

the systems are absolutely contradictory of one another, yet success

follows their application. There is one serious difficulty in the

application of these systems. After a time the patient becomes very

tired of the monotony of diet suggested, and growing discouraged,

relapse into old habits. If suggestion can be used with as much force

without such extreme modifications of diet, the results are as good,

and are always more lasting. The important factor is a reduction in

the amount eaten, without necessarily denying any but the very rich

foods. In this way patients can very soon be induced to take half

portions of what they have been previously eating and thus secure a

prompt reduction in weight.

It is important that the bowels of obese patients be kept freely open.

Tendencies to constipation seem to disturb metabolism in the direction

of fat deposition, and even fatty degeneration. Many of the cures at

watering places include the taking of laxative salts, or waters of

various kinds, and undoubtedly this is helpful at the beginning. But

the continuance of such treatment may seriously disturb peristalsis so

that it is important to have intervals of rest for the bowels, during

which, while there is a regular daily evacuation, there are no

tendencies to diarrhea. The suggestive influence of the taking of

salts has meant much for a great many so-called obesity cures. They

should be employed carefully, but must not be abused.

For fat already accumulated, only exercise will serve as a sure

remedy. For fat within the abdomen, the various leg exercises which

may be gone through in bed, and the trunk movements, especially those

of sitting up from a lying position, when frequently repeated, will

soon serve to dissipate accumulated fat. They will also encourage the

taking of outdoor exercises, as {297} well as relieve the patient from

many muscular discomforts, difficulties of breathing and heart

palpitation, which were not only annoying before, but discouraged the

taking of exercise.

CHAPTER IX

WEIGHT AND GOOD FEELING

Probably the most important single condition for the maintenance of

good health and _good feeling_ is the carrying of weight normal for

the height and age of the individual, or slightly in excess of normal.

Popular expressions contain many proofs of this. The proverb "laugh

and grow fat" is undoubtedly due to the recognition by all the world

that stout people are nearly always laughers, and as a consequence,

perhaps placing the effect for the cause, laughing has been regarded

as a factor in putting on flesh. [Footnote 27] There is no doubt that

the exercise for the diaphragm afforded by hearty laughing, with the

stimulation of the intra-abdominal circulation consequent upon

vigorous diaphragmatic movements, is an important element in producing

a healthy state of the important organs of the human economy contained

within the abdominal cavity. Dr. Abrams in his book, "The Blues,

Causes and Cure," attributes this disturbing condition of depression

so familiar to those who have much to do with nervous patients, to a

disordered blood and nerve circulation in the splanchnic area, and

calls it scientifically, splanchnic neurasthenia. This undoubtedly

sums up one important element in the causation of a great many

depressive conditions. Most of them are banished by frequent hearty

laughter which, with its exercise of the diaphragm, tends to stimulate

splanchnic blood vessels and nerves.

[Footnote 27: Those who are interested in fossil words will find many

curious confirmations of the connection between weight and good

health and good humor. A typical illustration is the word _buxom_,

derived from the German _biegsam_, which means "ready to obey," from

the original significance of being ready to bend, that is bendsome.

In our day it has come to have quite a material rather than an

ethical significance. A buxom woman is one who is round and full of

form and while she usually also is cheerful and tractable, the two

ideas are not necessarily connected. It is curious that what was

originally the obedient wife should now have become the stout and

healthy wife, as if stoutness and healthiness were somehow

inseparably connected with the preceding idea so that gradually one

portion of the meaning was lost sight of and now only the physical

significance remains.]

Thinness and Discontent.--In general, it is well understood that thin

people are likely to be more gloomy and discontented than those of

stouter build. The pessimists of the world have usually been lank and

lean. Shakespeare, in "Julius Caesar," has the great Roman declare

that he likes not "the lean and hungry Cassius," and that "discontent

is bred in such bodies." The issue shows his prophetic power.

Discontent with life is much more likely in thin people than in stout.

Most suicides are under-weight. Where nutrition is under the normal,

digestion is sure to be poor because the digestive organs themselves

suffer even more than others from lack of food, apparently giving up

some of their own substance at the call of other tissues; sleep is

nearly always disturbed, constipation is almost the rule, and muscular

action becomes distasteful. While in our day we hear much of people

overeating, the nervous specialist finds that many of his patients are

undereating. {298} These patients grow out of many discomforts,

dreads, and symptoms that often seem, even to the physician, to be due

to organic change, when they take on enough weight to relieve them

from the incessant calls for more nutrition to which insufficient food

has made them subject.

Physical Disadvantages of Thinness.--There are many dangers that go

with thinness besides the tendency to that irritability of the nervous

system which we have come to associate with neurotic symptoms. It has

long been known that a person who is under weight is much more likely

to contract tuberculosis than a normal individual. From carefully

selected statistics, the large insurance companies have determined,

that it is far more dangerous to insure a man who is twenty pounds

under weight and who has no family heredity of tuberculosis than to

insure a man with a family history of tuberculosis on both sides of

the house, provided he is well up to or above the normal weight, and

is not living in special conditions of danger from contagion. It is

contagion and not heredity that plays the most important role in

tuberculosis, and the element that is still more important is that of

vital resistance. Every adult of thirty years or over has probably at

some time had tuberculosis, for traces of its presence are found in

the bodies of all adults who come to autopsy. Seven-eighths of the

human race are, however, able to resist, and among these seven-eighths

by far the greater proportion are those who are above normal weight.

Of course, this matter of the relation of normal weight to good health

did not escape the acute observation of the old physicians.

Hippocrates, to take the first and greatest of them, realized that

while excessive eating and drinking was serious, there were many

people who suffered from not eating enough. One of his aphorisms runs,

"A slender and restricted diet is generally more dangerous [manifestly

he means to both the well and the ill] than one a little more

liberal." He appreciated, too, the fact that while the old may

restrict their diet with more or less impunity, this practice may be,

and indeed is likely to be, more serious in young people. He has

marshaled the ages and stated the effects of a low diet on them very

definitely:

Old persons endure fasting most easily, next adults; young persons

not nearly so well, and infants least of all, especially those who

are of a particularly lively disposition.

_Discomfort Due to Lack of Fat_.--Many of the vague discomforts of the

internal organs seem to be due to a lack of fat cushions round them,

and fat blankets to keep them from being too much subjected to the

vicissitudes of external temperature. Anyone who has noted in a series

of cases the difference between the condition of patients suffering

from a slightly movable kidney when they are well up to weight, and

when, on the other hand, they are considerably reduced in weight, will

have the significance of the first of these conditions brought home

very clearly. Most of the people who suffer much from cold in winter

are greatly benefited, as might be expected, by a blanket of fat. It

is rather easy to grow accustomed to carrying ten additional pounds of

fat when ten additional pounds of clothes would be an insupportable

burden. Some fat people are prone to complain of the cold. These are

not the plethoric but the anemic. This latter class often have a

sluggish circulation, besides a lack of hemoglobin. As a consequence

of this their {299} oxidation processes are slow and imperfect, and

this is one of the reasons for the over-accumulation of fat. The

healthy individual with normal heart and normal blood-making apparatus

will always be ever so much more comfortable with a reasonable

panniculus adiposus and fat cushions and coverings for the internal

organs.

_Muscular Weakness and Discomfort_.--There are a number of pains and

aches occurring in lean persons that are due to nothing else than the

weakness of muscle consequent upon the poor nutrition of their

muscular tissues. Muscles which do not receive as much nourishment as

they should, must necessarily be weak, and if asked to do much work

they will resent it. Ordinarily it is not realized how much work is

required even for such common muscular efforts as those that are

needed to hold the body erect, or to keep it in a stooping position at

a definite angle, or to move around on the feet.

I have seen patients lose their aches and pains, and become quite

capable of standing weather changes and ordinary hard muscular labor

without discomfort, simply as the result of a decided gain in weight.

All that was needed was the persuasion to eat more, and especially to

eat a full breakfast, the meal likely to be neglected. In some

persons, appetite will only return after the correction of

constipation and insistence on a certain amount of outdoor air every

day, not necessarily exercise--for bus riding or the open cars are

excellent appetizers.

Eating Enough.--It is very difficult to persuade some people to eat

enough! They have all sorts of excuses. They rather pride themselves

on the fact that they do not eat much. Persons who are twenty pounds

under weight will calmly tell you that they do not need more than they

eat. They are actually in debt to that extent to their tissues, yet

they are persuaded that they are paying nature's claims in full.

Sometimes the excuse is that they have heard, or read, of how much

harm is done by overeating; they have taken to heart the phrase that

people are digging their graves with their teeth, and so they are

actually cultivating the habit of undereating instead of allowing

their instinct for food to manifest itself. Many are found to be

following the good old saw of getting up from the table hungry. The

inventor of it is not known, but quite unlike the inventor of sleep,

it would have been a great blessing if he had kept it to himself by

patent right.

After a time habit for these people becomes second nature, and it is

hard to get them to eat enough. When people undereat it is the

digestive organs that, in my experience, always suffer the most. As a

consequence, the appetite decreases because of gradually acquired lack

of vitality in the digestive system, its nutrition having been lowered

by drafts upon it from other portions of the body. Quite contrary to

what is told in the old fable, the stomach apparently is not selfish

and does not keep the lion's share for itself. The decrease in the

amount of food brings on a decrease in digestive power.

Weight for Height.--The physician who wants to help patients by

suggestion must keep before him weight tables for height, as they have

been determined by statistics. When people are under weight, it

matters not what they may be suffering from, improvement will come if

they are made to gain in weight. To be able to show them that they are

considerably below the normal and to point out what this probably

means in lack of surplus energy, suffices of itself to make many

people understand the necessity for {300} effort in the matter and to

give them a strong suggestion as to probable relief of their symptoms.

The following tables are the best-known averages for men and women:

ADJUSTED TABLE OF WEIGHTS FOR INSURED WOMEN, BASED ON 58,855 ACCEPTED LIVES

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Combined

Ages

4' 11" 111 113 115 117 119 119 122 125 128 126 118

5' 0" 113 114 117 119 122 122 125 128 130 129 120

5' 1" 115 116 118 121 124 124 128 131 133 132 122

5' 2" 117 118 120 123 127 127 132 134 137 136 125

5' 3" 120 122 124 127 131 131 135 138 141 140 128

5' 4" 123 125 127 130 134 134 138 142 145 144 131

5' 5" 125 128 131 135 139 139 143 147 149 148 135

5' 6" 128 132 135 139 143 143 146 151 153 152 139

5' 7" 132 135 139 143 147 147 150 154 157 155 143

5' 8" 136 140 143 147 151 151 155 158 161 160 147

5' 9" 140 144 147 151 155 155 159 163 166 165 151

5' 10" 144 147 151 155 159 159 163 167 170 169 155

Combined 123 126 129 132 136 136 139 142 145 142 133

Heights

The average shoes of the average woman will raise her about 1-1/2 to 1-3/4

inches.

DR. SHEPHERD'S TABLE OF HEIGHT AND WEIGHT FOR MEN AT DIFFERENT AGES

15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

5' 0' 120 125 128 131 133 134 134 134 131

5' 1' 122 126 129 131 134 136 136 136 134

5' 2' 124 128 131 133 136 138 138 138 137

5' 3' 127 131 134 136 139 141 141 141 140 140

5' 4' 131 135 138 140 143 144 145 145 144 143

5' 5' 134 138 141 143 146 147 149 149 148 147

5' 6' 138 142 145 147 150 151 153 153 153 151

5' 7' 142 147 150 152 155 156 158 158 158 156

5' 8' 146 151 154 157 160 161 163 163 163 162

5' 9' 150 155 159 162 165 166 167 168 168 168

5' 10' 154 159 164 167 170 171 172 173 174 174

5' 11' 159 164 169 173 175 177 177 178 180 180

6' 0' 165 170 175 179 180 183 182 183 185 185

6' 1' 170 177 181 185 186 189 188 189 189 189

6' 2' 176 184 188 192 194 196 194 194 192 192

6' 3' 181 190 195 200 203 204 201 198

Correction of Underweight.--Underweight is undesirable for many

reasons, and gain in weight is often the solution of many problems in

ill feeling. It is well to bear in mind that most patients who are

under weight can be made to gain in weight by an appeal to their

reason and by proper directions and care in seeing that those

directions are carried out. Patients have told me that they could not

eat more and yet I have been able to persuade them that they must eat

more, and they have done so. Anyone who has much to do with

tuberculous patients knows that utter repugnance for food can be

overcome by will-power, when it is once made clear to the patient that

they {301} must eat if they want to live. The most interesting event

in the process is that with the increase in the amount of food taken,

instead of the appetite becoming more and more satiated, as patients

are likely to anticipate, and instead of the repugnance for food

growing, the appetite grows stronger, and the repugnance gradually

disappears. There is only one way to gain in weight; that is by eating

more than one has been accustomed to eat. Persons who are twenty

pounds under weight ought easily to gain three pounds a week, half a

pound a day, if seriously intent on doing so, but in order to do this

they will probably have to increase the amount they eat by double this

quantity. That means that a solid additional pound of food, quite

apart from the watery elements of the food, must be taken every day.

In the correction of under-weight details are all-important. Patients

must be given specific directions as to what and how much of the

various foods they should take. With regard to supposed idiosyncrasies

against such nutritious substances as eggs, milk and butter, enough is

said elsewhere to make it clear that, as a rule, these are merely pet

notions, beginning in some unfortunate incident and cherished until

they have become a mental persuasion strong enough to disturb the

digestion of these substances. What is true for quality of food is

true also for quantity. People must be made to understand that the

amount of food is to be increased. The results attained by this method

are well worth the efforts required for it. Of course, the bitter

tonics, especially strychnin and cinchona, will do much to help. Just

as soon as patients begin to gain in weight many of their neurotic

symptoms leave them. Their tired feelings are no longer complained of

and when they are up to normal weight they are quite other

individuals, both in good humor and efficiency.

If for years patients have been eating less than they should, then

they will have discomfort when they begin to eat more. They will have

no more discomfort, however, than would be occasioned if they took

more exercise than they had been accustomed to. The stomach and

intestines must be gradually accustomed to the new task of disposing

of more food. Unfortunately, the usual impression among these patients

is that discomfort in the abdominal region, by which they mean any

sense of fullness, proceeds from indigestion, and indigestion

signifies developing dyspepsia with all the horrors that are supposed

to go with it. In reality the slight discomfort which comes from

increased eating is usually not manifest whenever the patients are

occupied with something reasonably interesting. After a time the

organs will become accustomed to it, and then the discomfort will

cease.

_Nervous Patients_.--One of the strongest suggestions that we have in

our power for thin nervous patients, suffering from many and various

ills, is to have them gain in weight. Many of them will be found to be

distinctly under weight for their height. They insist that they cannot

eat more, that they are eating as much as they care to, and that they

have no appetite, that when they eat more they have discomfort, etc.

It must be made clear to them that their one easy road to health is to

gain in weight. If they are under weight this makes a very definite

purpose to put before their minds. The objection so often urged, that

they come from a thin family, must not be listened to. The unalterable

purpose to make them gain in weight must be insisted upon. If they can

be made to eat more than they have been {302} eating before, they will

surely gain in weight. To see themselves gaining in weight is a daily

renewal of the suggestion that they will be better when they get up to

their normal weight. It is much better than electricity or the rest

cure, or anything else that I know; it is perfectly natural and, above

all, because it may be made an auto-suggestion, it does not leave the

patient after a time dependent on anyone else.

CHAPTER X

VAGUE ABDOMINAL DISCOMFORTS--LOOSE KIDNEY

After the vague pains around joints so commonly called rheumatic, and

which occur so frequently that probably there is no one over forty who

is quite ready to confess that he has not had rheumatism, the most

important source of vague discomfort is the abdominal region. This

occurs particularly in people who are engaged in a sedentary

occupation which prevents much exercise, keeps them indoors, and gives

them abundant opportunity as a rule for introspection and dwelling

upon their sensations. There are few people who live the intellectual

life who have not suffered from some of this abdominal discomfort,

which they presumed must mean some definite lesion, or portend some

serious development, and yet, as a rule, they have lived for years

afterward without any of their fears proving true.

Physicians are not spared from this source of worry and discomfort.

They suffer from it even a little more than others. Their knowledge of

the possibilities of serious pathological developments within the

abdomen, especially after the age of forty, makes them a little more

concerned as to the significance of these vague discomforts.

At least half a dozen times a year, for the last ten years, I have

heard physicians say that they were sure that some organ or other

within was not performing its function properly, and that there was

probably some organic lesion. The thought has usually been in their

minds for months, sometimes for years, and they have come to be

thoroughly examined. Sometimes they rather expect to be told that they

should go to a surgeon. They are usually half concealing a question as

to how soon they should set about putting their affairs to rights and

how serious the outlook is. As a rule, I am able to dismiss them

without any further treatment than the injunction not to think so

persistently about certain obscure feelings which they are allowing to

occupy their consciousness. Sometimes I know they take the

advice--even oftener, perhaps, I know they do not. Once it has got

hold of us, it is hard to get away from morbid introspection, and I

sometimes hear of them consulting others. All of these patients are

improved for a time after their consultation by the reassurance that

so long as they have a good appetite--which is the case with all of

them--and their bowels are regular--which unfortunately is not the

case with most of them--and so long as they sleep well and have no

acute pain, there is little likelihood of any serious latent abdominal

condition.

Such reassurance cannot be given until the abdominal region is

carefully palpated, and especially the right side explored as

thoroughly as possible. {303} Here lies the appendix, the head of the

colon, which is sometimes the seat of trouble not necessarily

originating in the appendix. Just above them one may find a loose

kidney, for the right kidney is more likely to be movable than the

left, because of the overhanging liver, and finally the gall-bladder,

and the bile passages, so likely to be the seat of serious trouble. If

none of these organs are tender on deep palpation, if the kidney does

not come down when the patient is examined in the standing position,

if there are no serious derangements of digestion, except such as can

be attributed to nervous indigestion, and if there is no dilatation of

the stomach, and no enlargement of the spleen, there is no reason why

one should do anything but try to get the patient's mind off himself.

There is always the danger of overlooking an abdominal cancer, in

these eases, though with the care in diagnosis I have suggested this

is minimal. The best therapeutic test that I know to determine this,

if there should be any doubt, is to put the patient on an increased

diet and watch the scales. If he is able to digest the added food

well, and without trouble, and if he proceeds promptly to gain in

weight, there is much less than one chance in a hundred that he is the

subject of latent cancer in the abdominal region. The old farmer's

maxim is: "A sick hog don't get fat." When human beings properly

respond to increased feeding, it is probable, not only that there is

nothing serious the matter with them, but that the symptoms of which

they complained before may very likely have been due to lack of

nutrition. The digestive organs not having enough to occupy them, were

tempted to digest themselves, or at least to have their function

disturbed by the short circuiting of nervous energy looking for

something to do.

I have seen a number of these cases that had been operated on for

vague discomfort--some whose appendices had been removed, some whose

kidneys had been fastened up because they were slightly movable, some

whose gall passages had been examined for adhesions that were supposed

to exist, or perhaps for a stone that it was thought might be found

there, and except where some actual organic lesion was found and

relieved, none of them was materially improved when seen several years

after operation. I have heard reports of cures of these cases by

surgeons who felt that the removal of an appendix presumed to show a

catarrhal process, or a hyperemia, or an adhesion at its tip, had

meant the cure of vague abdominal discomfort which had continued for

many years and made the patient profoundly miserable. But these

reports were founded on the patient's condition at the end of

convalescence after the operation, and not on the condition that

established itself some months, or perhaps a year, later. Operations

on the abdomen, except for very definite indications, have, in my

experience, always done more harm than good, and I have seen serious

conditions--hernia, displacement of organs and disturbance of the

peristalsis of the intestines--develop subsequent to them.

I have in mind two typical cases. One was a physician whom I had seen

on a number of occasions, and who complained of vague discomfort,

mainly in the right side of the abdomen, though never acute, never

accompanied by fever, nor even by any disturbance of pulse when he was

not in an excitable mood. His bowels were not always regular, and he

had had some disturbance of circulation as the result of thrombosis of

veins on that side after an {304} attack of typhoid fever. My opinion

was that his discomfort was entirely due to the disturbance of

circulation. There was probably some interference with the normal full

circulation to the large intestine, in its ascending portion, that

gave him a feeling of uneasiness, or of consciousness of its function.

Eventually he became convinced that he was suffering from a chronic

form of appendicitis. After considerable persuasion he convinced a

surgeon friend that his appendix should be removed, and the operation

was done. I saw his appendix afterwards. It was supposed to be

thickened, but considering the normal limits of size of the appendix,

I could not think that it was beyond them in any marked way. At most

there was but a slight catarrhal inflammation.

For a time after operation he was much improved. He felt confident

that all his trouble has disappeared, and he took some pains to

impress me with the supposed fact that in these vague cases of

discomfort there was always some underlying organic lesion that needed

surgical treatment. During convalescence he had gained in weight, and

was looking very well. When I met him a year and a half later he said

that some of his discomfort had returned. He had grown thinner and was

feeling discouraged. Six months later he was about to submit to

another operation, this time for the breaking up of adhesions in the

neighborhood of his gall-bladder. He had become convinced that this

must be the seat of the difficulty. After this operation he was sure,

beyond peradventure, that his trouble was gone never to return. Two

years later I found him preparing to have his right kidney sewed up. I

had known that his right kidney was slightly movable, but it did not

move sufficiently to cause any disturbance of kidney function, and

certainly not enough to justify serious surgical intervention.

After this operation I met him once casually and he assured me that

now everything was surely all right. I have since heard that he

submitted to an operation either for the breaking up of some adhesions

around his stomach or in order to tuck up that organ for ptosis. It

had not been quite decided whether an adhesion caused a slight

hour-glass constriction of the stomach, with some dilatation of the

splenic end of the fundus, or whether there had been some actual

sagging. I am sure that after this operation, as after preceding ones,

with the strong suggestion that he ought to be better and an increase

of weight during convalescence, he lost his vague abdominal discomfort

for a time, though I have no doubt that it either has or will return.

When he gets something to so occupy his mind that he does not dwell

too much on his discomfort, he will not increase it to the extent that

makes it intolerable. Then he will remember that most people have some

discomfort, and he will learn to distract his mind, rather than allow

it to dwell on the thought of his particular ailment until it becomes

intolerable.

It has taken twelve years or more to develop this case to the point

where it is as instructive as it now is, and it is a typical example

of what may happen even to a physician. There are other cases in my

notes that are quite as instructive, two of them occurring in

thoroughly educated men, clergymen who were of good intellectual

capacity, but who became too much occupied with themselves. One of

these had more operations done on him than my friend the physician. He

first had his appendix removed, and was better for a time. Then his

kidney was fastened up, and improvement once more took place. After

this he lost in weight considerably and suffered so much {305} from

headaches that a friendly surgeon suggested that there must be

adhesions between his dura and his brain. Accordingly a trephining was

done, and these adhesions, real or supposed, were broken up. For a

time he seemed to be better. Then he had some urinary trouble. A long

prepuce, though one that was never tight or adherent, and only

required a little attention to cleanliness to keep it from giving

bother, was removed. Some disturbance of his appetite led him to limit

his eating for a time, and then he suffered from constipation. This

was diagnosed by a specialist in rectal troubles as due to abnormally

developed valves in his rectum, and these were cut. He still

complained very much of abdominal discomfort at times. This was

diagnosed as ptosis of his organs, and an operation was done to tuck

these up. After this he developed a large ventral hernia, which had to

be relieved by a subsequent operation.

I had followed the case carefully during many years, seeing him at

times, and I was always opposed to the idea of operation and fully

confident that none of the operations were really needed. He could not

be persuaded that what his case needed most was occupation of mind

with something besides his condition. Whenever I could persuade him of

this I had seen him gain in weight, get into much better spirits and

be almost able to take up his work again. Then he would become

discouraged, and before long I would hear of another operation that

was planned, or was about to be performed. During the course of one of

his many progressive losses in weight as a consequence of depression

of mind, he developed tuberculosis. He resisted this very well, but

eventually died rather suddenly of an empyema. A careful autopsy

showed nothing but the traces of former operations, and no reason why

they should have been done.

Another case: A friend, also a clergyman, had three operations done,

one of them circumcision, the second an appendectomy and the third on

a supposed floating kidney. None were indicated, so far as I could

see, by any definite symptoms, or justified by his condition. He had

vague abdominal discomfort, and this continued to bother him in spite

of treatment by various specialists, and his mind became so much

occupied with it that he was ready to submit to anything in order to

be rid of his burden of discomfort. At no time was it an ache, nor did

he ever speak of it as a pain. He had some tendency to dilatation of

the stomach and at times, when much occupied with indoor work and

neglecting muscular exercise, there was probably some delay of

digestion. His appetite was good whenever he would let it be; his

bowels were regular whenever he was eating sufficient to stimulate

them to normal function; he slept well, except when unnerved by

something, but the presence of this abdominal discomfort disturbed

most of his waking hours. He could stand it so far as it had gone, but

he was sure that it would become so much worse in the future that it

would be unbearable. He dreaded that cancer or some other awful

development would come after a time.

As a matter of fact, the main portion of the discomfort in these cases

is the dread of what may happen. It is a dread, just as misophobia or

claustrophobia or acrophobia or any of the other dreads that we

discuss in the chapter on that subject. The constant occupation with

this dread apparently inhibits to some degree the flow of nerve

impulses to the abdominal organs, and digestion, already disturbed, is

still more impaired. Indeed, the whole {306} of the discomfort seems

to be a consciousness of stomach and intestinal function rather than

anything more serious. The stomach will take two or three pounds or

even more of mingled liquids and solids at a meal and pass them on to

the intestines without forcing itself into the field of our

consciousness. Anyone who is aware what a thin-walled membranous bag

the human stomach is--what it most nearly resembles is perhaps the

familiar bladder of the cow--may well be surprised that, though it is

supplied with many sensitive nerves, it gives so little sign of the

load that is often placed in it. It may, however, be brought rather

poignantly into the sphere of consciousness by concentration of

attention on it.

The intestines function usually with the same lack of reflex. They

proceed to pass on this quantity of food, store up two or three days'

rations, digest what is nutritious and eliminate what must be

rejected, without rising into consciousness. If either stomach or

intestines once begin to attract attention, then it will be difficult,

unless care is exercised to distract the mind from them, to replace

and keep them back in the sphere of the unconscious once more.

Peristaltic movements are constantly taking place in the digestive

tract. Various things may interfere with peristalsis, and the

disturbance of it will almost surely cause some sensation. It may not

be serious, and digestive processes may continue, yet there may be

discomfort. If there is delay in the passage of food, gas accumulates

in the stomach, presses up against the diaphragm and interferes with

the heart action. This will give rise to many bothersome sensations,

some of which are felt in the heart region itself; others much lower

down on the left side, where it is rather hard to recognize just what

the real seat of them may be. A good deal of the abdominal discomfort

of which people complain, is due to such functional disturbances,

emphasized by the fact that digestive action has come into the sphere

of consciousness and now attention is being concentrated on it, to the

detriment of digestion itself, as well as to the increase of the

annoyance which the discomfort may occasion.

Operations for abdominal discomfort are quite contra-indicated, unless

there are very definite localizing symptoms of some pathological

lesion that can surely be relieved by operative intervention. To

operate on general principles is sure to emphasize the patient's

concentration of attention on his abdominal discomfort, if it does not

relieve it, and in most of these cases it utterly fails. The strong

suggestion of an operation will relieve for the time being, just as

operations for epilepsy seemed to relieve when that procedure was

first introduced, though now, unless there are definite localizing

signs, there is no question of such an operation.

Toxic Factors.--_Tea_.--A very interesting phase of abdominal

discomfort seems to be associated with the taking of nerve stimulants.

I have frequently found that patients who complained of vague

abdominal uneasiness, sometimes rising particularly at night to the

height of colicky feelings but always on the left side, were indulging

to excess in tea or coffee. In one case, a woman was taking, she

thought, about a dozen cups of tea a day. Just how much more than this

she actually was taking I do not know, for it is almost incredible the

amount of tea that middle-aged women who are alone may take. I once

found by actual count made for me, that a woman was taking almost a

score of cups of tea in each twenty-four hours.

{307}

Just as soon as there is a reduction in the amount of tea taken in

these cases, relief is afforded the patient. This relief will not,

however, be absolutely satisfactory because the craving for the tea

stimulation makes the patients irritable, and it takes but very little

to cause them to complain that they still have their old discomfort.

In the course of three or four days they realize that the root of the

trouble has been reached. If the discomfort has continued for a good

while, a sort of habit seems to be formed, and the attention of the

mind gives a sense of uneasiness, if not discomfort, in the left

abdominal region. Usually it is in the upper left quadrant and seems

to be stomachic in origin. The discomfort is apparently due to the

presence of air, or gas, which is not properly expelled because of

some lack of co-ordination of muscles, and then the warmth of a room

or of the bed at night, or the presence of some slightly irritant

substance makes the discomfort more noticeable. In the patient's

over-stimulated condition, there is inability to withstand it

patiently. In none of these cases is there a fever, though in all

there is some disturbance of the pulse as if the heart's action were

interfered with and the organ resented it.

_Coffee_.--In some cases the same vague abdominal discomfort occurs as

a consequence of taking too much coffee. This is seen in men more than

in women. The tea topers are nearly all women, though my attention was

first called to this vague discomfort, that made life miserable for a

tea tester, who spent most of his day tasting tea, though drinking

very little of it. With regard to coffee, individual idiosyncrasy is

an extremely important matter. Some men seem to be able to take five,

six or even more cups of coffee in the day without inconvenience; some

cannot take even a small cup of coffee after six o'clock at night

without being kept awake for several hours; others cannot take a large

cup of coffee in the morning without having considerable discomfort,

which is usually attributed to indigestion. I have known large, strong

men, who were much better for not taking any coffee, or at the most a

tablespoonful of it in a cup of milk in the morning to satisfy the

taste.

Loose Kidney.--Movable kidney is responsible for many of these cases

of abdominal discomfort. Where it exists to a marked degree it may be

relieved by operation. It occurs much more frequently in women than in

men because, for physiological reasons, the kidneys are normally more

movable in women and this is particularly true of the right kidney,

which would otherwise perhaps be injured by pressure between the

pregnant uterus and the liver. It is probable that many of the cases

of the kidney of pregnancy are really due to an abnormal fixity of the

kidney to a particular place, so that the growing uterus interferes by

pressure with its circulation and its function. Slight movability of

the kidney, then, should not be considered pathological.

I have seen a number of these cases. They seem to occur particularly

in women who have lost weight. The fat around the kidney is somewhat

absorbed during the course of loss in weight, and this leaves this

organ more movable and also less protected and consequently more

liable to irritation. One sees it rather frequently in many unmarried

women who have some strenuous occupation. Many of these young women

come back from their vacation at the end of the summer having gained

fifteen or twenty pounds in weight. If there has been any kidney

sensitiveness or movability before, {308} both have usually

disappeared. The kidney is well held in place because there is much

more fat within the abdomen, all the organs are better cushioned, yet

without any interference with their function.

During the course of the year these patients, school-teachers,

stenographers, and daily workers of various kinds, lose in weight.

When they have lost ten pounds the kidney begins to be sensitive again

and somewhat movable. By the time they have lost fifteen to twenty

pounds there is serious complaint in the right upper quadrant of their

abdomen extending at times over toward the navel, and the kidney

becomes quite movable. At this time the treatment must consist in

holding the kidney as firmly in place as possible, for dragging

downward will be followed by reflex symptoms in the stomach and

intestines. Disinclination to food, loss of appetite, and even the

occurrence of some nausea, as well as some constipation, are easily

traced to kidney reflexes. During the night there is no trouble,

because while the patient is lying down the kidney falls into its

proper position. On arising in the morning the kidney drops down out

of place. If a corset is put on at this time the kidney may be forced

still further out of place, giving rise, after a couple of hours, to

considerable discomfort. New shoes can be borne at first, but after a

time the pressure they produce shuts off circulation and causes

intolerable discomfort. To a less degree this happens to the kidney if

thus compressed and this explains the course of symptoms in many

cases.

_Mechanical Treatment_.--If the corset is adjusted before the patient

rises, and fits reasonably snugly, but not too tight, the contents of

the abdomen will all be kept in place, and the kidney will maintain

its normal position. When the corset is not sufficient to retain the

kidney in place, a simple pad, a towel or a napkin or, if there is

much sensitiveness, something more elaborate, especially adapted to

conditions, can be placed over the kidney, and when held firmly by the

corset will keep the kidney in its place. At first the kidney is

usually sensitive to this on account of having been pressed upon

during the preceding weeks or months. The patient must bear some

little inconvenience at first, must get accustomed to the new

conditions in which the kidney is kept in place, and must not expect

complete relief at once. Any improvement must be considered a step

forward, and further amelioration can be confidently promised. As in

all other cases of the use of apparatus or mechanical

aids--spectacles, false teeth or crutches--the patient must be content

to grow used to the new order of things, before expecting satisfying

relief.

This is the palliative treatment. The natural treatment of many of

these cases is to have the patient maintain such weight as will hold

the kidney in place, because of the fat within the abdomen, without

any necessity for external aids. This can be done more readily than is

often thought to be possible. These patients insist that they lose

their appetite when they settle down to work, but what they really

lose is the habit of eating a definite amount at stated intervals.

Very often it will be found that breakfast, which they took abundant

time to eat during vacation, is rushed. The luncheon suffers in the

same way and is small in quantity. They take only one good meal, and

one good meal is not sufficient to maintain normal weight.

_Question of Operation_.--When a kidney is so movable as to deserve

the adjective "floating," so that it moves considerably from its place

and, perhaps, even sags and may be felt in the subumbilical region, it

should be fastened up {309} by surgical means. There is a choice

between two evils. The fastening of the kidney in the loin does not

restore the normal condition, but puts it in an artificial condition.

The kidney supports are of such a kind that it was evidently meant to

be slightly movable. When it is fastened firmly in the loin, it is

likely to feel every jar, and certain post-operative cases that I have

seen, in which firm adhesions had supposedly taken place, complained

considerably of the discomfort occasioned by this. In a certain number

of cases, even after the operation, the kidney is still somewhat

movable, because the adhesions yield and some of the old distress

returns. All this must be realized before there is any question of an

operation. There must be not merely a little discomfort, but enough of

actual ache and of reflex disturbance that can be traced directly to

the kidney to warrant the operation.

No floating kidney should be operated upon in a patient who has lost

much in weight and has developed a sensitiveness of the kidney since

the reduction of weight. Definite efforts should first be made to

bring about increase in weight, so as to see whether this will not

restore the previous condition of reasonable comfort. At times it is

said that the disturbance of the stomach, that is reflex to such a

floating kidney, prevents the patient from taking and assimilating

enough food to restore normal weight. This will be true if attention

has been called to the condition very seriously, and if the patient is

persuaded that this is the reason why there is no appetite and poor

digestion. Ordinary palliative measures, such as a binder, or a

specially made corset, will be sufficient to prevent the kidney from

producing reflex disturbance of the stomach, and will exert a strong

suggestion to this effect under the influence of which the patient

will usually gain in weight.

_Intermittent Discomfort_.--The discomfort that comes with a loose

kidney may be quite intermittent. I have known patients to be bothered

by it for months, and then quite free from it for several years, only

to have their discomfort renewed so that they become quite worried.

Some definite local or mechanical condition can generally be found for

these variations in feeling.

In thin people a jolting ride over a rough road or stepping off a car

will occasionally be the beginning of the trouble, and as this also is

likely to cause a stone in the kidney to give its first

manifestations, there may be serious suspicion of a more grave

pathological condition than is really present. If this discomfort

continues only the X-ray can absolutely decide the question.

Once the mechanical conditions which cause the discomfort are

understood by the patient, the actual ache becomes much more easy to

bear. Apprehension makes it almost intolerable. Attention exaggerates

it, and makes diversion of mind difficult. Understanding helps all the

conditions and lessens the pain, not actually but mentally, until

after a time very little attention is paid to it.

{310}

SECTION VII

_CARDIOTHERAPY_

CHAPTER I

THE HEART AND MENTAL INFLUENCE

The heart is an organ so vitally important that we might expect it to

be carefully protected by nature from any interference with its action

through mental influence, emotional conditions, or voluntary or

involuntary feelings. As a matter of fact, it is extremely susceptible

to mental influence, stimulant or depressive, and to emotions of all

kinds. Psychotherapy, that is, the removal of inhibiting influences

originating in the mind, and the suggestion of favorable mental

influences, is probably more important for the heart than for any

other organ in the body. The law of reserve energy has its most

noteworthy applications with regard to it. When we are apparently so

completely fatigued that we cannot do anything more, a purely mental

stimulus may so enliven the heart as to give the body a new supply of

strength and energy. A man wandering through a desert, or swimming for

his life at sea, may be so exhausted as to be quite ready to give up

entirely, and be brought to the conviction that he has absolutely no

strength left for further effort, when a flash in the distance, or a

sound that indicates that help is near, or some other mental

incitement, will give renewed energy. It is probably through the heart

that there comes to us most of our power to accomplish things when we

are already so tired as to seem exhausted. On the other hand, it is

the failure of circulation in muscles, because of a slacking heart,

that produces the sense of exhaustion. Muscular work is easy or even

pleasant when we are in good spirits, while, whenever exertion is

undertaken in the midst of discouragement, we cannot accomplish nearly

so much as when conditions are so framed as to give stimulus and

encouragement.

If a perfectly normal heart can be so affected by mental conditions

and emotions as to be seriously disturbed in its work on the one hand,

or greatly stimulated into new activity on the other, it is to be

expected that a heart affected by disease will be similarly affected

and probably even to a greater degree. It is clear, then, that our

cardiac patients have to be guarded against unfavorable mental

conditions, and have to have all their reserve energy called out for

them by encouragement and by the best possible prognosis for their

reflection. This is especially true as regards the removal of the many

unfavorable suggestions which, because of ignorance, have in the past

gathered round most forms of heart disease.

{311}

Emotion and the Heart.--The mental and emotional influence over the

heart's action was the truth that lay at the basis of the old fallacy

with regard to the physiology of the heart. The literature of all

countries testifies that the heart was long supposed to be the seat

and origin of the emotions. Every one has experienced how the heart

jumps when something unexpected happens. People have fainted from

excess of joy as well as of grief. The physical side of emotion is so

generally associated with some modification of the heart beat that it

is no wonder that emotions were directly connected with the organ.

When people are in depressed states the heart is apt to beat more

slowly than usual, while when in states of exhilaration, even those

dependent merely on mental factors, the pulse is more rapid.

Melancholic states have occasionally been attributed to the slowness

of the pulse, but the slow pulse seems to be a symptom connected with

the mental condition rather than a causative factor. In the maniacal

conditions, the rapidity of the pulse, which is sometimes quite

marked, must probably be explained in the same way, as due to the

mental excitement under which the patient is laboring.

The Heart and the Nervous System.--Prof. Von Leyden ten years ago

recalled attention to the fact that the heart is literally the _primum

movens_ in man, and that before the central nervous system is laid

down, or there is any possible question of impulses flowing from

center to periphery, the heart, or at least its embryonic

representative, is beating as constantly, regularly, rhythmically, as

it is to do during all the subsequent life of the individual. Oliver

Wendell Holmes has expressed it poetically by stating that the angel

of life sets this heart pendulum going and only the angel of death can

break into the case and stop it.

_Primitive Heart Action_.--The original beating of the heart is

entirely automatic, and quite apart from any nervous initiative or

stimulus. The original bend in the primal blood vessel, which is to

represent the heart in the course of development, begins to pulsate

very early in the chick and evidently does the same thing in all other

living things. Notwithstanding this fact that the heart is thus easily

demonstrated to be the _primum movens_, the first exhibitor of

vitality, and might thus seem to be one of the organs or indeed the

one which should be safe from any nervous interference, later on

powerful connections with the nervous system are made, and heart

acceleration and inhibition become familiar phenomena. Every emotion,

as we have said, has its influence on the heart and even a certain

amount of voluntary control may be acquired. Indian fakirs are said to

be able to cause the heart to slow and almost to stop. The curious

phenomenon of suspended animation which they sometimes exhibit is said

to be due to this. Certain of the well-developed muscular subjects who

exhibit themselves at medical clinics are able to cause their hearts

to miss a beat, but this is said to be rather a result of will-power

over other muscles compressing the thorax, and interfering with the

heart, than direct influence upon the heart itself.

Mental Influence over Diseased Hearts.--Worry produces much more

serious symptoms in heart patients than in others. Anxiety about the

heart itself is often a source of serious detriment to a heart

patient. Most people have such a terror of having anything the matter

with their hearts that the haunting thought of such calamity is likely

to have a definite influence in preventing the development of such

compensation as will enable the heart to {312} do its work to the best

advantage. It used to be the custom to refrain from telling patients

suffering from tuberculosis that they had the disease. On the other

hand, people with heart disease were usually informed of that fact.

The reason given for the latter course was that heart disease may in

many cases be the forerunner of sudden death, and the warning

knowledge was supposed to enable a man to get his affairs in order. No

worse policy for either disease could well have been imagined. The

pulmonary patient should be told at once, the heart patient should, as

far as possible, be saved the depressing knowledge of his condition.

Dr. MacKenzie, whose practically illuminating studies of heart disease

give him a right to express opinions with regard to it (and when those

opinions concern the influence of the mind they are doubly valuable

because of the absolute objectivity of his studies), has some rather

strong expressions with regard to the importance of modifying the

mental state in heart cases. He says:

The consciousness of heart trouble has often a depressing effect on

people, whether the trouble be slight or serious. When such people

become convinced that the trouble is curable or not serious, their

condition at once becomes greatly improved. Cures by faith, whether

in drugs, baths, elaborate methods or religion, act by playing upon

the mental condition. But our employment of this element in

treatment should not be the outcome of blind unreasoning faith in

some rite or ceremony, bath or drug, but in the intelligent

perception of the nature of the symptoms. The reassurance of the

patient of the harmless nature of the complaint goes a great way in

curing him. The reassurance that with reasonable care no danger need

be feared is extremely helpful. Even in serious cases when there is

reasonable hope of recovery or a certain degree of recovery, the

encouragement of the patient may and does help forward his

improvement.

Heart Remedies and Suggestion.--Probably the best evidence we have for

the influence of the mind over the heart in diseased conditions, that

is, when there is definite organic change in the heart valves or

muscle, is to be found in the history of the many remedies that have

come and gone in heart therapeutics during the past generation.

Strophanthus, for instance, was very popular a quarter of a century

ago, and it seems as though in many cases it not only replaced, but

was more efficient than digitalis. How few there are who use it now

with confidence, and how general is the impression that it does not

affect the heart to any extent! The confidence with which the remedy

was given by the physician was conveyed to the patient and he "took

heart," as the expression is, and proceeded to get better. Even more

striking is the evidence afforded by other remedies. For a while it

seemed that cactus provided a heart stimulant and regulator of value.

Convalaria also gained a reputation as a heart remedy. Both are now

practically abandoned. Here, once more, the real remedy, when these

substances were employed, was, undoubtedly, the suggestion to the

patient in connection with the regulation of his habits of life, so

that his heart got a chance to catch up with its work. There are other

remedies with which we had similar experiences.

Even digitalis has had phases of confidence and distrust in it, that

are interesting to study in the light of what we now know with regard

to the influence of the psyche on the heart. One hears at medical

society meetings reports of the favorable action of digitalis within a

few hours of its administration. These are not examples of digitalis

action, but of mental influence. {313} Any heart patient after the

first visit of a physician in whom he has confidence is sure to

brighten up at once, heart action is ever so much better and symptoms

of mental depression, and even of circulatory disturbance, disappear.

It is this that has made the study of even the efficiency of digitalis

so difficult. There were times when most physicians employed it in

rather large quantities for all forms of heart disease. In some heart

cases it is absolutely contra-indicated. Fortunately many of the

preparations of digitalis used in the past were quite inert, and so no

harm was done. The results obtained were psychotherapeutic.

Cardiac Inhibition.--The importance of the role of the nervous system

and of the mental influences which control it in all functions is well

illustrated by what we have learned during the last half century with

regard to inhibition in the animal organism. We used to think that

while the nervous system sent down positive impulses--that is, nervous

stimuli which brought about the accomplishment of certain

activities--it had nothing to do with the stoppage of those

activities. Such interference was supposed always to be due to

external influences of various kinds, potent for the time, in the

organism. We have learned, however, that inhibition is one of the

important functions of the nervous system. The idea has now become so

familiar that sometimes we are apt to forget how great is its

significance. Lauder Brunton, in his article on "Inhibition," set

forth its role as we have come to know it.

The recognition of the part inhibition plays in vital phenomena is

undoubtedly one of the most important discoveries which have been

made in physiology since Harvey discovered the circulation of the

blood. It throws light upon an immense number of phenomena

previously inexplicable and enables us to form theories of a

satisfactory nature about many vital problems. It offers an

explanation of the nature of hypnotic states, which is at least as

satisfactory as that we have of the action of many drugs.

The nervous mechanism of the heart affords the best and most

commonly cited example of inhibitory action, and here it was first

studied by Weber and Claude Bernard in 1848. The cardiac ganglia

derived from the sympathetic preside over the movements of the

organ, and in response to the stimulus of the intra-ventricular

blood-pressure cause rhythmical contraction of the cavities. Their

action is, however, controlled by the pneumogastric nerve, through

which impulses of an inhibitory nature are constantly traveling and

acting as a restraining force.

As noted by Lauder Brunton, the late Professor Czermak had a small

glandular tumor in close contact with the right pneumogastric nerve

and he was able by pressure on this to compress the nerve to any

extent he wished, and either "to completely stop the heart or simply

retard it." He often performed this experiment so that it is not

nearly so dangerous as might be thought. We have some instances,

apparently too well authenticated to be doubted, in which the power of

the human will to inhibit heart action has been as strikingly

manifested as this mechanical disturbance of Professor Czermak.

Sometimes these stories of cardiac inhibition through the will are

dismissed as unworthy of credence, and doubtless many of them are mere

fiction, or have been exaggerated for sensational purposes, but some

of them are very suggestive examples of the power of the will over the

heart. If only a modicum of such power were to be employed, it would

seriously hamper heart action, and it must be the aim of psychotherapy

to prevent such inhibition.

{314}

At least one instance of voluntary heart inhibition was observed by

thoroughly trained and properly accredited scientists. A report of it

has been published. As a bit of documentary evidence, on a subject

that is usually considered so vague as to be scarcely worth

considering, Dr. Cheyne's description of the remarkable power of

Colonel Tonshend over his heart should be in the hands of those who

wish to influence hearts through minds and wills.

He could die or expire when he pleased, and yet by an effort, or

somehow, he could come to life again. . . . We all three felt his

pulse first: it was distinct, though small and thready, and his

heart had its usual beating. He composed himself upon his back and

lay in a still posture for some time. While I held his right hand.

Dr. Baynard laid his hand upon his heart, and Mr. Skrine held a

clean looking-glass to his mouth. I found his pulse sink gradually

till at last I could not feel any, by the most exact and nice touch;

Dr. Baynard could not feel the least motion in the heart, nor Mr.

Skrine discern the least soil of breath on the bright mirror. Then

each of us by turns examined his arm, heart and breath, but could

not by the nicest scrutiny, discover the least symptom of life in

him. We reasoned a long time about this odd appearance, and finding

he still continued in that position, we began to conclude that he

had indeed carried the experiment too far; and at last we were

satisfied that he was already dead, and were just ready to leave

him. This continued about half an hour. . . . As we were going away

we perceived some motion about the body, and, upon examination,

found his pulse and the motion of his heart gradually returning; he

began to breathe heavily and speak softly.

Nor must it be thought that the inhibitory faculty can act only in

slowing the heart. Normally a certain amount of inhibition is

exercised over the heart's action. If by any chance this should be

decreased then acceleration of cardiac activity may take place. Lauder

Brunton called attention to that in discussing another phase of

pneumogastric function. He said:

Paralysis of the pneumogastric, of course, does away with its

action. And hence we have among other symptoms of this condition

increased rapidity of the contractions of the heart from withdrawal

of the inhibitory influence.

If slowing of the heart action can be produced through the mind by

this mechanism of inhibition, so also under other circumstances may

acceleration occur.

Shock and the Heart--How large a role emotion plays in disturbing the

action of a heart that is already diseased, is illustrated by the

story told in serious histories, on what seems good authority, of the

dwarf of the French king, who was frightened to death by what he

thought were the arrangements for his execution. While we take great

pains as a rule to impress upon sufferers from organic heart disease

the necessity for their avoiding every kind of over-exertion, or

sudden movement of any kind, we do not always impress upon them the

even greater necessity for the avoidance of shock and fright, and

profound emotions. It must not be thought that emotional shocks have a

deleterious effect only in advanced cases of heart trouble. Almost any

physician will readily recall examples where emotion had much to do

with the break in compensation which indicates that the heart has for

a time been overworked.

A case in my own experience illustrates this: The patient, a student,

had suffered from severe so-called growing pains, undoubtedly

rheumatic, when he was about fourteen, and probably had acquired a

heart lesion at that time. {315} It did not, however, disturb him in

the slightest degree. The patient had never noticed any fatigue on

running up stairs; he had no shortness of breath; there were no

symptoms pointing to his heart. One summer while his family were in

the country he came into town for the day, and missing the last train

out, he went to the family home to sleep, though it had been closed up

for the summer. He let himself in without difficulty and was preparing

to go to bed when he resolved to get a glass of water. There being no

tumbler nearer than the dining-room, he went there. As he entered the

dining-room he struck a match. With the flash of the light he found

himself looking into the barrel of a revolver and a hoarse voice said,

"Hands up!" His hands went up. The next minute he was in the hands of

two "plain clothes" policemen who had been watching the neighborhood

because of recent burglaries. Noticing the light upstairs, they had

made their way in for the purpose of catching what they thought a

burglar at work.

The young fellow, who had never before fainted, collapsed almost at

once, and was unconscious for some minutes. The next day he was rather

prostrated and tired on movement. By resting a good deal for the next

week this passed off to a considerable degree, but then his physician

found that he was suffering from a serious heart lesion, with a

decided break in compensation. I saw him several months later. His

heart had never regained its old power, and his mitral valve was quite

unable to fulfill its function. Just what the mechanism of the almost

sudden break in compensation was after he had been for so long quite

immune from any effects of the rheumatism, is hard to say, but the

lesson of the case is easy to understand.

Place of Psychotherapy in Treatment.--The role of psychotherapy, then,

in heart cases consists in the recognition of the part that the mind,

the will and the emotions play in their influence over this important

organ. These psychic factors may produce disturbed conditions of

various kinds. The more experience the physician has with cardiac

cases of all kinds, organic as well as functional, the more powerful

does he recognize the influence of the mind over the heart to be. The

expression that a man is living on his will is no mere figure of

speech. Some cases we have cited seem to show that a favorable

attitude of mind keeps up heart action, where an unfavorable attitude

would almost surely allow the heart to fail. It is this very potent

influence then that must be used to as great advantage as possible in

the psychotherapy of cardiac patients.

Undoubtedly the most important phase of it is in prophylaxis. As far

as possible we must save our heart patients from emotions. The effect

of emotion on the heart is known. When that organ is already crippled,

emotion may produce a serious strain on it. It is as important to save

heart patients from joyful emotions as from those of contrary nature.

Many a son who, after years of absence, thought to surprise a dear old

mother by suddenly presenting himself to her, has learned to his cost

that an old heart may break from joy, almost as easily as from sorrow,

and may be as unfavorably affected by the glad emotions as by terror

or fright. We must also save heart patients from the unfavorable

influence of a bad prognosis, and of too serious a diagnosis, both of

which may be quite unjustified, for the rule is that the longer a man

has been studying the heart, the less likely is he to be confident in

his diagnosis, or unfavorable in his prognosis.

{316}

The curative place of psychotherapy is in the obtaining, as far as

possible, of placid easy lives for these patients. This does not mean

that they are to give up their occupations, for very often the

internal emotional life, which develops when they have nothing to do

but think about themselves, will be more serious in its effect upon

the heart than the ordinary vocation. Exciting incidents in life work

must, however, be avoided. If men are in occupations that require

exposure to excitement, then it may be advisable to change their

occupations. Brokers, speculators, actors, sometimes public speakers,

on whom appearances in public in spite of apparent placidity are often

a severe strain, may have to be guided into quieter paths of life. In

general, in every attempt to treat heart disease, and the neurotic

symptoms which develop in connection with it, the patient's mind must

be considered as one of the most important therapeutic factors.

CHAPTER II

DIAGNOSIS AND PROGNOSIS IN HEART DISEASE

The more carefully heart disease, and particularly individual patients

affected by various heart lesions, have been studied in recent years

the more it has come to be appreciated that the most important element

in the treatment of organic heart disease is the definite recognition

of the difficulty of exact diagnosis of most cardiac conditions and

the unfortunate tendency to make the prognosis worse than it really

is. Many heart affections are quite compatible with long life. In the

past both of these problems of diagnosis and prognosis have been only

too often solved unfavorably to the patient, to the serious detriment

of his power of physical reaction against the ailment. Many a patient

has been seriously disturbed and even his power of compensation

lessened by having a diagnosis of an organic affection of the heart

made with the usual prognosis, or at least strong suggestion of early

death that goes with it, when there was no justification for such an

unfavorable opinion.

Mental Attitude of Patient.--We do not pretend to cure tuberculosis,

but we do relieve its symptoms and bring about a remission in the

progress with a shutting in of the lesions. In heart disease something

of the same kind can very often be accomplished. This does not mean

that in advanced cases of heart disease much good can be accomplished

any more than in advanced cases of tuberculosis, though in both a

change of the mental attitude may lift the patient from what seems

almost a death-bed into renewed activity for a prolonged period.

Probably heart disease is more serious in its prognosis than

tuberculosis, yet undoubtedly the lives of many patients could be

prolonged nearly as much as in the pulmonary affection and a large

amount of suffering saved through mental influence. We do not hesitate

to change the occupation and the place of abode of the patient

suffering from tuberculosis. There is even greater reason for doing

this same thing when it seems advisable with patients suffering from

heart disease.

With regard to heart disease, the best authorities are now agreed that

it is better, as a rule, not to tell the patient himself unless it is

absolutely {317} necessary to do so in order to get him to take the

precautions that will prevent further deterioration of his cardiac

condition. The depression incident to the knowledge that one has a

serious heart lesion is not reacted against, and especially not during

a threatening break in compensation, and a more favorable time must be

waited for to reveal his condition to him. The danger of sudden death

in valvular heart disease is much less than is popularly supposed.

Only sufferers from aortic heart disease are likely to die without

warning, and this form of the disease is comparatively rare. The death

of the patient suffering from mitral disease is likely to be

lingering. Mitral disease is the commonest form of heart disease, and

the prognosis of it in ordinary cases is by no means so grave as is

usually supposed. I have seen a patient still alive with a mitral

murmur who told the story of having had his affection originally

diagnosed as mitral regurgitation by Skoda, the distinguished Vienna

diagnostician, over forty years before. This patient at the time I saw

him was nearly seventy years of age, still had the mitral murmur, but

his apex beat was scarcely if at all displaced and there was neither

enlargement of the ventricle nor apparently any degeneration of the

auricle.

The Apex Beat and Heart Murmurs.--In this regard an expression of

Prof. Carl Gerhardt of Berlin deserves to be recalled. That

distinguished clinician used to say that if the apex beat was not

displaced there was no good reason for thinking that any heart

affection which might be present was serious enough to require active

treatment. Heart murmurs have been made entirely of too much

significance and any man of considerable experience is likely to have

seen a number of patients who, because they had a heart murmur, had

been seriously and needlessly disturbed by having a physician tell

them that they had heart disease, with an air of finality that seemed

to the patients to say that they might prepare for the worst very

soon. Patients suffering from diseased hearts have to care specially

for themselves, but not to the extent of living such maimed lives as

is likely to be the case if they are depressed by an unfortunate

exaggeration of the seriousness of their condition.

Our best authorities in* heart disease have at all times proclaimed

their uncertainty as to the diagnosis of heart conditions from

murmurs, while mediocre men of comparatively slight experience have

not hesitated to declare their certainty in this difficult matter. It

is not an unusual thing to hear of a supposed expert having declared

upon the witness stand and under oath that he could tell whether a man

had heart disease by _listening_ to his heart, and some have even gone

the length of making their decisions in this matter while listening

for a few moments sometimes even above the clothing of the patient!

Needless to say, this is quite unjustifiable in our present knowledge

of the status of heart affections and only men of small experience and

over-confidence in themselves make any such declarations. The more

experience a physician has had in heart disease, the more careful he

is not to make positive declarations. One or two examinations may very

easily be deceptive unless there are signs quite apart from those in

the heart itself. Indeed, it is much more the state of the individual

than the state of the heart itself, or anything that can be found out

about it, except after a prolonged and repeated study, that enables us

to make definite decisions. Probably no one during the nineteenth

century had studied hearts more carefully than Prof. William Stokes,

whose books on the subject were so widely read. He wrote:

{318}

We read that a murmur with a first sound, under certain

circumstances, indicates lesion of the mitral valves. And again,

that a murmur with the second sound has this or that value. All this

may be very true, but is it always easy to determine which of the

sounds is the first, and which is the second? Every candid observer

must answer this question in the negative. In certain cases of

weakened hearts acting rapidly and irregularly, it is often scarcely

possible to determine the point. Again, even where the pulsations of

the heart are not much increased in rapidity, it sometimes, when a

loud murmur exists, becomes difficult to say with which sound the

murmur is associated. The murmur may mask not only the sound with

which it is properly synchronous, but also that with which it has no

connection, so that in some cases even of regularly acting hearts,

with a distinct systolic pulse, and the back stroke with the second

sound, nothing is to be heard but one loud murmur.

So great is the difficulty in some cases, that we cannot resist

altering our opinions from day to day as to which is the first and

which the second sound.

To the inexperienced the detailed descriptions of such phenomena as

the intensification of the sounds of the pulmonary valves; of

constrictive murmurs as distinguished from non-constrictive; of

associations of different murmurs at the opposite sides of the

heart; of pre-systolic and post-systolic, pre-diastolic and

post-diastolic murmurs, act injuriously--first, by conveying the

idea that the separate existence of these phenomena is certain, and

that their diagnostic value is established; and secondly, by

diverting attention from the great object, which--it cannot be too

often repeated--is to ascertain if the murmur proceeds from an

organic cause; and again, to determine the vital and physical state

of the cavities of the heart. . . .

There are too many cases in which murmurs have no such serious

significance as was often attributed to them when first studied, and

yet it used to be almost a universal custom among physicians, and the

custom still obtains with many, to tell a patient rather emphatically

whenever a heart murmur was present, that he had heart disease. Above

all, too much significance has been ascribed to murmurs in initial

cases of heart disease and these are just the cases that should not be

disturbed by unfavorable suggestion. The louder the murmur the less

likelihood there is of there being heart disease in the ordinarily

accepted sense of the term, that is, that the heart is so affected as

to be incapable of doing its work properly, for where loud murmurs are

present this is almost never the case. A murmur that may be heard a

foot distant is usually associated with perfect compensation.

If this were remembered by those who examine hearts generally, there

would be much less disturbance of heart action by unfavorable mental

influence. A great many more who are suffering from certain

symptomatic conditions of the heart not surely or necessarily

dependent on organic lesions, are plunged into depression by

unfortunate, premature or exaggerated expressions on the part of their

physicians. It is almost a rule to have men and even women patients

say that it makes no difference to them, that they should be told the

exact truth as to what their condition is. The future has been

mercifully hidden from us in most things and there is no doubt that

this plan is the better for human comfort and accomplishment

generally.

The truth is not easy to find and oftener in these cases lies on the

side of favorable prognosis and refusal to think the worst than the

opposite. In this there has been a great difference between the German

and the Irish schools of medicine. The three great Irish physicians,

Graves, Stokes and Corrigan, insisted on the place of the individual

and upon how much depends upon the general conditions in pulmonary and

cardiac disease. Our teaching in {319} America in this matter has come

not from the conservative British schools of medicine, but from the

German school, and that has had a notable tendency to exaggerate the

significance of heart signs over the general condition.

What a great distinction there is between this mode of looking at

these diseases and the German method was pointed out by Prof. Lindwurm

of Munich, when he translated Prof. Stokes' work on the heart into

German. Prof. Lindwurm said:

Thus our modern German works are to a greater or lesser extent only

treatises on the physical diagnosis of organic affections of the

heart. Stokes, on the contrary, resists this one-sided tendency

which bases the diagnosis solely on physical signs and disregards

the all-important vital phenomena; he lays less weight on the

differential diagnosis of lesions on the several valves and on the

situation of a sound than on the condition of the heart in general,

and especially on the question as to whether a murmur is organic or

inorganic, and whether the disease itself is organic or functional.

Broadbent on Cardiac Diagnosis.--What Stokes taught the

English-speaking world so emphatically in the first half of the

nineteenth century Sir William Broadbent was just as insistent about

in the latter half. It is evident, then, that clinical experience has

not changed its viewpoint in these matters in spite of all our study

of the heart in the interval. In his paper on "The Conduct of the

Heart in the Face of Difficulties" he has many suggestions that will

prevent the physician of less experience from taking too pessimistic a

view of heart symptoms. He said:

Moreover, the heart has very special relations with the nervous

system; it reflects every emotion, beats high with courage, is

palsied by fear, throbs rapidly and violently with excitement, and

acts feebly under nervous depression; but it is not only through the

cerebro-spinal system that the heart is influenced, it is in

immediate relation with the vasomotor nervous apparatus, and in a

scarcely less degree with the sympathetic system generally.

Normally, afferent impulses are constantly flowing from the viscera

to the central nervous system and by this reflex process their blood

supply is regulated, and their functional activity is governed.

These afferent impulses when perverted by functional derangement or

disease may become serious disturbing influences.

The nervous system in a large and increasing proportion of people is

unduly sensitive and excessively mobile, and the reactions to

influences of every kind are exaggerated. In some a little emotional

excitement gives rise to palpitation, and a piece of bad news or the

bang of a door seems to stop the heart altogether. _There is in such

subjects no form or degree of cardiac disease which may not he

simulated_. [Italics ours.] Add a touch of hysteria on the lookout

for symptoms and for someone to give ear to the narration of the

unparalleled agonies of the sufferer, and the difficulties of the

heart, and it may be added of dealing with them, are complete.

Typical Case.--We are prone to think that after the age of seventy the

existence of definite heart murmurs with some tendency to blueness of

the lips and of the fingers, with coldness of the hands, surely

indicates the presence of a serious heart lesion. It is in old people,

however, that such symptoms may be most deceptive. The outcome may

prove that physical signs ordinarily presumed to be surely indicative

of organic disease may be only signs of functional disorder, or at

most may represent certain organic affections for which even the old

heart is thoroughly capable of compensation. One such instance in my

own experience is so striking that I venture to give it in detail.

{320}

This was the case of an old physician friend of some eighty years of

age. His son had a summer lodge in the Adirondacks. Though for some

sixty years the father had been living at the sea level in New York

almost constantly, he went up to visit the son and be with his

grandchildren at an elevation of nearly 2,500 feet. His heart began to

bother him almost at once and he could not go up or down stairs or

take any exercise without considerable discomfort, marked shortness of

breath and a tendency to palpitation that was almost alarming. He

continued his stay for several months in the hope that he would get

used to the altitude, though there were always difficulties of

circulation manifested by blue lips and finger nails. He returned to

New York and placed himself under the care of a heart specialist who

found what appeared to be evident signs of heart deterioration of

muscular character complicated by valvular lesions. He consoled, the

old gentleman by the reflection that a heart that had served his

purposes so well for eighty years could not really be complained of if

now it should show some signs of deterioration. He also insisted that

any mental work would be almost sure to be injurious because of the

calls upon the circulation that it would make.

The old gentleman was ordered South for the following winter with an

absolute prohibition of any mental work. He had planned to revise an

historical work on which he had been engaged for many years and which

had served to keep him in good health perhaps more than anything else.

This was put away entirely and he proceeded to try to get well doing

nothing. Almost needless to say with nothing to do he did not get

well. He had been an extremely busy man all his life, had worked at

least twelve to fourteen hours a day for most of the preceding fifty

years, and for him to do nothing would be quite as impossible as for a

child to be kept in utter physical inactivity. His heart palpitation

continued and grew worse. He was waked up at night by starts that

seriously disturbed him and usually kept him from sleep for hours. As

he said himself, after he had read the morning paper and gone to

stool, there was nothing else for him to do all day except eat and

sleep, and these incidents had never occupied any of his attention in

the past. In spite of the doctor's orders he had his manuscript sent

to him and proceeded to work. At once he began to grow better. At the

end of three months he was feeling better than he had felt for several

years. When I saw him, about his eighty-first birthday, he was looking

better than he had for some time.

As he said himself in describing his case, his own experience had

taught him that the more fuss a heart made the less likelihood was

there of its having anything serious the matter with it, at least of

such a character as would terminate life suddenly or unexpectedly. The

serious heart lesions are those which give no symptoms, or but very

slight ones, and the sudden deaths in heart disease usually come from

the development of insidious symptoms that do not betray themselves to

the patient until the fatal termination is on them. The more the

patient himself has been disturbed by his heart, the less likelihood

is there of its giving out suddenly. The subjective symptoms are

usually due to the fact that the heart is actively overcoming external

interference, or resenting over-attention to it in its work. Certain

it is, that the neglect of it, so far as that is consonant with

reasonably regular life, is the very best thing and the most important

part of any prescription given for symptomatic heart disease, whether

organic or functional, is to forget it just as far as possible.

{321}

Heart Symptoms in the Young.--In young people particularly it is

important not to suggest the possibility of heart disease until there

are definite signs in the circulation apart from the heart which place

the diagnosis beyond all doubt. The psychotherapeutics of organic

heart disease that is most important is that of prophylaxis. Patients'

minds must be guarded as far as possible against disturbance from the

thought that they have heart disease, for this of itself adds a new

factor which tends to disturb compensation and adds to the heart's

labor because worry interferes with the vasomotor mechanism. In this

matter it seems advisable to repeat once more that there must be a

complete reversal of the customs that have existed until now with

regard to tuberculosis and heart disease. Consumptives have from the

very nature of their disease a tendency to hopefulness which soon

brings about a favorable reaction against the bad news, but heart

patients derive no advantage from the announcement and, indeed, if

they are of the nervous, worrying kind, the effect of it is likely to

be cumulative. A week after being told the worst a consumptive has

reacted vigorously and hopefully, and if he has a fair share of

immunity, the scare will do good by making him take the precautions

necessary to increase his resistive vitality. At the end of the same

time a heart patient will be just realizing all the significance of

the unfavorable diagnosis and prognosis of his case.

It may be urged that heart patients by knowing their condition will be

preserved better from injuring themselves by over-exertion, but what

we have said elsewhere about the value of exercise in the treatment of

heart cases shows how much patients may be injured by having their

exercise too much reduced and their activity inhibited by the dread

consequent upon the announcement made to them. It is perfectly easy to

insist with them that they shall not do sudden things, or take violent

exercise, or overdo activity, without disturbing them by the dread

words "heart disease."

CHAPTER III

CARDIAC NEUROSES

If, as all the authorities recognize, the attitude of mind toward

organic heart disease is extremely important and when favorable is a

most helpful therapeutic factor, it is easy to understand that in

neurotic conditions of the heart this is of even more significance.

The term "heart disease" is bound up with so many unfortunate and

persistently unfavorable suggestions that it seems advisable not to

use it with regard to non-organic conditions, even though it may be

associated with the epithets functional or neurotic. For these the

term cardiac neuroses, which avoids the implication of heart disease

in the ordinary sense, seems preferable. Many of the cardiac neuroses

are quite trifling. Many of them endure for years without producing

any serious effect or disturbance of the general health. Many

functional disturbances of the heart action which are extremely

annoying may disappear entirely with judicious regulation of life. The

one important condition in all of these cases is to be sure that the

patient does not worry over the condition, for that {322} hampers

heart activity and leads to functional disturbances of other organs

which make the heart's work harder.

Varieties.--There are many forms of cardiac neuroses. Indeed,

functional heart affections are so individual that it is hard to

classify them. In every case it is extremely important to study the

individual and recognize just what are the special factors bringing

about the disturbance of heart action.

_Palpitation_.--In a certain number of the cases it will be found,

indeed, that there is no real disturbance, but that in some way the

heart action has been brought above the threshold of consciousness and

has become noticeable to the patient. It must not be forgotten that

the heart is an intensely active organ. Several gallons of blood are

pumped through it every minute and yet it accomplishes its work, as a

rule, with such noiseless, frictionless regularity that most people

know nothing about it. When the action of the heart becomes conscious,

it is usually spoken of as palpitation. Patients are sure to think

that this must mean serious over-action, though, as a rule, no sign of

over-action or at most a slight exaggeration of the muscular sounds of

the heart will be found.

_Missed Beats_.--A further stage of this cardiac neurosis is the

missing of beats. This occurs particularly in those whose attention

has been directed for some time to their heart action by the presence

of palpitation. It may be due to nothing more than this

over-concentration of attention. It may be due, however, to mechanical

disturbances, an over-distended stomach, constipation, or certain

nervous factors.

_Arrhythmia_.--A third stage of cardiac neuroses consists of

irregularity of the heart action, in which not only are the beats

missed occasionally, but there may be certain heart sounds much less

vigorous than others and the spaces between the sounds may be very

unequal. This condition is usually said to be due to some serious

condition of the heart muscles, and undoubtedly it often is. There is

no doubt, however, that great irregularity of the heart may occur

entirely as a neurotic condition without any organic affection and

from factors quite extraneous to the heart itself.

Etiology.--There are three causative conditions for cardiac neuroses

that deserve careful study and that can be very much modified by

changing the attitude of the patient's mind toward his condition. The

first of these is an over-attention to self such as is particularly

induced by a life without much exercise and devoted to things

intellectual. The direct causation is probably intimately connected

with the second etiological factor in the production of cardiac

neuroses. This consists of an absence of sufficient exercise for the

heart itself, when it actually seems to disturb its own activity

because adequate calls for exertion are not made on it to use up

accumulated energy. Cardiac neuroses are seen particularly in those

who having had considerable exercise in earlier years, have settled

down to a sedentary life in which there are few calls made upon their

muscular system. The third etiological factor is the most important.

It is due to cardiac disturbance from the stomach and intestinal

tract; this will be discussed in a separate chapter.

Prognosis.--The prognosis in cardiac neuroses is always worse in the

patient's mind than it ought to be. If then the physician shows that

he is uncertain as to the real significance of the affection, some

hint of this uncertainty will be communicated to the patient with

resultant unfavorable suggestion. The {323} more carefully neurotic

heart affections have been studied, the better the prognosis becomes.

Morgagni in the olden time, Stokes and Corrigan in the early

nineteenth century, Broadbent and MacKenzie in our time, have all

emphasized the necessity for favorable prognosis. Even extreme

irregularity is quite compatible with long life without any symptoms

of serious circulatory disturbance. MacKenzie has, in his very careful

studies of heart action, shown that extra systoles may cause marked

irregularity in many forms without warranting unfavorable prognosis.

Arrhythmia may begin in comparatively early life, persist in spite of

treatment, and yet continue up to old age. Sir William Osler tells of

the case of the late Chancellor Ferrier of McGill University who died

at the age of eighty-seven after having exhibited an extremely

irregular heart action for the last fifty years of his life. He has

seen several other patients who have had heart irregularity for many

years without the slightest disturbance of their general health. His

experience is not uncommon, and probably every physician who sees many

cases of heart disease can recall a few of them. Ten years ago I saw a

man past seventy suffering from distinctly irregular heart action,

though he gave the history of having had cardiac irregularity for some

years at least, and he is still alive, past eighty, and with his heart

irregularity still present. I have a patient over seventy whom I know

to have had irregular heart action for fifteen years, and he himself

is sure that it has been present since he was about forty, at least.

It is cases of this kind, together with MacKenzie's recent studies of

the subject, that must be before the physician's mind when he makes

his prognosis for these patients. There must be no hesitancy about his

declaration. Patients think that physicians are prone to deny the

significance of heart trouble so as to avoid disturbing their

patients. The slightest hesitation, then, will be surely looked upon

as of ominous import.

The Intellectual Life and Cardiac Palpitation.--It is curious how many

people who give themselves to intellectual work and live an almost

exclusively indoor life have subjective symptoms relating to their

hearts. Many of the English literary men and women of the last century

had complaints of this kind. Sir Walter Scott described very vividly

his sensations as if his heart did not have room to accomplish its

functions, and said that he used to feel within his chest a fluttering

as if there were a bird there beating its wings against a cage too

small for it. Other literary people have told of this sense of

overfullness in the chest, as if somehow there were not room for all

the organs. This discomfort is mainly referred to the precordial

region. In oversensitive, nervous people it may be described as

painful, though analysis of what they mean by the word pain will show

that they have only a persistent feeling of pressure which is

uncomfortable and gives a sense of crowdedness in that region rather

than any genuine ache. Where the feeling is much dwelt on, however, it

may be exaggerated into pain, as, indeed, will any sensation, however

trivial, if attention is concentrated on it. On the other hand, in

practically all of these cases, just as soon as the mind is strongly

diverted by any pleasant occupation, the sense of discomfort

disappears not to reappear again until the patient has time to think

about himself.

Heart Surveillance.--Prof. Oppenheim of Berlin has in his usual direct

way expressed the power of the mind to influence the heart beat, and

he does {324} not hesitate to say that certain nervous people who have

been watching their hearts overmuch, and continually thinking about

them, are capable of playing all sorts of tricks on themselves and

sometimes even on their physicians, by this concentration of mind upon

their heart and its action. Prof. Oppenheim in his "Letters to Nervous

Patients," writing to a patient complaining of irregular heart action,

says:

Whenever you succeed in controlling the action of your heart by

means of introspection, there flows from your brain to your heart a

current of innervation which disturbs the automatic movement of the

organ. You now know what you have to thank for the irregularity in

the action of your heart. I have frequently proved this to myself in

your case: if I succeeded in feeling your pulse without your

becoming aware of it, holding your attention by a conversation which

interested you, the action of your heart was always absolutely

regular. If, however, I tried it under your control, while your

attention was anxiously directed to your heart, its action at once

became irregular, and you experienced the very unpleasant sensation

of palpitation.

Irritable Heart of Athletes.--A curiously interesting form of heart

neuroses has appealed to me very much because I have suffered somewhat

from it myself and owing to circumstances I think I have seen a larger

number of patients suffering from it than usually come to a single

individual. I refer to the tendency to irritability of the heart which

is so marked in men who have been athletes when they were younger, and

have taken a large amount of exercise during the years between fifteen

and twenty-five. If these men later settle down to a sedentary life

they almost inevitably suffer from a marked sense of discomfort in the

precordial region because of palpitation, and are apparently much more

liable than other people to have an intermittent pulse. Just what

these symptoms are due to is not always easy to discover, and in

different individuals there seem to be different accessory causes at

work. I have seen it particularly in professional men who while at

college have been on the teams and have played such hard games as

handball, hockey on the ice, and the like. I do not refer only to

those who have played an occasional game, but who every day of the

college year have had some severe muscular exercise.

Whether this irregularity of heart action has not at least been

predisposed to by over-exertion remains to be determined. Strenuous

athletics produce curious heart symptoms. Missed heart beats and

irregular heart action and even leakages at the valves are not unusual

even in the best of hearts after severe exertion. A careful

examination of the hearts of those who took part in a Marathon run at

Harvard some years ago showed that immediately after the race many of

them were irregular and some of them had leakages at the mitral valve

which lasted from one to twenty-four hours. These were probably due to

irregularity in the action of the papillary muscles as a consequence

of the fatigue. I had occasion to examine the hearts of some

theatrical dancers a few years ago, immediately after they came off

the stage. One of them is one of the most successful of modern dancers

and is able to occupy the better part of an hour in the severest kind

of exertion before an audience. Her heart was not only very rapid

immediately after she left the stage, but there were missed beats and

a distinct disturbance at the mitral valve. It was hard to determine

absolutely, but the sounds at all the valves were impure and there

{325} seemed to be imperfect closure or irregularity of action. In

another case there was a regular missed beat at every sixth or seventh

pulsation. This seemed to be due to an abortive systole. Usually

within an hour regularity of heart action is restored and the valve

sounds become normal. At times when the patient is run down for any

reason, the cardiac disturbance may persist for many hours, or even

until after long hours of sleep.

The patients I have mentioned seem to have developed their muscles to

a noteworthy degree and have enlarged and strengthened their hearts by

this exercise. Later on their occupation in life prevents them from

taking any severe exercise, or at least furnishes no opportunity for

it, and they often settle down to existence that, beyond a short,

quiet walk perhaps once a day, affords no exercise at all. Under these

circumstances the muscular development that they secured as young men

and which kept them in such magnificent health during their adolescent

years seems to prove a positive detriment to good health, or at least

to good feeling. The muscular system seems to crave to be kept up.

Occasionally I have been sure that the intermittent heart action so

often seen in these cases was due to the fact that the appetite, or as

I should rather put it, the habit of eating, which they formed while

they were accustomed to taking vigorous exercise, remains with them

during their sedentary life and as a consequence they overeat,

particularly of proteid food materials. The large consumption of these

materials gives rise to the presence of substances in the blood which

make all the muscles more irritable than usual, and this seems to add

particularly to the irritability of the heart.

_Dietetic Regulation_.--For many of these people a regulation of diet

seems to be the best possible remedy. They must be made to eat less

substantially, since they do not need the same amount of proteid

material to make up for muscle waste, now that there is no longer the

old use of muscles. Some of them become very heavy. These, however,

are mainly individuals who, besides eating abundantly of proteids,

also consume carbohydrates in large quantities. In these there is a

distinct disturbance of digestion and a tendency to dilatation of the

stomach with gas which interferes with the heart action and brings on

the intermittent pulse so often seen in them. In a certain number,

however, there are no accessory symptoms of indigestion, but the heart

symptoms are most prominent.

_Exercise_.--For these people the only real relief is afforded by a

certain amount of exercise every day. They become ever so much more

comfortable just as soon as their physician insists that they shall

have an hour's walk at least every morning and every afternoon and

that this walk shall be brisk and always have some definite purpose in

it, so that there is no mere sauntering or delaying on the way. Most

business men to whom this prescription of an hour's walk is given will

reply that it is impossible. Most clergymen will say that their duties

are such that they cannot arrange their hours for this purpose. As a

rule, it is not difficult to show the business man, however, that if

instead of riding to his business, he should walk every day, and this

will probably only take twenty minutes to a half-hour longer than if

he goes by trolley or even by automobile, this walk will provide him

with a full hour of brisk exercise in the open air. The walk back from

business will provide the other hour, whenever golf or some other

diversion cannot be provided instead. In most cities men live from

three to five miles away from their {326} business, and it is not too

much to ask them to take this walk. The muscular clergyman must be

made to understand that there shall be no trolley cars for his

ordinary clerical calls, or at least that none are to be taken unless

he has had his full two hours of brisk walk.

There is always the fear in the patient's mind that exercise, by

calling for heart exertion, is almost sure to make the condition

worse. This fear of itself further hampers heart action. When exercise

is first increased in those who have been living sedentary lives the

heart action for a time is brought more and more into the sphere of

consciousness and any irregularity that is present is likely to be

emphasized. A little persistence, however, soon shows that what the

heart actually was craving was the opportunity to expend some of its

energy and it was this pent-up force that was disturbing its action.

There is often the fear in physicians' minds lest the advising of

exercise should really do harm to the patient. They fear the presence

of perhaps a fatty condition, or of some obscure muscular condition,

or of some other heart lesion not easy to detect, yet likely to

produce serious symptoms. Stokes, who probably knew fatty heart

disease better than anyone else in the nineteenth century, outlined

his views of the therapy of it as follows:

In the present state of our knowledge the adoption of the following

principles in the management of a case of incipient fatty heart

disease seems justifiable:

We must train the patient gradually but steadily to the giving up of

all luxurious habits. He must adopt early hours, and pursue a system

of graduated muscular exercises; and it will often happen that,

after perseverance in this system, the patient will be enabled to

take an amount of exercise with pleasure and advantage, which at

first was totally impossible, owing to the difficulty of breathing

which followed exertion. This treatment by muscular exercise is

obviously more proper in younger persons than in those advanced in

life. The symptoms of debility of the heart are often removable by a

regulated course of gymnastics or by pedestrian exercise, even in

mountainous countries, such as Switzerland or the Highlands of

Scotland or Ireland. We may often observe in such persons the

occurrence of what is commonly known as "getting the second wind,"

that is to say, during the first period of the day, the patient

suffers from dyspnea and palpitation to an extreme degree, but by

persevering, without over-exertion, or after a short rest, he can

finish his day's work and even ascend high mountains with facility.

In those advanced in life, however, as has been remarked, the

frequent complications with atheromatous disease of the aorta, and

affections of the liver and lungs must make us more cautious in

recommending the course now specified.

Perhaps the most important therapeutic suggestion which Sir William

Broadbent has to make with regard to the cardiac conditions that have

come to occupy much of the patient's attention is of a negative

character. He says that "patients suffering from these functional

derangements of the heart usually make them a pretext for avoiding

exercise and often for taking stimulants or drugs, whereas exercise

and fresh air are what they need. The best way to prevent the

expenditure of superfluous energy on the part of the heart in the form

of palpitation is to give it a fair amount of legitimate physiological

work to do." Personally I have found that most of the cardiac tonics

seem to do harm, in the sense of increasing the subjective symptoms,

except in cases where the patient is run down in general health

because of failure to take sufficient food, when strychnin seems to be

of avail and in the shape of nux vomica acts as an appetizer as well

as a heart tonic. Sir William Broadbent has warned particularly with

regard to the use of alcohol in these cases. {327} Most patients find

that for the moment palpitation is lessened by alcoholic stimulation.

They pay for it afterwards, however, by an increased sense of

discomfort that sometimes lasts for 24 hours or more. As Sir William

Broadbent declared, "To relieve one attack of palpitation or fainting

by alcohol is to invite another, while the terrible danger of dropping

into alcoholism is incurred."

Lest it should be thought that even Broadbent is a little

old-fashioned and not quite to be trusted in the light of our

present-day knowledge, and above all lest it might be feared that

these older men made a better prognosis or emphasized the value of

exercise more than is compatible with our recent discoveries in the

physiology and pathology of the heart, it seems well to give

MacKenzie's opinion of these cases in full. This is all the more

important because, as I have said, the influence of German teaching

has led to the formation of rather different opinions in America,

especially among our younger physicians. Prof. Martius in this country

in his lecture for the Harvey Society gave quite a serious prognosis

for practically all heart irregularity. He almost went so far as to

lay it down as a rule of diagnosis that whenever a heart beats

irregularly there is something the matter with the heart muscle or

good reason to suspect a myocardial lesion of some kind. MacKenzie's

view is very different to this and he warns particularly against

permitting the influence of an unfavorable attitude of mind on the

part of these patients. He says:

The most serious thing about these cases is that the consciousness

of having an irregularity sometimes makes a patient introspective

and depressed. He keeps feeling his pulse, and communicates his

doleful tale whenever he find a sympathetic ear.

As the process which gives rise to it in elderly people is the same

as that which produces the tortuous temporal arteries, no more

significance should be attached to the one symptom than to the

other. I have followed cases for many years, and watched them pass

through seasons of sickness and of stress, and have seen no reason

to attach any serious import to this symptom. In rare instances the

heart, from being occasionally irregular, has after many years

become continuously irregular for short or long periods, and in a

few the permanent establishment of the nodal rhythm has been the

means of hastening the end. But this is infrequent, and in cases of

cardio-sclerosis has only happened in advanced life, and the patient

should on no account be frightened by being warned of the possible

occurrence of this unlikely contingency. In younger and neurotic

people I have never seen it lead to any bad results. It may appear

in serious affections of the heart, as in febrile complaints, but it

does not of itself add to the gravity of the condition, though I am

not sure that when due to an acute infection of the heart, as in

pneumonia and rheumatic fever, it may not be a sign of invasion of

the myocardium by the diseased process.

If the patient is aware of the irregularity, he should be assured

that there is no cause for alarm. It is useless to attempt to treat

the irregularity itself. If in other respects the patient is well,

then there is no need of any special treatment. If the patient be

suffering from conditions which seem to promote irregularity, such

as worry, fatigue, dyspepsia, the treatment should be devoted to the

removal of the predisposing cause. In people with temporary high

blood pressure, who show extra systoles, I find plenty of healthy

exercise in the open air specially beneficial, though until they get

trained, the extra systoles may at times become more frequent by the

exertion.

This last remark of MacKenzie's is particularly important, for at the

beginning of an attempt to relieve the symptoms by insisting on more

{328} exercise, the patient is almost sure to be disturbed by this

symptom of which he will often be conscious, and it takes a good deal

of experience on the part of the physician to reassure him that

because of the increased subjective symptoms at the beginning of the

treatment by increased exertion, he may not be doing harm rather than

good. As a rule, however, it is not long before the good results of

the exercise treatment of these cases begin to make themselves felt

and the patient is reassured. Regulated exercise of body and

occupation of mind are the two important factors even in the treatment

of organic heart disease. They are extremely important even in the

cases with alarming heart symptoms that occur in the very old, once

the acute symptoms have subsided. In all the functional heart

affections exercise is the most important therapeutic resource we

have. It would seem that in the course of muscular exercise some heart

tonic was manufactured, which in all but the cases of absolutely

failing hearts is the best possible therapeutic resource for the

stimulation and steadying of the heart action. Such an internal

secretion would not be surprising in the light of all that we have

learned of the physiological nexus of organs in recent years.

Many so-called cures for heart disease probably depend for their good

effect much more on the graduated exercise that goes with them than on

many of the other remedial measures, though it is these latter that

are usually vaunted most highly. We all now recognize how little value

there is in the Nauheim bath treatment for heart disease away from

Nauheim itself. The reason is because the resisted movements of the

early part of the cure and, above all, the graduated exercise of

walking up the hills around Nauheim, which are such important parts of

the treatment there, cannot be so well given with the baths at a

distance.