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Title: Psychotherapy
Author: Walsh, James J. (James Joseph), 1865-1942
Language: English
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Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

*** Start of this Doctrine Publishing Corporation Digital Book "Psychotherapy" ***

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

  A publication contemporary to this book is "Mother's Remedies"
  by Thomas Jefferson Ritter. It contains hundreds of suggestions
  that hindsight shows to be purely "mental" in their effect.

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

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

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

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

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

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


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


PSYCHOTHERAPY



PSYCHOTHERAPY



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



BY

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

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



  NEW YORK AND LONDON
  D. APPLETON AND COMPANY

  1912



COPYRIGHT, 1912, BY

D. APPLETON AND COMPANY



Printed in
New York, U. S. A.



TO THE JESUITS

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



{vii}


PREFACE

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

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

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

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

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


{ix}

CONTENTS

                                                    PAGE
Introduction                                          1


HISTORY OF PSYCHOTHERAPEUTICS

SECTION I

      _Psychotherapy in the History of Medicine_

   I. Great Physicians in Psychotherapy                  7

  II. Unconscious Psychotherapeutics                    19

 III. Genuine Remedies and Suggestive Exaggeration      25

  IV. Signatures And Psychotherapy                      35

   V. Pseudo-science and Mental Healing                 38

  VI. Quackery and Mind Cures                           46

 VII. Nostrums and the Healing Power of Suggestion      53

VIII. Amulets, Talismans, Charms                        60

  IX. Deterrent Therapeutics                            63

   X. Influence of the Personality in Therapeutics      69

  XI. Faith Cures                                       77



GENERAL PSYCHOTHERAPEUTICS

SECTION II

_General Considerations_

   I. Influence of Mind on Body                         84

  II. Unfavorable Mental Influence                      93

 III. The Influence of Body on Mind                    100

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

   V. Brain Cells and Mental Operations                124

  VI. Unconscious Cerebration                          134

 VII. Distant Mental Influence                         140

VIII. Secondary Personality                            147

  IX. Hypnotism                                        151



SECTION III

_The Individual Patient_

   I. Psychotherapy and the Individual Patient         163

  II. The Morning Hours                                165

 III. The Day's Work                                   171

  IV. The Middle of the Day                            179

   V. The Leisure Hours                                181

{x}

SECTION IV

_General Psychotherapeutics_

   I. General Principles of Psychotherapy              186

SECTION V

_Adjuvants and Disturbing Factors_

   I. Suggestion                                       194

  II. Exercise                                         198

 III. Position                                         207

  IV. Training                                         213

   V. Occupation of Mind                               218

  VI. Diversion of Mind--Hobbies                       224

 VII. Habit                                            229

VIII. Pain                                             235


SPECIAL PSYCHOTHERAPY

SECTION VI

_The Digestive Tract_

   I. Influence of Mind on Food Digestion              242

  II. Indigestion and Unfavorable States of Mind       250

 III. Psychic Treatment of Digestive Conditions        254

  IV. Appetite                                         262

   V. Constipation                                     268

  VI. Neurotic Intestinal Affections                   278

 VII. Muco-Membranous Colitis                          286

VIII. Obesity                                          290

  IX. Weight and Good Feeling                          297

   X. Vague Abdominal Discomforts--Loose Kidney       302


SECTION VII

_Cardiotherapy_

   I. The Heart and Mental Influence                   310

  II. Diagnosis and Prognosis in Heart Disease         316

 III. Cardiac Neuroses                                 321

  IV. Cardiac Palpitation and
      Gastro-Intestinal Disturbance                    328

   V. Angina Pectoris                                  335

  VI. Tachycardia                                      340

 VII. Bradycardia                                      342


SECTION VIII

_Respiratory Diseases_

   I. Coughs and Colds                                 345

  II. Tuberculosis                                     350

 III. Neurotic Asthma and Cognate Conditions           364

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

   V. Dyspnea--Cat and Horse Asthma                    373

{xi}

CONTENTS xi

SECTION IX

_Psychotherapy in the Joint and Muscular System_

   I. Painful Joint Conditions--Pseudo-Rheumatism      379

  II. Old Injuries and So-called Rheumatism            387

 III. Muscular Pains and Aches                         389

  IV. Occupation Muscle and Joint Pains                395

   V. Painful Arm and Trunk Conditions                 400

  VI. Lumbago and Sciatica                             402

 VII. Painful Knee Conditions                          409

VIII. Foot Troubles                                    413

  IX. Arthritis Deformans                              421

   X. Coccygodynia                                     428


SECTION X

_Gynecological Psychotherapy_

   I. Mental Healing in Gynecology                     430

  II. Psychic States in Menstruation                   434

 III. Amenorrhea                                       437

  IV. Dysmenorrhea                                     440

   V. Menorrhagia                                      447

  VI. The Menopause                                    450


SECTION XI

_Psychotherapy in Obstetrics_

   I. Suggestion in Obstetrics                         453

  II. Maternal Impressions                             461


SECTION XII

_Genito-Urinary Diseases_

   I. Prostatism                                       468

  II. Sexual Neuroses                                  472

 III. Sexual Habits                                    482


SECTION XIII

_Skin Diseases_

   I. Psychotherapy in Skin Diseases                   491


SECTION XIV

_Diseases of Ductless Glands_

   I. Diabetes                                         496

  II. Graves' Disease                                  500


{xii}

xii CONTENTS

SECTION XV

_Organic Nervous Diseases_

   I. Psychotherapy of Organic Nervous Diseases        508

  II. Cerebral Apoplexy                                513

 III. Locomotor Ataxia                                 524

  IV. Paresis                                          530

   V. Epilepsy and Pseudo-Epilepsy                     534

  VI. Paralysis Agitans                                542

 VII. Headache                                         546


SECTION XVI

_Neuroses_

   I. Nervous Weakness (Neurasthenia)                  555

  II. Chorea                                           561

 III. Tics                                             564

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

   V. Tremors                                          580


DISORDERS OF THE PSYCHE

SECTION XVII

_Psycho-Neuroses_

   I. Psycho-Neuroses (Hysteria)                       585


SECTION XVIII

_Disorders of Mind_

   I. Mental Incapacity (Psychasthenia)                597

  II. Hallucinations                                   603

 III. Dreads                                           612

  IV. Heredity                                         627

   V. Premonitions                                     634

 VI. Periodical Depression                             641

 VII. Insomnia                                         651

VIII. Some Troubles of Sleep                           663

  IX. Dreams                                           669

   X. Disorders of Memory                              678

  XI. Psychic Contagion                                688


SECTION XIX

_Disorders of Will_

   I. Alcoholism                                      694

  II. Drug Addictions                                  707

 III. Suicide                                          713

  IV. Grief                                            727

   V. Doubting                                         732

  VI. Responsibility and Will Power                    738


{xiii}

SECTION XX

_Psychotherapy in Surgery_

   I. Psychotherapy in Old-Time Surgery                746

  II. Mental Influence Before Operation                749

 III. Mental Influence and Anesthesia                  753

  IV. Mental Influence After Operation                 759


APPENDICES

   I. Illusions                                        766

  II. Religion and Psychotherapy                       776


INDEX                                                  781

{xiv}

{xv}

LIST OF ILLUSTRATIONS

FIG.                                                   PAGE

The Temple of Epidaurus as a health resort    Facing page 9

 1.--Expressions of the mouth                           102

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

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

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

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

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

 7.--Diagram of cells of cerebral cortex                113

 8.--Scheme of lower motor neuron                       114

 9.--Scheme of the visual conduction paths              115

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

11.--Isolated cell from human spinal cord               117

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

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

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

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

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

17.--Neuroglia cells from the spinal cord               122

18.--An artery from the cerebral cortex                 125

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

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

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

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

23.--Normal diaphragm curve in normal breathing         577

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

25.--Illusion of dual vision                            615

26.--Illusion of dual vision                            767

27.--Binocular vision                                   767

28.--Binocular vision                                   767

29.--The Müller-Lyer lines                              768

30.--Illusions of size                                  769

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

32.--Illusions of size and linear continuity            770

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

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



{1}


PSYCHOTHERAPY


INTRODUCTION

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

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



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

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


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

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

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


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

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

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

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

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


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


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

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

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

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

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

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


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

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

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

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

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

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


{7}

HISTORY OF PSYCHOTHERAPEUTICS

SECTION I

_PSYCHOTHERAPY IN THE HISTORY OP MEDICINE_


CHAPTER I

GREAT PHYSICIANS IN PSYCHOTHERAPY


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


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


FIRST PHYSICIAN

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

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


PSYCHOTHERAPY IN EGYPT

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

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

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

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

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

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

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

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

  [End Illustration]


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

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

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

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


MIND HEALING IN GREECE

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

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

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

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

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

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

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


ALEXANDRIAN PSYCHOTHERAPY

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

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


PSYCHOTHERAPY AT ROME

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

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


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

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

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


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


ARABIAN MENTAL MEDICINE

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

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


MEDIEVAL MIND-HEALING

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

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


MENTAL HEALING IN THE RENAISSANCE

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

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


PSYCHOTHERAPY AND MODERN MEDICINE

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

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

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


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

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


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

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


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

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


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

  [Footnote 2: London, 1901]

{17}

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

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

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


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


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

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

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

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

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

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

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

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

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


CHAPTER II

UNCONSCIOUS PSYCHOTHERAPEUTICS

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

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


REMEDIES PLUS SUGGESTION

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

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


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


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

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

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


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

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


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

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

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

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


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

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

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

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

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


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

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


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

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

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



CHAPTER III

GENUINE REMEDIES AND SUGGESTIVE EXAGGERATION

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


THERAPEUTIC PERSUASION

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


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

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

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


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


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

{28}

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

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


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

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


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

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


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

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

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

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


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


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

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


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

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


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


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


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

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


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


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


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



CHAPTER IV

SIGNATURES AND PSYCHOTHERAPY

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

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


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

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

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


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

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


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

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

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

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

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



CHAPTER V

PSEUDO-SCIENCE AND MENTAL HEALING

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


ASTROLOGY

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

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

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


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

{40}

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


HERBAL MEDICINE

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



ALCHEMY

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

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



MATHEMATICAL MEDICINE

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

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



MAGNETISM

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


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

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



ELECTROTHERAPY

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

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

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

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

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

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



LIGHT AND PSYCHOTHERAPY

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



THE X-RAY

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



RADIUM AND RADIO-ACTIVITY

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

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



SUGGESTION AND PSEUDO-SCIENCE

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



CHAPTER VI

QUACKERY AND MIND CURES

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

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

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

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


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

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


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

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

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

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

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

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

Dr. Holmes continues:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Holmes wrote:

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

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

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


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

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

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

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

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

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

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



CHAPTER VII

NOSTRUMS AND THE HEALING POWER OF SUGGESTION

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

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

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


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

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

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

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

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

Holmes says further:

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

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

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


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

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

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

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


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

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


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

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

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

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


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

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


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


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

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


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


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



CHAPTER VIII

AMULETS, TALISMANS, CHARMS

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


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

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

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


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

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


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


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

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



CHAPTER IX

DETERRENT THERAPEUTICS

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


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

{64}

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

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


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

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

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


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

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


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


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

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


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

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


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


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

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

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


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

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



CHAPTER X

INFLUENCE OF THE PERSONALITY IN THERAPEUTICS

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


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

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

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



IMPRESSIVE PERSONALITY

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

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

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

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

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

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


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

{73}

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

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


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

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


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

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


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

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

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

{76}


SUCCESS IN HEALING

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

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

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

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

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

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



CHAPTER XI

FAITH CURES

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

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


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


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

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


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

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

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

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


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

{81}

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

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

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

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

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


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


{84}

GENERAL PSYCHOTHERAPEUTICS


SECTION II


_GENERAL CONSIDERATIONS_


CHAPTER I


INFLUENCE OF MIND ON BODY


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

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

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

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

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

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


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

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


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


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


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

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

{87}

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


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


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


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

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

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

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


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

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


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

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


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

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

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


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

    [Footnote 12: Paris, Maloine, 1804.]

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

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

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

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

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


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

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


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


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

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

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

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

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

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

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



CHAPTER II

UNFAVORABLE MENTAL INFLUENCE

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


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

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


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

Plato, in the "Republic," says:

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

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

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


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

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

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


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

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


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

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


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

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


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


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


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

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


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

  [Footnote 14: McClurg, Chicago, 1903.]

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



CHAPTER III

THE INFLUENCE OF BODY ON MIND

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

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


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


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

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

{102}

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


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


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

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


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


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


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

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

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


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


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

{105}

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

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

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

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


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

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

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


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


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

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


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

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



CHAPTER IV

THE MECHANISM OF THE INFLUENCE OF MIND ON BODY

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

{109}

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


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


{110}

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


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


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

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


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


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

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


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



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


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


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


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

{113}

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

{114}


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


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


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


{115}

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


{116}


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


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

{117}


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


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


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


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


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

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

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


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


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


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


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

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

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


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


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

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

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

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


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



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


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

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

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

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

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

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

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



CHAPTER V

BRAIN CELLS AND MENTAL OPERATIONS


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

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


ATTENTION

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


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


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


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

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

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

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

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


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

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

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

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

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


MEMORY

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

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

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

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



UNCONSCIOUS CEREBRATION

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


ABSTRACTION OF MIND

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

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

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

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

{130}


PREOCCUPATION OF MIND

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

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

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

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


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


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


VITAL ENERGY BEHIND BRAIN CELLS

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

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

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


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


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


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


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



CHAPTER VI

UNCONSCIOUS CEREBRATION

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

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


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

{135}

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


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


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

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

{136}


SLEEP COMMUNICATIONS

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

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

      APRIL FIRST

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

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

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

    WHICH?

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

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


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


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


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

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

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


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

{138}

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

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


PATHOLOGICAL SIGNIFICANCE

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


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

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


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

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


MENTAL RELAXATION

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


REMEDIAL MEASURES

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



CHAPTER VII

DISTANT MENTAL INFLUENCE

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

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

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


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


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


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


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


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


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

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


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

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

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

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


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


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

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


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

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

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

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

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

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

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

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

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

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


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

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


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

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

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



CHAPTER VIII

SECONDARY PERSONALITY

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


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


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


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

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

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

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


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


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

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

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

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



CHAPTER IX

HYPNOTISM

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

{152}

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


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

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


FORMER METHODS OF HYPNOTIZATION

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

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


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

{154}

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


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

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

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

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


PRESENT DAY METHODS OF HYPNOTIZATION

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


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

{156}

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


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

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

{157}

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

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

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



PRACTICE OF HYPNOTISM

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


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


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

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

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

{159}

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

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


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

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


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

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


ANIMAL HYPNOTISM

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


DANGERS OF HYPNOTISM

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

  [Footnote 21: Philadelphia, Lippincott, 1909.]

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

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

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

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


{162}

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

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

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


{163}

SECTION III

_THE INDIVIDUAL PATIENT_


CHAPTER I

PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT


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

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

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

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

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

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

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


{165}

CHAPTER II

THE MORNING HOURS


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

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


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


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


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

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

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


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


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

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


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

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


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

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


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


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


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


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


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

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


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



CHAPTER III

THE DAY'S WORK

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


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

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

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


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

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


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


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


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

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

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


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

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

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


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

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

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

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


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

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


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


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

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

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


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


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

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



CHAPTER IV

THE MIDDLE OP THE DAY

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


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

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


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


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

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



CHAPTER V

THE LEISURE HOURS.

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


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


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


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


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


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


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


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

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


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


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

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


{186}

SECTION IV

_GENERAL PSYCHOTHERAPEUTICS_


CHAPTER I

GENERAL PRINCIPLES OF PSYCHOTHERAPY


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

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


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


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


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


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


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

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

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


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


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


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


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

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

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

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


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

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


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

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

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

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

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


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

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

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

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

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

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


{194}

SECTION V

_ADJUVANTS AND DISTURBING FACTORS_


CHAPTER I

SUGGESTION

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



CHAPTER II

EXERCISE

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


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


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


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

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


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

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

{201}

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


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

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

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


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



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

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

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


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


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


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

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

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

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


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

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


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

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


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

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


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

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


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

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


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


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



CHAPTER III

POSITION

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


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


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

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


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


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

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


Raising the Head.--Patients suffering from respiratory difficulties
usually learn to accommodate themselves to such changes of position as
will afford them the greatest relief. The difficulty of breathing
leads to such tossing about that the position easiest for the patient
is almost inevitably found. When respiratory difficulties first
declare themselves patients may not realize how much relief will be
afforded by raising the head, or by the assumption of a sitting
position. Often such patients prefer to sit in a chair. It should be
borne in mind that, wherever this is compulsory, dispositions can be
made so that the chair shall be as comfortable as possible, that its
seat edge shall not press upon the underportion of the legs so as to
impede blood circulation, nor press upon nerves, and that comfortable
arrangements shall be made for the arms. When the patient's head has
to be raised in the bed, it is much better to raise the mattress by
placing some large properly-shaped object underneath it, so as to
secure a gradual slant rather than have the patient's head and upper
portion of the thorax bent by pillows. In default of something better,
a chair placed so that the mattress lies along its back will be a
handy aid. This is a matter of nursing rather than strictly of medical
attendance, but unless the physician pays attention to it, it will be
neglected, or at least in many cases not used to the best advantage.

Whenever there is difficulty of expectoration, especially when
expectoration is abundant as in certain of the chronic bronchitises,
and above all in dilatation of the bronchi, the advantage of position
should be taken to aid in the expectoration. Patients who have to
cough up large amounts in dilatation of the bronchi and who have long
severe fits of coughing in the early morning, will often obtain a
great measure of relief by leaning out of bed with one hand on the
floor, doing their coughing in that position. Gravity helps in the
emptying of the pockets of the bronchi and in five minutes they
succeed in getting up satisfactorily as much material as would come
up, only after severe convulsive efforts for an hour, when gravity was
in opposition to their efforts. Children in whooping cough naturally
bend over in order to cough. They will cough easiest if placed on a
bed with a pillow beneath their chest so as to lift the face from the
mattress, or in the case of older children, with the head projecting
beyond the edge of the bed. This is only a trifle, but it will often
save children severe convulsive efforts. Tuberculous patients who have
to cough much, should be encouraged to find for themselves by trial
whether certain positions, leaning out of bed, may not be of great
service to them. There is often in advanced cases an accumulation of
material during {211} the night that must be expectorated, and the
patients are severely shaken up by their efforts to bring it up. I
have known cases where a considerable measure of relief was afforded
by leaning out of bed with the elbow on a pillow, a chair or
foot-stool somewhat lower than the level of the bed. The mechanical
help of gravity is particularly important where cavities exist and a
considerable amount of material has to be emptied out of them.

In modern surgical times one does not often see the emptying of a
purulent pleurisy through the bronchi, but I once had an opportunity
to see the termination of one of these cases in a very favorable way.
When I saw her the patient had already coughed up a cup full of
purulent fluid and, altogether, about a quart of pus was thus
evacuated. The patient had been so ill that the effort was
considerable, but the evacuation was greatly helped by having her lean
out of bed whenever material was to be expectorated. The patient is
still alive and in good health--fifteen years after the event.


Heart Cases.--Position is also often of very great importance for the
relief of the symptoms of patients suffering from heart affections.
For organic heart affections, rest in bed is often advised. It must
not be forgotten that this does not necessarily mean in a recumbent
position. Whenever there is difficulty of breathing in connection with
an affection of the heart, the recumbent position is extremely
uncomfortable. This is nature's safeguard against the accumulation of
fluid in the dependent parts of the lungs at the terminal capillaries
of the pulmonary circulation. Most of the natural demands have a
definite reason and are prophylactic rather than merely a symptom of
aimless discomfort. Patients with heart disease often want to sit up
in a chair. Their wish should, as a rule, be yielded to. There is no
need of their sitting in a narrow uncomfortable armchair, nor of being
incommoded by the position they have to assume. The end of a large
lounge, especially one that curves over towards the floor on which
pillows can be piled so as to make the patient comfortable, and yet
afford many changes of position, is the best.

In general, the arrangements should be such that changes of position
can be secured without much difficulty. These prevent hypostatic
pneumonia and guard the patient against serious accumulations in the
lung tissue because of sluggish circulation. Changes of position can
be used as valuable suggestions. Often the main portion of the
patient's symptoms consists of the intense fatigue due to one
position. This can be relieved and the patient made to feel that,
after all, the ailment to which he is suffering must not be so serious
since relief can be afforded so simply. Besides, when patients
complain, something must be done for them. Medicine cannot be given
for every symptom and yet some remedial measure there must be to
satisfy them. This satisfaction will often be secured by changes of
position, by slight local treatment, by the adjustment of pillows so
as to relieve fatigue of particular muscles and parts of the body, and
by the movements of the limbs and the head into other positions than
those in which they have become fatigued. The experienced nurse is of
the greatest possible value in these cases.


Restlessness.--Usually restlessness is considered to be an unfavorable
symptom of disease, just as are pain and tenderness. Like these,
however, it is really conservative rather than in any sense
destructive. Pain prevents serious changes from taking place without
our attention being effectively {212} called to them. Restlessness
induces the patient to change position frequently and often leads to
the discovery of some position in which there is much more comfort
than the one that had been assumed. Restlessness, in the recumbent
position, is usually nature's protest against the maintenance of a
posture in which, owing to failure of circulation, there may be
leakage of serum into the lung tissues with dangerous results.
Restlessness, in abdominal pain, often leads to such a change of
position as affords the best condition for the relief of the
discomfort as far as that may be brought about by position of muscles.
The man with colic very soon discovers that lying on his stomach may
relieve his pain. The drawing up of the knees in peritoneal conditions
is the result of a similar reaction. The physician must learn to
imitate nature, and recognize what mechanical conditions are likely to
be of help. As soon as these afford relief, they act as a strong
favorable suggestion, on the patient, and relieve dreads with regard
to his affection.


Joint Affections.--In painful joint conditions, position may help much
to bring relief or at least considerable mitigation of symptoms. In
rheumatism, for instance, of the acute articular type, a number of
small pillows can be disposed in various ways, underneath the
patient's limbs, between them and in other positions, so as to give as
much comfort as possible and will often be of great value. There
should be at least half a dozen pillows at the disposal of the
patient, besides three or four for the head. In certain relaxed
positions of the joints, there is more room within the capsule than
others and, almost unconsciously, the patients assume such positions
when there is pain from effusion. Occasionally, however, in the midst
of fever, or because of apathy, patients may not do this, and then
care should be taken to bring them some measure of relief. Generally
patients suffering from fever, with delirium of typhoid condition,
that is, when there is considerable apathy, should have their
positions changed gently from time to time to prevent discomfort
developing, and as a prophylactic against skin disturbances from
pressure. In children, this is particularly important.


Bladder Evacuation.--In emptying the bladder position may mean much.
After childbirth, especially the first, many women are quite unable to
empty their bladders while lying down, though if they are allowed to
assume the usual position there is little or no difficulty. In certain
sensitive men whose power over their bladder is disturbed by
self-consciousness, the presence of anyone in the room or near them,
makes it impossible for them to urinate, and this is particularly true
if they are lying down. In the milder forms of prostatism position
occasionally seems to have some influence in helping to empty the
bladder. When there is a prostatic bladder pouch behind the prostate,
it is quite impossible to empty this in the standing position. It may
be emptied in the prone position, that is, lying face downwards,
particularly if the pelvis is elevated above the rest of the trunk.
Undoubtedly some of the cures reported after operation, when the
operation itself effected no reduction in the size of the prostate (as
the removal of the testicles or vasectomy), the improvement was
brought about partly by the more favorable position in which, for
weeks after the operation, the patient emptied his bladder, and also
by the greater control gained over it, by the persuasion that the
operation would do him good. The same suggestion can be made in
connection with the new position for urination with just as good
effect.

{213}

Intra-abdominal Conditions.--There are many intra-abdominal conditions
in which position is of great importance for the relief of pain.
Appendicitis cases are found with the right knee drawn up because this
relieves the tension of the abdominal muscles, and probably also of
the large muscles that go to the thigh and lie behind the peritoneal
cavity. In most cases of intra-abdominal pain flexing of the knees on
the abdomen means much in affording relief, and patients usually
discover this for themselves. There are certain apathetic patients,
however, who need to be helped by suggestions. In certain of the
painful conditions, due to intra-pelvic conditions, relaxation of
muscles by flexion lessens the pain. Pressure upon the abdomen, as by
lying on a pillow, often does this also. Apparently one reason why
children with flatulent colic stop crying almost at once, when laid on
their stomachs, is because the pressure thus produced tends to bring
about a movement of the gas that, collected at one or two places, was
causing painful distention.


Importance to the Physician.--There are many other suggestions with
regard to position that will occur to thoughtful physicians in
particular cases. The one idea is to secure such an alteration of the
posture as is likely to bring about mechanically relief of pain. If
relief is afforded in this way, as has already been emphasized, a very
favorable influence is produced on the patient's mind. Above all, he
realizes that his physician not only understands his general
condition, but his experience with many patients suffering from the
same ailment has given him the power to direct even such slight
changes of position as will give comfort. Nothing that I know adds
more to the confidence that a patient has in his physician than the
realization of this sort of knowledge. Therefore, the necessity for
such consideration of each individual case as will enable the
physician to recommend such modifications of position to patients. At
the same time the patient's mind can be influenced very favorably by
attaching definite significance to these alterations, and having them,
as it were, repeat their favorable suggestions every time that he
thinks about them, and be pleased as to the relief they have afforded.
This is the sort of psychotherapy that is particularly likely to be
successful, and it needs careful cultivation and development.



CHAPTER IV

TRAINING

One of the most important factors for therapeusis in the sense of the
amelioration of defective motor conditions, the relief of disturbing
sensory affections and the restoration of or compensation for
defective functions of various kinds is training. By this is meant the
training of the power of attention and its concentration in such a way
that defects are overcome. There are many examples of almost marvelous
improvement of function brought about in this way that are familiar,
but it is well to recall some of them here in order to illustrate the
uses to which this therapeutic mode may be applied. A blind man is
able to read by means of his finger tips, and to recognize raised
letters that seem quite beyond the possibility of tactile recognition
by {214} ordinary individuals gifted with all their senses. The
peculiar skill is simply due to the individual being able by
concentration of attention upon slight variations in touch sensation
to recognize even minute differences readily and so read raised
letters with comparative ease and rapidity.

Over and over again it has been shown that neither the congenitally
blind nor those whose vision has become defective have any better
sense of touch than the average person. With an esthesiometer, their
power to recognize the distance between the points of a calipers is
shown to be no better than that of an ordinarily sensitive individual.
This is illustrated in other ways. Certain blind persons, even those
born blind, are known to be able to distinguish colors more or less
accurately, that is, at least the three primary colors. Their power to
do this is consequent upon a faculty of recognizing differences in
heat absorption. The ordinary seeing person going into a room in the
dark recognizes at once the difference between a pencil and a piece of
metal of the same shape and size by its weight and the greater
tendency of the metal to feel colder. When we are not sure whether a
pillar in a structure is of stone or an imitation, we determine this
by touch, and the fact that stone absorbs heat rapidly while wood and
other imitations of stone do not. It is the same faculty for
distinguishing specific heat that enables certain blind people to
recognize colors. If pieces of cloth of different colors are put over
snow when the sun is shining on them, it will be found that black
absorbs much more heat than the colored cloths, or white, and
consequently that the snow melts faster beneath the black. After black
comes red, then green, then blue. It is this difference in the power
to absorb heat that the blind recognize and thus distinguish colors
after long patient training of themselves.


Obstacle Sense.--An example of the value of training is the so-called
obstacle sense which has been rather carefully studied in recent
years. By means of it blind people are able to avoid larger obstacles
and to know when they are passing an open door or window on a corridor
or a building alongside a street. Blind children have been known to
play in a garden where there were trees and other obstacles and
carefully avoid them even while moving rather rapidly. This sense is
disturbed whenever there is loud noise in the vicinity. It is not very
active and yet it is of considerable value to the blind. Its
disturbance by noise would seem to indicate that it is due to some
sense faculty in the tympanum, or ear drum. It exists in everybody,
but remains quite undeveloped except in those who need it and
therefore learn to make use of it.


Touch and Sight.--The triumph of training is to be seen in the cases
of those who are born blind and deaf and who yet are taught to
understand through lip and throat reading by the tips of the fingers
and taught to talk by being shown patiently the method by which others
accomplish it, though the only avenue to their brain is the dull sense
of touch which means so little for the ordinary individual. The cases
of Laura Bridgeman and of Helen Keller illustrate how a sense that is
usually quite neglected can be made to supply the place of both the
eyes and the ears by patient, persistent training. Lip reading by
sight is, of course, a very interesting example of the same principle
that can be learned by anyone who has good sight in a comparatively
short time. There are compensations of this kind and powers of
development latent in every sense and function of the body that can be
{215} employed to make life interesting and to restore usefulness
after nearly every form of lesion or defect. Practically all of this
compensatory power is mental, hence its place in psychotherapy. We do
not increase the power of the sense but by concentration of attention
the mind is rendered capable of obtaining definite information from
sensory stimuli that are present in every person but that are
ordinarily neglected.


Hearing.--One of the most surprising instances of the value of
training for cases in which favorable results seemed quite out of the
question, is Urbantschitsch's method of training the deaf to hear.
After investigating it personally I reported it in the _International
Clinics_.   [Footnote 24] Patients who could hear but very little,
indeed, only the loudest noises, were trained by means of loud
shouting and the hearing of loud notes gradually to catch sounds more
and more easily until not infrequently they could hear rather well.
Sometimes even those who were thought to be absolutely deaf to sound
were found to be able to hear very loud sounds and then it was
invariably discovered that by practice they could be made to hear much
more. The secret of the success consisted not in any increase in the
power to hear, but entirely in training the attention to recognize and
differentiate sounds so that what seemed at first a confused murmur
gradually became intelligible. It is exactly the same process as that
by which a man learns to read with his fingers. He is not able to
differentiate the letters but after a time it is possible to do so
without difficulty.

  [Footnote 24: Lippincott & Co., Phila., Vol. IV, 8th series, 1899.]


Equilibrium.--There are typical examples of almost as striking
increase of muscle sensation, or rather of ability to distinguish
minute differences in muscular sensation, noted in those who train
this faculty carefully. Acrobats succeed in developing wonderful
control over muscles and marvelous response to slight disturbance of
equilibrium. The ordinary individual has comparatively small balancing
powers, but the slack-rope performer seems almost to defy the laws of
gravity, because he has learned so to coordinate all muscular action
as to enable him to maintain his balance. He has trained himself to
distinguish every variety of message from his semicircular canals. Of
itself neither of these senses gives us very much information, indeed,
only as much as we ask for from it, but when we pay careful attention
to the minute details of the information that it imparts, we are able
to use it to great advantage.


Muscle Training.--It is this power of training to enable us to
appreciate minute sensations that forms the basis of the Frenkel
treatment of tabes. For the proper guidance of the muscles the
muscular sense is all-important, though ordinarily we are quite
unconscious of the information it conveys. This is seriously disturbed
by the degeneration in tabes. The patient can, however, be taught to
use even the slight amount of it that remains to great advantage or
else to avail himself of some other compensatory sensations which will
enable him to guide his muscles in various motions much better than
before.

This same faculty can probably be employed in many other conditions.
Frenkel has shown that it is applicable in paralysis agitans and
markedly relieves the rigidity that is so annoying a symptom. It gives
these patients something to occupy their minds, too, which means a
great deal for their {216} general condition, for occupation of
attention saves them from neurotic disturbance of themselves.

Sufferers from infantile paralysis can be taught to do many things
with their weakened muscles that seem to be quite impossible to them.
It requires patience to get results, but they mean so much that the
efforts are well worth while. After cerebral incidents, sometimes
actual apoplexies, sometimes injuries, occasionally serious effusions
due to kidney diseases, there may be disturbance of motor functions.
It is surprising how often training will enable the sufferer to use
his muscles much better in these cases than at first seemed possible.
I have seen a man who had lost most of his power for writing after a
cerebral incident regain it as a consequence of being taught to write
from his shoulder, instead of from the forearm as had been his custom.


Heart Training.--In recent years we have learned that training is not
only good for the external muscles and enables them to do more work
without discomfort, but that it is particularly beneficial to the
heart muscle whenever that organ can respond to it favorably. At all
of the heart cures in recent years, exercise of some kind or another
is one of the important features and the failure of physicians
generally to secure as good results while pursuing all the other
methods followed at these cures, seems to show that exercise was
probably the most important factor. Nauheim is the typical heart cure
and there, besides the resisted movements in the bath, there is the
graduated exercise of the walks around the town, all of which, owing
to the situation, lead up hill. Walking up hill, even though it be a
gradual ascent, might seem to be the worst possible exercise for heart
patients, yet it proves eminently beneficial.


Respiratory Training.--Shortness of breath is often a bothersome
symptom, especially for stout people, and prevents them from taking
necessary exercise. When it cannot be traced directly to some
affection of the heart or of the circulatory apparatus, it is usually
due to lack of exercise. Much can be done for it by deliberate
training. In the modern time, with elevators so common, people seldom
have to walk up-stairs, and consequently one of the modes of exercise
that was particularly likely to furnish some training in deep
breathing is absent. Any one who has seen the shallow breathing of
many of the patients who come to Nauheim and how much it has improved
by the gradually increased walks up the hills around the valley, will
appreciate how much training in deep breathing means. This exercise of
the diaphragm will often give benefit besides in making the bowels
more regular, and in getting rid of the accumulation of fat in the
abdomen, which is one of the mechanical causes of the interference
with the diaphragm and consequent shortness of breath.


Training the Appetite.--Just as training may be used for the sensory
and motor systems that are external, so it may also be used for many
internal functions analogous to these. There are a great many people
who eat too little. They are the nervous, irritable persons with no
fund of reserve energy to draw on when anything happens, and who are
in their years before middle life likely to be the victims of
infectious disease. They suffer much from lack of proper covering in
the winter time and from a certain protection that is afforded to the
nervous system generally by being up to weight. Often their
under-weight is a life-story, and occasionally it is a family matter.
When {217} they suffer from neurotic symptoms a gain in weight nearly
always does them good. They complain that when they increase their
diet they have uncomfortable feelings. This is only what is to be
expected, since the muscularis of their stomach--much more important
than its secretory function--has not been accustomed to as much
exercise as is now being demanded of it.

On the other hand, for those who are over-weight, training in eating
less is the one important therapeutic factor. If their diet is cut
down suddenly, they soon become discouraged. If there is a gradual
reduction of food quantities, variety being allowed, so that they may
eat practically everything they have been eating before, the system
gradually accommodates itself to less and less food. This is the only
sensible way of bringing about reduction in weight. It requires
constant attention over a long period, but it can be done with
excellent success.

In the same way the bowels may be trained to perform their work
regularly. Habit means probably more with them than any other factor.
Our digestive tract, however, is largely dependent on habit. We get
hungry three times a day or twice a day, according to the custom that
we have established. Countries differ radically in the matter, and
nearly always, when a man goes from one country to another in early
years, he changes to the habits of the new country, though if he comes
after middle age he usually clings to those that he is used to.


Training to Stand Pain.--There are many painful conditions, especially
involving the muscles in the neighborhood of joints, that are worse on
rainy days and are spoken of as rheumatism, that can be very much
improved by training in the use of muscles. As men grow older and gain
in weight, the lack of exercise in their sedentary lives incapacitates
their muscles for activities of many kinds. The consequence is that
where most strain is put upon them, in the neighborhood of joints,
they readily become tender and painful. It is this class of cases
particularly that is benefited by irregular practitioners of all
kinds. Mental healing, osteopathy, Eddyism, the many liniments,
rubbings and manipulations prove beneficial. What is needed is
training in the use of muscles so as to enable them to do the work
that is required of them without discomforting reaction. This is
particularly true for the leg and foot muscles. Exercises that
strengthen the muscles of the calf and of the thigh, and particularly
such as require free movement of the foot, are almost sure to relieve
these patients of many annoying symptoms. Pains around the ankles and
in the knee and hip, worse in rainy weather, disappear as a
consequence of such gradually increased use of these muscles as gives
them increased nutrition and power. This subject is discussed more
fully under Foot Troubles and Painful Conditions of the Knee.

There may be a training in bearing discomfort which is of great value
to over-sensitive patients. Some nervous patients seem to suffer
merely from their ordinary physiological functions. These are the
patients who abuse the drugs that are supposed to bring relief. There
is just one mode of treatment that is successful with them: they must
be told to bear their discomfort for a while without seeking drug
relief, but always securing freedom from discomfort by means of
attention to other things, until gradually they have succeeded in
diverting their minds from the concentration of attention on their
functions which is causing their disturbance. The whole programme
{218} need not be outlined to them or they will perhaps have a
revulsion of feeling against it that will make its accomplishment
impossible. They can, however, be made to stand their discomforts for
a time with the promise that it is for the best, since there will be
eventually an improvement.


Intellectual Faculties.--Nearly every one of our faculties can be
trained to do much better work than we have any idea of if we only are
willing to take the trouble and give the attention. I have often shown
people who came complaining of loss of memory that if they wanted to
train themselves to remember they could do so. The memory probably
cannot be bettered any more than can the sense of touch in the blind
man, but by attention to minute details, in the concentration of the
mind on certain subjects, it can accomplish results that seemed quite
impossible before. All systems of improving the memory are founded on
this method of concentrating attention on what one wishes to remember
and connecting it with other things that we know by experience are
readily remembered.



CHAPTER V

OCCUPATION OF MIND


Two classes of patients frequently apply to physicians for relief from
various discomforts. They are, first, people who have no regular
occupation and who often are in what is supposed to be the happy
position of being able to do just what they please. The second class
consists of those who take their occupations too seriously, so that
they never get away from them and, as a consequence, disturb their
physical functions. The feelings that these two classes complain
of--for, when analyzed, their symptoms prove really to be
uncomfortable feelings--can usually be "bothered" away and, if not
entirely forgotten, made to disappear when the patients become deeply
interested in something other than their usual occupation. The first
class of patients needs occupation of mind; the second needs diversion
of mind, and that subject will be taken up in another chapter.


Uncomfortable Sensations, Their Location and Causes.--These pains and
aches, as patients call them, though it is well to remember that they
are only discomforts, senses of unequal pressure, of constriction, or
perhaps only unusual feelings, or consciousness of sensation, may
occur in every part of the body. Perhaps they are most commonly
complained of in the head. Many of the so-called headaches that are
more or less continuous consist of these senses of pressure or of
constriction over a particular part of the skull. Sometimes there may
be a sense of pressure at the back of the eyes. Very often there is a
feeling of heaviness at the back of the head that makes the patient
feel as if relief would come if the head were allowed to drop forward
and if sleep could be thus obtained. Every other portion of the head,
however, even within the cavities, may have some of these
uncomfortable sensations. In some persons, there is a tightness in the
throat. In others, there is a feeling of fullness of one cheek and the
dread that they may not be able to use it properly in talking.
Sometimes the uncomfortable feeling is within the nose. Not
infrequently the discomfort is in the ear.

{219}

All of these may be due to local conditions which need to be
corrected, but in most cases nothing is found locally, or at most
there is some functional disturbance so slight that, though it is
shared by a great many people in our climate, others do not complain
of it at all. It seems evident, therefore, that the discomfort must
result from the sensitiveness of the individual emphasizing the
significance of some slight disturbance.

Every portion of the body may suffer from these discomforts. The upper
part of the back, especially below the base of the neck, is a favorite
location in men, and particularly in those who bend over a desk. The
lower part of the back is affected in such men as tailors and cutters
who stoop incessantly at their work. In women, the lower part of the
back is likely to suffer, and this is usually attributed to genital
conditions, but constipation may play quite as large a role as the
genital organs. Some of the stooping occupations of women, at the
sewing machine or dressmaking, or even harder occupations, as
sweeping, washing, and the like, may also be responsible. The
commonest source of discomfort is, perhaps, the upper left-hand
quadrant of the abdomen. This seems to be due to the distention of the
stomach, either by gas or by liquid. Vague discomforts may occur
around the umbilicus, often due to the presence of gas, with or
without borborygmi.

Generally the local condition is only an occasion, and the real cause
of the complaint is the lack of occupation of mind and consequent
concentration of attention on any organ whose function happens to be
disturbed sufficiently to make one conscious of its action.


_Lack of Occupation_.--For all of these cases the most important
therapeutic factor is occupation of mind and diversion of attention.
In our time, social conditions allow a large number of people to have
very little occupation. For instance, many women of the well-to-do
classes have absolutely nothing that they must do. Various phases of
this are discussed in previous sections.

As a rule, it is useless to try to relieve these discomforts by
anodynes. Many an opium habit has been formed by a turning to opium in
such cases. The coal tar products are greatly abused here, for they do
not bring relief to queer feelings nor to a sense of pressure or
discomfort; they rather add to depression. What they are efficacious
for is acute pain. The coal tar products relieve even toothache or
neuralgia, as well as a real headache, but I have had patients tell me
over and over again that the continuous headaches from which they
suffered were not relieved in the slightest degree by phenacetin or
acetanilid. Occasionally one hears of hyoscine or hyoscyamus suggested
for these conditions, but they are quite as useless and as much
contraindicated as opium or the coal tar products. As a rule, these
headaches are relieved by lying down; they disappear during sleep. The
real indication for treatment, however, is found in the fact that all
of these vague discomforts are much better or even disappear when the
patient is intensely occupied, or at least pleasurably engaged.

What these people need is occupation that really catches their
interest and takes attention from themselves. One of the most striking
expressions of this truth that we have comes from the poor, sad, mad
poet, Cowper:

  Absence of occupation is not rest;
  A mind quite vacant is a mind distressed.


{220}

And surely poor Cowper, himself the victim of depression, saved from
himself only by the suggestion that he should put into poetic form the
thoughts that came so abundantly to him, could well understand the
depth of wisdom in his couplet. The story of Cowper's life is enough
of itself to encourage physician and patient to persevere in the
effort to lift depression by occupation, since the fruits of that
occupation may prove so valuable.


_Mental Short-Circuit_.--The minds of these people must do something,
and since there is nothing really occupying for them to do, in a very
expressive modern phrase, they are doing their possessors. As we
suggest elsewhere, the nearest simile is that of the short-circuiting
of a dynamo. Mental energy is exerted harmfully within the machine
instead of in doing work.

See what happens in these cases when by some chance the women, or the
men, who complain almost constantly are suddenly deprived of the means
which enabled them to live an aimless life. The physician often has
patients who have been in affluence but after a financial panic are in
straitened circumstances. It is interesting to note what an excellent
tonic effect, in younger people always, in older people very often,
the change of life has on these chronic valetudinarians. Sometimes
this is attributed to the simpler life which they lead when poorer,
occasionally to the lack of responsibility, or other similar reason.
Nearly always it is easy to see that the real cause of the improvement
in health is the occupation of mind with serious interests outside of
self.


Regulation of Life.--In the matter of occupation, and especially
occupation of mind, the formation of habits and the training of the
will are extremely important. In his book on "The Education of the
Will," which was so popular that it went through over thirty editions
in France, M. Jules Payot [Footnote 25] emphasizes the necessity for
deliberately arranging the details of life so that time shall not hang
heavily on the hands, he reverts to certain rules of life of the old
religious orders, and to the habits advised by spiritual directors. He
counsels that every one should make an examination of the day's
happenings at the end of it, in order to see just where the failures
lay and in what accomplishment was made. At the end of this
old-fashioned examination of conscience, he counsels that a set of
resolutions for the next day be made and an arrangement of work for
various times, so that even more may be accomplished.

  [Footnote 25: English translation by Dr. Smith Ely Jelliffe.
  New York, 1909.]

M. Payot further suggests that a certain time be given up to
reflection, or as he calls it, meditation, on the significance of life
and on the consideration whether something valuable is being made of
it. Without this he insists that it is easy to let one's self slip
into habits of life in which absolutely nothing is accomplished for
self or others. If there is no real accomplishment, then pleasure soon
palls, because pleasure has a place only as an interval in the midst
of labor and as a relief from effort. These reversions to the old
modes of life and thought of the monastic communities show how little
of real advance there is in life, and what excellent conclusions
serious men came to even in the distant past. Certainly for many of
the leisure class in modern times only the use of periods of
reflection and the examination of {221} results obtained will serve to
prevent that utter waste of time which leads to the intense
dissatisfaction that is often reflected in the general health.


Thought for Others.--After forgetfulness of self, the most important
factor in psychotherapeutics is thoughtfulness for others. Ordinary
diversions are quite insufficient to occupy most people. One must have
a serious occupation that appeals deeply, and then diversions of mind
will be useful for purposes of recreation. Pleasure, so-called, if
pursued not as an interruption from work but for its own sake and
without serious occupation, palls, and after a time its votaries find
life is scarcely worth living. The pursuit of pleasure as the sole
interest of life is one of the most fruitful resources of depression,
discouragement and neurotic symptoms with which modern physicians are
brought in contact. The only way to be sure of having compelling
interests is to be so much occupied with other people that one forgets
self.

  Yet mere flippant excitement and superficial entertainment is
  nothing but a cheap counterfeit of what is needed. Voluntary effort
  is needed, and this is the field where the psychotherapist must put
  in his most intelligent effort. There is no one for whom there is
  not a chance for work in our social fabric. The prescription of work
  has not only to be adjusted to the abilities, the knowledge, and
  social conditions, but has to be chosen in such a way that it is
  full of associations and ultimately of joyful emotions. Useless work
  can never confer the greatest benefits; mere physical exercises are
  therefore psychophysically not as valuable as real sport, while
  physically, of course, the regulated exercises may be far superior
  to the haphazard work in sport. To solve picture puzzles, even if
  they absorb the attention for a week, can never have the same effect
  as a real interest in a human puzzle. There is a chance for social
  work for every woman and every man, work which can well be chosen in
  full adjustment to the personal preference and likings. Not
  everybody is fit for charity work, and those who are may be entirely
  unfitted for work in the interest of the beautification of the town.
  Only it has to be work; mere automobiling to charity places or
  talking in meetings on problems which have not been studied will, of
  course, be merely another form of the disorganizing superficiality.
  The hysterical lady on Fifth Avenue and the psychasthenic old maid
  in the New England country town both simply have to learn to do
  useful work with a concentrated effort and a high purpose. From a
  long experience I have to confess that I have seen that this
  unsentimental remedy is the safest and most important prescription
  in the prescription book of the psychotherapist.


_Care of Children_.--Probably the most important therapeutic factor in
the cure of the ills which come to unoccupied women is the finding of
some occupation that will absorb their hearts as well as their
intellects, that is, satisfy their feelings as well as appeal to their
intelligence. That very acute observer and kenner of her sex, Mrs. St.
Leger Harrison, who is Charles Kingsley's daughter and writes under
the pseudonym of "Lucas Malet," said in "Sir Richard Calmady": "Feed
their hearts and the rest of the mechanism runs easy. I have known
disease to develop in a perfectly healthy woman simply because the
heart was starved." For most women the only thing that will entirely
satisfy the heart or keep it from hunger is children. Fortunately an
interest in other people's children can, under certain circumstances,
be almost as satisfying as in one's own.


_Interest in Others_.--Probably the best possible occupation that a
childless woman can have is the care of others. Charity in one form or
another satisfies the emotions as well as creates interest and gives
varied occupations. Even the frequent disillusions that are
encountered in charity work only add variety {222} to the experience,
and do not discourage those who have the real charity instinct. For
women particularly, as we have said, some charity that brings them
much in contact with children is the surest preventive of
over-occupation with themselves and over-emphasis on their feelings
and sufferings. Many a woman in our large cities owes her freedom from
the neurotic symptoms to which her sisters are subject, to her
interest in tuberculous children. There is just enough of suffering to
arouse all the pity of the visitor, without so much of anguish as
would deter the more delicate from being interested in the work.


_Touch with Real Suffering_,--For patients who think they have much to
suffer, yet whose complaints are all of subjective feelings of
oppression and depression, there is no better remedy than to come in
touch with real suffering. I have known not a few neurotic young
women, who were preparing for themselves years of suffering by
over-attention to little pains and aches, saved to a life of
usefulness and even happiness by having to nurse near relatives
through the last stages of fatal cancer. When these neurotic persons
are brought intimately in touch with real suffering, have their
sympathies aroused, and see how well human nature can bear pain when
it has to, and yet not be impatient, nor wish to end it all, then a
renewed life comes over them and they cease to be preoccupied with
themselves.


_Sympathy as a Remedy_.--In former days, when hospitals were not so
well provided and trained nurses non-existent, all forms of suffering
had a wider appeal and aroused more active sympathy than at present.
It is true that patients, in both hospitals and homes, suffered from
the lack of trained nursing, and that was an even greater
disadvantage. But it is, nevertheless, too bad that more actual touch
with suffering does not come to people now, for nothing is so sure to
make little ills disappear as the sympathy aroused by the sight of
real suffering. Certainly, our cancer cases might well be a strong
therapeutic factor for many of the neurotic ills of the world. They
are, of course, deterrent to many people. It would seem to add
needlessly to human suffering for some of the delicate to have to be
in contact with what is one of the most awful afflictions that flesh
is heir to. If death and suffering were not inevitable, we might try
to save people from the suffering which sympathy entails. But there is
no avoiding them; soon or late they are sure to come to everyone. The
upbuilding of character, consequent upon intimacy with them, is of
great value, and really brings so much of contentment to people who
are over-worried about little things that it is worth while to recall
how valuable this sympathy for suffering is in psychotherapy.

I have spoken of this phase of occupation as if it referred only to
women. There are many men of whom one may well say that they need more
human sympathy in their lives and that if they had it their supposed
ills would drop from them, or seem so slight as to be quite
negligible. Over and over again, I have seen men who had become too
occupied with themselves lose their pains and aches in an interest in
some real charity. Charity, however, not philanthropy, is the secret.
The sitting on a board of trustees of a charitable institution may
mean little though even this usually has its good effect; but close
contact with the poor, intimate personal relations with other human
beings who are in suffering, are quite as necessary for men
over-occupied with themselves as for women.

{223}

_Care of the Incurable_.--Mother Lathrop (Hawthorne's daughter) in her
cancer work prefers not to take patients suffering from incurable
cancer into the homes that she has for them, if they can in any way be
cared for reasonably at their own home. Of course, the main reason is
because there is so much of cancer in the community (one in thirty of
the population now die of it), that it is impossible to take care of
all the cases that apply for admission. Another excellent reason is
that it would be too bad to take out of a home the opportunity for
self-discipline that is afforded by the care of one of these patients,
when it does not inflict an intolerable burden on someone already
overworked. As a rule, the effect of attendance on such a patient does
so much for character upbuilding, and for a proper realization of
values in life, that trivial things fall into their right places.
Anyone who has seen the development of character, And the growth in
amenity of disposition of those who bear such a burden with patience,
will realize just what is meant by the expressions used.


Finding Mental Occupation.--For many of his patients the physician
simply must find occupation of mind. Not a little racking of brain is
needed for this, until experience helps. One form of occupation of
mind that seemed quite unpromising at first, but that has in a number
of cases proved of value, is the committing to memory of passages in
verse. A generation ago it was quite common for people to have their
memories stored with fine passages from authors which they could
repeat literally. Latin verse particularly was learned by the school
boys of fifty years ago. Frenchmen know their classical poets, and
some of the Italians also know theirs with wonderful fidelity. It is
said that, even in his advanced years, Pope Leo XIII could repeat long
passages of Dante and often found a relief from pressing cares of
state in the ponderings of the great thoughts recalled by the verses.
I have known half a dozen Italian clergymen who could from memory
follow up a line of Dante, taken anywhere in the poet's writings, with
the rest of the passage.

Such well-stored memories furnished much more abundant food for
thought to their possessors than do those of the modern time. Our
modern system of education has done away, to a great extent, with
learning by heart, but as one of those educated under the older system
and who is still able to recall many passages from Pope, or
Goldsmith's "Deserted Village," or "The Traveler," or from Virgil or
Horace, I feel sure that this is a serious mistake. In some cases I
have deliberately tried to make up for it by having people, even well
on in years, settle down to memory lessons again. Under disorders of
memory I suggest the use of this practice as a valuable training which
serves first to dispel the idea that memory is failing when it is only
lack of attention and of concentration of mind that is at fault, and
secondly, because after a time there can be observed an actual
improvement of the memory faculty. Here I would insist on its value as
an occupation of mind for those who lack some serious interests. I
have found it to be ever so much better as a diversion than reading or
the theater. If the interest in it can be awakened, it represents a
valuable adjunct in the treatment of some rather difficult cases of
mental short-circuiting. Lord Chesterfield, in one of his letters,
suggested to his son that even very brief periods during the
day--those that are ordinarily used for the fulfillment of bodily
necessities--might be employed to store the memory with valuable
quotations, great thoughts {224} greatly expressed, and this should be
recalled. After a little practice not near so much time is required
for memory work as might be imagined, and the effects are excellent.

Much of this may seem too trivial for the physician to occupy himself
with and quite apart from his duties as a practitioner of medical
science. But it must not be forgotten that medical science is as yet
quite imperfect and the practice of medicine is an art. What we have
to do, is to treat individual patients rather than cure cases, for
that is why medicine is a profession. Each affected individual who
comes to us is quite different from any other. In spite of our
grouping them under certain heads, the diseases of the race are as
distinct from one another as the features of the individuals affected.



CHAPTER VI

DIVERSION OF MIND--HOBBIES


There are two classes for whom diversion is of the utmost value. The
first are over-occupied with themselves; and the second group are so
occupied with some one interest in life, or with one narrow set of
interests, that it becomes an obsession, never leaving them. Constancy
of mental occupation with one set of thoughts proves seriously
disturbing after a time, especially if the only amusements available
are so superficial that they do not really act as a diversion. Many of
the so-called neurasthenic or psychasthenic states (I would prefer to
call them conditions of nervous weakness and of psychic impotency,
because the simpler names carry with them no suggestion of a definite
ailment) are really the consequence of this lack of any true
diversion. The patients do not get any genuine rest.

The typical example of such lack of diversion is the business man who,
contrary to the wisdom of the ages, takes his business home with him.
If we accept Ramon y Cajal's theory of attention, by which whenever a
particular portion of the brain is occupied with a subject the
capillary blood vessels in that particular part are pulled wide open
by the contraction of the neuroglia cells, certain of the brain
tissues in these cases are constantly in a state of congestion. It is
not surprising that such men suffer from insomnia. It is scarcely less
to be wondered at if their digestion suffers, since that function is
so important that it requires most of the nervous energy that a man
can provide at certain times. Besides his brain cells are never really
resting. If a man goes to sleep with a thought and wakes with it, even
though he may not be quite conscious of the fact, his mind has been
occupied with it. Brain cells need definite periods of rest. These
cells are not getting such rest--hence the development of many
pathological conditions.

I have described the extreme case, but it is not exaggerated. Writers,
editors, scientific investigators and generally those whose work does
not bring them much in contact with others, are likely to thus suffer.
Contact with others, even on business matters, seems to have a
relaxing effect. Social amenities and personal interests prevent
absolute concentration of mind over long periods. In some people even
milder degrees of preoccupation with a {225} single subject may work
harm. Some people are able to stand concentration of mind for many
hours a day for years. Others cannot. We have come to recognize that
more than eight hours a day is a mistake, but there are many people
who cannot work more than a four-hour day. The sooner this is
recognized and diversion of mind provided, the better for them. This
is one of the most important benefits that psychotherapy can confer on
many of the so-called neurasthenics.


Possibility of Diversion of Attention from Ills.--The necessity for
diversion of attention from one's ills is best realized by considering
what happens in the opposite direction. Headache, toothache, and many
other uncomfortable feelings, especially discomfort associated with
abdominal disturbances, can be entirely banished from the mind by
pleasant association with friends, by an interesting play, by a game
of cards, or, indeed, by almost anything that takes up the attention
completely. It is well understood that the severer forms of pains can
not be thus banished, but discomforts that make life miserable for the
patient may be entirely relieved for the time being. If this power of
mind to divert attention from the ills of the body means so much, it
is not hard to understand that if this mental influence be directed in
the other way, that is, to emphasize the ailment by attention to it,
it will not be long before symptoms become quite unbearable.


Hobbies.--A hobby is the physical salvation for a man who wants to
work hard, yet not become so absorbed in his work that it becomes an
obsession. Unfortunately, it is not possible to create a hobby for a
man or a woman in a short time. It must be a growth for many years
until it has become a portion of one's life. It must, as far as
possible, be something to which one turns with as much interest as to
one's regular occupation, so that the time taken from it, even for the
necessary vocation of life, is more or less resented. If a man has two
occupations that are intensely interesting, then he gets the best
possible rest. Otherwise it will be necessary in many cases for the
physician to help him in the choice of another interest in life. It is
not enough that there should be a vacation once a year, or a
conventional day off on Sunday. There must be much more than this,
deliberately planned and faithfully carried out.


_Gladstone_.--Men with hobbies have done some of the best of the
world's work; busy for many hours every day, they have yet lived to be
eighty and even ninety years of age, and have been industrious to the
end. A typical example in our generation was Gladstone, the great
English statesman. Few men had their minds occupied with more serious
problems than he for nearly forty years of a busy existence. In spite
of this, he found time to make a study of Greek literature and of
ecclesiastical writers; He acquired even more authority perhaps in
these subjects than in political science, doing the work of several
men, yet he lived to be an extremely old man. He welcomed the
opportunity to get away from one kind of work in order to devote
himself to another, but this occupation of an entirely different set
of brain cells gave those that had been previously at work opportunity
for complete rest. Very probably, except at times of special crisis or
stress of anxiety, his political problems did not disturb his studies
of Greek literature, not because he insisted on keeping them away, but
because this other interest was so absorbing that it required no
special effort to occupy his mind completely with it.

{226}

_Virchow_.--For more than a year I lived close to the great German
pathologist, Virchow, and found that his varied interests were
probably the secret of his power to devote himself to work for many
hours a day, take only a small amount of sleep and yet live healthily
and happily for over eighty years. Frequently he did not leave the
Prussian legislature until 1 a. m., or even later, and yet he seldom
failed to be at his laboratory before 7:30 o'clock in the morning,
though it was several miles from his home and took over half an hour
to get there. Besides pathology, he was deeply interested in
anthropology and in most of the biological sciences, and his favorite
hobby was the practical care of the health of the city of Berlin. From
the time when Berlin, just after the Franco-Prussian war, began to
grow out of the half-million provincial town that it was, into the
great world capital that it became, a transformation that took less
than twenty years, Virchow had charge of the health of the men engaged
on the sewer farms of the city. Berlin, unlike other great capitals,
is not situated on a large stream that will carry off its excreta, and
consequently a new problem in sewage disposal had to be met. The
sewage was spread over fields outside the city and proved, as might be
expected, a magnificent fertilizer. The whole cost of sewage disposal
was recouped from the sale of the farm products.

Prophecies of dire disaster of many kinds were made when this system
was first proposed. It was said that the men engaged on the farms
would suffer from all sorts of disease, especially respiratory and
intestinal diseases, that the farm products would be insanitary, and
the whole plant would be such a disease producer for the city as to
become a nuisance. Virchow was put in charge of the sanitary side of
the project, and how well he fulfilled his obligations is shown by the
statistics. The people who worked on the farms were healthier than the
average inhabitants of Berlin, and were especially free from
intestinal disease. Every phase of disease that occurred among the
workers on the farms, and there were many thousands of them with their
families, was reported to Virchow. Every night, the last thing before
he went to bed, he looked over this report and if there were any
suspicious cases, made arrangements for the prevention of the spread
of disease.

This of itself might seem work enough for one man, but it was only a
diversion for Virchow, turning his mind away from his other
intellectual work completely during certain hours of the day. His
visits to the farms, his planning for the prevention of the spread of
disease, his deep interest in the reports and the constant improvement
of conditions, instead of hampering his other intellectual activity by
wasting brain force, probably proved restful by diverting the blood
stream away to the cells that occupied themselves with this other and
very different problem, and so proved a benefit, not an evil. Perhaps
other men might not have had the store of nervous energy to enable
them to carry on work in this way, but for those who have, this is the
ideal arrangement. There are many others whose names might be
mentioned here. John Bigelow and Pope Leo XIII are typical recent
examples. Great workers are usually long livers, barring accident, and
all of them have had variety of occupation.


Necessity for Diversity of Occupation.--Even for those of lesser
intellectual capacity, it is advisable to have, in a lower order of
intellectual occupation, two very different things in which there is
intense interest. The blasé {227} attitude in which the individual
finds no interest in anything and nothing worth doing, makes it
impossible to secure such relaxation as will give relief from worry.
So long as nothing happens to call for special resistive vitality,
such people may go on nursing their unhappiness. It is from this
class, however, that the suicides come. The mind becomes occupied with
the worries that it cannot get away from, sleep is interfered with;
the worries become an obsession, and brain exhaustion results. It is
usually said that suicides are insane, and to this extent certainly
the expression is true. Certain brain cells have so long been occupied
with a particular subject, because the mind has no other interest to
divert attention and blood supply to other portions, that these cells
are overborne and become utterly beyond the control of reason and
will.


Intervals in Work.--The old university rule of long ago was that no
one should do more than two hours of intellectual work continuously at
the same subject. Certain of the monastic orders required scholars and
students to take a break from an intellectual occupation for a
measured interval at least every two hours. The modern business man,
and even the literary man or reporter, would think this preposterous.
The rule is, however, founded on good common sense, for it relieves
the tension and keeps conditions of strain from inveterating
themselves in such a way as to do harm.

As a matter of fact, better work is accomplished if it is done in
two-hour intervals, with a break of fifteen minutes to a half-hour
between, than if the attempt is made to work longer. This may not be
true for certain forms of creative literary work, where, when the mood
is on, it is easier to finish things than if a break occurs, but these
are exceptional cases, and even here there may be serious abuse. Many
of the men who work late at night eventually get into habits that
seriously impair their sleep. This system of rest prevents such a
strain from being put upon the physical organs underlying attention as
will prevent them from promptly relaxing when the call upon them has
ceased.

There are, of course, men for whom no such rules as these seem to be
needed, because they apparently thrive on work. These are exceptions,
however, that prove the rule. They will usually be found on
investigation to have been men who lived very simply and permitted
themselves very little excitement. There is great danger in imitating
them because most of them had a superabundant vitality which expressed
itself in longevity as well as in a noteworthy capacity for work. They
had superabundant brain power to run their business (even though it
was deeply intellectual), but then, too, these men were careful not to
throw extra burdens upon their digestive organs, nor to abuse
stimulants, nor to permit a regular routine of work to be disturbed.
When symptoms of nerve weakness begin to show themselves, even the
exceptional men must be warned of the danger. The causes of the
exhaustion of nervous vitality should be pointed out, and an
improvement of habits insisted upon.


Amusement and the Mind.--The theater, as it is at the present time,
affords very little opportunity for mental relaxation. Most of our
theatricals are mere show that occupies the eye but does not seriously
catch the attention, especially after a certain number of types of
these performances have been attended. The humor of the comedians of
our musical comedy may, for {228} a certain number of people, mean
something as a diversion of mind, but it does not last. Unfortunately,
practically all their humor runs along the same line, most of it is
extremely superficial, much of it is borrowed and wears signs of its
origin, not a little of it is mere horse-play, which may divert
children but not grown men, and so the theater as a mental relaxation
has lost nearly all of its effect. Other diversions are sometimes more
hopeful. For baseball enthusiasts, attendance at a game may be such a
complete occupation of mind as to furnish thorough relaxation.

The kind of work that provides mental relaxation for others often
proves exhausting to those who do it. Humorists, especially those who
have to grind out paragraphs or columns of humor every day or every
week, are usually melancholy men. The story of Grimaldi illustrates
how serious may be the effect of work that seems mere play if pursued
too singly. This humorist on one occasion consulted a specialist in
mental diseases, for certain symptoms of nervous breakdown and
depression that were causing him much annoyance and even more
solicitude. The specialist believed in diversion of mind, and, having
been to see Grimaldi the night before and enjoyed him hugely, though
he did not recognize him off the stage, counseled him to go and see
that humorist and have his "blue devils" banished for good. "If
Grimaldi won't cure you of your depression," he added, "I don't know
anything that will." "My God!" the humorist said, "then don't leave
me in despair. Man, I am Grimaldi!"


Sports.--Unfortunately in our modern life we have to a great extent
lost the idea of sport. The conventional make-shifts of life in a camp
that is really a luxurious country house, or on a luxurious yacht, do
not replace the complete diversions that came with real camping,
hunting, fishing, sailing and the like. People now go to the country,
but take the city with them. They live in country hotels and make five
changes of clothing in the day, if not more. If men are interested in
hunting and fishing and can go into the forest (unfortunately even the
Adirondacks can scarcely be so designated now and we have to go into
the Canadian wilderness to get away from the pall of regular life and
civilization), complete recreation is secured. This makes a real
vacation which does not mean absolute freedom of mind, but freedom
from other cares so that one may with complete absorption apply
himself to something different. During the year sports for grown-ups
are difficult to obtain. Some men continue well on in middle life to
play tennis, hand-ball, and certain other games, _O fortunati nimium_,
that make the best kind of diversion. Fortunately, in recent years
golf has become a favorite and for many makes a genuine diversion.


Children's Diversions.--In recent years we have so interfered with the
normal natural development of the child that there is need to
emphasize certain details in this matter. The modern child is apt to
be precociously occupied with books and adult interests, because he is
brought so much into the foreground of family interests. True play for
some city-bred children is almost an anomaly. Exercise and air they
get. They are conducted solemnly to the park by a nursemaid, who is
instructed to see that they do not play with other children unless
quite as well dressed as they are themselves, and their dress is often
so elaborate that it is quite impossible for them to think of any real
play. There is absolutely no recreation for the child in this
procedure: on {229} the contrary, a new effort of will is required to
walk with the stately propriety that is expected of it. Then the child
is preoccupied with the thought of its clothes. Relaxation of mind is
often quite out of the question, and yet we wonder why children are
nervous and do not sleep well, why they have night terrors and do not
digest their food properly, while all the time they are living
unnatural lives that give no proper outlet for their energies and
little diversion for their mind.

Games are important, but their true spirit has gone out in recent
years. There are still a few young people who play for the sake of the
sport, but everything now seems to be a preparation for some sort of
contest. Only those are engaged in these contests and the preparation
for them whose muscular development is such as to suggest that they
will help to win. Winning, and not sport, has become the purpose of
our games. This makes the participants worry about the games and
associate them with dread of errors and ill chances. It is true that
the interest for the contestants during the game is sufficient to make
up for this and make the game valuable as relaxation; but those who
need such relaxation most--the boys and girls who are underdeveloped
muscularly--must sit and watch the contests, and this, after one has
become accustomed to it, like newspaper reading and the theater,
constitutes a poor apology for the complete relaxation of mind and
diversion of brain-cell energy that used to come with sports when they
were freely indulged, for the sake of the sport and not for the sake
of winning.



CHAPTER VII

HABIT


Few people realize how powerful a factor for physical, as well as
moral, good and evil is habit. The old expression that habit is second
nature is amply illustrated in the most familiar experiences. The
child, unable at the beginning to make any but the most ill-directed
movements, learns during its first two years to make the most complex
co-ordinated movements--first with difficulty, then with ease, and
finally with such facility that there is no need for it to pay any but
the most perfunctory attention to their execution. Walking requires
the co-ordination of a large number of muscles so that the absolute
position of every muscle in both the legs and in the trunk, at least
as far as the shoulders, must be definitely known and their activity
properly directed. Perhaps nothing brings out more clearly the
difficulty of walking, though it depends on only one factor, the
co-ordination of the two sides of the body, than the story of the
Italian Tozzi twins. They were born with two heads and shoulders and
with only one pair of legs. It was found that each head ruled the leg
on its own side of the body. It was impossible for the creatures to
walk. They lived to adolescent life, yet never succeeded in walking.
The intimate association of the lower parts of their trunk and the
long years of companionship of their brains, did not enable them to
accomplish what seems to us so commonplace a co-ordination of movement
as walking.


Formation of Habits.--The co-ordination of the two limbs is after all
only a small portion of walking. The body must be held erect, the
curve of {230} the spine must be managed so that the center of gravity
is kept well within the base, and gluteal and femoral and calf muscles
must all be co-ordinated with one another. In a few months a child
learns to do all this, and in a couple of years it executes all the
co-ordinate motions with such certainty that walking becomes not only
an easy matter but an absolutely unconscious accomplishment that can
be carried on while the mind is occupied with something else or while
it becomes so abstracted that surrounding objects are not noticed.

A far more difficult co-ordination is required for talking. It is only
when we analyze how nicely adjusted must be every movement, in order
to pronounce consonants and vowels properly and to combine them in
various ways, that we realize how complex is the mechanism of talking.
A difference of a hundredth of an inch in the movement of the tongue,
or less than that in the movements of various muscles of the larynx,
makes all the differences between clear articulation and a defect of
speech. In the course of the years up to seven, the child learns this
wonderful co-ordination apparently without difficulty, but really at
the cost of constant well-directed effort. There is no time in human
existence when the child really learns so much as during the first
four years of its existence, even if it learns nothing else except to
walk and to talk. The foolishness of obtruding other things,
information and study of various kinds, on the child's attention at
this time should be manifest.


_Unconscious Regulation of Muscles_.--What is thus prefigured in early
life invades every activity in later years. The boy who learns to ride
a bicycle must at first devote all his attention to it, but after a
while rides it quite unconsciously, his muscles having learned by
habit to accommodate themselves automatically to all the varying
positions of his machine. Anything well learned by habit is never
forgotten. How hard it is to learn to swim, yet, after years away from
the practice of it, the art comes back at once. The same is true of
skating, and of the nice adjustments of muscles required in various
games. Such is the influence of habit in forming a second nature. It
is no wonder that Reid, the Scotch philosopher, should have written:

  As without instinct the infant could not live to become a man, so
  without habit man would remain an infant through life, and would be
  as helpless, as unhandy, as speechless, and as much a child in
  understanding at threescore as at three.

Commenting on this Prof. J. P. Gordy, in his
"New Psychology," [Footnote 26] says:

    [Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.]

  Strong as this statement seems, it is probably an understatement of
  the truth. Without habit, we should rather say, a man would be as
  helpless, as speechless, as unhandy at three-score as at birth.
  Habit is the architect that builds the feeble rudimentary powers of
  the child into the strong, developed powers of the full-grown man.
  If a child's vague, purposeless movements give place to definite
  movements performed for definite purposes, if his sensations become
  more definite, if his perceptions become clearer, if his memory
  becomes more accurate, if he reasons more and more correctly and
  logically, it is because of habit.


Law of Habit.--The law of habit is that every time we perform any
action, mental or physical, or allow ourselves to be affected in any
way, we have more proneness to, and greater facility in the
performance of that action or in {231} experiencing that affection
under similar circumstances, than we had before. In the chapter on
Tics, I call attention to the fact that all the curious gestures by
which we are individualized, are due to the law of habit. It is
infinitely amusing to watch a group of people and note the endlessly
different habits of which they have become the victims. There are
tricks of speech and tricks of gesture eminently characteristic and
often quite laughably individualistic. We imitate, especially those of
whom we think much. Sometimes it is only when a father's attention is
called to them in his sons that he realizes the ludicrousness, or at
least laughableness, of some of the things he does, and he proceeds to
correct both generations of their faults.


PHYSICAL HABITS


Habit and Food.--Most of our likes and dislikes for food are neither
physical nor physiological, but simply habitual. We have become
accustomed to certain things, and so we like them. We are unaccustomed
to them, and do not care for them. It is amusing when people put
forward these lacks of habituation as if they were physiological
idiosyncracies. Many thin people do not like butter and milk. The real
reason for this is not any peculiarity of digestion, or any gastric
incompatibility, at least in 99 cases out of every 100, but the mere
fact that they are not habituated to their use. That is one of the
reasons why they are thin. Our tastes for curious foreign foods are
nearly all deliberately acquired. Not one in ten ordinary Americans
likes olives or caviar when first tasted. Nearly every curious article
of food is "caviar to the general" at first trial. Later it becomes
impossible to understand how we could have had any objection to them.
At times, even an actual craving for them asserts itself as a
consequence of the habitual use, and then deprivation means positive
discomfort.


Slow Eating.--One of the most valuable habits that a man can
cultivate, but one of the most difficult to acquire in our time, is
that of eating slowly. Most Americans bolt their food to a degree that
would be quite appalling to them if they realized what they were
doing. Pieces of potatoe as large as the end of the thumb are
swallowed. Bread and milk may be eaten so hurriedly as to be as potent
a source of digestive disturbance as fried onions. There seems no
doubt from what we know of Fletcher's experience and Chittendan and
Follin's studies that a man derives more nutrition from food that is
masticated properly, that he can get along and do his work on less
material and that, above all, there is not the same tendency for him
to put on weight that is so common among people after reaching middle
age.

Sir Andrew Clarke used to have his patients chew a definite number ol
times on each bite--say thirty times. Even so great a man as Gladstone
submitted to this rule and gradually learned to accustom himself to
eating very slowly. Fletcher's system of chewing the food until it
passes down the esophagus of itself without any swallowing effort is a
better rule. It is a surprise to most people how unconsciously
swallowing can be accomplished in this way and how little liquid is
needed in order to prepare food to be swallowed. The formation of the
habit, however, is not an easy one. Persistence and frequent reminders
are needed, or else the beginnings of the habit are soon dissipated
and old bolting habits reassert themselves.

{232}


Water Drinking.--In drinking, habit is as supreme as in eating. The
majority of people who work outside and perform muscular labor crave
and take an abundance of water. Many of those who live indoors,
especially in steam-heated houses, may need it quite as much if not
more, but get out of the habit of drinking water. As we need about
three quarts of water per day for use in our economy, this no water
habit often becomes a serious factor in the production of
physiological disturbances. We have replaced water drinking and the
milk drinking of the olden times by tea and coffee, and as these are
stimulants, habits form very readily with regard to them. I have known
people who were sure they would be miserable without their half-dozen
cups of tea or coffee each day, and who actually would be miserable
for a few days, when deprived of it. They were seriously impairing the
efficiency of their nervous system by so much stimulation.
Unfortunately, it is just those whose nervous systems have least
stability, and are already the subjects of more stimulation by
conscious introspection than is good for them, that are most likely to
form the tea and coffee habits, and who are most harmed by them,
though they find it hard to understand the reason therefor.


Air and Exercise Habits.--Habits with regard to exercise and fresh air
are particularly important. In this matter it is only habit that can
be really helpful. To work at high pressure indoors for several days,
and then, when one is quite on edge, to take a lot of severe physical
exercise is not good. Every human being should go out between meals. I
am not one of those who believe much in exercise for exercise's
sake--what is needed is fresh air. Our sanatorium patients who sit
out-doors all day have fine appetites. The advice to a busy man that
he must form the habit of being out between every two meals for from
half an hour to an hour would usually evoke a strenuous protest, but
all he needs to do is to get up half an hour earlier and walk down to
his office, and if he will walk back in the evening he will have
plenty of air and exercise between his meals.


Change of Habits.--Patients do not want to change their habits. They
come to a doctor to be treated. They want some medicine that will,
without further inconvenience, rid them of certain discomforting
symptoms. At the beginning, at least, patients resent interference
with their habits. They are quite satisfied, and to modify them
requires an effort that must be continued for some time. The changing
of old habits and the formation of new habits are most important for
the ordinary ills to which mankind is prone. Modifications of habit
constitute real hygiene and are not mere corrections of symptoms,
permitting the habits that have led up to them to go on.

Patients may conclude that it is too much trouble to change their
habits. We all know persons who feel that they can not give up their
coffee. As to whether or not the modification of a habit is worth the
trouble it involves, the patient must be the judge after the case is
put properly before him. It is possible that he may learn to endure
the inconvenience given him by his symptoms rather than to stand the
inconvenience of changing a nicely settled habit, and forming a new
one. The reward should be put very plainly before him, however, and
besides, the consequences of his habit in the future should be
suggested so that he may realize just what it will lead to.

{233}


MENTAL HABITS

It is evident from the foregoing that physical habits have much to do
with making life easier and saving expenditure of nervous energy, but
just this same thing holds good for mental states. With care, a proper
habit of mind and of the mental attitude towards difficulties in life,
can be so cultivated as to ward off many of the discouragements, and
most of the causes of depression that weigh heavily on some people.
The natural disposition can not be entirely overcome, but habit, as a
second nature, can modify the personality so as to make conditions
much better than before.

With this wonderful power in habit, it is too bad that its force for
good is not used. It is especially important that its force for evil
shall not allowed to dominate human actions so as to make them harder
of accomplishment. Many people, who are greatly troubled by the
inconveniences and discomforts necessarily associated with human life,
worry over it to such a degree as to make themselves sick. The
expression I have quoted elsewhere of the old man who said, "I have
had many troubles but most of them never happened," is a typical
example of what the habit of looking at things from a wrong standpoint
means to many people. They are confirmed pessimists. Their one
consolation, when a small evil happens to them, is that perhaps this
may be sufficient to ward off the greater evil that fate surely has in
store.


Pessimism.--Pessimism has been defined as sticking one's nose in a
dungheap and then asking, "How is it that it smells bad around here?"
Some people are always nursing a grievance. No matter how many times
they may happen to have been undeceived, still the next time the
opportunity occurs they are sure that fate or friends or someone has
it in for them and that the worst may happen at any time. In the
expressive words of a recent slang phrase, they have a "perennial
grouch." This state of mind toward the environment not only prevents
the physical and mental good that cheerfulness brings with it, but it
unfavorably influences physical conditions within the body. People
suffering from indigestion are usually morbid, petulant, and hard to
get along with. Many a dyspeptic makes this an excuse for his bad
temper. Anyone who has had to study these cases much soon comes to the
conclusion that the beginning of the digestive disturbance was the
gloomy outlook on life, which flowed inward to disturb the digestion
and all the other animal functions.


Depression of Mind and Body.--Patients suffering from melancholia
nearly always lose in weight. As a result of their lowered vitality,
there is a suppression of the nervous impulses which rule over
nutrition, with a consequent loss of weight. In cases where there are
only tendencies to depression and gloom, the effect upon the digestive
system is not so marked but there is no doubt that there is some
effect, and that the indigestion in these cases is more often than not
a result of the depressed state of mind, rather than the depression of
mind the result of the indigestion.


Moodiness.--The habit of looking at the gloomy side of things is
easily formed and, once acquired, it becomes very forceful. Many a man
who was quite cheerful when young, becomes moody as he grows older.
Nearly everyone permits moods more than is good for him. The attitude
of mind that should be cultivated is one in which it is realized that,
though there may be {234} many sources of evil in the world there is a
preponderance of good even in the worst environment, and that
opportunities for making the best of things will be found by any
cheerful disposition. _Mrs. Wiggs of the Cabbage Patch_ is a typical
example in fiction of the optimism that counts. Miss Helen Keller in
real life is a typical example of how the most untoward circumstances
can not crush the spirit of man if he only wishes to be cheerful--if
he only tries to lift himself above his surroundings, no matter how
discouraging they may seem to be. No one is without discouragement and
causes for unhappiness. "Happy he who has least," the Greek dramatist
said.

The difference between the optimistic and the pessimistic point of
view is much more a matter of habit than is usually thought to be the
case. Indeed, there is good reason for assuming that it is so largely
a matter of habit, that other factors count for little. We all know
individuals who, after having, been cheery, bright, hopeful and
helpful, have had some incident sour them and then they have been just
the opposite. This did not come all at once; it was a growth. They
felt hurt and aggrieved, and then began to look at things through dark
glasses, and after a time could see nothing on its brighter side. Not
infrequently, as doctors well know, the growth of such a moody
disposition has been the signal for the development of a series of
complaints, if not of actual symptoms, and men and women who have not
been in the doctor's hands before now become valetudinarians. This new
physical condition is often attributed by their friends, by
themselves, and even by complacent physicians, to the effect upon them
of the trial or disappointment that struck them. Only too often it is
wholly due to the cultivation of a habit of pessimism consequent upon
a shock that for the moment pushed their cheerfulness into the
background. Strong characters will not be thus easily affected, but
weaker characters need not suffer such a change of disposition and
with it a deterioration of health or well-being unless they so will
it.


MANNERS AND DISPOSITION

Habit can modify nature so much as to make what is practically another
man. We all know how the dancing master can transform a country gawk
into a refined, courteous society man (not gentleman, for that is
something else) of graceful carriage and even handsome bearing. He
cannot do this for all the pupils that come to him, for it is
impossible to make a silk purse out of a sow's ear, but for anyone
that comes with good will the revolution in manners is often a
revelation to those who have known the man before. When the exterior
can be changed so much, the interior attitude toward other people
certainly can be greatly modified.

Persons of a melancholic disposition may be surprisingly cheerful, and
even gay, with comparative strangers when they make the effort to be
so. For many people, meeting with strangers is an excellent remedial
measure. It stirs them up to present the best side, and it occupies
attention to the exclusion of themselves in a way that is extremely
beneficial. If people would only form the habit of being as courteous
to their own folks as they are to others, the disposition involved in
this would often save them from certain symptoms, and save their
physicians from many complaints.

{235}

Happiness is the basis of good health. The phrase is often put the
other way: Good health is the basis of happiness. Without health there
is no happiness. But every physician knows that many a patient
suffering from real organic ills, and having much physical pain to
bear, still has many hours of happiness in working for others. This
happiness reflected back upon his physical life is not able to cure
his ailments, but does so lessen the significance of the symptoms as
to make the ailment more bearable.


THERAPEUTIC IMPORTANCE OF HABIT

The most important therapeutic element in the formation of good
habits, mental and physical, is that habit does away with the
necessity for conscious regulation of many details of life. Without
habits of doing things, we have to make numerous decisions and keep on
making them under conditions that require special effort and waste of
energy. When habit asserts itself, there is little or no difficulty.
Habits of living in airy rooms, of taking exercise, of food regulation
as to quantity and quality, of methods of taking food as regards
mastication, the quantity of fluid ingested, the hours of meals and
the like, can all be formed and then followed without effort. Just
inasmuch as life can be ruled by habit, nerve force is conserved. This
is as true for our attitude towards life, our disposition and
consequently our satisfaction with life, as for anything else that we
do. Habitual cheerfulness, habitual readiness to make allowance for
others and to be helpful to them, habitual self-control--all of these
things can be cultivated. Properly cultivated, they save much of the
wear and tear of life, and make for contentment and happiness much
more than many of the things for which men strive so anxiously because
they seem to promise happiness.



CHAPTER VIII

PAIN

Pain, while always a dreaded symptom of disease, seems, with the
increase of comfort and the gradual abolition that has come in our
time of many of the trials of existence, to have had its terrors
increased. Even a slight pain or ache is dreaded, and if continuous or
frequently repeated, becomes for many people a trial that is almost
impossible to bear. This is all the more to be deplored because
ability to stand a certain amount of pain, with reasonable equanimity,
is almost a necessary condition of rapid recovery from disease or
injury. Placidity of mind favors the flow of nerve impulses for
reconstructive purposes, while over-reaction to pain inhibits the
natural processes of repair. According to Shakespeare's heroine:
"There was never yet philosopher that could endure the toothache
patiently." Pain is usually supposed to be an essentially physical
phenomena for which mental influence can be of little, if any,
benefit. As a matter of fact, however, the mental attitude towards
pain modifies it to a considerable degree. I have quoted Hippocrates'
declaration that a greater pain drives out a lesser pain. Any strong
preoccupation of mind will greatly lessen pain at any time.

{236}

Pain is not, after all, in the nerves, nor in the central nervous
system, but in the consciousness. Just as there is no sound unless the
waves in the air arouse recognition in the consciousness, so there is
no pain unless the disturbance of nerves finds its way above the
threshold of consciousness. Nerves may be racked, yet no sensation may
be felt. There may be pain in the mind apart from the nerves, and
slight nervous affections may produce severe pains. The whole question
of the treatment of pain involves the individual much more than it
does the affliction which causes the pain. What seems unbearable pain
to many may be little more than a passing annoyance to others. What
would be, under ordinary circumstances, intolerable torture,
especially to sensitive people, may, because of intense preoccupation
of mind, remain absolutely unnoticed. Maniacal patients sometimes
inflict what would normally be extremely severe pain on themselves by
burning or mutilation without any manifestation of pain. In the
excitement of a panic men may suffer what would, under other
circumstances, be excruciating agony, and yet not know that they are
hurt.

To a mind that is without serious interest, even slight pain, if
continuous, soon becomes unbearable. The course of pain, where there
is no diversion of mind, is an interesting study. While suffering, we
seem always able to bear the pain of the present moment, and it is
only the cumulative effect of the pain that is past and the
anticipation of the discomfort to come, that make the pain unbearable.
Nearly, always it is much more the dread of what the pain may mean,
and the lack of power to endure which gradually develops as a
consequence of suffering, that constitute the worst features of pain.
At the beginning of a period of pain we stand it well, as a rule, but
its continual nagging debilitates us and heightens our susceptibility
until we cannot nerve ourselves to further endurance. If our power of
endurance were not thus gradually lessened the pain would not seem
severe. There are many neurotic people whose susceptibility to pain
has been so much increased by their lack of self-control and their
tendency to react easily to pain, that even slight pain becomes a
torment. Psychotherapy should gradually train these people to a power
of endurance.


Pain from Over-Attention.--Much of what is called pain is really due
to such concentration of mind on a particular portion of the body that
the ordinary sensations of that part, usually accomplished quite
unconsciously, become first a source of uneasy discomfort and then an
ache or pain. There may be some slight physical disturbance which
calls attention to the part, but there is no really serious
pathological condition. While such pains are spoken of as imaginary it
must be remembered that this does not mean that they are non-existent.
On the contrary they may be much more real to the patient than
physical ailments. A pain in the mind is a much more serious condition
than having it in the body.

While pain may be thus created by concentration of attention, it must
not be forgotten that what the mind can do in increasing pain is even
more important than in originating it. Slight discomforts by
concentration of attention on them may be made insupportable. It is
this element in pain, above all, that the physician requires skill to
alleviate. Habits of introspection and the lack of serious occupation
of mind of many people leave them the victims of over attention to
themselves. In trying to relieve their pain it may be {237}
comparatively easy to alleviate their physical condition, but the
mental condition, once aroused, may remain, and may easily tempt to
the use of habit-forming drugs or others that may do serious harm. The
story of the evil effects of headache powders in recent years, and of
the opium habits formed in olden times, are a significant commentary
on this fact. It is probable that in most of these cases, the
discomfort for which remedies were frequently taken was of a kind that
should have been treated only partly, if at all, by drugs. It is more
important to lessen susceptibility than to try to cure the pain.

The relation of the mind to what is often considered severe physical
pain, has come to be generally recognized in recent years. Neuralgias,
for instance, have often been reported as recurring after fright, or
strong emotion, or worry. It is at moments when patients are much run
down in health that pains are particularly likely to be unrelievable,
and during periods of emotional strain that anodyne drugs are most
called for and are most likely to be abused.


Rest and Pain.--In any study of pain and its relief, one must always
recur to that classical contribution to medicine, now in the fiftieth
year of its publication and still as important as when it was written,
Hilton's "Rest and Pain." He calls attention to the fact that what he
wrote was only a development of what many practical physicians had
thought long before his time. He quotes a prize essay of the French
surgeon, David, written in 1778. Hilton's development of the idea that
pain is usually a signal on the part of nature for rest, and that rest
will usually enable her to overcome the pathological condition and so
relieve the pain without recourse to drugs, is, and ever must be, the
basic element in the therapeutics of pain. How many forms rest may
take can only be judged by a careful reading of Hilton's book. The
oftener one reads it, the better one realizes how much of precious
common sense and acute clinical observation there is in it. It is
essentially a book of psychotherapy. It treats the patient's mind
first and then through that changes his habits, persuades him of the
need of rest, directs how that rest should be taken and so leads up to
his natural cure.

Every treatment of pain must include rest of mind as well as body.
Hilton has particularly dwelt on the rest of body. Rest of mind is
just as important. Many pains could be easily borne were it not for
the worry that accompanies them. A slight pain becomes greatly
annoying because the patient's general condition makes it impossible
to stand discomfort with equanimity, and there has been no training in
self-control. In spite of all our advance in medicine, we are not
likely ever to make life so free from pain that people can go through
it without needing self-control. Training in self-control is an
important psychotherapeutic prophylactic. If, with a certain amount of
capacity to bear discomfort, there goes such rest of mind as does not
exaggerate or emphasize the condition, then many of the pains of life
lose their power to annoy, all of them are distinctly lessened and the
relief of them by accessory physical methods becomes easier.


Pain in Its Relation to Life.--There is an unfortunate tendency to
exaggerate the significance of pain. We have cultivated irritability
in the physical sense, rather than the power of endurance. Patients
should, as far as possible, be lifted out of this condition of
over-delicate sensitiveness and put into a state where the idea of
pain is not so serious. Only in this way can {238} the more or less
inevitable discomforts of life be borne without such reactions as
seriously interfere with health. It may be said to be other than the
physician's business to secure this magnanimity, but as magnanimity is
needed in our patients, and there is no one else to respond,
physicians must start its cultivation. The necessity for learning to
bear minor discomforts, at least without exaggerated reaction, need
not be presented to the patient directly, but can be gradually made a
part of the system of treatment. By absorption in other interests, the
consciousness of these discomforts disappears without the necessity
for recourse to drugs.


Self-Denial.--Many thoughtful people are sure that what is needed to
make a large number of our generation more happy, or at least less
miserable, is training in self-denial and in self-control. The word
self-denial has come to have a very distant sound for most of our
generation. From early childhood anything that is unpleasant is
shunned and anything that is difficult is likely to be shirked. The
head-master of Eton College has recently insisted that too much is
being done to please young folks and too little to stimulate them to
activity. He declares that, as a rule, any undertaking begins to be
useful just where it ceases to be simply pleasant. Unpleasantness is
avoided to such a degree that the habit of thinking that it has no
part in life comes to be a second nature. As a consequence, the
reaction to any continued unpleasantness is likely to be exaggerated
and make the subject very miserable, and sometimes disturbs and
discourages, whereas it should have the effect of stimulating to
reactive efforts, to bring out the best that is in us.

Hinton emphasizes the fact that an ingredient of pain is necessary to
all health or pleasure. The fatigue and the hardship associated with
mountain climbing is a portion of the essence of the pleasure in it.
All healthy, pleasant exercise has an accompaniment of fatigue and
some aches and pains. What is needed, then, in our time is the
training to do things for the sake of doing them. We should be
neglectful of the discomfort that may be associated with them, or we
should even consciously rejoice in the fact that this very discomfort
is of itself a sign that functions are being used to such an extent,
that their limits are being expanded, their limitations overcome.

It may well be said that it is not the physician who, as a rule,
should do this; it should be accomplished in the early years by the
teachers and trainers of the young. True enough. But physicians can at
least help in reforming the tradition in this matter so as to
neutralize the present state of mind which seems to look upon pain as
an evil. Pain is always either a conservative sensation or an actual
stimulus to function. Besides, many of the present generation who come
to us, having had no training in the precious qualities of self-denial
and self-control under difficulties and discomforts, must have this
knowledge supplied for them as far as possible by suggestions of
various kinds. It is more difficult to accomplish much in this matter
for the adult, but even in apparently hopeless cases of over-attention
to self and incapacity to bear discomfort, much can be accomplished by
patience and persistence.

The common dread of suffering is quite unwarranted by what we know
about the effect of pain. There are many motives that may be adduced
to make it seem less terrifying than it now is to many people. The
effect of pain upon character is always excellent. The difference
between two brothers, as we have said, one of whom has had the
discipline of pain or suffering and {239} the development of sympathy
that comes with it, and the other who has not had the advantage of
this great human experience, is likely to be marked. In the one there
is a depth of human nature that enables him to appreciate and even to
express the meaning of life better than his apparently more fortunate
brother. Practically all the men who have ever got close to the heart
of the mystery of life, and expressed it in poetry or other form of
literature or art, have gone through suffering as a portion of their
training. Even the suffering that comes from ill health is never
wasted. Men have gone through it who have thought that the ecstasy of
relief following it made the experience worth while.

Men are not deterred from action by the prospect of even severe pain.
Probably no greater physical suffering can possibly be invited than is
sure to come to those who go on Arctic expeditions, or who undertake
prospecting in Alaska. Of course, many of the prospectors find
themselves in the bitter cold of the North without having realized
what they would have to stand. But Arctic explorers, as a rule, know
exactly what they have to expect. Most of of them have been through it
all before, yet they deliberately choose to go again for rewards that,
to an average man's eyes, seem trivial. The memory of past pain is
rather pleasant. Virgil's "Perhaps it will be pleasant to recall these
trials at some future time" is not poetic exaggeration.


_The Discipline of Pain_.--There is only one way to learn how to bear
pain, and that is by practice in it. There might be no necessity for
this in case life were arranged differently. But all men must die, and
death inevitably involves a painful process. Suffering is practically
unavoidable for the majority of men. Even in the midst of every
possible material comfort, cancer may come with all its hideous
connotations. It is important, then, that everyone should be prepared
to stand some pain. Certain suggestions help in bearing special pains.


Pain Diffusion.--Pain along one nerve may readily become diffused.
This diffusion will sometimes cause discomfort, and even tenderness,
at a distance from the original seat of the pain. Such diffusion tends
to produce in the patient's mind the idea that the underlying
pathological condition is spreading, though it is only a sign that the
nervous system is becoming irritable and easily responding to sensory
disturbance. Dr. Head's investigations ("Brain," 1893), should be
known to physicians, and the conclusions that flow from them should be
presented to patients who are sometimes suffering quite as much from
their apprehension of the spread of pain, and its significance, as
from the discomfort itself. Dr. Head says:

  If I have an aching tooth, the pain is at first localized to the
  tooth affected. The longer the toothache continues the more I become
  worn out, and the pain is rapidly accentuated by a "neuralgia," that
  is, a pain in the face. The neuralgia is soon accompanied by
  distinct cutaneous tenderness over a definite area on the face
  corresponding to the tooth affected. If I am anemic, or if the pain
  remains untreated until my bodily health is affected, I no longer
  have a localized area of tenderness, but the pain, and with it the
  tenderness, spreads until the whole of one-half of the head and even
  the neck may be intensely tender. Thus at last the pain of an aching
  tooth has produced tenderness over areas which bear no relation to
  the affected organ.

As pain can be suppressed by diversion of mind, or concentration of
thought on something that creates great preoccupation, it must not be
{240} forgotten that pain may almost be created by concentration of
attention on certain areas of the body, or certain nerve tracts.
Over-attention will actually make sensations intolerable that are at
first quite indifferent, or at least very easy to bear. Sensitive
people, in the ordinary meaning of that term, are those who are much
given to paying attention to their sensations, and who therefore have
much to complain of them. There is much in modern life that has the
tendency to produce this sybaritic condition in which even slight
discomforts become the sources of almost unbearable annoyance.

Even where there is no good physical reason for the occurrence of
pain, thinking may produce discomfort. The one thing that Freud's work
has made clear is that in neurotic persons the memory of a mental
shock or strain may be transferred to some portion of the body related
in some way to the shock, and then prove to be the source of
hysterical pains and also of hysterical palsy. The case told by him in
which the young woman massaging her father's limbs allows them always
to rest on her own lap during the process, and after his death suffers
from an hysterical, painful condition in this region, is a typical
illustration. Her sympathy for her father, accentuated by his
subsequent death, and her sorrow at a time when her nursing efforts
made her particularly susceptible, led to an explosion of nervous
energy along those nerves which had always felt the impress of his
legs. The hysterical condition resulted. This is an extreme case. In
milder forms it would be possible to explain many otherwise
inexplicable pains and aches in sensitive young people along these
same lines.

More than once I have seen young women, who had been asked to rub
father or mother with liniment, complain of tingling pains in their
fingers which were followed by some redness so that one would be
tempted to think of Weir Mitchell's disease, though evidently the
pathological cause at work was the slight disturbance of the vasomotor
system due to the liniment and the rubbing, emphasized by the
sympathetic feelings, and by the over-attention which this brought
about. Whenever women have, for a prolonged period, to nurse others in
whom they are deeply interested, and have to perform some habitual
action that is somewhat fatiguing for them, after the death of the
patient there will not infrequently be the development of hysterical
or neurotic over-sensitiveness in the parts employed. This may give
rise even to an hysterical joint, or to severe neurotic pains. Once
these cases are recognized, the attention can be diverted from
themselves and they can be made to understand that their grief and
sympathy are being concentrated on the part and by transfer are
producing physical manifestations. The pain is not imaginary, but the
condition will improve as soon as the mind is diverted from it.


Neurotic and Organic Pain.--The distinction between pain due to a
neurosis and to a definite lesion is often difficult to make. If there
is a definite localization of pain, it is almost surely not neurotic,
but organic. If there are certain positions in which pain is felt
while it disappears in others, there is some local inflammatory or
congestive condition and not mere hypersensitiveness of nerves at the
bottom of it. These positions of maximum pain are important. When pain
radiates a great deal, even though there may be complaint of a
particular region, it is usually neurotic. If patients are asked to
tell exactly where their pain is, and they indicate its location by a
wave of the hand, it is probable that the condition is neurotic. When
there is a definite {241} localized point of tenderness with the pain,
even though there may be radiations, usually the condition is based
upon some organic trouble. It must not be forgotten, however, that
slight local troubles may by concentration of mind on them, become
exaggerated and that, in spite of the fact that there is or was at the
beginning a definite localization of pain with some tenderness, the
neurotic elements may, after a time, become manifest and prove to be
much more important than the others.

Pain that is definitely influenced by motion, as by the jarring effect
of walking, or by bending and stooping, is practically always organic.
The best differential diagnosis between neurotic abdominal conditions
and organic trouble can be made by the help of information obtained in
this way. If the appendix is inflamed, or the gall bladder infected,
or contains a calculus, or if the kidney has a calculus, these are all
made worse by movements, by jarring, by stooping as in tying the
shoes, by riding on rough roads, and the like. If patients who suffer
from obscure abdominal conditions associated with pain of which they
complain much, can, at certain times, indulge with impunity in these
exercises and motions, it is probable that their attacks are neurotic
in character. Especially is this true if the indulgence in these rides
and motions is without effect when they are in pleasant, agreeable
company, though there may be some complaints when they have to ride
alone, or under conditions that are less pleasant. If a hint of this
distinction by which the physician differentiates one form of pain
from another is given a neurotic patient, the suggestion will serve
the purpose of producing complaints whenever the opportunity presents
itself. Such patients take such suggestions, as a rule, without
wishing to deceive, but they become persuaded that their sufferings
are of the character asked for.


{242}

SPECIAL PSYCHOTHERAPY

SECTION VI

_THE DIGESTIVE TRACT_


CHAPTER I

INFLUENCE OF MIND ON FOOD DIGESTION


With the progress of biological chemistry, digestion came to be
considered a purely chemical process. Now we realize that even more
important than the chemical factors of digestion is the individual
liking for particular kinds of food, and the mental attitude of the
patient toward digestion.

Not only may mental factors interrupt or hamper digestive processes
generally but, as the investigations of Pawlow at the Imperial
Institute of St. Petersburg show, they may modify very materially the
chemical processes within the stomach. If, for investigation purposes,
a stomach pouch be experimentally segregated in a dog from the rest of
the stomach, and the dog be fed food that he has a particular liking
for, the gastric juice manufactured will be especially strong and
effective. If the food given be less to the dog's liking, the gastric
juice is not nearly so efficient in its activity. Finally, if food be
consumed for which the dog does not care, but which he takes because
hunger compels him, the gastric juice manufactured for its digestion
is quite weak and the process of digestion is slow. If this is true
for an animal like the dog, whose psyche is comparatively of much less
importance than that of human beings, the corresponding influences in
men and women will be even more emphasized. This is only what common
experience has always shown us. The human stomach is not a test-tube
in which mere chemical processes are carried on, but its vital
activity is of great importance. That vital activity depends to a
large extent on the state of mind, on the relish with which food is
eaten, on the individual likes and dislikes, and on the emotional
condition during digestion.


Prejudices and Digestion.--Perfectly good food materials may become
difficult or impossible of digestion as the result of learning
something about their mode of preparation. In the country this is
often noted, with regard to butter, milk, and even eggs. The story of
the farmer's wife who wanted to trade her own butter for an equivalent
amount made by someone else illustrates the influence of mind over
relish for food. She was candid enough to say that the reason she
wanted to exchange the butter was that a mouse had been seen in the
cream, and her children could not, therefore, eat it. She took {243}
back home with her exactly the same butter in another crock, and there
was no further difficulty, though before this the children would have
been actually sick if compelled to eat the butter. I once saw a family
of three women who had vomited because they heard that the dishes had
been washed in a slop pan, though this proved to be a mistake. Such
occurrences emphasize the necessity for properly predisposing the
mind, and for removing unfavorable suggestion, if digestion is to
proceed properly.


Mental States and the Stomach.--The typical example of the influence
of the mind on the digestive tract is to be found in the experiences
of Flaubert, the French novelist, while writing "Madame Bovary." When
he was writing the scene in which he describes the effects of the
arsenic which Madame Bovary takes, he himself suffered from
practically all the symptoms due to the drug. In order to describe it
faithfully he had studied it carefully. He had the pains, the
vomiting, the burning feeling and even the garlicky, metallic taste in
his mouth. Such an incident is extremely exceptional, yet its
possibility is recognized, and it illustrates how sensitive some
people are to the action of mental states upon the body, and how large
a role a strongly excited imagination can play in producing definite
physical symptoms. There are many more such realistic imaginations
than we have, perhaps, been inclined to suspect. It is over these
particularly that the psychotherapeutist can exert his influence by
helping to modify the cause of their symptoms, the mental attitude
which exists, rather than by trying to change the symptoms which are
only effects, for diseases must, as far as possible, be treated in
their causes.


_Disgust and Disturbance of Digestion_.--Max Müller's story, told in
his book on "Language," to show how language might have been a human
invention from imitation of natural sounds, illustrates the influence
of an unfavorable state of mind in disturbing digestion. An
Englishman, traveling in China, fearful lest he should not be able to
obtain food that he cared for, because of his lack of knowledge of the
language of the country, was rather surprised on his first day's
journey into the interior, to be served with a stew made of some kind
of dark meat that tasted very well indeed and with which he was so
much pleased that he asked for a second helping. Just as he was about
to eat the second portion, he thought it well to ask the waiter what
sort of meat it was, as he wished to be able to obtain the same kind
at other places. Calling the waiter to him, he said, pointing to the
dish of meat with a questioning tone, "Quack, quack?" The waiter at
once shook his head and said, "Ugh! bow wow!" The Englishman pushed
the second portion away and got up from the table.

Tinder the same circumstances nearly everybody would feel the same
qualmishness--at least all who had been brought up according to our
Western notions. Reason has little or nothing to do with it. It is a
question of feeling. The dog is much more cleanly in its habits than
the hog, but we in the West are used to the idea of eating hog-meat
just as they in the East are used to eating dog-meat. The objection,
of course, might be urged that the difference between the hog and the
dog is that we do not eat carnivorous but only herbivorous animals.
But the slop-fed hogs from the neighborhood of our large cities,
constituting a goodly portion of those brought to market, eat meat
quite ravenously. They certainly are not exclusively herbivorous.
There is no {244} principle behind our objection to dog meal
then--only the unfamiliarity of the idea of eating it.

The treatment of patients with digestive disturbances requires a
careful analysis of the conditions of mind towards foods. If prejudice
exists with regard to certain foods, there will be no relish for them,
and unless these prejudices can be removed, the foods either will not
be taken, though they represent important nutritional elements, or
else they must be taken in such small quantities and digested with so
much consciousness of their presence and such difficulty as to be a
disturbing factor for health. Persuasion, the custom of the country,
habit, training, mean much for this modification of mental attitude.


_Custom and Food_.--In recent years many parts of animals, not
generally eaten before, have come to be consumed with a relish because
of the removal of prejudices against them. It might be thought that
organs like the kidney, the essential function of which is excretory,
and through which so much of the offensive waste products of the body
pass, could not be a relished article of food. But it has become quite
a dainty. The liver, owing to the peculiar nature of its function, its
very special flavor, and the staining with bile, might be expected to
be objectionable. It is not, but, strange to say, a third organ of the
abdominal cavity, the spleen, which has none of the external
objectionable features of kidney or liver, is not yet eaten, and most
people would probably find it rather difficult to eat it. This
difficulty would result, not because of anything in the organic
substance itself, but because of the lack of accustomedness to it.
There are a number of people who now have trained themselves to eat
it. Such apparently impossible portions of the animal as the
intestines, even those of the hog, are eaten with relish by a great
many people, though there are others who have never been able to get
used to them. The dainties of some peoples are utterly repulsive to
others. The French like brains and other special portions of animals
that are not much eaten by Anglo-Saxons. Fried brains in black butter
sauce are enough to turn the stomach of some people by the very
thought of it, though it is a highly prized dish in the south of
France.

In Italy most visitors eat snail soup with relish before they know
what it is. It seems to be a special kind of gumbo soup. Down at
Marseilles, gourmets occasionally eat angle-worms and find them to be
a very appetizing dish. In all of these things the question of relish
and peaceful, happy digestion depends entirely on the attitude of
mind. The first men who ate eels must have been looked upon with
considerable suspicion by their neighbors as viper eaters, and
probably they themselves were not comfortable over the feat. It has
been said that the first man who ever swallowed an oyster performed as
great a feat as any of our important inventors or discoverers.


_Gastric Antipathies_.--To the great majority of mankind the idea of
eating horseflesh is repulsive. Numbers of people in various parts of
Europe have found, however, that after the initial repugnance is
conquered, it is quite as pleasant to eat as cow's meat. To my taste,
at least, it is much more palatable than venison or bear meat. At the
beginning, its sweetish taste has a curious reflex effect. Taken in
connection with the thought that this is horse meat, the taste is apt
to produce a sensation of nausea. This is readily overcome, though the
first time it is necessary to keep constantly inhibiting {245} the
mind from acting unfavorably upon the stomach during the course of
eating and digestion. Custom, I learned from many, soon made it quite
as savory as beef.


_Food Varieties and the Mind_.--How easy it may be to overcome many
prejudices in the matter of food digestion under the stress of
necessity and the influence of example, was well illustrated during
the siege of Paris. The Parisians, though a most delicate people in
the matter of eating, were able to accommodate themselves to the
conditions, and practically every kind of animal was eaten with a
relish. Before the siege, to most of them it would have seemed quite
impossible, that they should sit down with complacency to the dishes
which afterwards were so appetizing. At the beginning there was a
definite attempt to conceal the eating of rats, mice, cats and dogs
under various names, and by various modes of preparation. But it was
not long before there was an end of this pretense. The animals in the
zoological garden proved a veritable life-saving store of meat. Every
one of them was eaten, people were glad to get them, and paid high
prices for them. Camel steaks, elephant cutlets, lion and tiger stews,
appeared under their own names, even at the banquets of the wealthy.

What is true of the mental attitude for meats influencing not only the
relish for them, but their digestion, is also true for many
vegetables. There are unfavorable suggestions in the minds of many
with regard to the supposed indigestibility of potatoes, turnips,
carrots, beans and occasionally with regard to tomatoes, lettuce, or
the like. A few definite physiological idiosyncrasies against these
vegetables, or certain of them, do actually exist. The attitude of
mind, however, is largely responsible for the discomfort that occurs
after the consumption of most of them. Patients who ought to consume
more starchy substances, or whose bowels need the residual materials
that are contained in these vegetables, for the sake of their effect
upon peristalsis, should be persuaded to take these vegetables, first
in small quantities and then in gradually increasing amounts. Many of
them can thus be brought to a diet at once more nutritious and more
likely to help out intestinal function. Their objection to them is
usually but a fancy.


Genuine Food Idiosyncrasies.--There are certain genuine idiosyncrasies
with a physiological basis which prevent the taking of certain kinds
of food, or cause disturbance if they are taken, but these are rare.
Their presence should never be considered as demonstrated by
subjective signs alone for these are eminently fallacious. In certain
cases, however, so rare as to be almost always curiosities in medical
practice, there are definite objective symptoms of the idiosyncrasy.
These consist of urticarial rashes, tendencies to vomiting, or
diarrhea, or both. Sometimes these result from the most bland and
nutritious of foods. I have notes of the cases of two children--whose
father could not eat eggs without vomiting--and to whom fresh eggs fed
at the age of two and three years, always produced this same effect.
Even small portions of egg would cause it. It mattered not how the egg
was prepared, nor even whether it was carefully concealed in custard
or in cake provided there was a certain amount of it, the food eaten
with it would be vomited. There are many such idiosyncrasies for shell
fish, cheese, and such fruits as strawberries, pineapples,
pomegranates and the like, but they are demonstrated by objective
signs. But by far the greater number of food dislikes are entirely
{246} subjective and the subjective feelings can probably always be
overcome by habit and training.


Food Dislikes.--_Milk_.--Nothing makes more clear the absolute
dominion of the mind over the stomach than the likes and dislikes of
people for various kinds of milk. Most Americans can take cow's milk
with good relish, though there are a few to whom it is distasteful. In
this country we have not had much experience with the milk of other
animals. Even goat's milk is not commonly used. The very thought of
taking it disturbs many people, and to take it with other food would
almost surely produce disturbance of digestion. I have seen people
while traveling quite upset over the discovery that goat's milk had
been put into their tea or coffee. Mare's milk is commonly used in
some parts of Europe and in many parts of Asia, but it would be quite
impossible to most of our people. Sheep's milk is used in some places.
Ass's milk is commonly used in parts of Asia and may be obtained in
Spain and is said to be less likely to disagree with children in
summer than cow's milk. Most American mothers would rather not hear of
it.

The same thing is true of the milk products. Some people find certain
kinds of cheese quite out of the question though other people relish
them. It requires special training, not of stomach but of mind, to
enable one to eat certain cheese, though once the habit has been
acquired such articles are delicious. It is only in recent years that
some forms of cheese with greenish tints have become popular in
America. To serve them at a dinner a generation ago disgusted many
people. Now a dinner does not seem complete without them.

The beverages of various countries illustrate this same principle. The
wines the Spaniards care for are not palatable to the Italians, and
_vice versa_. Beer, as the result of familiarity, is now drunk
everywhere in Europe, but when it was first introduced into Italy from
Germany, it was considered impossible to understand how anybody could
take it and pretend that its taste was pleasant. The question is said
to have been once asked of one of the Congregations at Rome whether it
was permissible to take beer on fast days. The Cardinals who tasted it
declared that not only did it seem to them permissible but that it was
a mortification to drink it and therefore it was proper Lenten
exercise.


_Eggs_.--Many people have a supposed natural repugnance for eggs which
they are sure indicates that these are not good for them. As a result,
the physician gets all sorts of stories with regard to the supposed
effects of eggs. One person tells you that more than two eggs a day
makes him bilious. Another will tell you that they are too heavy for
him. A third will tell you that they are distinctly constipating. A
fourth will tell you that they produce a tendency to diarrhea. Here,
as with regard to milk, the experience of the tuberculosis sanatoria
has shown that there are but few people who cannot, when properly
persuaded and when eggs are given in various forms, take from four to
six eggs in the day without injury, and even without inconvenience. In
these cases, it is largely a matter of mental attitude towards the
food. In many instances, it will be found that the disinclination
began in some experience in childhood when an egg was not very good,
or when it was served insufficiently cooked, or when, perhaps, eggs
always cooked one way were made a staple of the diet for a
considerable period. There are over one hundred {247} ways of cooking
eggs and this variety of preparation will often make them palatable,
and nearly always digestible.

Over and over again I have seen people who had thought that eggs made
them bilious, and who accordingly had for long refused to eat them,
put in circumstances (from tuberculosis, diabetes, or obesity) where
eggs had to form a considerable portion of the diet. Then there was no
difficulty about eating and digesting eggs. In three cases in my
experience patients with an objection they thought constitutional,
developed glycosuria, and then nearly all their desserts were
custards, and eggs became a standing dish in their daily diet. In
every case not only was there no trouble, but they got to like the
eggs and wondered why they should ever have had any prejudice against
them. Two of the patients were women, the third a man who had not
touched eggs for many years. His wife's comment was: "Eggs always made
him bilious when he did not take them, but now that he is taking them
freely they no longer make him bilious."


Mental Changes and Digestion.--The change that has come over the
public mind with regard to sour milk is a typical illustration of how
much a difference in the mental attitude towards a food product may
mean for its satisfactory consumption by many people. Sour milk,
though many farmers and working people thought it a pleasant acid
beverage, was for long looked upon as a product fit at most to be fed
to the pigs, if, indeed, there might not be question even of the
advisability of this. Only the very poor who craved the nutritious
value there was in it, continued to take it to any extent. Even if the
milk still tasted sweet, but broke when it went into the tea, that was
enough to make it quite impossible for many sensitive stomachs.


_Lactic Acid as a Bactericide_.--Then came Metchnikoff's announcement
that his studies showed sour milk to be an extremely valuable food
material, but much more than that, an important auxiliary for the
lessening of microbic life in the intestines. He seemed to be able to
demonstrate that a great many bacteria, whose products, absorbed from
the intestines, hastened that process of deterioration in the tissues
that we call old age, were inhibited when sour milk or lactic acid
bacteria were present. The general health of the person who took sour
milk was, as a consequence, much better. Not only this, but processes
of deterioration being lessened, prolonged life and even old age could
be promised to those who drank sour milk in sufficient quantities.
Metchnikoff had been brought to the study of this question by what he
had seen on the Steppes of Russia. Among the nomad tribes a principal
part of whose diet consists of soured mare's milk, he found a large
proportion of very old people. In looking for the reason for this
disproportionate longevity, he came to the conclusion that the sour
milk had something to do with it. Then laboratory observations and
experiments as to the influence of the bacillus, that causes the
souring of the milk, on the growth of other bacteria, and especially
such bacteria as are usually found in the human digestive tract,
seemed to show that the lactic bacteria had a strong inhibitory effect
on nearly all the pathologic flora of the intestines.

As the result of these studies, all the world is now quite willing to
take its share of sour milk. We no longer hear the complaint that
uncomfortable feelings in the digestive tract are the result of taking
milk that was a little sour.

{248}

Since this doctrine of Metchnikoff's has come to be popularly known,
fewer patients have insisted that they could not take milk in such
quantities as the physician thought desirable for them. Before that, a
persuasion with regard to the ease with which milk becomes
contaminated with microbes, and the dread that it might thus be a
source of disease, or at least of disturbance of digestion, made it
very difficult of digestion for many people. Now that they have a good
authority who insists that, even if it should become somewhat soured
in the ordinary way, this, far from making it a pathological article
of diet, rather adds to its value from a therapeutic standpoint, has
changed the attitude of mind of these people.

We need a similar feeling with regard to eggs in order that they may
be eaten by many people who now refuse them because they fear the
possible evil results of taking even a slightly tainted egg. Our
recent pure food investigations have shown that the bakers in our
large cities have been for many years using canned eggs, and that
these would be quite impossible of consumption except disguised as
they are in the midst of baker's products. Sometimes these eggs have
been kept for several months before being canned. All the cold storage
eggs that cannot be disposed of otherwise are thus treated. In spite
of the common use of these canned eggs by a large proportion of the
city population no serious results have come from them. The change
that comes over eggs in time does not apparently spoil their nutritive
quality, but only disturbs their taste. The main element in the change
is the production of hydrogen sulphide. This gas has a very unpleasing
odor, but its presence is not of pathological significance. This gas
is a common ingredient in those mineral waters that are known as
sulphur waters, and that have a reputation for curing many forms of
digestive disturbance, especially chronic cases of nervous
indigestion. What is true of sour milk, then, would seem to be true of
eggs that have been, to some degree, spoiled, and at least no serious
results may be expected from them. If serious results were to be
expected, we should have had many evil reports of them in recent
years. Whether considerations of this kind will help patients, who
need to get over qualminess with regard to eggs, because they are
always suspicious lest they should not be fresh, will depend a good
deal on the suggestive value of such information as presented by the
physician.


_Another Organic Acid_.--Sauerkraut has shared the fate of sour milk,
and because of its acid bacteria has been accepted by Metchnikoff as
an ally. Yet sauerkraut used to be thought quite out of the question
for invalids, especially those suffering from digestive disturbances.
I recall the case of an old German shoemaker who had lived very much
on sauerkraut when he was a young man and then, having made money in
the manufacture of shoes, had not had much of it for thirty years,
pleading with me, when he was old and it was rather hard to get
anything to stay on his stomach, that he should be allowed to have
sauerkraut. On the principle that what a man craves is usually what
does him good, I allowed it. The physician with whom I was in
consultation was perfectly sure there would be trouble, and the family
were confident that his physicians evidently had given up all hope and
were quite ready to yield to his caprices and let him take anything
that he cared for. He not only took the sauerkraut without any
trouble, though I must confess to some misgivings myself (for I am of
those who unfortunately do not care for it and, therefore, {249} was
prejudiced), but after having eaten a large plateful of sauerkraut
twice a day for several days, he began to crave other things that
would not stay down before, retained them well, digested them without
difficulty, and got over that attack of indigestion and lived for
several years afterwards. His own mental attitude was a better index
than our supposed knowledge, though science has now come to confirm
his state of mind.


_Bacon and a Change in Suggestion_,--Another food material with regard
to which there has been a complete change of view in recent years, is
bacon and hog products generally. Pork in all forms used to be
considered quite indigestible, and was one of the first things that
people suffering from indigestion--or the fear of it--eliminated from
their diet. Now we know how valuable a food product it is, especially
for those inclined to suffer from constipation, or who are under
weight. Many people still look surprised when advised to eat it
regularly. Here we have a typical example of the change in the mental
attitude toward a particular article of food bringing about a
corresponding difference as regards not only the appetite for it, but
also its digestibility. Many persons, who used to have no appetite for
breakfast, now find that after eating a crisp piece or two of bacon,
they develop an appetite for other foods. Bacon has become a fetish
for some people and is considered a help, not a detriment to
digestion.

I recall a case in which I had very nearly the same experience with
bacon as I related with regard to sauerkraut. The patient was an
elderly woman, probably nearly ninety years of age, who, because of a
crippling deformity, had not been able to get outside of the house for
many years. She sat in a wheel chair, transported herself from one end
of an apartment to another, spent most of her time by the window, but
was very helpful in many little things about the house and occupied
her hands with knitting and sewing. In spite of her condition, she was
cheerful, pleasant, happy, and all her life had had a good digestion,
her only trouble being a tendency to asthma as she grew old. I came
back to the city after a summer vacation to find that she was not
expected to live because nothing would stay on her stomach. She was
sinking, and the end seemed not far off. I was asked to see her more
because I had been her regular physician for some years, and it was
thought that it would console her to see me than with any real hope of
betterment. It had been extremely hot weather and this seemed to be an
unfortunate circumstance. At my visit, I asked her if there was
anything that she cared for. She shook her head and yet there seemed a
hesitancy. I urged her to tell me if there was anything that she
wanted, but only after considerable urging did she venture to say that
there was something, only that she knew that she could not have it.
Putting her thumb on the top of her little finger, she said, "Oh, I
would like so much to have just a teenie-weenie bit of bacon." I said
that she should certainly have it. Then taking courage, she asked if
she could not have a little cabbage with it. I said, "Certainly." Her
friends thought that it was just a yielding to one of the last wishes
of an invalid with the idea that nothing could much harm her, since
she was so near the end. She had eaten cabbage and bacon all her life;
she ate it again with a relish, and in spite of the heat kept it down
and digested it well. She had bacon and cabbage next day, and for
several days; she gradually got strong and lived several more years of
her happy contented life.


{250}


CHAPTER II

INDIGESTION AND UNFAVORABLE STATES OF MIND


Indigestion is the characteristic disease of our time. There are few
men or women over thirty who have not suffered from it. The working
classes are spared the most, but with the frequent suggestions in the
newspapers and the introspection which has become so common,
indigestion is often complained of even among them. Sedentary
occupations, involving mental work and little physical effort, seem
especially to predispose to some form of indigestion. Few of those who
live what is called the intellectual life escape suffering from some
of its symptoms. Not infrequently men have been hale and hearty
specimens of muscular manhood when they took up some profession which
compels them to be indoors, yet before long, they begin to complain of
discomfort after eating, of tendencies to constipation, of headaches,
of depression, of incapacity for mental effort after meals, and all
these symptoms are attributed to the almost universal disease,
indigestion.

It is possible for the general attitude of mind to have a great effect
on digestive processes, and the symptom-complex which is called
indigestion, or dyspepsia, is probably much more dependent on the mind
than on any other factor. In many cases it is primarily due to
over-concentration of attention on digestion. In others it is due to
over-occupation with business, worry, or serious thought at times when
the digestive processes need all the energy. In many cases so-called
dyspepsia is due to an unfavorable state of mind toward digestive
processes in general, because of unfavorable auto-suggestion.
Normally, stomachic sensations reach our consciousness only under
special circumstances. When, however, much attention is paid to them,
even the slight sensations that occur with normal digestion may rise
above the threshold of consciousness and become subjects of
solicitude. If they do so, then the increased attention likely to be
paid to them surely interferes with function and changes what may be
merely physiological into pathological processes.


Disease Suggestions.--An unfortunate state of the public mind with
regard to indigestion in general has been cultivated by many
publications on the subject. People dread its occurrence, and fear
that the first sign of discomfort in their gastric region is a signal
of the beginning of a progressive affection. They fear the worst, and
the consequence is a reaction quite out of proportion to the gravity
of the ailment. So much has been said particularly of mistakes in diet
that just as soon as they feel, or often rather think they feel, the
first symptom of beginning dyspepsia they begin to study how to modify
their diet so as to prevent its progress. They begin to eliminate
various supposedly indigestible foods. Usually among the first things
that are greatly reduced in quantity, or are entirely eliminated, are
the fats and certain of the starchy vegetables. Because of expressions
heard and read as to its harmfulness, the fearful ones also are
usually timorous about taking fluid at meal times. As this is about
the only time when they are likely to take fluid, unless it be summer,
they soon suffer for lack of it. Eating only food that {251} leaves
little residue and taking insufficient fluid leads to constipation.
This reacts still further to disturb digestion, and to interfere with
appetite.

This leads to further reduction in the amount and variety of food,
with the consequence that insufficient nutrition to supply energy for
bodily needs is taken. The digestive system gives up to the body as
much as it possibly can, not only of the food materials to be
consumed, but of its own substance. Thus it weakens its own vitality,
with a lessening of appetite and of digestive power. Hence, a vicious
circle of change is instituted, the consequences of which are easy to
see. After a time the patient is taking only the blandest foods,
constipation has become an important element in the case, and the mind
is constantly occupied with solicitude over the digestion and the
choice of materials at meals.


Contrary Suggestion and Digestion.--Hudson, in "The Law of Mental
Medicine," insisted on the necessity for not suggesting to children
the possibility of indigestion of various substances, for that is
almost sure to disturb digestive functions. Children sometimes hear
the remark that father or mother cannot take a certain article of food
because it disagrees with them. The imitative faculty of the child is
sure to be aroused, with the consequence that this particular food is
not eaten with relish nor given a fair show for digestion, and will be
the source of some stomach disturbance. Not infrequently substances
thus spoken of are among those that are especially likely to do
children good, such as milk or eggs, or occasionally butter. The harm
done by the remark may, therefore, even be serious, for these foods
should constitute a large proportion of the child's diet. Indeed, an
excellent prophylactic in the matter of indigestion is to prevent as
far as possible all conversation at table about the indigestibility of
food. Unfortunately, this has, in late years particularly, become a
favorite subject of table conversation.


Transferred Feelings.--Professor Cohnheim called attention to the fact
that many uncomfortable feelings are likely to be mistranslated
because they are referred to organs with which there is nothing wrong.
Whenever this function is hampered in any way, there are many
uncomfortable feelings associated with the digestion of food. The
custom has been to refer the origin of all these to the stomach.
Cohnheim thinks that it is much more likely that they really originate
in the intestines, though the rule has been to take the patient's
feelings as an indication and to treat the stomach. It is not an
unreasonable thing for patients to be deceived as to the exact
location of discomfort. Even in so acute a process as toothache it is
possible to mistake the particular tooth that is giving trouble, and,
as dentists know, a perfectly quiescent tooth is sometimes blamed for
pain that is coming from another. Fillings have been removed, teeth
have been treated, good teeth have been extracted, because patients
insisted on the significance of their feelings in such cases. The
stomach must not always be blamed. Sometimes the only source of
supposed gastric discomfort is the constipation present which is
usually easy to relieve.


_Gastric Reflexes_.--While the mind may serve to disturb digestion and
produce gastric discomfort by over-attention, there are many reflexes
that center in the digestive tract, the origin of which may be in
distant organs. Fright often produces a sensation as of cold at the
pit of the stomach. Looking down from a height has the same effect in
some persons. Discordant noises {252} have the same effect on people
of sensitive hearing and certain reactions to touch may be similarly
reflected. There are a number of affections which produce
uncomfortable reflex sensations in the gastric region. This is the
hypochondrium of the olden time. Whenever feelings were complained of,
for which there was no actual basis in the hypochondriac region, it
came to be spoken of as hypochondriasis, a word that has an innuendo
of imaginativeness about it. Dr. Head's studies with regard to the
transfer of sensations from one portion of the body to the other, show
us that there is a good physical reason in reflexes for many of these
complaints. An explanation of this to patients will often relieve
their minds greatly and make their discomfort seem much less serious.
Dr. Head said:

  With orchitis or prostatitis, we also occasionally find that the
  patient complains of a pain at the epigastrium, representing the
  stomach area. This is put down to hypochondriasis and if it occurs
  in a woman as a consequence of ovaritis, she is said to be
  hysterical. But this phenomena is no more "hysterical," whatever
  that may mean, than is the reference of the pain and the tenderness
  of an aching tooth to the back of the head or the shoulder.
  [Transfers which have been observed actually to take place.]

  This is the phenomenon I have been accustomed to call
  "generalization" of visceral pain and tenderness, and is of such
  common occurrence as to form a very important factor in the clinical
  picture of many diseases.

  The order in which generalization takes place, leads one to speak of
  the relative "specific resistance" of the centers for the sensory
  impulses from various organs. No very definite rule can be laid down
  to govern every case, but each case must be considered on its
  merits. However, the area which appears most easily on a woman, as a
  secondary affection, is the tenth dorsal; then, perhaps the sixth
  dorsal, or inframammary, and then the various gastric areas,
  beginning first with the ensiform or seventh dorsal. In a man the
  tenth dorsal appears rather less readily while the ensiform appears
  with great ease.

Affections of other organs within the abdomen may produce like
reflexes. A chronic appendicitis, for instance, will often be
reflected in the stomach area. So will the presence of gallstones, or
of disturbances of the biliary mucosa. Loose kidney often produces
stomach reflexes. Any disturbance of the intestinal function will
produce gastric irritation and inhibition of digestion. Most of the
other primary conditions are more serious. Often the patient is aware
of their existence, and it is a relief to him to find that the stomach
symptoms are not the index of further pathological development, but
only reflex conditions. This of itself does much to make the condition
more bearable.

Patients who are suffering from symptoms of indigestion often have
areas of their skin surface that are at least very sensitive, if not
actually tender. They feel the pressure of their clothing over a
particular portion of the body, usually on the left side of the
abdomen somewhat above, though at times also below the umbilicus.
Though not painful, as a rule, it is decidedly uncomfortable and
produces a constant desire to loosen the clothing, or lift it from the
part. Mere loosening, it is soon found, does no good, because the
clothing continues to touch the skin and it is not the constriction or
pressure but the contact that produces the discomfort. Sometimes there
is a distinct lesion of the stomach. This cutaneous hyperasthesia may,
indeed, rise to the height of extreme tenderness in cases of gastric
ulcer, or the like. But there is no {253} doubt that a certain amount
of this sensation is present with all functional disturbances of the
stomach and that the reflex sensitiveness of superficial nerves is
only what might be expected from what we now know of this subject.


_Discomfort and Digestion_.--Just as certain food materials disagree
because of the state of mind, so certain feelings in the gastric
region, even in the skin surface, sometimes disturb digestion and lead
to changes of the diet unwarranted by the condition. Patients conclude
that, if the skin is so tender, then the underlying organs, the
disturbance of which causes this tenderness, must be in a serious
condition. For these patients the explanation of the present state of
our knowledge as to reflex disturbance of sensory nerves will be of
therapeutic value. They must be taught that pain is reflected from one
nerve branch to another, and is not communicated by continuity of
tissue, or by sympathetic affection from the stomach mucous membrane
through the stomach wall, and then from the abdominal wall to the skin
surface. This knowledge will prove reassuring.


Division of Energy.--After this mental occupation with digestion
itself, which by consuming nervous energy lessens the amount available
for digestive purposes, probably the most common factor in the
production of indigestion is the concentration of mind on serious
subjects, while digestion is proceeding. An old English maxim is that
some people have not enough brains to run their liver and their
business. The liver in old-time pathology was considered the most
important of the abdominal organs and was taken by metathesis for them
all. Most of us have only a limited amount of vital energy and,
usually, we can accomplish only one thing well at a time. If we try to
do intellectual work while digestion is going on, both the
intellectual work and the digestion suffer. If we persist in
attempting to do both, we will surely disturb the digestive organs and
we may bring about grave neurotic disturbances in the central nervous
system. We may be able for a time to accomplish the two things at the
same time, but it will not be long before evil results will be seen.
Nervous, high-strung people should be reminded of Lincoln's anecdote
of the little steamboat on the Mississippi which had not steam enough
to blow its whistle and run its paddle wheels at the same time, so
that whenever the engineer wanted to blow the whistle he stopped the
boat.

Indeed, much of the indigestion that we see is due to this dissipation
of energy through the attempt to do two things at the same time. Those
who live the intellectual life are the most frequent sufferers.
Worries and anxieties that are allowed to trouble the mind during
digestion time are sure to disturb digestion eventually because they
use up energy that is needed for physical purposes.

A change of environment that takes us away from the ordinary cares of
life, is often sufficient to make all the difference between ease of
digestion and extremely uncomfortable dyspepsia. By worry the mind
apparently becomes short-circuited on itself and uses up a large
amount of the available energy in nervous impulses that do not find
their way outside the central nervous system at all, but are used in
disturbing associated nerve cells. Just as soon as a change of scene
and occupation calls for a different set of thoughts and other
feelings, energy is released for work outside the central nervous
system itself, digestion begins to improve, and in a comparatively
short time what seemed to be a serious gastric disturbance, disappears
almost completely.

{254}

_Lack of Sleep Repair_.--In my own experience one of the most
characteristic stigmata of these cases of indigestion which are due to
exhaustion through other channels of vital energy, is that they feel
much better in the evening than in the morning. They are, therefore,
tempted to stay up late and so do not get the necessary rest. Their
excuse for late hours is that they need recreation. To that excuse I
have no objection. They do need more recreation; they need more hours
during which their minds are absolutely free from business cares; but
these hours must not be taken from their sleep, for they need rest
even more than recreation.


_Worries and Irritations During Meals_.--The presence of worries or
irritation during meals or shortly after, as well as unfavorable
states of mind towards digestion itself, and occupation of mind with
serious affairs during digestion, are likely to be sources of serious
disturbance of digestion. A fright, a fit of anger, nagging,
irritation, or any disturbing emotions, may hamper digestion. An
experiment that is sometimes performed in the physiological laboratory
on the cat nicely illustrates this. If the laboratory cat is fed some
dainty that it likes, mixed with bismuth in order that its stomach and
intestines may be made opaque to the x-rays, and then be examined by
means of the fluoroscope, the peristaltic processes of digestion by
which food is mixed in the stomach, passed out into the intestines,
and by which intestinal digestion is stimulated, may be seen to go on
very interestingly. If, now, the cat is made to arch its back, and
manifest the usual signs of extreme irritation, the process of
digestion is interrupted, and will not be resumed till some time after
the cat quiets down. The lesson is obvious.



CHAPTER III

PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS

If discouragement and solicitude make a healthy stomach digest
imperfectly, the same mental factors will play an even more serious
role with a diseased stomach. Certainly without the mind's aid, there
can be little hope of such a reactive vital resistance as will enable
the organ to recover from the organic ailment.

So many cases of indigestion are due to mental persuasion alone, that
after a time there is danger that the physician may be over-confident
in his diagnosis, and may occasionally overlook serious organic
lesions. Before attempting psychotherapy in these cases, the physician
must assure himself that no organic lesion is present. This is
particularly true for cancer in the middle-aged and ulcer in young
women. At times these lesions are latent except for certain vague
digestive symptoms. After careful consideration it is generally
possible to make a definite decision, and then the indications are
clear. Even when an organic lesion is present, a modification of the
mental attitude will often be of great service to the patient.
Suggestion will even make a cancer patient gain in weight, though one
must be careful of that very fact because the apparent improvement may
occasion delay until the case becomes inoperable.

Once the presence of these serious organic lesions of the stomach can
be {255} excluded, the bringing of influence to bear on the patient's
mind for the improvement of his digestion is indicated. It is true
that there are certain reflex disturbances of the digestive tract
consequent upon affections of other abdominal organs. Chronic lesions
of the appendix may produce stomach symptoms as will also pathological
conditions of the biliary tract. A floating kidney, various affections
of the pelvic organs, especially in women, and of the urinary organs
in men are sometimes said to produce seriously depressing effects upon
the stomach. Where this occurs, the first indications undoubtedly are
to put the patient into as good condition as possible before making
any decision. Where a lesion of the stomach itself exists suggestions
with regard to the increase of diet may do harm. They will not do harm
in the reflex conditions, and so patients can be brought into better
physical condition. As a consequence of this, their symptoms in other
organs will often disappear. In case the symptoms do not disappear the
patients are in better condition to stand and react from operative
intervention.

Before concluding as to the character of the stomach symptoms we must
make sure that other important organs are not affected. Most cases of
tuberculosis begin with stomach symptoms, which often make their
appearance before there is cough or any definite localizing symptom of
the disease. Often there is only a disturbance of pulse, and perhaps a
slightly increased range of temperature. If the patient has been
exposed to tuberculosis, a careful investigation of the lungs should
be made. Any disturbance of the liver or pancreas (especially cancer)
will almost surely give rise to stomach symptoms. Latent cancer in any
part of the body, however, will, by its depressing toxemia, produce
loss of appetite, consequent loss of weight, and a number of symptoms
that are sure to be referred to the stomach. I have seen cancer of the
prostate, without disturbing urination, produce such symptoms for
months before it was recognized. I have seen cancer of the rectum in a
comparatively young woman treated as piles, without an examination,
the development of the piles being attributed to the gastro-intestinal
symptoms which were consequent upon the presence of the cancer.


MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION

It is often said that this teaching as to the effect of the mind on
digestion and its eminent usefulness for the treatment of dyspeptic
conditions, is due to the attention that has been attracted to this
subject as a consequence of the prominence of Eddyism, New Thought,
Mental Healing, and the like. There are absolutely no good grounds for
any such assertion. Here in America, more than twenty-five years ago,
before there was any question of the modern mental healing movements,
our greatest medical clinician, Dr. Austin Flint, expressed himself
very emphatically with regard to mental influence over digestion, and
to solicitude of mind as one of the most frequent etiological factors
in dyspepsia.

Dr. Flint was thoroughly scientific in his medical observations, was
no seeker after notoriety, and he was reading his paper before the
older physicians of the period, and all of those who took part in that
first meeting of the New York Medical Association strove to make their
papers of scientific value. His words, then, must carry great weight:

{256}

  Dyspepsia formerly prevailed chiefly among those who adopted, to a
  greater or less extent, the foregoing maxims [the finicky rules of
  dyspeptics which he deprecates and corrects as quoted later in this
  chapter]. It was comparatively rare among those who did not live in
  accordance with dietetic rules. The affection is much less prevalent
  now than heretofore, because these maxims are much less in vogue.
  The dyspeptics of the present day are chiefly those who undertake to
  exemplify more or less of these maxims. It seems to me, therefore, a
  fair inference, that dyspepsia may result from an attempt to
  regulate diet by rules which have for their object the prevention of
  the affection which they actually produce. It is to be added that an
  important causative element involved in the practical adoption of
  these rules is the attention thereby given to digestion. It is by
  introspection and constant watchfulness of the functions of the
  stomach, that the mind exerts a direct influence in the causation of
  this affection.



Dietetic Rules of a Former Day.--In order to make definite just what
were the views of the olden times which he deprecates, he stated them
briefly and forcibly:

  The views generally entertained, at the time to which I have
  referred, largely by physicians and almost universally by
  non-medical sanitarians, may be summed up in a few maxims as
  follows: Eat only at stated periods, twice or thrice daily, and
  never between meals, no matter how great may be the desire for food.
  Never eat late in the evening or shortly before bedtime. In the
  choice of articles of diet, carefully select those which reason and
  personal experience have shown to be best digested; and never yield
  to the weakness of eating any article of food simply because it is
  acceptable to the palate. In order to avoid the temptation of
  overeating, let the articles of food be coarse rather than
  attractive, and eschew all the devices of the cuisine. Always leave
  the table hungry. Study personal idiosyncrasies, and never indulge
  in kinds of food which, although wholesome for most persons, are
  injurious to a few who are peculiarly organized. With reference to
  this last maxim, bear in mind that "what is one man's meat is
  another man's poison." In order to secure, as effectually as
  possible, a proper restriction in the quantity of food, it was
  recommended by some physicians and to some extent practiced, that
  every article be carefully weighed at meal times, and that a certain
  quantity by weight be never exceeded. Vegetarianism or Grahamism was
  advocated and practiced by many. Total abstinence from drink was
  considered by a few as a good sanitary measure, compelling the body
  to derive the needed fluids exclusively from fruits, vegetables, and
  other solid articles of diet. Restriction in the amount of drink, as
  far as practicable with regard to the power of endurance, was very
  generally deemed important, so as not to dilute the gastric juice.

When to his question, "Do you regulate your diet," the patient
answered promptly and often emphatically in the affirmative, Dr. Flint
insisted always: "This is a good reason for your having dyspepsia; I
never knew a dyspeptic get well who undertook to regulate his diet."
When the patient asks then, "How am I to be guided," the reply is,
"Not by theoretical views of alimentation and indigestion, no matter
how much they appear to be in accord with physiological and
pathological doctrines, but by the appetite, the palate and common
sense." He then goes on to answer certain other objections that
patients are wont to urge, and says:

  But the patient will be likely to say, "Am I not to be guided by my
  own experience and avoid articles of food which I have found to
  disagree with my digestion?" The answer is, that personal experience
  in dietetics is extremely fallacious. An article of diet which may
  cause inconvenience of indigestion to-day may be followed by a sense
  of comfort and will be readily digested to-morrow. A variety of
  circumstances may render the digestion of any article of food taken
  at a {257} particular meal labored or imperfect. As a rule articles
  which agree with most persons do not disagree with any, except from
  casual or accidental circumstances, and from the expectation, in the
  mind of the patient, that they will disagree. Without denying that
  there are dietetic idiosyncrasies, they are vastly fewer than is
  generally supposed; and, in general, it is fair to regard supposed
  idiosyncrasies as purely fanciful. Patients not infrequently cherish
  supposed idiosyncrasies with gratification. The idea is gratifying
  to egotism, as evidence that Providence has distinguished them from
  the common herd by certain peculiarities of constitution.


Dietetic Instructions.--Finally Dr. Flint has a series of instructions
for those suffering from indigestion:

  Do not adopt the rule of eating only at stated periods, twice or
  thrice daily. Be governed in this respect by appetite; and eat
  whenever there is a desire for food. Eat in the evenings or at
  bedtime, if food be desired. _Insomnia is often attributable to
  hunger_ [italics ours]. In the choice of articles of diet, be
  distrustful of past personal experience, and consider it to be a
  trustworthy rule that those articles will be most likely to be
  digested without inconvenience which are most acceptable to the
  palate. As far as practicable, let the articles of diet be made
  acceptable by good cooking. As a rule, the better articles of food
  are cooked, the greater the comfort during digestion. Never leave
  the table with an unsatisfied appetite. Be in no haste to suppose
  that you are separated from the rest of mankind by dietetic
  idiosyncrasies, and be distrustful of the dogma that another man's
  meat is a poison to you. Do not undertake to estimate the amount of
  food which you take. In this respect different persons differ very
  widely, and there is no fixed standard of quantity, which is not to
  be exceeded. Take animal and vegetable articles of diet in relative
  proportions as indicated by instinct. In the quantity of drink,
  follow nature's indication; namely, thirst. Experience shows
  abundantly that, with a view of comfortable digestion, there need be
  no restriction in the ingestion of liquids.


Removal of Solicitude as a Remedial Measure.--Many dyspeptics have no
subject that they occupy themselves with more seriously than their
digestion, and they thus divert blood needed for digestive purposes as
well as nervous energy that would help in it from the stomach to the
brain, in order to exercise surveillance over the process. As has been
well said, "Probably much more than half of the indigestion is really
above the neck." This does not mean that there are not cases that need
definite stomachic treatment, or even that patients who have succeeded
in functionally disturbing their digestion by thinking over much about
it, will not need gastric remedies.

The explanation of the many fads and remedies that _cure_ indigestion,
real or supposed, is exactly this tendency of the suggestive influence
of such remedial measures to lessen the patient's solicitude about
digestion. Any change in diet that carries with it the persuasion that
for any reason digestion ought to be better, will, because of this,
make digestion better. Any habit of taking warm or cold water before
meals, or of chewing in a particular way, or of taking a particular
kind of food different from what is usually taken--exclusively cereal,
uncooked, largely fruit, vegetarian, etc.--will lift the concentration
of attention on the digestive process, and so give the stomach a
chance to do its work without interference from the brain.

Du Bois has quoted some striking testimony in this matter from Baras,
who wrote on the "Gastralgias and Nervous Affections of the Stomach
and the Intestines" as early as 1820. Baras had himself been a
sufferer from {258} gastric discomfort, fullness after eating,
eructations of gas, constipation, and general depression. He consulted
most of the distinguished medical practitioners of his time. With one
exception they were convinced that he was a sufferer from chronic
gastro-enteritis. They added more and more to his concern about his
stomach, and furnished him with numerous sources of autosuggestion. In
spite of all that they did for him, his condition grew worse and
worse, he lost in weight, and was sure that his case was hopeless. He
was cured in a single day. His daughter was attacked with consumption,
and "in the moment my attention," says Baras, "was centered entirely
upon my child, I thought no more of myself, and I was cured."


Brain Workers and Indigestion.--Perhaps the best proof of how
necessary it is that people should not continue to occupy their
intellect seriously during the time when digestion is going on, is to
be found in the frequency with which complaints of indigestion occur
in literary folk. The complaints are heard most from literary folk
because they are more likely to tell their stories. They have their
work, and thoughts of it, always with them. So there is a constant
call for nervous and mental activity and for much blood in the brain
tissues. This subtracts from the nervous energy necessary for
digestion, and makes it impossible to conduct it with that perfection
which comes naturally to people who banish all other thoughts and keep
their minds free for the pleasures of the table and social intercourse
at meal time.

Nervous indigestion is so common among literary folk, teachers and
scientific workers, that various causes have been suggested for it.
Dr. George Gould, in his "Biographic Clinics," calls attention to it
and suggests that the cause is probably the need of properly fitted
spectacles. In our own time, when we are much more careful in the
matter of eyeglasses, and when most writers and professors wear
scientifically adapted glasses, the complaints still continue. The
reason is evidently something associated with the almost continuous
work that they do. Such people, too, are much more self-conscious than
others. They think more about their digestion and what they eat. They
often think that they differ from other people and have special
idiosyncrasies for food. These thoughts are sure to culminate in
nervous indigestion.


Food Faddists.--Literary folk and people who live the intellectual
life are very prone to take up with fads of various kinds and find
surcease from their sorrows in all sorts of out of the way dietaries,
modes of eating, food limitations and specializations. They constitute
a majority of the food faddists. Some of them--sure that they should
not eat meat--are strenuous vegetarians. Others confine themselves
entirely to food the life of which has not been completely destroyed
by cooking. They are fruit faddists, nut faddists, milk-product
faddists, and the like. Some of them try to persuade the world that it
eats too much; others that it eats too frequently. Some of them take
but a single real meal a day and have apologies for the other meals.
All want to lead people to their particular mode of life, as if all
the world had been wrong until they came to set it right. Some want
the rest of the world to chew seventy-times-seven before they swallow
and to adopt other exaggerations of attention to eating that are quite
contrary to instinct, the most precious guide that we have in the
matter of food choice and food consumption.

These intellectuals are always improved by their fads, no matter what
they {259} may be. The reason is apparent. Their original digestive
disturbance was due to over-occupation with intellectual work. Then
they began to worry about their digestion and feared that nearly
everything they ate would disagree with them. This fear and solicitude
still further interfered with digestion. Next they acquired the new
fad. They became persuaded that they could eat certain things in
certain ways. They no longer disturb their digestion by anxiety about
it, but, on the contrary, help it by favorable suggestion. Now under
the new regime everything will surely go on well. Besides, they
usually learn the lesson of not doing intellectual work close to their
meals, and of spacing their work better. They learn to do a daily
stint of work and no more. One of the fads that goes with most food
fashions is abundant outdoor air. This always does good. Between the
favorable mental influence, the lessened work, especially just after
meals, and the increased outdoor air they get better and then they
attribute it all to their special fad about food. The _"cure"_ is due
to psychotherapy and common sense, and not in any way to the special
fad.


Worry.--Worry of any kind will have the same effect as the
over-attention of the literary man or teacher to his work. Anyone who
brings his business home with him is likely to suffer and, unless he
has a superabundant supply of energy, will impair his digestive
function as a consequence of attempting to do business after dinner,
perhaps also stealing some of it in before and during breakfast.


PREVENTION AND CORRECTION

The important rule with regard to the mental attitude of the patient
toward uncomfortable feelings due to digestion must be, first to
correct all other possible sources of the trouble, and only after
these have been proved not to be factors in the case, should there be
any question of modification of diet. This is just the opposite rule
from that which obtains, and by which patients begin to meddle with
their diet at the slightest symptom, or supposed symptom, of
indigestion. My custom is to tell patients at once that there is
probably something else besides their diet at fault. It is not that
they eat too much, nor too great a variety, but that perhaps they eat
too rapidly. Without reducing their diet, and above all without
eliminating supposedly indigestible things from it, there should be
formed a habit of eating more slowly. This will usually result in the
reduction of the quantity eaten, but the variety of food should be the
same, and the patient should not be permitted to limit his diet to a
few supposedly bland, unirritating materials. In that event,
constipation will assert itself, particularly if there is limitation
of the amount of fluid taken.


Longevity of Dyspeptics.--There is one consolation that may be given
to nervous dyspeptics, though in the midst of their worst symptoms
they may not be sure whether it is a genuine consolation or not. It
has been noted that many of those who live to extreme age tell the
story of having suffered from nervous dyspepsia in middle-life. Their
solicitude about themselves makes them safe against over-indulgences
of many kinds in food or drink that might prove hurtful to them. Much
of their discomfort is indeed due to the fact that they do not eat
quite enough. If they succeed in avoiding the {260} pitfalls of the
infectious diseases, and especially tuberculosis during their earlier
years, and most of them are likely to because of the great care they
take of themselves, they often live to old age. Certainly of two men,
one of whom eats very heartily and the other very sparingly, the
latter is much the more likely to attain old age. There are those who
declare that the valetudinarian life, "half dead and alive," which
even Plato satirized nearly 2,500 years ago, ever renews the question
as to whether life is worth living or not. It is particularly
dyspeptics who seriously discuss this question--yet with all their
complaints, they actually do live longer lives.


Pharmaceutic Remedies.--This insistence on the importance of mind in
the treatment of indigestion does not imply that tonic remedies, and
especially such substances as strychnin, which stimulate appetite and
add tone to the muscles of the stomach, should not be used when duly
indicated. They are always helpful. Alone, these remedies give but
temporary relief and after a short time the system becomes accustomed
to them. If prescribed in connection with changes in the patient's
habits, and especially such as divert his attention from his digestive
tract, and from wrong persuasions as to food taking, the good they
accomplish will be lasting. Nervous people usually have an increase of
acidity. They are liable to overdo everything, and even the stomach
overdoes its acid forming function. For this, alkaline remedies such
as rhubarb and soda will do good. But, just as with strychnin, the
benefit is but temporary unless the patient's habits and attitude of
mind are modified so as to eliminate their solicitude as a constantly
disturbing factor.


Circumstantial Suggestions.--There are many changes of habits that are
of great value in the treatment of nervous and allied forms of
indigestion. These changes often make a great difference in the
general health of the patient and thus help to improve digestion.
Besides their influence as alteratives, they are valuable from the
mental influence which they exercise. It requires a definite exertion
of will many times, perhaps, each day to bring about the omission or
performance of certain actions, and this act of the will is
accompanied by the repeated suggestion that this will cause
improvement in the digestion. Many of the cures effected by special
diet. Habits of exercise, health resort regimes and the like, owe
their efficacy to this accompanying repeated suggestion of acts for
the formation of new habits or the breaking of old ones.


Physiological Measures.--There are, of course, certain details with
regard to digestion in which the patient's mental attitude needs to be
changed by instruction rather than persuasion, by knowledge of
physiology rather than by psychology. In the taking of food itself,
chewing is, of course, the most important consideration after its good
preparation by the cook. If patients are told to chew their food
carefully, however, without further directions than this, it will
usually be found that they begin to chew their meat a great deal and
their vegetables scarcely more than before. It is, however, vegetables
that must be chewed particularly. The meat-eating animals bolt their
food. They have only cutting and tearing teeth. Their instinct is
correct, for the saliva has nothing to do with the digestion of meat,
and therefore no chewing is necessary. On the other hand, the
vegetable-eating, and especially the grain-eating animals, chew
carefully. Most of them are ruminants, that is, after a preliminary
thorough chewing of their food, they swallow it, and then {261}
afterwards at their leisure bring it up once more into the mouth and
chew it again.


_Mastication and the Stomach_.--If food is not chewed well, and occurs
in large masses in the stomach, not only is it not dissolved easily,
but the work of passing it out to the intestine is delayed. The reflex
which brings about the opening of the stomach and the ejection of food
into the intestine is best brought about by the liquefaction of the
stomach contents. During the mixing process all the food, as far as
possible, becomes fluid and then is passed on. Large pieces of any
kind are delayed, however, hamper the emptying of the stomach and
interfere with stomach motility. The stomach is only a thin-walled
membranous viscus which finds difficulty in dealing with food in
lumps. It is different from the stomach of the hen, which, having no
teeth, swallows grains of all kinds without chewing, but also by
instinct swallows small stones which, in its thick-walled, muscular
gizzard, are used for grinding up the food.


_Exercise_.--The taking of exercise is an important habit that needs
to be changed in the case of dyspeptics. Many of those who live a
sedentary life, and are much occupied with intellectual or business
matters, are almost sure to take little or no exercise. If earlier in
life they were accustomed to take much, the lack of it leads to
serious disturbances of nutrition. They have formed certain habits as
to the amount of food they eat, and these continue, so that they
consume more heat-making material than they can use. In the process of
dissipating it, there is likely to be much nervous energy wasted,
usually to the discomfort of the patient. This is likely to be
eventually reflected back to the stomach, with disturbance of appetite
and digestion.

We now know that the motor function of the stomach is much more
important than its secretory function. Its main purpose is to mix the
food and pass it on in small quantities, at intervals, to the
intestines. When patients have a sense of uncomfortable fullness in
the gastric region after a hearty meal, or of discomfort after the
taking of food, especially if much liquid is taken with it, they are
prone to attribute these feelings to imperfect secretion not
completing digestion as it should, and permitting fermentation with a
production of gas and consequent stomach distention. The real reason
for their discomfort is not secretory, but motor. It is due to a delay
in passing on the food and to stomach distention because the gastric
muscle is not in good tone.

People who have been used to taking exercises have their muscular
system in good tonic condition. This includes the involuntary muscles,
as well as the voluntary, and if they are neglecting air and exercise,
the whole muscular system becomes flabby. Hence the uncomfortable
sense of distention, because the stomach walls do not contract readily
for the expulsion of food. A second important factor is also
present--the muscles of the abdomen. Ordinarily they support the
abdominal organs without any sense of effort. If by lack of exercise
they have diminished in tone, however, when a hearty meal is eaten,
the abdominal muscles have to support this additional weight since the
stomach itself sags, and the consequence is a feeling of pressure on
the left side of the abdomen about the level of the umbilicus. To
relieve this feeling the tendency of the patient is almost always to
lessen the amount eaten. If he is not distinctly overweight this will
do harm rather than good. Instead he {262} needs to take sufficient
exercise to tone abdominal muscles and reflexly also tone even
involuntary muscles, and with them the gastric muscularis.


_Air_.--Almost more important than exercise is an abundance of fresh
air, and without this muscles soon fail to respond to voluntary or
involuntary impulses. If people do not spend two or three hours in the
air every day, they are likely to develop an over-sensitive condition
in which all nervous sensations are exaggerated. The reason men and
women differ so markedly in their reaction to pains, aches and
discomforts, is mainly that their habits of being out in the air
differ correspondingly. Men are out much and, as a rule, stand
discomfort better. Women are out little and are more sensitive to
pains and aches. The more a man is out, the less is he likely to
notice discomforts and aches that he would otherwise complain about.


_Sleep_.--Another important factor is the amount of sleep. Over and
over again I have found that patients who were beginning to complain
of discomfort, which they associated with the word indigestion, were
taking too little sleep, and as soon as I persuaded them to add an
hour or more to their sleep their gastric symptoms began to improve.
It is easy in our large cities to acquire the habit of shortening the
hours of rest. This is sometimes done so gradually that the individual
scarcely realizes how much he has cut into his sleeping period. Some
people who have to get up at seven or half-past seven in the morning
go to bed about twelve, but really do not get settled for sleep until
nearly one o'clock. Sometimes people read interesting books just
before going to bed, or while in bed, and it is nearly two o'clock
when they get to sleep.

Many people have the habit of reading themselves to sleep. This may be
an excellent way to get rid of bothersome thoughts, provided the
reading selected is not of too absorbing a character, and provided
also as soon as sleepiness comes its call is heeded. Some write
letters late at night. Writing always keeps one awake, though reading
may be helpful for sleep. If this abbreviation of sleep becomes
habitual, the first organs in the body to set up an objection is the
digestive tract. It is one of the hardest worked systems in the body,
having to dispose of its quantum of food three times every day, and if
the organism does not receive due rest, the digestive tract suffers
first. People who get insufficient sleep often have no appetite in the
morning, and suffer from uncomfortable feelings in the gastric region.
What they are too prone to do is to meddle with their diet, and this
practice always does harm.



CHAPTER IV

APPETITE


Two classes of patients come to the physician complaining of lack of
appetite. The first and more important class consists of those who are
eating too little, who are consequently under weight, and who must be
made to eat more. The other class consists of those who eat enough but
complain that they do not relish their food. Careful questioning
usually elicits sufficient information to enable one to decide that
most of these latter are eating too {263} much, or unsuitable food,
and at too frequent intervals. They are usually overweight, and there
is need to reduce the amount they eat. In both of these classes the
physician is tempted to conclude that medicines should form the
principal part of the treatment. We have a number of tonics and
stimulants that undoubtedly initiate a desire for food, or at least so
increase the circulation in the stomach that patients feel much more
inclined to eat than they otherwise would. There are a number of
remedies, also, the so-called anti-fat group, which produce a
disinclination for food.


Power of Mind Over Appetite.--Appetite, whether in deficiency or in
excess, is best regulated through the patient's mind. Patients
frequently state that they cannot eat more than they do, that they
have no inclination for food, and yet, after a little persuasion, they
can be made to increase the amount they have been eating, and then
that can be gradually raised until they are taking what is for them a
normal quantity. There are many things that we swallow without caring
for them. Most medicines we not only do not like, but positively
dislike. We put them down, they accomplish their purpose, and food
will act nearly in the same way. There are few cases where food is
positively rejected. Patients can be persuaded to eat more, and after
a time will be surprised to find that their desire for food increases
with the habit of taking it. On the other hand, patients can be made
to see that they are taking too much food really to enjoy its
consumption. Their appetites are perpetually cloyed, and to them food
has none of the pleasant flavor that exists when it is taken in
moderation.


_The Will to Eat_.--In various parts of this book there is emphasized
the necessity for the exercise of the human will in order to aid in
the accomplishment of even physical functions. The basis of many
nervous symptoms is a lack of sufficient nutrition to steady the
nervous system. Some people not only lack will power, but also
judgment in the matter of eating; they prefer to err on the side of
insufficiency lest they should over-eat. For these people the
important remedial measure is to dictate the amount that they shall
eat, and gradually to increase it until they are eating enough for
their nutritional purposes.

When this advice is given to patients, they are willing to agree that
a gain in weight would be good for them, but they cannot understand
how they can eat more since they are now eating all they can, or
certainly all they care to. Appetite grows by what it feeds on, and
increase in appetite is a function of the habit of eating.

But some patients, after having tried the prescription of eating more,
are still in the same condition, and find that they cannot put on
weight. What is needed in such cases is an inquiry into all the
conditions of the daily life, their habits of eating and the amount of
time that they take for their meals. They are probably eating one good
meal a day, their dinner in the evening--but they confess that the
other meals are not satisfactory. If their habits are rearranged, the
will to eat does the rest. Sometimes they complain of uncomfortable
feelings after eating and this makes them eat less at the next meal.
There are various mental elements that disturb the efficacy of the
will to eat, consequently these patients do not get on. What they need
is emphatic insistence on the necessity for persistent effort in
regular eating day after day, meal after meal, and it is not long
before improvement comes not {264} only in weight, but also in
appetite. I have known patients to gain five or six pounds a week
after having tried weeks in vain to gain a single pound.


_Sitophobia_.--Many people read much of the possibilities of evil in
overeating, and they conclude that a limitation of diet would be
better for them. After a time some of these people of nervous
constitution acquire an actual dread of over-eating and develop what
has been called sitophobia, or dread of food. Before anything can be
done with them, this dread must be removed. The problem is discussed
more fully in the chapter on Weight and Good Feeling, but here it
seems necessary to emphasize that it is often quite impossible by
ordinary medical means to produce an appetite in these patients. Their
mental persuasion with regard to food must first be removed. If it
cannot be removed, improvement is usually out of the question. No
medicines are sufficiently powerful to overcome a fixed unfavorable
idea with regard to food. The same is true as to sleep, or any other
natural function--it comes and must go through the mind.


Disturbance of Mind and Its Influence on Appetite.--The basis of the
psychotherapy of the digestive tract is the fact that appetite is a
function of the state of mind rather than of the state of body. We all
know how easy it is to lose the appetite by emotional disturbance. We
may come into the house after a brisk walk, when we know that dinner
is going to be better than usual, quite ready to anticipate the
pleasure we are to have in eating it and with appetite craving that
dinner shall not be delayed, we find a telegram announcing the death
of a friend or the illness of a relative or some other bad news, and
in an instant our appetite has disappeared. It makes no difference to
us for hours whether we eat or not. What we eat gives us no
satisfaction. It will be taken entirely from a sense of duty and
without pleasure and will digest slowly, even if it does not produce
discomfort.


_Feelings and Appetite_.--There is no need for a serious stomach
condition to develop, to diminish, or eliminate appetite. The sight of
an accident on the street, especially if blood is shed, will entirely
take away the appetite of many persons. Now that suicide beneath the
wheels of subway trains has become a rather frequent way of going out
of life, physicians note that nervous patients who happen to see these
sad affairs have no appetite, not alone for the next meal, but
sometimes for several days. Some people have no appetite at all if
there is a dead body in the house where they live. I have known people
who felt it almost a desecration to eat under such circumstances. Even
much less than this may serve to diminish appetite. An offensive odor
of almost any kind is quite sufficient to take away the appetite of
many people. For some the odor of cooking food, if they have been in
it for some time, is almost sure to cloy any desire for food.

Cooks suffer from loss of appetite for this reason. The sight of a
disagreeable stain on a tablecloth, or of a waiter's thumb in the
soup, or of some unpleasant characteristic of the waiter, may be quite
enough seriously to disturb the appetite of sensitive people.

We know all this very well, and yet we are prone to think of appetite
as something regulated by instinct, and representing the real needs of
the organism in its cravings and the limitations of the necessity of
food by its satisfaction. In our sophisticated modern life instinct
will often fail entirely to fulfill these purposes. Appetite for those
who live much indoors is a question of {265} habit and regulation
rather than of instinct. It has to be voluntary to a large extent, not
only as regards the quality but also the quantity of food. We eat the
things that we care for, but how much of them we shall eat is another
matter. That depends on how we happen to be disposed at the moment,
and whether there is any good reason for eating more or less at the
given time.


Appetizers.--There is a whole group of substances recommended as
appetizers, most of which are effective, but their effect is likely to
be temporary, and to fail particularly in those cases where an
appetite is most needed. Anything that will increase the circulation
in the stomach will usually add to appetite; consequently warm drinks,
alcoholic liquors and spices of various kinds have this effect. In
vigorous people, a dash of cold on any portion of the body, is
followed by a strong reaction of the circulation. Cold drinks,
therefore, will sometimes serve as an appetizer, especially in hot
weather. Almost anything that has a certain peculiarity of taste, and
that is taken with the definite suggestion that it will produce an
appetite, will almost surely have that effect. All sorts of articles
of diet have in various countries acquired a reputation as appetizers.
Fermented mare's milk is effective in central Europe; a glass of
buttermilk in Ireland; some very hot soup with one of the strong
spiced sauces in it in England; and various curious combinations of
fruit and other materials in the shape of what are called cocktails,
in America. Anything that stimulates the stomach a little unusually,
and is accompanied by the idea that it is likely to increase the taste
for food, almost surely adds to appetite.

This question of appetizers is as yet a mystery to us. It is eminently
individual and yet much depends on racial customs, the habits, the
environments and the family training. It is surprising what curious
materials serve to excite the appetite. Caviar, in spite of the
distaste of "the general," is undoubtedly a good appetizer for many
people. Bismarck herring, or kippered herring, acts in the same way.
In the old days men used to take what were called red herrings and
undoubtedly found in the eating of them a renewal of desire for food,
when there had been absence of appetite. There are some people in whom
a little taste of cheese serves the same purpose. Bitter tastes
usually increase appetite. Salt under certain circumstances has a
similar effect. Acid fruits sometimes stimulate a jaded desire for
food. Nearly always the effect of these various appetizers is
increased by the attitude of expectancy. They have the reputation of
being appetizers and so, though often at first somewhat disagreeable,
they eventually prove to be helpful stimulants.


Appetite and Habit.--For those who live an indoor life, and have that
nervous disposition that disturbs instinct, the only safeguard for
nutrition is a definite formula for eating which must be followed
strictly, especially by those who are below the normal in nutrition.
In the chapter on Weight and Good Feeling I discuss the failure of
appetite following a diminution of the amount of food. The stomach may
be described as unselfish, and in times of scarcity it gives up to
other organs more of the nutrition that comes to it than it should. As
a consequence, it is not so well able to fulfill its functions of
digestion and of craving for food, which is part of its function, as
it would otherwise be. It is the people who are eating a proper amount
and have been eating it, whose digestive tracts are in a condition to
crave the proper {266} amount of food. Those whose habits have
unfortunately led them into eating amounts too small, also suffer in
not having the proper desire for food.

Nervous people particularly are likely to lack appetite in the early
morning. Those who are under weight will almost invariably confess
that they take little breakfast. Their reason for so doing is that
they have no appetite. For most of them what is really true is that in
the early hours of the day their will has not yet taken properly hold
of their economies and everything is in a depressed state. These
patients usually confess that they wake feeling not rested but tired,
fearing the day, and wondering now they will be able to get through
it. Only toward the middle of the day do they feel like themselves,
while towards evening they wonder how they could have been so
depressed in the morning. What these people need is the rousing into
activity of their functions. Occasionally, especially in summer, a
cold sponge on rising in a room into which an abundance of air is
admitted will do much for them. Often a walk of even ten minutes
before breakfast will make all the difference between appetite and
lack of it. Above all, however, they should be made to feel that if
they want to eat they can eat--if they want to they can reestablish
the habit of taking breakfast, and then it will be a pleasure instead
of a burden.


_Food and Caprice_.--Those complaining of lack of appetite should
learn not to let caprice rule them in the matter of eating. There are
people who by habit eat too much. What they must do, as pointed out in
the chapter on Obesity, is to unlearn the habit of overeating, and
that is almost as hard to break as the habit of taking stimulants.
Most nervous people undereat, but they must take themselves in hand,
eat three meals a day, and reestablish the habit of taking as much at
these meals as they ought. What each one should consume is eminently
individual, depending altogether on the sort of heat engine that each
one is. Family traits mean much in this. Some must eat much more than
others to keep up their weight and strength, because they are wasteful
heat engines. As a rule, tall, thin people must eat more in proportion
to their weight than shorter individuals of stout build. They expose
more surface for heat dissipation. In this each person must learn for
himself his own necessities. When there is a question of regulating
eating by reason, the rule must be remembered that there is a tendency
in people living indoors to take too little rather than too much.


_Appetite and Food Preparation_.--There are many curious things with
regard to the formation of the habit of eating that show how easily
the appetite or instinct is vitiated. Women, for instance, are nearly
always prone not to eat enough if they have to prepare their own
meals. When a mother and daughter or two sisters live together, they
usually prepare one good meal, but the other two meals are likely to
be picked up any way. The presence of a man in the household makes all
the difference in the world. Meals are prepared regularly for men.
Even for a boy of five to fifteen, meals are regularly prepared, and,
as a rule, the presence of a child makes for regularity in eating.


_Habit of Overeating_.--On the other hand, it is easy to form habits
of eating that go quite beyond appetite and vitiate the desire for
food quite as seriously in the opposite direction. Many stout people
take snacks between meals; women, already too heavy, indulge in the
afternoon tea habit with a surprising amount of substantial food taken
with the tea; many a stout man {267} takes a glass of beer
occasionally and never fails to take something to eat at the same
time, mainly with the idea, as he says to himself, that by taking
something to eat the beer will be less likely to do him harm. Stout
children are likely to form the habit of eating too frequently. When
they come home from school they have a piece of something; before they
go to bed they have a glass of milk, and a piece of cake, and
sometimes are encouraged in these bad habits by their parents. Any
child who is more than ten per cent. above weight, should be kept
strictly to its regular meal times, and should not be allowed to put
on additional weight, for this will be very hard to get off in adult
life. To carry more than ten per cent. of over-weight is a burden, and
not a benefit.


Frequent Eating as an Appetizer.--Thin people should be encouraged to
indulge in some of these between-meal privileges. Very often a thin
person who has been accustomed to take comparatively small amounts at
meal times, will find it easier to gain in weight by indulging in
luncheons between meals than by increasing the amount of each meal.
Large meals on stomachs unaccustomed to them, and somewhat less
vigorous than they ought to be because of lack of nutrition, may be
the cause of considerable discomfort if abundant meals are taken where
small ones have been habitual. In this case, multiple feeding at
shorter intervals will gradually increase tissue strength. After the
patient has come up to normal weight, regular intervals between meals
may be determined and sufficient quantities taken at each meal. Nearly
all thin people sleep better, and are more comfortable if they take
something shortly before going to bed. Most people will eat their
breakfast better after such an indulgence than if fourteen hours
elapse between the evening and the morning meal.


Nervous Loss of Appetite.--Nervous patients often say they have no
appetite, that, even though they eat, their food has no taste. Such
people have often lost their eating instinct to a certain degree. They
eat merely from routine, or because food is placed before them. They
would usually just as soon not eat and they have no instinctive
directions as to quantity. If a number of courses are presented to
them, they eat such as they care for and take a conventional amount of
each kind of food presented, but they have no particular feeling to
guide them in the matter of quantity. There are moods in which these
patients care to eat. There are others in which eating seems a hard
task. If they are in reasonably poor circumstances and have not to
prepare a meal for others they are likely to neglect the preparation
of one for themselves, take almost anything that happens to be at
hand, and then consider that they have eaten.


Instinct and Natural Life.--If one expects the natural guidance of
one's instincts then one must give these instincts a proper
opportunity. Instinct is a part of our animal nature, and unless other
portions of our animal nature are given rather free play, or at least
the opportunities for their natural life, we cannot depend on any
single one of the instincts to be a safe guide. Man was meant to live
much outside. He was meant to take considerable exercise and to have
to get his food by severe exertion. We have changed this. We live
indoors to a great extent in an equable temperature, we very seldom
tire ourselves by exercise, and it is not to be wondered at if we have
not that craving for food that comes to the man who lives a more
animal existence. The {268} Scotch surgeon, Abernethy, once said that
the best possible tonic for the appetite was "to live on a shilling a
day and earn it"--of course, he meant by manual labor. He talked at a
time when the English workmen got but three shillings a day for
fourteen hours of work.


Application of Principles.--What is needed for the mental treatment of
patients with defective appetite, is that they should be made to
realize that appetite is a function of habit, rather than of absolute
natural craving in the conditions in which men and women live at the
present time. The most important physical factor for appetite is not
exercise, as has often been thought, because this, by consuming
material, is naturally supposed to increase the craving for material
to renew the tissue, but air, for it is oxidation processes that
stimulate metabolism and make the call for a fresh supply of
tissue-building material. People without an appetite must be made to
understand that they should spend a considerable portion of the time
between meals in the open air. Sitting in the open air is often even
more effective than exercise under similar conditions, especially in
weak people. The reason is exercise exhausts energy, and sometimes
does not leave enough vitality for digestion, or even for the craving
for food. Exercise is, of course, excellent for those of stronger
constitution, and especially those who have been accustomed to it.

Those who need to eat more, must keep constantly before their minds
the suggestion that if they want to eat they can, and that if they
actually do eat more, satisfaction with eating grows, and appetite is
restored to its normal place of influence. This is as true for those
who are convalescing from some ailment, or who are in the midst of
some progressive disease such as tuberculosis, as it is for the merely
nervous persons whose lack of will and inefficiency of judgment have
disturbed their eating habits. The will to eat is the most important
appetizer that we have. The old Scotch physician's rule that if food
stayed down it would do good, and that if the residue of it passed
through the intestinal tract there was nothing very serious the matter
with the patient, applies to the majority of patients who come to be
treated for obscure ailments, especially of a chronic character,
whenever they are associated with or developed on a basis of lack of
normal weight.



CHAPTER V

CONSTIPATION


To judge by the frequency of advertisements for laxatives of various
kinds, constipation must be an extremely common affection. At least
one out of every three city dwellers suffers, it is said, from
constipation. Proper regard for the taking of food calculated to help
this important function, the formation of appropriate habits, and the
proper disposition of the mind so as to relieve worry and anxiety,
will cure the majority of these patients. There are some who need
additional treatment, pharmacal or mechanical, but these are few.
Undoubtedly the mind plays the most important role in the therapeutics
of the affection. It is influenced partly through instruction, {269}
partly by the modification of unfortunate auto-suggestion, and partly
through auxiliary favorable suggestions of one kind or another.


Prophylaxis.--What is needed in most cases is such instruction as will
lead to a better observance of certain common-sense laws of health,
rather than the addition of remedies which eventually only complicate
conditions.

Many people believe that unless they have an ample movement of the
bowels every day all sorts of serious results are likely to follow. If
they do not have the expected movement before noon, they suffer during
the afternoon from headache that is probably due more to worry than to
any physical cause. Ordinarily it is quite out of the question that
the retention of the contents of the lower bowel for a few hours
should produce any such serious effects as these patients immediately
begin to feel. Especially is this true when on the day previous there
has been, as is often the case, a sufficient movement of the bowels,
due to the use of medicine. Some people have become so anxious in the
matter that they foster the development of feelings of discomfort both
in their abdominal and intracranial regions.

This over-anxiety is all the more important because recent
observations have made it clear that over-occupation of mind actually
hampers peristaltic movements of the intestines, and thus prevents the
muscular action which would gradually pass the excrementitious
material on to the lower bowel, to be evacuated in the normal way. _It
cannot be too often repeated that nature resents too close
surveillance of her functions and operations_. Just as soon as the
over-anxiety is relieved, and patients are made to appreciate that if
they do not have a movement to-day they may wait without serious
solicitude till they have one to-morrow, the amount of medicine
required to bring about movements of the bowels is at once reduced.


The Mind and Peristalsis.--Analogous to Pawlow's ingenious
experiments, with regard to digestive secretion in the stomach, are
Kronecker's experiments at Berne upon the motor function of the
intestinal tract. Pawlow showed that the appetite depended, not on
physical conditions so much as on the mental state of the animal and
its desire for a particular kind of food. Kronecker, by isolating a
loop of intestine in which a metal ball was placed, showed that it was
possible to modify peristalsis very materially by affecting the
psychic condition of the animal. There was a distinct difference in
the movements of the intestine, in the passage of a metal ball, when
the animal was called and expected to go for a walk with its master,
than when it was threatened with punishment or rendered depressed for
some other reason. In animals, the psyche plays a very subordinate
role in inhibition and stimulation compared to that exercised by man's
higher nervous system, since in him this portion of the organism is so
much better developed than in the animal. The condition of the human
mind in its possibilities of unfavorable influence over the intestinal
function, is, therefore, extremely important.

The more one knows about the curious power of the mind even over so
material a function as intestinal peristalsis and movement, the more
is one convinced of the necessity for a properly disposed mind toward
intestinal function, if it is to be accomplished with regularity and
without disturbance. Many persons thoroughly under hypnotic influence,
who are told that they will have a movement of the bowels at a certain
hour the next day will have it. Indeed, this constitutes one way of
treating certain forms of constipation in nervous, {270} preoccupied
people. There are many stories that illustrate the influence of
auto-suggestion upon the bowels. We have already mentioned Flaubert's
suffering as a consequence of realistic absorption in "Madame
Bovary's" poisoning by arsenic when he was writing that scene in the
book. Boris Sidis has told the story of a man who used to have a
disturbance of the bowels at every new moon, as the result of his
memory, acting unconsciously, reminding him of his mother's habit of
giving him a purgative about that time. These may be and doubtless are
exceptional cases, yet they illustrate the influence of mind and show
how much it must be the effort of the physician to use this effective
adjuvant just as much as possible in this very common and often
obstinate affection in which drugs so often fail, or are
unsatisfactory.


So-called Intestinal Auto-intoxication.--Those who are anxiously
interested in the subject are likely to have read so much of
intestinal auto-intoxications, of which a great deal has been written
in recent years, that they will be quite sure the slightest delay in
intestinal evacuation may be serious, or at least may profoundly
disturb their economy. As a consequence, just as soon as the hour at
which they should have a movement passes, they begin to worry about
it. In a couple of hours they feel tingly all over, and they know that
there most be poisonous substances in their circulation. After two or
three more hours, they begin to have a headache. Then they have to
give up work, and still more devote themselves to concentration of
attention on the disturbed condition. Their sleep will be disturbed,
perhaps will be delayed; they wake unrested and fearful of the awful
effects of intestinal auto-intoxication. In most people this state of
feeling is entirely due to suggestion.

So much has been said in recent medical literature of the influence of
absorption of poisonous substances from the intestinal tract--the
so-called intestinal auto-intoxication--that it is a surprise to learn
how little we know, definitely and absolutely, about this subject, and
how many theories have come and gone. Arthur Hertz, in his
"Constipation and Allied Intestinal Disorders" (Oxford Medical
Publications, 1909), reviews the whole subject very interestingly but
shows that we are entirely without any definite conclusive evidence
for what has been talked about so much. The idea had often occurred,
and been expressed vaguely, in medical literature in the old time, but
began to have its great vogue when the high-sounding Greek term
copremia (literally "excrementitious-substances-in-the-blood") was
invented, toward the end of the first quarter of the nineteenth
century. Naturally this had a strong suggestive effect. Bouchard took
it up a generation later, and then intestinal auto-intoxication,
another mouth-filling term, came to occupy much attention as an
explanation for various vague conditions, and especially nervous
discomforts of many kinds. Bouchard's method of proving his theory by
showing how much toxic material was reabsorbed from the intestines,
using the urine for injection into animals, was open to many
objections. Now it has been quite discredited.

Bouchard's disciples exaggerated and theorized even beyond their
master, until intestinal auto-intoxication became the same sort of a
refuge for the puzzled physicians of our time--like rheumatism or the
uric acid diathesis, for those of a score of years ago. Various
methods of demonstrating the toxicity of substances absorbed had a
vogue for a time, but they have now lost their significance. There are
only a limited number of people who seem to suffer {271} from the
symptoms attributed to such reabsorption. Some people who are quite
constipated have none of the symptoms at all, while a delay of an hour
or two in the evacuation seems to affect other people very much. These
latter are especially nervous persons. It now seems very clear that
the liver acts as a safeguard against the absorption of poisonous
materials from the intestinal tract, and that neither degenerate
proteid materials, nor bacterial toxins, are allowed to affect the
system to any serious degree. After all our study, as Dr. Hertz
insists, we have as yet no evidence that poisons are absorbed.


Reassurance as an Element in Treatment.--The most important element in
the rational treatment of constipation is to make patients understand
that under ordinary circumstances the symptoms of auto-intoxication,
of which so much is said, do not develop until there has been
long-continued accumulation of excrementitious material and under
conditions favoring absorption. Even then nature learns to protect
herself against untoward conditions. We have some very striking
examples of good health in spite of even very rare movements of the
bowels.


_Examples of Intestinal Tolerance_.--There is the famous case of the
French army officer who, from his earliest years, did not have regular
movements of the bowels, but secured evacuations of them by artificial
aid once every two months or more. He lived to the age of past fifty,
and then died from an intercurrent disease not connected with his
intestinal condition, having in the meantime enjoyed good health. He
was able to accomplish his duties as an officer without any special
allowances, and he was on the sick list much less than many brother
officers whose intestinal condition left nothing to be desired. This
remarkable man succeeded in doing his life work without his condition
being known by others to any extent, and it was only inconvenience,
and not serious illness, that he suffered from. After his death, it
was found that certain folds of the lower bowel were so large as to
meet across the lumen of the bowel, making shelves and pouches in
which fecal material gathered, preventing the movement of all material
above.

In the Orient, it is said that many people, especially of the better
class, do not expect to have movements of their bowels every day. Some
of them, indeed, do not encourage intestinal evacuations oftener than
once a week, sometimes even more seldom. As their diet is more largely
vegetable than ours, this is all the more surprising. This custom does
not contribute to their good odor, but this they compensate for by
using various Eastern perfumes. The average length of life of such
people is not much below the Occidentals and the difference is
probably accounted for to a great extent by other unhygienic
practices, rather than this failure to have regular movements of their
bowels. In the meantime, they do not suffer any particular
inconvenience, and live life quite as free from the ordinary pains and
aches as do the people of the West. Of course, in such cases the
custom has been established early, and nature has grown accustomed to
it. Nature seems to be able to stand almost anything, if she can only
survive it long enough to neutralize its effects by some of her
marvelous means of compensation.

A case under my observation some years ago deeply impressed upon me
how thoroughly the human system can learn to get along in spite of
extremely unfavorable conditions in the matter of intestinal
evacuation. The case was that of a young woman suffering from some
internal trouble and there was {272} a possibility of the growth of a
tumor. Some charitable people had been interested in her case, and the
question had arisen whether the tumor might not be physiological. Her
story was a very curious one. She and her sister worked in a mill.
They came from a family that had been reduced in circumstances, and
were much more sensitive, as regards the decencies of life, than were
their fellow workers. In order to get to the toilet, the working girls
had to pass a window of an office where a number of men were at work.
The other girls did not seem to mind it, but these two girls were so
sensitive that they preferred not to use the toilet room at the
factory. They had to leave home shortly after six o'clock in the
morning. They did not get home until nearly seven. For a time, they
succeeded in accomplishing their intestinal functions during the hours
of their stay at home. Gradually, however, this habit was broken, and
at first they went two or three days without an evacuation, then four
or five days, and finally a week. It then became their custom to take
a large dose of epsom salts on Saturday night and spend most of the
day on Sunday getting rid of the accumulated excrementitious material
of the whole week.

They taught Sunday School in the afternoons, and as the elimination of
the accumulation of week-long material interfered with this, they
gradually acquired the habit of doing their Sunday School work on
alternate Sundays, each taking the other Sunday for evacuation
purposes. It might be expected that this serious abuse of function
would soon lead delicate girls, compelled to work full eleven hours a
day, into rapid serious breakdown. But it did not. This state of
affairs continued for more than a year. Then finally one Sunday, the
more delicate of the two girls found it impossible to open her bowels
at the end of two weeks, and though she stayed at home the next Sunday
found it likewise impossible. Had not the directress of the Sunday
School, who had become interested in them, succeeded in gaining their
confidence, it is possible that they would not have consulted
physicians even for some time longer, though about three weeks had
passed without an evacuation.

Probably every physician in active practice has women patients who
have been constipated for successive periods of three or four days at
a time, for several months, without much disturbance of the general
condition. While, then, there are many nervous persons who are quite
sure that they begin to notice definite symptoms within a few hours
from the failure to have a motion of the bowels at the time when they
had been expecting it, it seems certain that this is generally rather
the result of anxiety and nervous worry than consequent upon any
actual absorption of toxic materials--intestinal auto-intoxication--as
these patients, with a naïve liking for nice long names, find such
satisfaction in describing their condition. A simple explanation of
the complete lack of inconvenience that is found in so many cases of
constipation, will neutralize the unfavorable auto-suggestion that
exists, and make these people much less likely to suffer.


_Individual Variation_.--Another suggestive item of information that
should be given those who are over-sensitive and anxious in the
matter, is that different individuals vary very much in the need for
intestinal evacuation. Perfectly healthy people have lived long and
happy lives, having an intestinal evacuation only once every two days.
Whether it may not in exceptional cases be rarer than this without
serious injury, immediate or remote, {273} experience has not
definitely settled. Many of these people with infrequent intestinal
movements, have gone on utterly unconscious of the frequency or
infrequency of the calls of nature, paying no attention at all to the
matter until by some chance remark or a newspaper health item, it is
brought forcibly to their notice. They have not had a symptom before
of any kind, but now they begin to note all sorts of symptoms because
they try to order their lives after the supposed rule that they have
heard or read.


_Anatomical Peculiarities_.--On the other hand, some people normally
have two evacuations a day, and seem to require them if they are to
remain in the best physical condition. While daily evacuation is to be
considered normal, individual departures from it in either direction
must be respected as quite within the bounds of good health. Sometimes
there are anatomical reasons, as the capacity of the large intestine.
Sometimes there are physiological factors, as the amount of food
taken, or the fullness or rapidity of function in the digestive tract.


Amount of Food as a Causative Factor.--Frequency, or infrequency, of
bowel movements seems to depend to a great degree on the amount eaten.
It is well known that two men of the same weight and doing the same
work often seem to require quite different amounts of food to enable
them to accomplish their tasks. This is what might be expected, since
it holds true also for the consumption of fuel in heat machines.
Engines built in exactly the same way often require quite different
amounts of fuel in order to release the same amount of energy. Where
men are large eaters, the amount of excrementitious material left will
usually provoke, if not actually demand, more frequent evacuation than
where the amount eaten is small. Variety of food also has an important
bearing. Men who live largely on beef, milk, eggs and food materials
that do not leave much residue, do not require, indeed they cannot
have, frequent evacuations. Those who live almost exclusively on
vegetables, with large amounts of residue, will require more frequent
evacuation of the bowels. Certain other dietetic habits, as the amount
of fluid taken with the meal, or whether food is eaten in the solid
state or cooked into purees, stews and the like, make a decided
difference, the reasons for which are obvious.


Habit in Treatment.--For the regulation of the bowels and the proper
treatment of constipation in nearly all cases, more weight must be
given to the directions laid down for the patient's attitude of mind
and habits of life than to drug treatment. The patient must be made to
realize that the directions given to him are much more important for
the effective relief of his condition, than is the medicine
prescribed. As a rule, medicine is meant only to afford relief from
immediate inconvenience, in the hope that after a short time new
habits will be formed which will remove the habitual constipation by
correcting certain hampering conditions that have unfortunately become
established.


_Habitual Evacuations_.--By far the most important element in the
treatment is to make the patient realize that habit plays the largest
role in the regular evacuation of the bowels. A child, even under two
years, can, by tempting it at certain times to evacuate its bowels, be
gradually brought to establish a habit that will save much
inconvenience for nurses and the family. This has actually been done
for most human beings now alive, and this same thing can be done at
all stages of life. If a particular time be chosen, and the {274}
individual habitually goes to the toilet at that time, results may be
confidently expected. It is rather important that the time chosen be
one when there is not much hurry nor anxiety, and when it is
reasonably certain that the same time can be taken every day. It is
surprising how much so simple a bit of advice as this will do for many
people who have considered that they have been suffering great
discomfort from habitual constipation. Between the persuasion that an
occasional failure to have a movement is not serious and the definite
habit of journeying to the toilet room at a particular time, whether
the desire is felt or not, many cases of habitual constipation will
disappear with, perhaps, only the necessity for the administration of
such drugs as will prove laxative to a slight degree during the first
two or three weeks.


Ingestion of Fluids an Important Influence.--After the suggestion of a
habit and its extremely efficient influence, the most important idea
that a patient suffering from constipation must be made to grasp, is
the necessity for fluids. That there shall be easy movement of
excrementitious material in the digestive tract, there must be fluid
enough ingested to keep the residue, after digestion, thoroughly
moist, so as not to allow it to become dry and compact. To secure
this, a reasonable amount of liquids must be taken. So much has been
said in recent years about the actual and possible harm of taking much
fluid with meals, because of the danger of diluting the gastric juice,
dilating the stomach and the like, that many persons who eat under the
control of their reasons rather than their instincts, have very
materially lessened the amount of liquids taken at meal time. This is
undoubtedly one of the reasons why constipation has become more common
in the last half century. In the olden time considerable quantities of
fluid were taken at meals. With people in our time deliberately
diminishing the quantity, there is often not enough fluid ingested to
keep the human economy in proper working order. Prof. Hawk's work
shows how utterly wrong was this limitation.

The ordinary excretion of water through the kidneys should be at least
three pints, another pint is exhaled from the lungs--the quantity is
even more than this in steam-heated houses where no provision for
moistening inhaled air is made--and probably still another pint is
needed for other purposes, perspiration, nasal and ocular secretion,
and the like. Two quarts and a half to three quarts of liquid must be
daily ingested then, and unless special care is taken to see that this
amount is consumed the system may have to get on with much less, but
as can readily be understood, not without difficulty. The ordinary
glass of water does not contain half a pint; the ordinary tea cup
probably holds not more than from four to six ounces. A glass of water
and a cup of tea or coffee is about the limit of consumption of fluids
at meals for ordinary people, and some take even less. Except in hot
weather, comparatively few regularly take any fluids between meals. At
the most, then, three or four pints of liquid is taken, instead of
five or six, and the consequence is that the intestinal contents are
deprived of their fluids by the call of the system for more liquids.
Peristalsis has, therefore, to overcome the sluggish movement of the
excrementitious material, which usually does not contain as much
liquid as would make its movement easy and normal.


Residual Material.--The next most important consideration after the
amount of fluid in the intestines, is the amount of the residuum which
the lower bowel has to move. Evacuation of the intestines is to a
great degree {275} a mechanical arrangement. When sufficient material
is contained in the lower bowel, it pushes on ahead of it the matter
that has been gathered there during the immediately preceding time,
and so leads to an accumulation in the rectum that brings about reflex
evacuation. It is only indigestible material that is thus excreted. If
sufficient indigestible material is not taken with the food, there
will not be sufficient residue left after digestion to call for the
exercise of the evacuant function of the intestines, and the
consequence will be sluggishness and failure to bring about daily
movements. Originally nature provided food materials so arranged that
the amount of indigestible material was sufficient for the exercise of
peristaltic function; or rather perhaps, the regularity of peristaltic
movement is of itself a development from the habits that were
gradually formed in moving the residue that is normally left from food
materials in the state in which they are produced by nature.

Food materials are no longer taken to any great extent in the form in
which they are provided by nature. We have learned to eliminate the
coarser indigestible portions. Bread used to be made of the whole
wheat, and of rather coarse flour, leaving a large residue for
peristalsis to exercise itself on. Now only fine white flour is used,
leaving a minimum undigested. Vegetables used to be taken with much
more waste material attached to them than is the case now. After being
baked, potatoes were often eaten with the skins on, apples and other
fruits were eaten unpared and many of the coarser vegetables, turnips,
carrots, beets, and greens of various kinds that leave large
proportions of waste were much more commonly used. Movements of the
bowels depend on this residue. If it is not present the bowel
movements will not take place with the regularity observed when food
with more residue is consumed.


Diet--Prof. Otto Cohnheim, in his lecture before The Harvey Society in
New York, December, 1909, emphasized the necessity for a mixed diet.
The less vegetables are taken, the less cellulose remains undigested
to stimulate peristalsis. Liquids find their way through the
intestines by a system of percolation, and do not excite peristaltic
movements. Meat, if well digested, is almost entirely dissolved in the
stomach and becomes a fluid. Vegetables are passed on to the
intestines as a rather thick paste. Occasionally, in the midst of this
paste there are portions of food of good size. Those excite
peristalsis; hence the necessity for vegetables in the diet, if
peristaltic movements and regular evacuations are to take place. This
physiological law is poorly understood. Patients have heard so much
about the indigestibility of starches, that whenever they have any
uncomfortable feelings in their abdominal region, supposed to be due
to indigestion, they commonly eliminate vegetables from their dietary
with the consequence that their disturbed condition is likely to be
emphasized rather than improved.


_Limitation of Diet_.--Just as soon as a patient's attention is
attracted forcibly to any tendency to constipation, he is almost sure
to conclude that this is a symptom of indigestion and he proceeds to
put into practice all the rules which he has heard and read for the
treatment of indigestion. The first of these is elimination from the
diet of all indigestible food products, including most of the
vegetables. The result is a vicious circle of cause and effect by
which constipation is rendered worse than before. This needs {276} to
be explained to intelligent patients in order to make them understand
that some of the new habits which they have been forming and which
they are prone to think highly hygienic, of cutting off all food
containing indigestible material, are really important factors in the
causation of further intestinal disturbance. It will often be found
that the real reason for patients' inability to have daily evacuations
of the bowels, is that they have become persuaded that various forms
of food are either indigestible on general principles, or else are
indigestible for them. For this reason they have eliminated from their
diet most of nature's ordinary and quite natural provocations to
intestinal evacuation, only to have to substitute artificial means to
the same end in the form of the various laxatives.

It is important to talk this matter over with patients; otherwise the
true cause of their constipation may be missed. For instance, from the
very beginning of human life an excess of fat acts as a lubricant of
the intestine, and as a material by means of which other and more
concentrated objectionable matter that needs to be eliminated is
carried out with as little friction as possible. Mother's milk
contains from one-fourth to one-third more fat than the baby can use
in its economy. This is meant to furnish a lubricant for the large
intestine. It is a residue that will aid in securing movements of the
bowels at regular intervals.


_Fats_.--Many people who come to their physicians complaining of
habitual constipation have been told, or have read, that fat is rather
indigestible, and, as a consequence, they have eliminated from their
dietary all fatty materials. Even butter they use but sparingly, and
they exchange the cream in their tea or coffee for plain milk; they
carefully remove as much as possible of the fat of meat and they
abstain from all sauces in which fat is employed. Such practices make
normal, natural, regular evacuations of the bowels extremely
difficult.


_Sugars_.--Another food material that is a valuable aid to nature for
the stimulation of peristalsis is sugar. In its digestion, a certain
amount of fermentation takes place, and the gas from this stimulates
peristalsis. Of course, there may be excessive fermentation, and then
harm rather than good, is done. Ordinarily a certain amount of sugar
is demanded by nature and practically all the food materials, even the
meats, contain it. All the starches from vegetables have, as the end
products of their digestion, various forms of sugary material. These
are just the classes of foods that many nervous persons, suffering
from constipation and anxious about their digestion, eliminate from
their diet under the mistaken notion that they are indigestible, or
are productive of undesirable fermentations. When they do so, it is
not surprising that their constipation should be emphasized and that
they should have to ingest other irritant materials, laxatives, to
replace the sugars. It is probable that where constipation exists in
the bottle-fed infant, the addition of a little brown sugar to the
water with which the milk is diluted, is the safest and most natural
way of correcting the sluggishness of the intestines.


_Supposed Idiosyncrasies_.--The physician will in many cases meet with
the objection that some of these materials that he is recommending
disagree with his patient. Most of the presumed idiosyncrasies in the
matter of food are founded on extremely insufficient evidence.

Not infrequently young persons who are thin and inclined to be {277}
constipated, and who need to take fats plentifully, do not care at all
for butter. Sometimes this is founded on nothing more than the fact
that at some time or other the butter provided for them was rather
poor, and they got out of the habit of eating it. Now they assume that
their disinclination is physiological. In this regard, as with milk, a
little careful persistence will usually convince the person that there
is no natural obstacle and no good reason why they should not partake,
in moderate quantities at least, of this extremely valuable article of
food.

Often the supposed idiosyncrasy against a food is due to no better
reason than that on a single occasion it disagreed, owing to its
preparation, the circumstances under which it was eaten, or the
materials with which it was associated. An aversion, for instance, to
so nutritious and so valuable a food-stuff as hog-meat will be
acquired for no better reason than that fried ham or bacon disagreed
with the patient on one or more occasions. Such people when told that
ham, boiled so thoroughly that it crumbles in the fingers, is a
favorite mode of giving meat to convalescents in European hospitals
and that it agrees very well with them, will often be tempted to try
it. Then they find they have been harboring an illusion as to their
supposed idiosyncrasy for hog-meat. Nearly the same thing is true of
bacon. A trial or two of crisp bacon, with the fat so thoroughly
cooked out of it that it may be eaten out of the fingers without
soiling them, will often convince those who doubt of their ability to
eat it, how tasty a nutriment it is. Bacon is one of the most precious
dietetic adjuvants in the treatment of constipation.


Exercise.--There is always a serious difficulty in the treatment of
constipation in stout people. To counsel fats and starches and liquids
in the quantities necessary to bring about regular natural movements
of the bowels, through the mechanical presence of a sufficient amount
of residue, will often add greatly to their weight. For them,
exercises are needed. Not exercise in general, for many a man who
takes abundant exercise may be constipated. I have patients with this
complaint who are letter carriers, expressmen, even stevedores, and
the like. The mere absence of a sedentary occupation will not
guarantee against constipation. Motormen and conductors not
infrequently suffer from it. What is needed particularly is exercise
directed to the strengthening of the abdominal muscles, and the
increase of peristalsis.

For this certain leg exercises that can be readily and easily done in
less than five minutes each day will be found useful. A patient may be
directed to lie on his back, lift up the leg as high as possible in
the extended position, and do that with each leg an increasing number
of times every day. At the end of a month he is able to lift each leg
up forty or fifty times at each trial. This exercise twice a day,
morning and evening, just before and after sleep, will usually relieve
the constipation. The bringing up of the thigh on the abdomen as far
as possible, not only acts as a sort of massage upon the abdomen
itself, but the bellying of the large muscles within the pelvic and
abdominal regions mechanically helps the movement of the intestinal
contents. If, in addition to this, the patient gradually accustoms
himself to rise to a sitting from a lying position, the constipation
will almost invariably yield. In stout people, the presence of fat in
the abdominal wall seems to weaken the muscles so that the intestines
are not compressed as they should be in ordinary conditions, and
peristalsis seems to be thus interfered with.

{278}

A heavy wooden (bowling) ball rolled on the surface of the abdomen,
beginning low down in the right lower quadrant up towards the liver,
across just above the umbilicus, and then down on the left is often
advised. It is a good remedy but not better than the simple exercises
of the leg and abdominal muscles suggested. The use of the ball has
the advantage of novelty, and of distinctly adding to the suggestive
value of the exercise treatment. It is particularly valuable for
women. All of these exercises have a distinct value from their
suggestive side. If thus twice a day for three minutes people are made
to recall while doing the exercises the necessity for taking an
abundance of fluid, forming a habit with regard to movements of the
bowels and eating so as to encourage peristalsis, a definite good
effect will be produced. In the treatment of stout people
particularly, it is important to remember that the use of sufficient
salt, and then of certain of the natural salts, as Carlsbad or Hunyadi
Janos, may be of distinct advantage for their obesity. If taken
regularly in small amounts, that is, just enough to help to a movement
of the bowels, and if varied from time to time and occasionally
interrupted while some other form of laxative is taken, much good may
be done. It is as well to take simple irritants of this kind as some
of the irritant foods that will have a tendency to add to their
accumulation of fat, though they may increase peristalsis.


Influence of Position.--Little things may mean much in the matter of
the regular movements of the bowels. In my student days in France, our
little hotel in the Quartier had the old-fashioned water-closets
consisting of a hole in the floor in one corner, and a place to put
one's feet properly beside it, thus reverting to the old-fashioned
natural method of bowel evacuation. Some of the American students
found it an uncomfortable proceeding at the beginning, but, on the
other hand, some of them who had suffered from constipation in America
were no longer troubled that way. I have found in quite a few cases of
younger men that the suggestion to revert to this natural mode of
evacuation helped in the formation of the habit of having bowel
movements at a regular time. How much of the effect was physical and
how much was mental seemed hard to decide. The suggestion was
particularly valuable in my experience with patients of the better
educated classes.



CHAPTER VI

NEUROTIC INTESTINAL AFFECTIONS


There is a whole series of intestinal affections dependent on nerve
influence that get worse and better under stress of emotion or relief
from it. Probably the commonest of these is constipation, which is
dealt with in a separate chapter. Often these nervous intestinal
conditions are associated with other neurotic manifestations. On the
other hand, patients are seen who are absolutely without any other
sign of the neurotic habit, and have nothing like hysteria, yet who
suffer severely and rather frequently from intestinal neuroses. Most
of the people who react symptomatically to the eating of strawberries,
or of shellfish, or of pork in any form, or cheese or other milk
products, also have a definite tendency to certain skin neuroses and
to suffer from intestinal troubles as a consequence of emotional
states. It is hard to trace {279} real causation in many of these
cases, because it is so easy to accept the patient's expressions that
they must have taken cold, or they must have eaten something that
disagreed with them.


Neurotic Diarrhea.--But it must not be forgotten that nervousness
alone, without any additional factor, may produce a disturbance of the
functions of the intestines, and may even increase peristalsis and
bring about severe diarrhea. Anyone who has observed students going to
examinations has surely seen many examples of this. There are some
individuals--fortunately they are rather rare--who always suffer from
diarrhea when they have to take a serious examination. Some of these
cases are pitiable because the effects are quite beyond control, and
make it almost impossible for them to do justice to themselves.


_Fright and Loss of Bowel Control_.--Severe disturbance, such as
fright, may bring on this paralysis of proper regulation of
peristalsis, with consequent imperative intestinal evacuation. A
classical case in history is that of James II, for whom the Irish
soldiers invented a special name because of the tradition that he
suffered from an intestinal accident in one of the battles with
William of Orange. The imputation of cowardice on the last of the
unfortunate Stuarts has been completely wiped out by the investigation
of recent historians, and James' character for bravery has been
thoroughly vindicated. The fact that the story should have gained
credence shows that there is a general persuasion and popular
tradition that such intestinal incidents do occur from fright. An
incident told of the Franco-German War illustrates this, though I do
not vouch for the facts. Wishing to test the bravery of some soldiers
whom he was to send on a very dangerous expedition, and above all to
try how they would bear up even before the threat of instant death, an
officer of the French troops is said to have asked that half a dozen
brave men be sent to him. Without a word, he announced that there had
been treason in the ranks, and that the army needed an example. They
were condemned to be shot. A platoon of soldiers was drawn up, the men
were placed with their backs to a wall and they were asked whether
they wished to be blindfolded. They refused though they protested that
they did not know why they were being put to death. Then the word fire
was given. All of the men, excepting one, fell down, though the guns
of the firing party had been loaded with blank cartridges. The one who
remained standing was told that he was the man who would be selected
to go on the expedition, which, though perilous, was also of great
glory for himself and profit for his country. He said that he was
ready to go, but he asked permission to be allowed to change his
clothing, as he had not been able to keep as good control over his
intestinal muscles, as he had over his muscles of station.

Fright often has this effect in children. These stories and traditions
illustrate the influence of the mind and of deep emotions over the
intestines, and while only profound mental disturbance will produce
the most serious effects, there seems no doubt that lesser emotions do
interfere with normal function. This phase of the subject serves to
strengthen the contention that over-attention to the bowels may bring
about constipation by causing increased inhibition of peristalsis,
just as severe emotional disturbance may paralyze inhibition and so
bring about increased peristalsis with consequent diarrheal symptoms.

{280}

Habitual Diarrhea.--There are certain forms of chronic diarrhea,
usually considered most intractable, that owe their origin and
continuance to neurotic conditions of the intestine, rather than to
any gross organic lesion. In these cases the bowels acquire the habit
of emptying themselves two or three or more times a day, and the
stools are seldom formed. All sorts of physical treatment are employed
for these conditions, usually without avail, but whenever the
patient's mind can be set at rest, and his attention distracted from
his bowels by thorough occupation with some interesting work, the
intestinal disturbance gradually becomes less annoying. Ordinarily,
when stools have been frequent for a prolonged period, the case is
considered more or less unamenable to treatment. So far as ordinary
drug remedies go, this is true. What is needed is attention to the
patient's mind, to his habits of life, and to his worries, and the way
that he takes them. The illustrations given of the influence of the
mind over the bowels should make it clear that this therapeutic
principle can be of far-reaching significance and must be applied
deliberately and with confidence in the results.


_Worry as a Factor_.--Very often it will be found that the diarrhea is
particularly bothersome on days when the patient is worried. In a
clergyman friend and patient who was building a church, the approach
of days on which bills and notes became due, was always the signal for
a diminished control over his bowels, and there were frequently three
or four stools in the day. On his vacations, when eating unusual
things, drinking unaccustomed water, exposed to changes of
temperature, all the factors that give many people diarrhea, he was
perfectly regular because the worries had been lifted from his mind.
In another case, where for fifteen or twenty years a writer living
much indoors had had tendencies to diarrhea, always made worse by
worries, self-discipline and the refusal to let troubles occupy him by
always turning to something else, did him so much good that he
considered himself cured. In his case the return of a manuscript from
a magazine would always affect his bowels unfavorably. If, as
sometimes happened, he found that the manuscript had been returned
only for some corrections, there would be an immediate relief of his
condition.


Change of Mode of life and Intestinal Control.--An interesting phase
of the neurotic or mechanical disturbance of peristalsis is found in
the interference with regular movements of the bowels when persons are
aboard trains for long distances, or for more than twenty-four hours.
There are very few people who are not bothered in some way by such a
journey. Those of a nervous temperament are likely to suffer from
diarrhea. This is usually attributed to catching cold because of
drafts, but in recent years, when well guarded Pullmans eliminate
drafts to a great extent, the bowel disturbance continues. For the
majority of people, however, constipation results. The cause of it
seems to be due to a disturbance of peristalsis in the line of
inhibition because of the vibration and jolting of the train. The more
or less conscious assumption of definite positions of the muscles of
the abdominal region in order to save the body from the action of the
unsteady movement of the train, seems to be reflected in the sphere of
peristalsis with consequent constipation. There are other features,
such as a lessened consumption of food and water and absence of
exercise, that seem also to have an influence. If the journey is for
several days patients should be advised to walk out during the longer
stops.

{281}

Mental Influence and Indifferent Remedies.--The best evidence that we
have of the influence of mind upon the intestinal tract, and the
importance of employing that factor for therapeutic purposes, is found
in the number of cases of various intestinal disturbances, often
apparently chronic in character, which have been cured by the
administration of quite indifferent remedies. Dr. Hack Tuke in his
"Influence of the Mind on the Body" reports a number of cases in which
bread pills were used with good effect. _Pillulae micarum panis_ were
not an infrequent prescription in preceding generations. They are
usually supposed to have been effective only against the curious
symptoms that develop in hysterical women, but it must not be
forgotten that neurotic manifestations connected with the abdominal
region may occur very freely in men, and that treatment by suggestion
in connection with some remedy, real or supposed, is the most
efficient cure. The "British and Foreign Medical Review" for January,
1847, has a series of cases among naval officers which were reported
by a surgeon of long standing and wide experience. These cases include
painful intestinal psycho-neuroses, occasionally accompanied by
diarrhea, and sometimes by constipation and sometimes even by
dysenteric movements, all cured by bread pills when these were
administered in certain definite ways, and the patient's attention
concentrated on their expected effects. Bismuth lost its effect in one
case of repeated colic, opium was beginning to lose its effect. The
patient was then told that on the next attack he would be put under a
medicine which was generally believed to be most effective, but which
was rarely used on account of its dangerous qualities, and that would
not be used unless he gave his consent. At the first sign of his next
attack, a powder containing four grains of ground biscuit was
administered every seven minutes while within the hearing of the
patient the greatest anxiety was expressed lest too much should be
given. The fourth dose caused an entire cessation of pain. On four
other occasions, the same remedy was employed with equal success for
the same sort of attack. In a seaman who was suffering from obstinate
constipation which resisted even the strongest purgatives, including
Croton oil, pills consisting of two grains of bread were administered
every seven minutes, and the patient watched with very apparent
anxiety lest an overdose should be given. Within two hours he began to
have nausea at his stomach, which had been foretold as one of the
symptoms to be expected, and his bowels were freely open almost
immediately after. Apparently the administration of the bread pills
eventually cured his constipation.


Skin and Intestinal Sympathy.--Curious intestinal conditions are, as I
have said, often associated with neurotic manifestations of other
kinds. Attacks of hives and other neurotic skin disturbances are
common in association with nervous diarrhea. Sometimes the attack of
hives precedes the intestinal disturbance; sometimes it accompanies
it. Soon after eating the offending material, the skin manifestations
may begin and other symptoms follow. Only a few minutes elapse, even
when the patient does not know that the offending material has been
eaten, because it is concealed in some combination, yet the reaction
takes place evidently not from digestive absorption, but from
intestinal reflex. Very often there is vomiting, as well as diarrhea.
It is not hard to understand that in these cases there is produced an
irritation of the intestinal mucosa, corresponding to that seen in the
skin. Whenever {282} this occurs, it is not surprising that there
should be evacuation of the contents of the digestive tract in every
way that nature has provided for removing irritating material. The
simple nervous diarrhea is often spoken of as an "intestinal blush,"
as the neurotic disturbance of the bladder which causes frequent
urination is spoken of as a "vesical blush." Blushing is certainly the
external manifestation that corresponds most closely to the
disturbance that is probably the basis of these curious
manifestations.


_Urticaria and Diarrhea_.--Patients who suffer from urticaria readily
are almost sure to have other neurotic disturbances, and their
intestines seldom escape. On the other hand, those who have an
idiosyncrasy for certain kinds of food are almost sure to have other
nervous neurotic disturbances, which emphasize the fact that these
curious idiosyncrasies are of reflex nervous origin, rather than due
to any chemical irritation.

Some of these lesions of the intestinal tract related to urticaria may
affect, either primarily or secondarily, the biliary structures. Under
these circumstances there may be symptoms resembling true biliary
colic with some jaundice and pain that radiates toward the right
shoulder. Whether these bile symptoms are due to the occurrence of
actual urticarial lesions in the bile duct, or so close to the papilla
of entrance of the gall passages into the intestine as to occlude it,
is doubtful. Practically all the symptoms of the presence of biliary
calculus may be thus simulated. The differential diagnosis can only be
made by the rapid clearing up of the symptoms, and by the history of
the case. As a rule, where there is the story of repeated attacks of
neurotic intestinal disturbance, the physician and especially the
surgeon, should be slow to conclude as to the presence of a serious
pathological condition anywhere in the intestinal tract, unless the
symptoms are absolute. This is all the more necessary because now, in
patients' minds, the words appendicitis or biliary calculus are
associated with the thought of operation. This thought sometimes gives
rise to so much dread as to seriously disturb the appetite and still
further predispose the patient to the repetition of neurotic
intestinal trouble.

In the chapter on Abdominal Discomfort, the necessity for absolute
assurance of some definite lesion before there is any question of
operation, is insisted on. Here the disturbing mental influence of
suggestion, with regard to certain serious abdominal conditions, may
be emphasized. Many painful conditions in the abdomen are either
primarily or secondarily due to appendicitis. Most of these are quite
acute, and practically all amenable to definite diagnosis. There is,
however, a tendency to exaggerate the place that this organ holds in
the pathology of chronic cases. Many women who suffer from nothing
more than hysterical abdominal conditions are told by someone that
they have recurrent attacks of appendicitis, though there is nothing
except their suggestive complaints of pain on which to found such a
diagnosis, and then it becomes extremely difficult to remove this idea
from their minds, and contrary suggestion applied over a long period
is the only therapeutics that favorably affects them.


Intestinal Idiosyncrasies.--I have had the opportunity to see a series
of cases of intestinal idiosyncrasy in a family that has been an
interesting study for many years. One of the members has the most
exquisite case of susceptibility to various articles of food that I
think I have ever seen or heard of. {283} Even the eating of a little
unrecognized pork in sausage will give rise to a diarrhea so intense
that there is no peace for hours, and slight movements take place
every few minutes. Towards the end of the attack, there is always
considerable blood in the stools. Often the attack is preceded by
vomiting. While in most people the idiosyncrasy is limited to one
article of food, this patient has it for all of the articles that are
usually the subjects of idiosyncrasy. Besides pork, shell-fish will
produce vomiting and diarrhea within a few minutes, strawberries act
detrimentally at once, and cheese produces an almost immediate
reaction.

The most interesting feature of this case is that occasionally an
attack of diarrhea that is extremely severe, will occur merely as a
consequence of a strong emotional stress. Any great anxiety will have
this effect. The knowledge that someone has a telegram for her whose
contents she can not ascertain for a time, will act as a cathartic.
She also has other neurotic manifestations, especially of an
urticarial character, that are equally interesting. On a number of
occasions, when she has particularly prepared for some special event
such as a wedding or reception, for which a new gown has been provided
and preparations made with considerable solicitude to the end that she
shall appear at her best, she has suffered from a severe attack of
angio-neurotic edema affecting either her lips or her eye-lids so that
it was absolutely impossible for her to be present at the social
engagement. This has happened to her over and over again. On the first
two occasions, one eye was closed completely by the edema. In each
case she attributed it to the sting of an insect. There was no sign of
any sting, there was no itching or inflammation, the condition
presented all the signs of angio-neurotic edema, had come without
warning, and disappeared in from 36 to 48 hours without leaving any
mark or trace of its origin.

There is absolutely not a sign of hysteria in this individual, nor is
there any tendency to what would be called an emotional neurotic
condition. On the contrary, she is lively and sensible, the life of
her friends when they are ill, their consolation when they are in
trouble, and she herself has shown the power to bear trials and
difficulties. It is only the peripheral circulation in the intestinal
mucosa, and in the skin, that passes from under her control. She
neither laughs nor cries without reason and she has no other
exaggerated nerve reactions. Even more interesting is the fact that
the angio-neurotic condition can be traced in the preceding
generation, while the tendency to an intestinal neurosis complicated
by diarrhea exists in a sister in this generation. Examinations are
always a source of grave distress to the sister. Although she is a
bright intelligent woman she does not do justice to herself because of
her nervousness. Usually she has a vomiting spell in the morning
before the examination, and rather serious intestinal disturbance
during the day. That this is entirely neurotic is clear from its
constant disappearance immediately afterwards, and its constant
reappearance whenever there is this form of emotional stress.

In certain of these cases of supposed neurotic, intestinal troubles,
one cause of the condition sometimes fails of recognition. Many of
these people are found on inquiry to be taking much more salt than
usual. It is hard to understand how this occurs, but I have seen it in
a number of cases, sometimes in men, but much more frequently in
women. Some sort of a vicious {284} circle has been formed: probably
their original tendency to diarrhea led to a craving for salt, because
of the excessive serous evacuations. Somehow, then, the habit of
taking more salt was formed and its presence reacted to produce
irritative conditions in the patient, which, combined with neurotic
tendencies, produced the intestinal disturbance. I have seen chronic
diarrhea, mucous diarrhea, and even mucous colitis, associated with
the over-free taking of salt. When salt was eliminated from the diet
the cases at once improved. We now realize the value of a salt-free
diet for many conditions disturbing osmosis, and the presence of serum
where it should not be. It is probable that most people take more salt
than is good for them.


Intestinal Troubles Due to Air.--One of the most annoying intestinal
troubles due to a neurosis is the passage of air from the intestines,
or in some people a rumbling through them, which is distinctly of
neurotic origin. It is increased under emotional stress or whenever
there is anxiety with regard to it. This is much more common in the
old than in the young, as if relaxation of tissues had much to do with
it. Old men seldom complain of it to their physicians, but for obvious
conventional reasons, we are rather often asked to control it in older
women, and are occasionally asked to treat poignant cases of it in
young women. The older women are often stout, of flabby constitution,
and one has almost to accept the conclusion that the real trouble is
such a relaxation of the intestinal walls that the empty intestines do
not fall together as they used to, but rather tend to lie apart from
one another with the production of spaces into which gases, perhaps by
diffusion from the blood, find their way and are expelled. Usually
these patients were stouter than they now are.

Often after these patients have walked outside for some time,
especially if they have become quite tired, and then sit down inside
and become warm, the expansion of the air in the intestines leads to
some rumbling and the production of flatus. This experience is so
common with elderly people, when they come in in cold weather, that
they do not feel quite right unless it actually happens. The odor of
the flatus is seldom offensive.


_Air Swallowing_.--There seems to be no doubt that a certain amount of
air is swallowed, that it finds its way along the intestines, and
then, with the change of temperature on coming into the house,
expansion takes place and the air finds its way out. In certain
patients the habit of swallowing air may grow, and the necessity for
its evacuation, either by eructation or flatus, may be a source of
great discomfort. The latter form of relief may be impossible owing to
conditions, though it is quite as natural as other forms of the
evacuation of the bowels, and it must not be considered pathological
unless it becomes too frequent. People of other civilizations than
ours are not so sensitive in this matter. A late distinguished Chinese
Ambassador to this country relieved himself of an accumulation of gas
in his lower bowel quite as indifferently as he would have of gas in
his stomach--but without so much as "by your leave" and evidently
without a thought of anything unseemly in the act--apparently to his
own great satisfaction, though sometimes to the consternation of the
bystanders. Utterly failing to understand why he should not permit
himself this satisfaction, he peremptorily refused to conform to our
Western refinements in this matter.

In many of these cases habit may add to the necessity for relief of
this {285} kind, and habit may require considerable self-discipline
and training of organs to overcome it. To attempt to control this form
of intestinal trouble by ordinary intestinal remedies, and especially
by carminatives, is almost sure to increase it rather than do any
good. It is the patient's mental attitude toward the affection that
must be modified, and the intestinal bad habit must be brought under
control.


_Intestinal Uneasiness_.--In young women the cases are much more
serious, for the presence of gas in the intestines sometimes leads to
such dread of physical events over which they fear they may have no
control, that it makes it impossible for them to carry on their
ordinary occupations, hinders their conformance with social usages, or
even their association with any but very near friends. The cases are
not frequent, but are poignant when they occur. Many young women
suffer from rumblings in the intestines whenever more than four hours
have passed since their last meal. This phenomenon is not likely to
manifest itself unless they are nervous, excited and worried over
something, but is particularly likely to be troublesome when they are
with persons whom they are most solicitous to impress favorably. The
manifestation is undoubtedly associated with emptiness of the
intestines and relief will usually be afforded by taking something to
eat, even something so simple as a glass of milk and some crackers,
shortly before the time when the rumblings are usually heard. Dread of
this annoyance plays a large role in it, and it is due to an
exaggeration of peristalsis with the consequent crowding into larger
masses of small quantities of air that ordinarily would find their way
much more slowly along the intestinal tract. Milk of bismuth will do
more than anything else, though the presence of a certain quantity of
food is probably the best prophylactic and remedy.

Besides these cases, there are some that are even more annoying. These
occur in young women who have all the symptoms of an approaching
intestinal evacuation, and then find when they have excused themselves
that there is nothing but gas to be passed. This gas is nearly always
quite inoffensive, and is evidently air that has been present in the
intestines for some time, and has in the midst of the excitement of
peristalsis been forced on into the rectum and gives the sensation of
an approaching stool. These cases are coming into notice much more
commonly since young women have taken up business occupations. The
symptoms are worse in those who are constipated, though sometimes in
these cases there are recurring attacks of diarrhea showing that the
normal function of the intestine is disturbed. It is more annoying
just before and during menstruation than at any other time.


_Physical Basis_.--Whenever the patients are run down in weight there
is a distinct exaggeration of the condition. Whether the loss of
weight, by removing fat from within the abdomen, does not tend to make
the intestines more ready to take up air and to produce these
manifestations is a question worth considering. The most annoying
cases that I have seen were in people who had lost considerable weight
and though there had been some tendency to the condition before they
lost weight, it was doubtful whether the symptoms were greater than
those often seen and which are not productive of special annoyance
except in very sensitive people. In three of these cases that have
been under my observation in recent years, improvement came promptly
when weight was put on. The presence of an abundance of fat in {286}
the abdominal cavity seemed properly to balance the intestines and to
dampen peristalsis.

Reassurance, absence of worry, occupation of mind with interests that
keep it from putting such surveillance on the intestinal tract as will
surely be resented, must be the chief care of the physician. Without
these any relief afforded will be only temporary. With psychotherapy
relapses will occur, for these individuals are in a state of unstable
intestinal equilibrium, but practically all the successful remedies of
the past have been founded on it and its effect may be renewed over
and over again under various forms.



CHAPTER VII

MUCO-MEMBRANOUS COLITIS

Probably the severest, certainly the most interesting of the neurotic
conditions of the intestines, is muco-membranous colitis. The only
lesions discovered are those which point to a functionally increased
secretion of tenacious mucus from the lower bowel. No definite
pathological changes are known. The colic seems to be due to nothing
more than the effort of the large intestine to push off the thick
mucus which has been secreted, and which in many cases clings to the
bowel walls. This may be of such consistency that it is passed from
the bowel in the shape of tubular casts. These casts have often been
seen in place in the lower bowel. While the word membranous used in
connection with the disease has produced the impression that this
might be a form of diphtheritic affection, it is now known that it is
only due to an abnormally increased function, and not to any
structural pathological condition or infection of the lower bowel. The
membranous material is often gelatinous, and so the casts may hang
together in long pieces.


Neurotic Etiology.--It might be thought that such a cast could not be
formed, remain in situ in the lower bowel for a considerable period,
and then be passed as a whole, or in quite long portions, without
causing serious tissue disturbance in the mucous membrane. As Sir
William Osier says, in spite of the apparent improbability, the
separation may and usually does take place without any lesion even of
the surface of the mucous membrane. The epithelium seems to be left
intact. Owing to the curious nature of the stools, the disease has
been recognized for a long time and the descriptions of this disease
by the older authors are very interesting. Muco-membranous colitis
occurs mainly in nervous individuals, and is much more frequent in
women than in men, but it is not limited to women. Some of the
severest cases have occurred in men, and Woodward, in the second
volume of "The Medical and Surgical Reports of the Civil War," has an
exhaustive description of the disease as it occurred among soldiers.
It is particularly those who are worried and run down from overwork
and excitement who are likely to suffer from it, but it occurs
typically in people who, _faute de mieux_, worry about themselves.
Most of its victims are self-centered, though not hysterical.


Recent Increase in Number of Cases.--According to all the authorities,
there has been a considerable increase in the number of cases in
recent years. {287} At one watering place in France, Plombiêres, which
has acquired the reputation for relieving, or even curing the disease,
about 400 cases had been under treatment during the course of about
two years. This increase was attributed by Boas of Berlin to two
causes. First the struggle for life has become much more intense in
our day, and the nervous conditions which are practically always the
basis of muco-membranous colitis, have as a consequence become more
frequent. Not only this, but mild cases that were not called to the
attention of physicians in the past, have become so emphasized by the
nervous worries of the strenuous life that now they seldom escape the
physician's attention. Besides our generation is getting away from the
old-fashioned idea of patiently standing many pains and aches, and
refusing to call in a physician unless the condition persists or seems
to be producing serious results. There are more cases of the disease,
but physicians also see more of the cases than formerly because
patients come for treatment for slighter causes.

Dr. Boas considered that, besides the strenuous life, there was
another prominent factor in the increase of the disease. This is the
abuse of laxatives and purgatives. Many of these have their principal
effect on the lower bowel. In consequence the nervous mechanism of
this structure has been irritated to a point where occasionally
explosions of nerve force take place. This causes an increase of the
secretion, and a tendency to cramp-like contractions. While there is
undoubtedly much of truth in this, there is no doubt that the most
important factor in the disease is the patient's nervous condition.
Only those who are inclined to be introspective, to worry much about
themselves, and who are constantly examining their stools for the
presence of mucus, suffer severely from the affection.

Very few cases have been seen among the working classes. Most of the
cases have hypochondriacal symptoms that sometimes go to the extent of
real melancholia and the full persuasion that they have an incurable
disease, a visitation on them for some real or fancied lapse from the
laws of health in earlier years. The affection usually lasts a long
time, or has been in existence for some years when the physician is
asked to see it, and patients are made most miserable by it.

Unfavorable Suggestion and Over-attention.--The pathological
physiology of this disease, for, as has been said, it has no pathology
in the proper sense of the word, is in many cases a problem of mental
influence. For some reason, the patient gets his or her lower bowel on
his or her mind. There is so much talk of constipation and its evil
effects in the newspapers, in advertisements and by suggestion from
bill-boards and in the magazines as well as, sad to relate, in
parlors, drawing-rooms and even dining-rooms, that it is easy for
those who are introspective and nervous about themselves, and who have
some little tendency to constipation already, to become much worried
about it. If, then, as was suggested by Boas, they take laxatives in
profusion, the irritation set up further fixes the attention on this
portion of the body. After a while, in these people, a goodly portion
of the waking hours are spent in thoughts with regard to the lower
bowel. The morning thought is the possibility of a stool to-day,
followed by conjecture as to its character. After the stool has taken
place, if there seems anything abnormal about it, comes a morbid dread
of the consequences of having such stools.

{288}

This constant attention sends down a lot of impulses to the lower
bowel. Anyone who has studied the psychology of attention knows how
much influence can be exerted on the skin, or on the mucous surface by
mental influence. Hyperemia is produced, and this leads to over-action
of the glands of the large intestine. These glands secrete a glairy
mucus which is necessary to protect the bowel from the offensive
material that is always present, and from the hardened material that
is so often there when there is a tendency to constipation. This mucus
is secreted in large quantities, while at the same time a hyperemia of
the colon tends to interfere with peristalsis and consequently to
delay the passage of contents and to keep the mucus in place. An
accumulation goes on for some time, until irritation is set up by the
presence of such a large quantity of material in the intestine, and
then colicky efforts for its removal are occasioned. All of this
process is accompanied by suggestive reactions upon the mind that
further complicate the case. This story of the affection points out
the indications for treatment. Unless the patient's mind can be
diverted from its constant attention to the lower bowel, the
possibility of cure is distant, and even after such diversion any
return of attention is likely to bring on a relapse.


Treatment.--The treatment of this affection emphasizes its neurotic
origin. We have had any number of cures for it and each one has
actually relieved many patients. The more trouble the cure involves,
and the greater the impression produced on the patient's mind the more
likely is there to be a relief of symptoms. All sorts of drugs have
been employed. Many of them have for a time been heralded as more or
less specific. The important thing, however, was that the patients
should come predisposed to believe that they were going to be
improved, and then that suggestion should be made at frequent
intervals--a combination of auto-suggestion through the administration
at regular intervals for a long period of simple remedies with the
confident suggestion of the physician that the patient will get
better. Local treatment of various kinds has been reported to bring
about improvement. The more difficult this is, and the longer it
takes, as well as the more bother it involves for the patient and the
attendant, the better the response to it is likely to be. Long rectal
tubes were found beneficial in many cases, though they failed in many
others, and most physicians have seen relapses occur in spite of the
continuance of the treatment that at first did much good. High
injections of water containing various drugs, and of olive oil
sometimes bring improvement though they afford no guarantee against a
relapse. Mineral waters do good only in the suggestive environment of
the spring.


_Surgery and Suggestion_.--The symptoms have sometimes been so severe
and the complaints of the patients have been so great that even
surgery of serious character has been recommended and tried in some of
these cases. The making of an artificial anus in the right inguinal
region, so that for a time the feces are not allowed to pass over the
colon mucous membrane has been tried. This gives decided relief from
the symptoms, but when the artificial anus is allowed to close,
recurrences often take place. It has been suggested, therefore, that
the artificial anus should be allowed to stay open for months, but
even this seems to afford no guarantee against a relapse. In recent
years the appendix has been taken out through the opening in the right
inguinal region, and a portion of it allowed to remain through which,
when {289} fastened to the abdominal wall, injections might be made
into the colon. In these cases ice-water has been found probably of
more effect than any drug solutions. This rather serious surgical
procedure is, however, as yet on trial, and we do not know enough
about the after-course of the cases to be sure that it has any
permanent effect.

A strong suggestion is involved in the removal of the appendix, and
the use of the stump of it as an irrigating tube. When the treatment
consists of something that is so strongly excitant of feeling as
ice-water, applied directly to the colon, it is easy to understand
that suggestion reaches the limit of its possibilities. No wonder
these cases improve, though we are not sure as yet what happens after
the appendix opening is allowed to close, or is deliberately sutured.
I should expect a recurrence of symptoms, if ever a time came when the
patient was run down in weight and worried by external conditions,
introspection, and above all by concentration of attention on the
intestines.


_Direct Suggestion_.--The question is whether suggestion can be used
to advantage in these cases without employing any of the radical
measures that have been suggested. There is no doubt that at certain
watering places where a specialty is made of this disease, and to
which patients go, sure that they are going to be much better than
before, and where they see patients all round them who are improving,
they often get complete relief. This is only what might be expected.
Whether a similar effect can be produced by simple suggestion when the
patient is thoroughly convinced that the physician understands the
case, and that if they will respond he can cure it, remains to be
seen. I know that mild cases improve rapidly under simple hygienic
measures, with a renewal of confidence in the possibility of relief,
and with the diversion of the patient's mind from the intestinal
difficulty. This is the most important factor in the treatment, as it
is the most important factor in pathology. If the patient's nerve
centers can be kept from sending down impulses causing exaggerated
action of the glands, then there is some hope of relief. A habit has
been formed in the matter, and a habit can only be broken by a series
of acts, just as it was formed. It is not effort for a few days nor a
week that counts in these cases, but diversion of mind for long
periods, until normal function is restored. It is usually quite
impossible to keep up this improvement constantly in nervous patients.
There are setbacks, but then this is true in every form of nervous
affection. It is, then, that the renewed suggestion of the physician
is needed.


_Resort Cures and Suggestion_.--Physicians often tell patients that
muco-membranous colitis is incurable, or at least emphasize strongly
that it is very refractory to treatment, and that it is prone to
relapse even after improvement. After a certain number of physicians
have insisted on these points, it is inevitable that patients should
not respond readily to treatment, and that they should be solicitous
about themselves, even when improvement does come.

It is most important then to bring about the neutralization of these
unfavorable suggestions. This is what is particularly accomplished at
the health resorts where muco-membranous colitis is successfully
treated. At these the patients see other sufferers from the disease
who proclaim how much better they are and some at least who are
entirely cured. The waters {290} used at these health resorts are not
nearly so efficient when used at a distance because of this lack of
additional suggestion.

The most efficacious treatment of muco-membranous colitis then is to
bring the patient up to normal weight, for they are often thin people,
quiet their solicitude about themselves, give them a bland and
irritating diet and get them away from worries or anxieties about
themselves or others. I know cases in physicians where the effect of
worry of any kind can be traced very clearly in the increased symptoms
of their colitis and the greater frequency of attacks. It is
particularly important not to give habit-forming drugs in these cases
for they always do harm. Where the pain is much complained of the
coal-tar anodynes are useful, but ice in the rectum or even
suppositories of gluten, or of cocoa butter without any medication
often prove useful. Most of these patients watch prescriptions that
are given them rather carefully and make up their mind beforehand
whether they are likely to do them good or not and the event usually
follows their premonition. They often have habits of self-drugging
which must be stopped and always carefully inquired into for they will
sometimes continue to take things for themselves in spite of being
under the doctor's care. If they have heard of surgical treatment for
their affection they are likely to think that they will have to come
to it eventually and this prevents a favorable attitude of mind
towards their affection. Unless this is secured no treatment will
prove efficient. With it almost anything that keeps up the suggestion
will greatly relieve and often will actually cure the condition.



CHAPTER VIII

OBESITY

Obesity, popularly considered to be an over-accumulation of fat, is
sometimes thought to exist only when there is the large development of
abdomen which is more properly designated corpulency. In its strictly
scientific sense it represents excessive over-weight, that is, above
twenty per cent. more of weight than is normal for the height of the
particular individual. (See table of weight for height in chapter
Weight and Good Feeling.) The Latin derivation of the word gives also
its etiology. Ob-ese means having eaten too much. It is a question of
failure of due proportion between the taking of nutrition and the
oxidation processes within the body. More food being taken than is
needed, there is an accumulation of it in the form of fat, and this is
deposited by natural preference in certain places, such as the
abdomen, the breasts and in the _panniculus adiposus_ beneath the
skin. The fats and starches are most readily converted into this fat,
but under certain circumstances proteid material may be turned into
fat, and then a true pathological condition develops resembling
diabetes in certain ways.

The metabolism of fat is rather simple, but this may be disturbed by
bad habits. When such large quantities of sugar-making materials are
taken that they are beyond the power of the normal metabolism to
dispose of, they are excreted in the urine with the production of what
is known as physiological {291} glycosuria. In the same way, the
eating of a superabundance of fat-forming food leads to the deposition
of fat in the tissues where, when in excess, it is just as much wasted
as if it were excreted. Physiological glycosuria is, however, usually
considered to be dangerous, inasmuch as its frequent occurrence may
disturb the normal metabolism of sugar, and lead to diabetes. In the
same way, the over-consumption of fat-forming materials may disturb
the fatty metabolism, and lead even to the changing of proteid
materials into fat. This represents a real disease requiring careful
management, while ordinary obesity needs only the exercise of the
patient's will to secure such proportion between the amount of food
taken, and the amount of exercise and fresh air, as will not only
prevent accumulation of fat but will lead to the reduction of any
accumulation that may, through neglect of this care, already have
taken place.


Over-eating.--The putting on of weight depends on the individual's
craving for food, and his satisfaction of his appetite. While it is
not ordinarily looked at from this standpoint, this craving for food
and the habit of satisfying it which is developed, is not very
different from the craving for stimulants and the habit that forms
with regard to them. People insist that they can not eat less--that
their appetite simply requires them to eat. We have all heard this
story over and over again from the man who craves alcoholic
stimulation. Usually the obese can be persuaded more easily than the
inebriate to break off their habit, but they relapse into it even more
easily than he does. It is comparatively easy to limit the appetite,
or rather to forego the satisfaction of eating abundantly, for a week
or two weeks or even a month, but the effort finally becomes appalling
and the consequence is a relapse. If the patient really wants to lose
weight, in nine cases out of ten it is a comparatively simple matter.
The trouble is that they want to lose in weight without giving up the
satisfaction of eating.


Under Exercise.--The second factor in obesity--lack of sufficient
exercise, is even more important than the habit of over-eating. This
is illustrated very well by the cases of certain animals who, without
any tendency to fat accumulation by nature, but rather the contrary,
acquire fat to a marked degree, owing to the habits that are forced on
them by their relations to human beings. A typical example is the pet
dog. Dogs living their natural active lives, have little tendency to
put on superfluous flesh. Kept in the house in cities, they
practically always put on weight until, after some years, many of them
are quite incapable of moving except in an awkward waddle, often
comically symbolizing their mistresses in this respect. Besides the
inactivity, the dog is subject to the influence of the other cause of
obesity, the over-eating of fat producing material. Another typical
example, and one that provides evidence of the pathological tendency
to fat accumulation, is found in the Strasburg geese from whom the
fatty goose livers for _pates de foie gras_ are obtained. Geese are
placed in a warm underground room, in a mass of cement that gradually
hardens round their feet keeping them almost completely inactive, and
then they are fed abundantly with fat-forming materials. The absence
of light and air, and the immobility, leads to the production of the
fatty changes, eventually producing the enlarged fatty livers, which
delight the gourmet's palate.

What is true of the dog and the goose is exemplified in the lives of
all other {292} animals. The fattening process is well understood by
butchers--keep the animal inactive and supply an abundance of
fattening food. The inactivity is even more important than the food.


Prophylaxsis.--Of course, if obesity is to be successfully treated,
cases must be seen early and before there has been a large
accumulation of fat. When people are more than 10 per cent. over
weight they are in the danger zone, and with 20 per cent. above the
normal, decrease must come or the condition becomes inveterate. It is
between these two points and not when they are forty or fifty pounds
over weight that they need the advice of a physician and the careful
institution of regular life to prevent further fat accumulation. After
the body has carried thirty or forty pounds over weight for some time,
it has acquired the habit of accumulating fat, rather than using it,
and this, once acquired, is hard to break. Every additional pound
tempts to the formation of lazy or sluggish habits because of the
additional weight that has to be carried around. Everyone knows how
hard it is to walk a few blocks a little briskly carrying a suit case
that weighs thirty pounds. Even twenty pounds soon proves to be a
burden. Fat in the tissues, though it seems to be a portion of the
individual, is really quite outside of him and consists of extra food
material that the body is carrying round, having accumulated it for
the purpose, apparently, of using it at some time when it should be
necessary. While carrying this burden, people have little inclination
to an active life. Inactivity lowers oxidation processes and leaves
them with an additional tendency to fat accumulation because of lack
of oxidation. In a word, a vicious circle of cause and effect is
formed. Accumulation of fat prevents the taking of proper exercise,
and lack of exercise leads to further accumulation of fat!

Not only should the treatment of obesity begin early in a particular
case, but, in families where there is a recognized tendency to take on
fat, it should begin early in life.

Children should not be so fed that they become mere specimens,
illustrative of how early fat accumulation may occur, and to what a
degree it may go. Just as soon as baby shows signs of an accumulation
of fat above its normal weight for age and size, there should be just
such a regulation of its diet as would be considered necessary if it
were an older person, and showed the same unfortunate tendency. This
is particularly important if the parental relatives on either or both
sides of the house show tendencies to fat accumulation. We are sure
that in diabetes the over-eating of starchy and sugary substances
produces what is, at the beginning, an alimentary or so-called
physiological glycosuria, though it is doubtful whether any glycosuria
is ever absolutely physiological. This may lead to a pathological
glycosuria and the production of a true diabetes. So, also, the
tendency to accumulation of fat, as the result of what might be called
alimentary obesity, may lead eventually to the production of an
essential obesity in which even the proteid materials of the food may
be changed into fats, just as in the case of diabetes they are changed
to sugar. This fat is then stored up in the tissues though there is no
need at all for such an accumulation, and the food stuff is wasted
quite as much as in diabetes.


The Will in Treatment.--The important element in the treatment of
obesity is the readiness of the patient to follow directions. Nine out
of every {293} ten stout people are thoroughly able to control the
accumulation of fat and even to bring themselves down to about normal
weight, if only they _will_ to do so. This is no easy matter. It is
not an affair of a few weeks, or even a few months. Just as in the
case of over-indulgence in alcohol, it will probably be a life
struggle. It is well worth the while, however, for life is longer and
is larger without the accumulation of fat, which is not only so
uncosmetic, but is so preventive of real enjoyment of life.
Unfortunately, the cosmetic side of it, that is, the absurdity of
going round among one's friends with a very prominent abdomen, or with
noticeable protuberances, is the particular motive that appeals to
most people. While women may be quite ready to stand many discomforts
for cosmetic effect when dictated by fashion, they are not ordinarily
persistent enough in their efforts to prevent fat accumulation to be
successful in this much more important purpose.

Such patients make the rounds from physician to physician, and from
quack to quack, and go from patent medicine to patent medicine, to
find something that will enable them to lose weight without the
necessity for their taking any trouble. It is the old, old story that
the nerve specialist who is known occasionally to treat his patients
by hypnotism has so often presented to him. Patients who are sufferers
from alcoholism, or drug addiction, or some other vicious habit,
present themselves and ask if they cannot be hypnotized and then lose
their tendency to fall back into the old habit. There is no
possibility of this. If they are willing to cooperate, all of these
habits may be overcome, but a constant effort will be required and,
even after the habit is broken, there always remains a distinct danger
of relapse. Patients suffering from obesity want to transfer the
burden of working it off to someone else's shoulders, or they want
some specific remedy that will bring about reduction in weight yet
permit them to indulge in all the pleasures of their artificially
excited appetite. They follow directions for a few weeks, often
half-heartedly, and then give up the struggle.


_Food Temptations_.--With obesity, as with indulgence in alcohol, the
main difficulty is the occasion. Most of these fat people are placed
in circumstances in which tempting food passes them three times a day,
and it is hard to refuse it. If a hot punch or a fragrant cocktail
were several times every day passed under the nose of a man with a
tendency to inebriety it would be beyond the bounds of reason to hope
that he should withstand his craving. Just as soon as those who want
to reduce in weight are put in conditions in which only simple food,
though there may be a reasonably good variety of it, is presented to
them, the difficulty of limiting the amount they eat is comparatively
easy. This necessitates, as a rule, refusing invitations to dinner at
friends' houses, especially at the beginning of a reduction cure,
avoiding hotel _menus_ and giving up various social functions. It may
even involve changing home customs from those of luxury back to
simplicity. The question is whether this is worth while or not. When a
husband is likely to indulge over much in alcoholic liquors a wife is
apt to consider it easy to deny herself the privilege of such liquors
on her table and of avoiding places where he is likely to be tempted.
The rest of the family are usually quite satisfied to stand some
self-denial so that unfortunate results may not follow.

Where father or mother are suffering from obesity this same thing may
be necessary with regard to rich and highly seasoned foods. This would
be a {294} hardship to inflict on the family were it not for the fact
that the health of all the members will be distinctly benefited and a
return to simple food, nutritious and with a variety that makes it
eminently wholesome, will be good for them as a prophylactic measure.


_Motives for Self-Control_.--The task of keeping the weight down is so
difficult that very few people with a tendency to over-weight are
equal to it. They need the help of every motive possible for
encouragement. It is well to make these persons realize that
over-weight, according to the statistics carefully gathered and
collated by the large insurance companies in recent years, is a
serious bar to great expectancy of life. In a large series of cases it
was found that not a single individual recorded as being more than
twenty per cent. over the normal weight that he should have for
height, died of old age. Furthermore no one of over-weight attained
the age of eighty years, though 44 under-weights passed this age, and
two of them even reached the age of ninety. Death from nearly every
known cause is more frequent among the over-weights than in the normal
population, except in the single instance of tuberculosis.

What was thus demonstrated from statistics, carefully gathered in
modern times, has been a commonplace in medicine since the earliest
days. Hippocrates summed up Greek experience in the aphorism "persons
who are naturally very fat are apt to die earlier than those who are
slender." Practically all the commentators since his time have agreed
with him. In early years thinness may be quite as dangerous.

If there were no other reason but the greater frequency of _diabetes_
among the obese, this of itself would be sufficient to act as a strong
deterrent motive. It may well be used as such, especially in families
where a tendency to diabetes has been manifest. Diabetes figures as a
cause of death in life insurance statistics five times more frequently
among those who are over-weight than in the general population. Those
who are under-weight suffer from the disease in fatal form less than
one-half as frequently as the average. Hence, obesity and diabetes are
evidently closely related. As we have suggested, the disturbance of
metabolism due to the failure to use sugar properly in the system and
to its consequent elimination, corresponds in some, as yet not well
understood, way to the other metabolic disturbance by which
unnecessary fat is accumulated in the system. It is probable that the
over-eating of starchy foods and fats which leads to obesity, causes
in some people a breakdown of metabolism in the matter of the proper
disposal of sugar, and this initiates diabetes which becomes a
pathological condition, after a time quite beyond control.


Sleep and Exercise.--After the reduction of diet, the most important
feature of any successful treatment of obesity must consist of an
increase in the amount of exercise. Both of these can be accomplished
only through the patient's will, and by frequently repeated
suggestion, and auto-suggestion, of the necessity for constant
surveillance in both these matters. Any form of exercise that is
pursued faithfully is beneficial. Exercise in the open air, because it
encourages oxidation, is preferable to gymnastic exercises, but the
care of a trained instructor, the influence of example, the habit of
taking it at regular hours, make gymnastic exercise of value in this
condition. A regular walk every day is invaluable if it can be
secured. Women can be tempted {295} to walk even three or four miles,
if the habit is gradually formed, and if they realize the necessity
for it. It is important that too much sleep should not be indulged in.
One of the difficulties with pet animals is that they sleep so much
more in domesticity than in the state of nature. Sleep must be
absolutely regulated for the obese. The old monastic rule "seven hours
for a man, eight hours for a woman and nine hours for a hog" must be
emphasized.


Heredity.--There always remains in these cases the influence of
heredity. Many people are sure that because they come from families
with the tendency to obesity, it is impossible for them to overcome
this assumed heredity, and that the only thing for them is to bear the
affliction with equanimity. They usually do this while indulging their
taste for the luxuries of the table rather freely. This question of
heredity, however, has come in recent years to occupy a very different
position in the minds of biologists from that which it held a
generation ago. We know now that the evidence for acquired characters
being transmitted is so trivial as to be quite negligible.

The children of stout parents are likely to acquire their parents'
habits as to the consumption of food, in such quantity and quality as
will almost inevitably put fat on them. It is this habit much more
than any hereditary element, which is the underlying cause of the
obesity. There may be some influence of heredity, but it is much less
than has been thought, and even where it exists, it is not so
inevitable as has been considered. There are cases in every
physician's experience where the children of stout parents who, for
some reason, have been brought to habits of spare eating, have been
thin all their lives. On the other hand, anyone who has seen the
change that has come over the sons of spare, lanky farmers, in whom
both father and mother were of the thin type, yet who in the midst of
the luxury of city life have taken on weight, will be convinced that
personal habits mean much more than any influence of heredity in the
production of obesity.

Where there is normal occupation of mind and body with strict
regulation of the hours of sleep, and simple though abundant food,
there is little tendency for people to become obese, even though there
may seem to be hereditary tendencies. In a considerable experience
with religious communities I have often noted that the member of a
family who enters a religious order often goes but slightly above
normal weight, even though other members of the family may become
distinctly fat. This is not because of rigid self-denial in the matter
of food, that is to such an extent as to take less food than is
necessary, for most members of the religious communities work too hard
for this to be possible, but because they live the regular active life
and have the simple food of the community. This is true in spite of
the fact that their indoor life would seem to predispose them to the
accumulation of fat. After fifty most of them put on weight because
this is the physiological accompaniment of that period of life, but it
is not this form of fat accumulation that the physician is called upon
to treat as a rule, but that in people between the ages of twenty and
forty.

If the prevention of over-weight is taken up in time, if habits are
broken before they become tyrannous, if proper self-control is
cultivated early in life, there are very few people that need fear the
oncoming of obesity. There are some pathologically obese families in
which this will not be true, but they are as rare as diabetic
families. The most important element in any {296} treatment is the
rousing of the patient's mind and his will to take up seriously the
task of unlearning habits of overeating and not allowing sluggishnes