Health Through Will Power

CHAPTER IX

THE WILL AND AIR AND EXERCISE

Very probably the most important function of the will in its relation to health is that which concerns its power to control the habits of mankind as regards air and exercise. It is surprising to what an extent people neglect both of these essentials of healthy living in the midst of our modern sophisticated life, unless the will power is consciously used for the purpose of forming and then maintaining habits with regard to these requisites for health. It is a very fortunate thing that instinct urges the child, particularly the infant, to almost constant movement during its waking hours. Children that are healthy and that are growing rapidly, boys somewhat more than girls, are so constantly in movement that one would almost think that they must be on springs. Whenever they discover that they can make a {134} new movement, they proceed to make it over and over again until they can do it with facility. There is no lolling around for them; as soon as they wake, they want to be up and doing, no matter what the habits of the household may be. They are constantly on the move. We know that this is absolutely essential for growth as well as for the proper training of their muscles, but it is a very fortunate thing that children do it for themselves, for if their mothers were compelled to train them, the task would be indeed difficult. All mother has to do is to control them to some extent and keep them from venturing too far, lest they should hurt themselves.

When the control of instinct over life is gradually replaced by reason, this tendency to exercise gradually diminishes until it is often surprising to find how little people are taking. As it is mainly the need for exercise that forces people out into the air, indoor life comes to be the main portion of existence. This is all contrary to nature, and so it is not surprising that disease, in its original etymological sense of discomfort, develops rather readily. The lack of exercise in the air permits a great many people to drift into all sorts of morbid conditions in which they are quite miserable. This {135} is, of course, particularly true as regards nervous ailments of various kinds; only under the term nervous ailments should be included not alone direct affections of the nervous system or functional disturbances of nerves, but also a number of other conditions. Nervous indigestion, insomnia, neurotic constipation and many of the symptomatic affections associated with these conditions, tired feelings that interfere with activities, headache, various feelings of discomfort in the muscles and around the joints, inability to control the emotions and other such common complaints—if that is the proper word for them—all these are fostered by a sedentary life indoors. They frequently make not only the patient himself—or oftener herself—miserable, but also all those who come in contact with her.

Above all, it must not be forgotten that lack of exercise in the open air has a very definite tendency to make people extremely sensitive to discomforts of all kinds, mental as well as physical. Many a man or woman whose life seems full of worries, sometimes without any adequate cause at all, who goes from one dread to another, who wakes in the morning with a sense of depression, find that most of these feelings and sometimes all of them, {136} disappear promptly when they begin to exercise more in the open.

Nothing dispels the gloom and depressions consequent upon an accumulation of cares and worries of various kinds like a few weeks in the woods, where every moment is passed in the fresh outdoor air, which actually seems to blow the cobwebs of ill feelings away and leaves the individual with a freedom of mind and a comfort of body that he almost expected never to enjoy again.

Undoubtedly the most important factor for the preservation of health is an abundance of fresh air. At certain seasons of the year this is not only easy and agreeable, but to do anything else imposes hardship. In our climate, however, there are about six months of the year in which it requires some exercise of will power to secure as much open air life as is required for health. There are weeks when it is too hot, there are many weeks when it is too cold. The cold air particularly is important, because it produces a stimulating vital reaction than which nothing is more precious for health. We have no tonic among all the drugs of the pharmacopeia that is equal to the effect of a brisk walk in the bracing air of a dry cold day. After a long morning and {137} perhaps a whole day in the house, even half an hour outdoors will enable us to throw off the sluggishness consequent upon confinement to the indoor air and the lack of appetite and the general feeling of physical lassitude which has followed living in an absolutely equable temperature for twenty-four hours. Sometimes it requires no little effort of the will to secure this, and to continue it day after day without missing it or letting it be crowded out by claims that are partly real and partly excuses, because we do not care to make the special effort required.

What humanity needs is regular exercise in the open air every day. As it is, between the trolley car and the automobile, very few people get what they need. Any one who has to go a mile takes a car or some other conveyance and between waiting for the car and certain inevitable delays it will probably take ten minutes or more to go the mile. In five minutes more one could walk that distance and secure precious exercise besides such diversion of mind as inevitably comes from walking on busy city streets and which makes an excellent recreation in the midst of one's work. For it is quite impossible in our day to walk along city streets absorbed in abstract mental {138} occupations. One of the objections to walking is that after a while it can be accomplished as a matter of routine without necessarily taking one's mind away from subjects in which it has been absorbed. It is quite impossible for this to happen, however, on modern city streets. "The outside of a horse", it used to be said, "is good for the inside of a man." The main reason for this was because it is impossible for a man to ride horseback, unless his mount is a veritable old Dobbin, without paying strict attention to the animal. The same thing is true as regards city pedestrianism, especially since the coming of the auto has made it necessary to watch our steps and look where we go.

A great many people would be ever so much better in health if they walked to business or to school every morning instead of riding, for the young need it even more than the older people. Especially is this true for all those who follow sedentary occupations. Clerks in lawyers' offices, typewriters and stenographers, secretaries—all those who have to sit down much during the day—need the brisk walking and need it not merely of a Sunday or a Saturday afternoon, but every day in the year. Many of them, if they walked two and three miles to {139} the office, would probably require only fifteen minutes, at most half an hour, more than if they took a train or trolley, but they would have secured a good hour of exercise in the open air.

On the other hand the unfortunate crowding of trolley and elevated and subway trains in the busy hours when people go to and from their work makes an extremely uncomfortable and often rather depressing commencement and completion of the day's work. I know of nothing that makes a worse beginning for the day than to have to stand for half an hour or longer in a swaying, bumping car, hanging to a strap, crushed and crowded by people getting in and out. The effect of coming home under such circumstances after a reasonably long day's work is even more serious, and any little sacrifice that will enable people to avoid it will do them a great deal of good. Fifteen or twenty minutes of extra time morning and evening would often suffice for this and would at the same time add a bracing walk in the open air to the day's routine.

When first begun, such a practice would make one tired and sore, but that condition would pass in the course of a few days and be replaced by a healthy feeling of satisfaction {140} that would be well worth all the effort required. We should need ever so much less medicine for appetite and for constipation if this were true. A great many people who stand during the day would probably deem it quite out of the question for them to walk three miles or more to and from their business, for their feet get so tired that they feel that they could not endure it. What they need more than anything else, however, is exercise that will bring about a stimulation of the circulation in their feet. Standing is very depressing to the circulation. It leads to compression of the veins and hence interference with the return circulation, with lowered nutrition which often predisposes to flat foot or yielding arch and tends to create corns and callouses: walking in reasonably well fitting shoes on the contrary tends to make the feet ever so much less sensitive Our soldiers have had that experience and have learned some very precious lessons with regard to the care of their feet, the principal one being that the best possible remedy for foot troubles is to exercise the feet vigorously in walking and running, provided the shoes permit proper foot use.

I have often known clerks and floorwalkers {141} who have to stand all day or move but a few steps at intervals, who were so tired at night that they felt the one thing they could do was to sit down for a while after dinner and then go to bed, but who came to feel ever so much better after a brisk walk home. It was rather hard to persuade them that, exhausted as they felt, they would actually get rested and not more tired from vigorous walking, but once they tried it, they knew the exercise was what they needed. The air in stores is often dry and uncomfortable for those who are in them all day. It is usually and quite properly regulated for the customers who come in from the streets expecting to get warm without delay. In dry, cold weather particularly, an evening walk home sets the blood in circulation until it gets thoroughly oxidized and the whole body feels better. Such a brisk walk will often prevent the development of flat foot, especially if care is taken to spring properly from the ball of the foot, in the good, old-fashioned heel and toe method of walking. Once flat foot has developed, walking probably is more difficult, but even then, with properly fitting shoes, the patients will be the better for a good walk after their work is over. It requires some will power to acquire the {142} habit, but once formed, the benefit and pleasure derived make it easy to keep up the practice.

Those who walk thus regularly will often find that their evening tiredness is not so marked, and they will feel much more like going out for some diversion than they otherwise would. Probably nothing is more dispiriting in the course of time than to come home merely to eat dinner, sit down after dinner and grow sleepy on one's chair until one feels quite miserable, and then go to bed. There should be always, unless in very inclement weather, an outing before bedtime, and this should be looked forward to. It will often forestall the feeling that the day is over after dinner and so keep the individual from settling down into the dozy discomfort of an after-dinner nap as the closing scene of the day. Good habits in this matter require an effort of the will to form; bad habits almost seem to form of themselves and then require a special effort to break.

It is surprising how many of the dreads and anxiety neuroses and psycho-neurotic solicitudes and neurasthenic disquietudes and other more or less morbid mental states disappear under the influence of a brisk walk for three or {143} four miles or more every day. I have tried this prescription on all sorts of people, including particularly myself, and I know for certain that when troubles are accumulating the thing to do is to get outdoors more, especially for walking; then the incubus begins to lift. Clergymen, university professors, members of religious orders, school teachers, as well as bankers, clerks and business people of various kinds, have been subjected to the influence of this prescription with decided benefit. Some of them assert that they never felt so well as since they have formed the habit of walking every day. It must, however, be every day, and it must not merely be a mile or so but it must be at least three miles. That means for a good many people about an hour spent in actual walking, but it is well worth the time and effort. Above all, it repays not only in health and in better feelings but in the increased amount of work that can be done on the day itself. A whole day passed indoors will often contain many wasted hours, while if a walk of a couple of miles is planned for the morning and one for a couple of miles more in the afternoon, very satisfactory study or other work can be done in the intervals. Almost needless to say, a brisk walk in the {144} cooler weather will create an appetite where it did not exist before. Women often need counsel in this matter more than men, and regular walking for them is indeed a counsel of health. Very few women in these modern times walk much, and to walk more than a mile seems to them a hardship. This is responsible for more of the supersensitiveness and nervous complaints of all kinds to which women are liable than anything else that I know of. It is also one important factor in the production of the constipation to which women are so much more liable than men. We see many advertisements with regard to the jolts to which the body is subjected every time the heel is put down and of the means that should be taken to prevent them, but it must not be forgotten that men and women were meant by nature to walk erect and that this recurring jolt has a very definite effect in stimulating peristalsis and favoring the movement of the contents of the intestines. Besides, if the walking is brisk, the breathing is deeper and there is some massage of the liver, as also of the other abdominal viscera, while other organs are affected favorably. Walking for women—regular, everyday walking—would be indeed a precious habit, but now {145} that women have occupations more and more outside of the house, this is one of the things they must make up their minds to do, if they are to maintain health, remembering that making up the mind is really making up the will.

Over and over again I have seen a great many of the troubles of the menopause or change of life in women disappear or become ever so much less bothersome as the result of the formation of regular habits of walking out of doors every day. Unfortunately, there is a definite tendency about this time for women to withdraw more and more from public appearances and to live to a considerable extent in retirement at home. Nothing could be much worse for them. They need, above all, to get out and to have a number of interests, and if these interests can only be so arranged as to demand rather prolonged walks, so much the better. This is more particularly true for the unmarried woman who is going through this critical time, and the question of walking regularly every day for three or four miles must be proposed to her. It will require a considerable effort of the will. More than two miles at the beginning will probably be too tiring, but the amount can be gradually increased {146} until at least four miles on the average is covered every day. Above all, for the feelings of discomfort in the cardiac region so often noticed at this time, regular walking is the best remedy in most cases, always of course presupposing that there is no organic heart condition, for in that case only a physician can give the proper direction for each case. By the exercise of the lungs that it requires, it will probably save most people from colds and coughs which they have had to endure every winter. Lastly be it said that practically all men and women, though more particularly the men who have lived well beyond the Psalmist's limit of threescore and ten, have been regular daily walkers, or else they have taken exercise in some form in the open air which is the equivalent of walking. One of the most distinguished of English physicians, Sir Hermann Weber, who died just after the end of the war in London, was in his ninety-fifth year. He had practised medicine regularly until the age of eighty and continued in excellent health and vigor until just before his death. During the last year of life, he contributed an interesting article to the British Medical Journal on the "Influence of Muscular Exercise on Longevity." He attributed his vigor at the age of {147} ninety-five as well as the prolongation of his life to his practice of spending every day two or three hours in the open air. He walked, as a rule, forty to fifty miles a week. Even in the most inclement weather he rarely did less than thirty miles a week. Many another octogenarian and nonagenarian has attributed his good health and long life to the habit of regular daily exercise in the open.

Instead of using up energy, the will so used brings out latent stores of energy that would not otherwise be employed and thus adds to the available amount of vitality for the individual. Doctor Thomas Addis Emmet, only just dead, over ninety, in his younger years as a busy medical practitioner never kept a horse. It would not be difficult to cite many other examples among men who lived to advanced old age and who considered that they owed their good health and long life to daily habits of outdoor exercise.

CHAPTER X

THE WILL TO EAT

Eating is usually supposed to be entirely a matter of appetite which instinct directs to the best possible advantage of the individual. This is quite true for those who are living the outdoor life that is normal or at least most healthy for men, and when they are getting an abundance of exercise, and may I add also have not too great a variety of food materials in tempting form presented to them. Under the artificial not to say unnatural conditions which men have to a great extent created for themselves in city life, confined at indoor sedentary occupations, some of them—and they are much more numerous than is usually imagined—eat too little, while a great many, owing to stimulation of appetite in various ways, eat too much.

Eating therefore for health's sake has to be done through the will and as a rule by the {149} formation of deliberate habits. It is easy to form habits either of defect or excess in the matter of eating and indeed a great deal of the ill health to which mankind is liable is due to errors in either of these directions. Having disturbed nature's instincts for food in modifying the mode of life to suit modern conveniences, we have now to learn from experience and scientific observations what we should eat and then make up our minds to eat such quantity and variety as is necessary to maintain health and strength in the particular circumstances in which we are placed.

While the greatest emphasis has been placed on the dangers to health in overeating, the number of people who, for one reason or another, eat too little is, as has been said, quite surprising. A very large proportion of those under normal weight are so merely because they have wrong habits of eating. Indeed, it may be laid down as a practical rule of health that wherever there is no organic disease the condition of being underweight is a symptom of undereating. A great many thin people insist that the reason why they are underweight is that it is a family trait and that father and mother, or at least one of them, and some of their grandparents exhibited this {150} peculiarity; and thus it is not surprising that they should have it. A careful analysis of the family eating in such cases has shown me in a large number of instances, indeed almost without exception, that what my patients had inherited was not a constitutional tendency to thinness, but a family habit of undereating. This accrued to them not from nature but from nurture, and was acquired in their bringing up. Most of them were eating one quite abundant meal a day and perhaps a pretty good second meal, but practically all of them were skimping at least one meal very much. In some way or other, a family habit of eating very little at this meal had become established and was now an almost inviolable custom.

A great many thin individuals, that is persons who are somewhat more than ten per cent. under the average normal weight for their height, either do not eat breakfast at all or eat a very small one. It is not unusual for the physician analyzing their day's dietary to be told that the meal consists of a cup of coffee and a piece of bread. Sometimes there is a roll, but more often only part of a roll, though occasionally in recent years there may be some fruit and some cereal; the fruit will usually be a half of one of the citrus fruits {151} which contains practically no nutrition and is only a pleasant appetizer, while more often than not the cereal will be one of the dry, ready-to-eat varieties which, apart from the milk or cream that may be served with them, contain in the usual small helpings very little nutriment. Such breakfasts are particularly the rule among women who are under weight. Sometimes lunch is comparatively light so that there are two daily apologies for meals. To make up for these, the third meal may be very hearty. City folk often eat at dinner more than is good for them. This may produce a sense of uncomfortable distention and overfulness followed by sleepiness which may be set down as due to indigestion, though it is just a question of overeating for the nonce.

It would be much more conducive to health to distribute the eating over the three meals of the day, but it requires a special effort of the will to break the unfortunate habits that have been formed. Particularly it seems hard for many people to eat a substantial breakfast and a determined effort is required to secure this. It would seem almost as though their wills had not yet waked up and that it was harder for them to do things at this time of day. It is especially important for working {152} women, that is, those who have such regular occupations as school-teacher, secretary, clerk and the like, to eat a hearty breakfast. They can get a warm properly chosen meal at home at this hour, while very often in the middle of the day they have to eat a lunch that is not nearly so suitable. As a consequence of neglecting breakfast then, it is twenty-four hours between their warm, hearty meals. Even when they eat a rather good lunch, some eighteen hours elapse since the last hearty meal was taken, and one half the day's work has to be done on the gradually decreasing energy secured from the evening meal of the day before. With this unfortunate habit of eating, most of that was used up during the night in repairing the tissue losses of the day before, so that the morning's work has to be done largely "on the will" rather than on the normal store of bodily energy.

It is surprising how many patients who are admitted to tuberculosis sanatoria have been underweight for years as a consequence of unfortunate habits of eating. Not infrequently it is found that they have a number of prejudices with regard to the simple and most nutritious foods that mankind is accustomed to. Not a few of the younger ones who {153} develop tuberculosis have been laboring under the impression that they could not digest milk or eggs or in some way they had acquired a distaste for them and so had eliminated them from their diet; some of them had also stopped eating butter or used it very sparingly. At the sanatoria, as a rule, very little attention is paid to the supposed difficulty of digestion of milk and eggs and perhaps butter. The patients are at once put on the regular diet containing these articles and the nurse sees that they take them even between meals, and unless there is actual vomiting or some very definite objective—not merely subjective—sign of indigestion, the patients are required to continue the diet.

It is almost an invariable rule for the patients of such institutions to come to the physician in charge after a couple of weeks and ask how it was that they could have thought that these simple articles of food disagreed with them. They have begun to like them now and are surprised at their former refusal to take them, which they begin to suspect, as the physician very well knows, to have been the principal reason for the development of their tuberculosis.

There are people who are up to weight or {154} slightly above it who develop tuberculosis, but they do not represent one in five of the patients who suffer from the affection. In probably three fourths of all the cases of tuberculosis the predisposing factor which allowed the tubercle bacillus to grow in the tissues was the loss of weight or the being underweight. There is a good biological reason for this, for there are certain elements in the make-up of the tubercle bacillus which favor its growth at a time when fat is being lost from the tissues rather than deposited, for at that time more fat for the growth of the tubercle bacillus is available in the lungs than at other times. Often among the poor the loss in weight is due to lack of food because of poverty, or failure to eat because of alcoholism, but not infrequently among all classes it is just a question of certain bad habits of eating that might readily have been corrected by the will. It is surprising how many people who complain of various nervous symptoms—meaning by that term symptoms for which no definite physical basis can be found, or for which only that extremely indefinite basis of a vague reflex, real or supposed, from the abdominal organs—are underweight and will be found to be eating much less than the average of {155} humanity. These nervous symptoms include above all discomforts of various kinds in the abdominal region; sense of gone-ness; at times a feeling of fullness because of the presence of gas; grumblings, acid eructations, bitter taste in the mouth, and above all, constipation. As is said in the chapter on "The Will and the Intestinal Functions," the most potent and frequent cause of constipation is insufficient eating, either in quantity or in variety. It is especially in the digestive tract of those who do not eat as much as they should that gas accumulates. This gas is usually thought to be due to fermentation, but as fermentation is a very slow gas producer and nervous patients not infrequently belch up large quantities, it is evident that another source for it must be sought. Any one who has seen a number of hysterical patients with gaseous distention of the abdomen and attacks of belching in which immense quantities of gas are eructated, will be forced to the conclusion that in such nervous crises gas leaks out of the blood vessels of the walls of the digestive tract and that this is the principal source of the gas noted. What is true in the severe nervous attacks is also true in nervous symptoms of other kinds, and neurotic indigestion so called {156} is always accompanied by the presence of gas.

Apparently the old maxim of the physicist of past centuries has an application here. "Nature abhors a vacuum" and as the stomach and intestines are not as full as they ought to be, nor given as much work to do as they should have, nature proceeds to occupy them with gas which finds its way in from the very vascular gastrointestinal walls. This is of course an explanation that would not have been popular a few years ago when the chemistry of digestion seemed so extremely important, but in recent years, medical science has brought us back rather to the physics of digestion, and I think that most physicians who have seen many functional nervous patients would now agree with these suggestions as to the origin of gaseous disturbance in the gastrointestinal tract in a great many of these cases.

Besides the physical symptoms, there are a whole series of psychic or psycho-neurotic symptoms, the basis of which undoubtedly lies in the condition of underweight as a consequence of undereating. Over and over again I have seen the feeling of inability to do things which had come over men, and {157} particularly women, disappear by adding to and regulating the diet until an increase in weight came. Extreme tiredness is a frequent symptom in those under weight, and this often leads to their having no recreation after their work because they have not enough energy for it; as every human being needs diversion, a vicious circle of influence which adds to their nervous tired condition is formed. I have seen in so many cases the eating of a good breakfast and a good lunch supply working people with the energy hitherto lacking that enabled them to go out of an evening to the theater or to entertainments of one kind or another, that it has become a routine practice to treat these people by adding to their dietary unless there are direct contra-indications.

Dreads are much more common among people who are underweight than among those who eat enough to keep themselves in proper physical condition. I have had a series of cases, unfortunately only a small one in number, in which the craving for alcoholic liquor disappeared before an increase in diet and a gain in weight. I shall never forget the first case in which this happened. The patient was a man of nearly sixty years of age who held a {158} rather important political office in a small neighboring town. He was on the point of losing it because periodical sprees were becoming more frequent and it was impossible for him to maintain his position. He was over six feet in height and he weighed less than a hundred and fifty pounds. I had tried to get him to gain in weight by advice and suggestion without avail. Finally, I had to make a last effort to use whatever influence I had to save his political position for him, and then I succeeded in making him understand that he would have to do as I told him in the matter of eating, or else I would have nothing more to do with him.

It was not without some misgivings that I thus undertook to make a man of nearly sixty change his lifelong habits of eating. That is something which I consider no physician has a right to do unless there is some very imperative reason for it. Here was, however, a desperate case. It was in the late afternoon particularly that this patient craved drink so much that he could not deny himself. As he ate but very little breakfast and had a hasty scanty lunch, he was at the very bottom of his physical resources at that time, and at the end of a rather demanding day's work. We had {159} to break up his other habits in the hope of getting at the craving. He had taken coffee and a roll for breakfast. I dictated a cereal, two eggs and several rashers of bacon and several rolls. I insisted on fifteen minutes in the open before lunch and then a hearty lunch with some substantial dessert at the end of it. This man proceeded to gain at the rate of a little more than three pounds a week. By the end of two months, he weighed about one hundred and eighty pounds and had not touched a drop of liquor in that time and felt that he had no craving for it. That is some ten years ago, and there has been no trouble with his alcoholic cravings since. He has maintained his weight; he says that he never felt so well and that above all he now has no more of that intense tiredness that used to come to him at the end of the day. Every now and then he says to me in musing mood,—"And to think that I had never learned to eat enough!"

For these very tired feelings so often complained of by nervous patients, once it has been decided that there is no organic trouble—for of course kidney or heart or blood pressure affections may readily cause them—there are just two things to be considered: These are {160} flat-foot or yielding arch, and undereating. When there is a combination of these two, then tiredness may well seem excessive and yet be readily amenable to treatment. Persons with occupations which require standing are especially liable to suffer in this way.

Undereating in the evening is especially important for many nervous people and is often the source of wakefulness. It is the cause of insomnia, not so much at the beginning of the night, as a rule, as in the early morning. Many a person who wakes at four or five and cannot go to sleep again is hungry. There is a sense of gone-ness in the stomach region in these cases, which the patients are prone to attribute to their nerves in general, or some of them who have had unfortunate suggestions from their physicians may talk of their abdominal brain; but it is surprising how often their feelings are due simply to emptiness. Any thin person particularly who has his last meal before seven and does not go to bed until after eleven should always take something to eat before retiring. A glass of milk or a cup of cocoa and some crackers or a piece of simple cake may be sufficient, but it is important to eat enough. Animals and men naturally get sleepy after eating and do not sleep well if their {161} stomachs are empty. Children are the typical examples. We are all only children of a larger growth in this regard.

When the last meal is taken before seven and people do not go to bed until nearly twelve, as is frequently the case in large cities, the custom of having something to eat just before bed is excellent for sleep. I have known the establishment of this habit to afford marked relief in cases of insomnia that had extended over years. The people in my experience who sleep the worst are those who, having taken a little cambric tea and some toast and preserves with perhaps a piece of cake for supper, think that this virtuous self-control in eating ought to assure them good rest. It has just the opposite effect. Disturbed sleep, full of dreams and waking moments, is oftener due to insufficient eating than to overeating. The people whom I know who sleep the best and from whom there are no complaints of insomnia, are those who, having eaten so heartily at dinner that they get to the theater a little late, attend the Follies or some late show for a while and then go round to one of the Broadway restaurants and chase a Welsh rarebit or some lobster a la Newburg, with a biscuit Tortoni or a Pêche Melba down {162} to their stomachs and then go home to sleep the sleep of the just.

Just as there are bad habits of eating too little that are dangerous and must be corrected by the will so there are bad habits of eating too much that can only be corrected in the same way. While it is dangerous to be under weight in the early years of life, it is at least as dangerous to be overweight in middle life. With the variety and abundance of food now supplied at a great many tables, it is comparatively easy for people in our time to eat too much. The result is that among the better-to-do classes a great many people suffer from obesity, sometimes to such an extent that life is made a burden to them. There is only one way to correct this and that is to eat less and of course to exercise more. Reduction in diet means the breaking of a long established habit and that of course is often hard. The whole family may have to set a good example of abstinence from too great a variety of food and especially from the richer foods, in order that a parent may be helped to prevent further development of obesity and to lose gently and gradually some of the overweight that is being put on, and which now, by conserving heat and slowing up metabolism {163} generally within the body, makes it so easy for even reduced quantities of food to maintain the former habit of adding weight.

In this matter of obesity, however, just exactly as in the case of tuberculosis for those who are underweight, prevention is much better than cure. The people who know that they inherit such tendencies should be particularly careful not to form habits of eating that will add considerably to their weight. After all, it is not nearly so difficult a matter as is often imagined. There is no need, unless in very exceptional cases, of denying one's self anything that is liked in the ordinary foods, only less of each article must be eaten. Even desserts need not be entirely eliminated, for ices may be taken instead of ice cream; sour fruits and especially those of the citrus variety—oranges and grapefruit—and the gelatine desserts may be eaten almost with impunity. The phrase "eat and grow thin" has deservedly become popular in recent years because as a matter of fact it is perfectly possible to eat heartily and above all to satisfaction without putting on weight. It is, of course, harder to lose weight, but even that may be accomplished gradually under proper direction if there is the persistent will to do it.

In recent years another disease has come to attract attention which represents the result of an overindulgence in food materials that can be limited without much difficulty. This is diabetes which used to be comparatively rare but has now become rather frequent. An authority on the disease declared not long since that there are over half a million people in this country now who either have or will have diabetes as the result of the breaking down of their sugar metabolism. It is not surprising that the disease should be on the increase, for the consumption of sugar has multiplied to a very serious degree during the last few generations. A couple of centuries ago, those who wanted sugar went not to the grocery store, but to the apothecary shop. It was kept as a flavoring material for children's food, as a welcome addition to the dietary of invalids and the old, and quite literally as a drug, for it was considered to have, as it actually has, to a slight extent at least, some diuretic qualities that made it valuable. A little more than a century ago, a thousand tons of sugar sufficed for the whole world's needs, while the year before the war, the world consumed some twenty-two million of tons of sugar. It is said that every man, woman, and {165} child in the United States consumed on the average every day a quarter of a pound of sugar.

Our candy stores have multiplied, and while two generations ago the little candy stores sold candies practically entirely for children, eking out their trade with stationery and newspapers and school supplies, now candy stores dealing exclusively in confectionery are very common. There are several hundred stores in the United States that pay more than $25,000 a year rent, though they sell nothing but candy and ice-cream sodas. Corresponding with the increase in the sale of candy has come also the consumption of very sweet materials of various kinds. French pastries, Vienna tarts, Oriental sweetmeats, Turkish fig paste, Arabian date conserves, and West Indian guava jelly, are all familiar products on our tables. Chocolate has become one of the important articles of world commerce, though almost unknown beyond a very narrow circle a little more than a century ago. Tea and coffee have been introduced from the near and the far East and by a Western abuse consumed with such an amount of sweetening as make them the medium of an immense consumption of sugar.

There is no doubt that unless good habits {166} of self-denial in this regard are formed, diabetes, which is an extremely serious disease, especially for those under middle life, will continue to increase in frequency. The candy and sugar habit is rather easy to form; every one realizes that it is a habit, but it is sometimes almost as hard to break as the tobacco habit. We were meant to get our sugar by the personal manufacture of it from starch substances. If a crust of bread is chewed vigorously until it swallows itself, that is, dissolves in the secretions and gradually disappears, it will be noted that there is a distinctly sweetish taste in the mouth. This is the starch of the bread being changed into sugar. We were expected by nature to make our own sugar in this way, but this has proved too slow and laborious a way for human nature to get all the sugar it cared for, so most people prefer to secure it ready made. Sugar is almost as artificial a product as alcohol and is actually capable of doing almost as much harm as its not distantly related chemical neighbor. It is rather important that good habits in the matter should be formed and we have been letting ourselves drift into very unfortunate habits in recent years.

CHAPTER XI

THE PLACE OF THE WILL IN TUBERCULOSIS

Probably the very best illustration in the whole range of medicine of the place of the will in the cure of disease is afforded by tuberculosis. This used to be the most fatal of all human affections until displaced from its "bad eminence" within the last few years by pneumonia, which now carries off more victims. As it is, however, about one in nine or perhaps a few more of all those who die are victims of tuberculosis. This high mortality would seem to indicate that the disease must be very little amenable to the influence of the will, since surely under ordinary circumstances a good many people might be expected to have the desire and the will to resist the affection if that were possible. In spite of the large death rate this is exactly what is true.

Tuberculous infections are extremely common, much commoner even than their high mortality reveals. After long and critical discussion with a number of persistent denials, it is now generally conceded by authorities in the disease that the old maxim "after all, all of us are a little tuberculous" is substantially correct. Very few human beings entirely escape infection from the tubercle bacillus at some time in life. The great majority of us never become aware of the presence of the disease and succeed in conquering it, though the traces of it may be found subsequently in our bodies. Careful autopsies reveal, however, that very few even of those who did not die directly from tuberculosis fail to show tuberculous lesions, usually healed and well shut off from the healthy tissues, in their bodies. One in eight of those who become infected have not the resistive vitality to throw off the disease or the courage to face it and take such precautions as will prevent its advance. All those, however, who give themselves any reasonable chance for the development of resistance survive the disease though they remain always liable to attack from it subsequently if they should run down in health and strength.

Heredity, which used to be supposed to play so important a rôle in the affection, is now known to have almost nothing to do with the spread of the disease. Family tendencies are probably represented by nothing more than a proneness to underweight which makes one more liable to infection, and this is due as a rule to family habits in the matter of undernourishment from ill-advised consumption of food. Probably a certain lack of courage to face the disease boldly and do what is necessary to develop bodily resistance against it may also be an hereditary family trait, but environment means ever so much more than heredity.

There is a well known expression current among those who have had most experience in the treatment of patients suffering from tuberculosis that "tuberculosis takes only the quitters", that is to say that only those succumb to consumption who have not the strength of will to face the issue bravely and without discouragement to push through with the measures necessary for the treatment of their disease. In a word it is only those who lack the firmness of purpose to persist in the mode of life outlined for them who eventually die from their affection of the {170} lungs. No specific remedy has been found that gives any promise of being helpful, much less of affording assured recovery, though a great many have been tried and not a few are still in hopeful use. Recent experience has only served to emphasize the fact that the one thing absolutely indispensable for any successful treatment of tuberculosis of the lungs is that the patient should regain weight and strength and with them resistive vitality so as to be able to overcome the disease and get better.

To secure this favorable result two conditions of living are necessary but they must be above all persisted in for a considerable period. First there must be an abundance of fresh air with rest during the advancing stage or whenever there are acute symptoms present, and secondly an abundance of good food which will provide a store of nutritive energy and make the resistive vitality as high as possible. Curiously enough this "fresh air and good food" treatment for the disease was recognized as the sheet anchor of the therapeutics of consumption as long ago as Galen's time, the end of the second century, when that distinguished Greek physician was practising at Rome. Nearly eighteen hundred {171} years ago Galen suggested that he had tried many remedies for what he called phthisis, the Greek equivalent of our word consumption or wasting away, and had often thought that he had noted a remedial value in them, but after further experience he felt that the all-important factors for cure were fresh air and good food. He even went so far as to say that he thought the best food of the consumptive or the phthisical, as he called them, was milk and eggs. A great deal of water has flowed under the bridge of medical advance since his time and at many periods since physicians have been sure that they had valuable remedies for consumption; yet here we are practically back at Galen's conclusion more than fifty generations after his time, and we are even inclined to think of this mode of treatment as comparatively new, as it is in modern history.

The influence on consumption of the will to get well when once aroused was typically exemplified in the career of the well-known London quack of the beginning of the nineteenth century, St. John Long. He set himself up as having a sure cure for consumption. He was a charlatan of the deepest dye whose one idea was to make money, and who knew {172} nothing at all about medicine in any way. He took a large house in Harley Street and fitted it up for the reception of people anxious to consult him. For some seasons every morning and afternoon the public way was blocked up with carriages pressing to his door. Nine out of ten of his patients were ladies and many of them were of the highest rank; fashion and wealth hastened to place themselves and their daughters at the mercy of the pretender's ignorance. His mode of treatment was by inhalation. He assured his patients that the breathing in of this medicated vapor would surely cure their pulmonary disease, and because others were intent on going they went; many of them were greatly benefited for a time and these so-called cures proved a bait for many other patients.

J. Cordy Jeaffreson in his volume "A Book about Doctors", written two generations ago, has told the story of St. John Long's successful application of the principle of community of treatment and its effectiveness upon his patient. Like Mesmer he realized that treating people in groups led them mutually to influence each other and to bring about improvement. St. John Long {173} had in one of the rooms in Harley Street "two enormous inhalers, with flexible tubes running outward in all directions and surrounded by dozens of excited women— ladies of advanced years and young girls giddy with the excitement of their first London season—puffing from their lips the medicated vapor or waiting until a mouthpiece should be at liberty for their pink lips." In our generation of course we had various phases of similar treatment, including nebulizers and compressed air apparatus and medicated vapor, all working wonders for a while, and then proving to have no physical beneficial effect.

What is surprising is to find the number of cures that were worked. St. John Long had so many applicants for attention that he was literally unable to give heed to all of them. The news of the wonderful remedy flew to every part of the United Kingdom and from every quarter sick persons, wearied of a vain search after an alleviation of their sufferings, flocked to London with hope renewed once more. This enabled St. John Long to select for treatment only such cases as gave ready promise of cure. He made it a great preliminary of his treatment that his {174} patients should eat well as a rule and on one occasion when he was called into the country to see a man suffering in the last stages of consumption he said quite frankly, "Sir, you are so ill that I cannot take you under my charge at present. You want stamina. Take hearty meals of beefsteak and strong beer; and if you are better in ten days I will do my best for you and cure you."

It is easy to understand that if he made it a rule for his consumptive patients that they should eat well or not expect relief from his medicine he would secure a great many good results. Especially would this be true in many cases that came up to him from the country, had the advantage of a change of climate, and of environment and very soon found that they had much more strength than they thought they had. They had been dreading the worst, they were now led to hope for the best; they took the brake off their will, they fed well and it was not long then before they proceeded to get well.

As even a little experience with consumptive patients shows it is often difficult for them to follow directions—and keep it up—in the matter of fresh air and good food and here is where the question of the will in the {175} treatment is all important. Many a consumptive has in early life formed bad habits with regard to eating, especially in the direction of eating too little and refusing for some reason or other to take what are known to be the especially nutritious foods. Not infrequently indeed it is their neglect of nutrition in this regard that has been the principal predisposing factor toward the development of the disease. This bad habit must be overcome and often proves refractory.

Then it is never easy to give up the pursuit of a chosen vocation and pursue faithfully for a suitable period the humdrum monotonous existence of prolonged rest every day in the open air with eating and sleeping as almost the only serious interests, if indeed they can be called such, permitted in life. It is only those who have the will power to follow directions faithfully, whole-heartedly and persistently who have a reasonable prospect of getting ahead of their disease and eventually securing such a conquest of it as will enable them to return to their ordinary life as it was before the development of tuberculosis.

Unless patients are ready to follow directions as regards outdoor air and good food the {176} cure, or as specialists in tuberculosis prefer to call it the arrest of symptoms in the disease, is almost out of the question. Above all it is extremely important that those who suffer from pulmonary tuberculosis should be ready to follow directions at an early stage of their disease, before any serious symptoms develop, for it is then that most can be done for them. Many a sufferer from tuberculosis makes his or her cure extremely difficult, certainly ever so much more difficult than it would otherwise have been, because the dread of going to see a physician—lest they should be told that their affection is really consumption and demands immediate strenuous treatment—causes them to put off consultation with some one whose opinion in the matter is reliable.

This is indeed one of the principal reasons why tuberculosis of the lungs still continues to carry off so many victims every year,— because people are afraid to learn the truth. They dare not put the question to a definite issue and refuse to believe the possibility that certain disturbing symptoms represent developing tuberculosis. They defer seeing an expert; they take this and that suggestion from friends; they buy cough remedies which {177} they see advertised, sometimes they tinker with so-called "consumption cures." After a while an advance of their symptoms makes it absolutely necessary to see a physician but often by this time their disease has progressed from an incipient case rather easy to be treated and with an excellent prognosis to a more advanced stage at which cure is ever so much more difficult; or by this time it may even prove that their strength has been seriously sapped and they have not enough resistive vitality left to bring about reaction toward the cure.

The all-important thing for all those who have at any time lived near consumptives, whether relatives or others—for the disease is almost invariably acquired and not hereditary—or who have worked for any prolonged period in more or less intimate contact with those who had a chronic cough or who subsequently developed tuberculosis, is that on the first symptom that is at all suspicious they should make up their minds to have the question as to whether they have tuberculosis or not definitely settled and that they should be ready to do what they are told in the matter. The first symptom is not a persistent cough as so many think, nor continued loss of {178} weight, which is an advanced sign as a rule, but a continued rapidity of pulse for which no non-pulmonary reason can be found.

The old idea that consumptives should not be told what their affection was, lest it should disturb their minds and discourage them so much as to do them harm, has now been abandoned by practically all those of large experience in the care of the tuberculous. The opposite policy of being perfectly candid and making the patients understand their serious condition and the importance of taking all the measures necessary for cure, yet without permitting them to be unnecessarily scared, has been adopted. Their will to get well must be thoroughly aroused. After all, it must be recalled that tuberculosis is an extremely curable disease. It is now definitely known that more than ninety per cent. of humanity have at some time had a tuberculosis process, that is to say a focus of tuberculosis active within their tissues. Only about one in nine of the deaths in civilized countries is from tuberculosis. That means that at least eight other people who have not died from the disease but from something else have had the affection, yet have recovered from it. Instead of the old shadow of {179} heredity with its supposedly almost inevitable fatality, so that young people who saw their brothers and sisters or other relatives around them die from the disease felt that they were doomed, we now know that the hereditary factor plays an extremely minor role if indeed it plays any serious rôle at all in the development of the disease.

No affection is so amenable to the state of mind and the will to be well as tuberculosis. That is exactly the reason why so many remedies have come into vogue and apparently been very successful in its treatment and then after a while have proved to be of no particular service or even perhaps actually harmful so far as their physical effect is concerned. It cannot be too often repeated that anything whatever that a patient takes that will arouse new hope and give new courage and reawaken the will will actually benefit these patients. No wonder then that scarcely a year passes without some new remedy for tuberculosis being proposed. All that is needed to affect favorably patients suffering from the disease is to have some good reason presented which makes them feel that they ought to get better and then at once they eat better and proceed to increase {180} their resistive vitality. The despondency that comes with the lack of the will to be well hurts their appetite particularly and no tuberculosis patient can ever hope to recover health unless he is eating heartily. With better eating there is always a temptation to be more outdoors and the ability to stand cooler air which always means that the lungs are given their opportunity to breathe fresh cool air which constitutes absolutely the best tonic that we have for the affection.

It has been recognized in recent years that the only climates which give reasonable hope of being helpful for the tuberculous are those which present a variation of some thirty degrees in their temperature every day. Whenever this is the case chilly feelings are always produced in those who are exposed to the change, even though the lower temperature curve may not go down to anywhere near freezing. If for instance the temperature at the hottest hour of the day, say three o'clock in the afternoon, is 90° F. and that of the later evening or middle of the night is 60° F., chilly feelings will be produced. Just the same thing is true if the temperature is between 30° F. and 40° F. shortly after the middle of the day and then goes down to {181} near zero at night. These chilly feelings are uncomfortable, but they produce an excellent reaction in the circulation and set the blood coursing from the heart to the tissues better than any medicine that we have. In the midst of this the lungs have their resistive vitality raised so as to throw off the disease.

This is probably one of the principal reasons why mountain climates have been found so much more helpful for the treatment of tuberculosis than regions of lower elevations. Whenever the elevation is more than fifteen hundred feet there will almost invariably be a variation of thirty degrees between the day and the night temperature. There are of course still greater variations, even sixty or seventy degrees sometimes where the altitudes are very high, but this is often too great for the tuberculous patients to react properly to, in their rundown conditions. Besides, the air is much rarer at the higher elevations, breathing is more difficult, because the lungs have to breathe more rapidly and more deeply in order to secure the amount of oxygen that is needed for bodily necessities from the rarified air. The middle elevations then, between fifteen hundred and twenty-five {182} hundred feet, have been found the best for tuberculosis patients, and they are very pleasant during the summer time, though never without the chilly discomfort of the drop in temperature. During the fall and winter, however, many patients become tired out trying to react to these variations of temperature and want to seek other climates where they will not have to submit to the discomfort and the chilly feelings. If they come down to more comfortable quarters before their tuberculosis has been brought to a standstill by the increase of their resistive vitality, it is very probable that they will lose most of the benefit that they derived from their mountain experience. Here is where the will comes in. Those who have the will to do it and the persistence to stick at it and the character that keeps them in good humor in spite of the discouraging circumstances which almost inevitably develop from time to time, will almost without exception recover from their tuberculosis with comparatively little difficulty, if they have only taken up the treatment before the disease is so far advanced as to be beyond cure.

In the older days consumptives used to be sent to the Riviera and to Algiers and to {183} other places where the climate was comparatively equable, with the idea that if they could only avoid the chilly feelings consequent upon variations of temperature it would be better for them. Many of the disturbing symptoms of tuberculosis are rendered less troublesome in such a climate, but the disease itself is likely to remain quiescent at best or perhaps even to get insidiously worse, as tuberculosis is so prone to do. These milder climates require much less exercise of the will, but that very fact leaves them without the all-important therapeutic quality which the lower altitudes possess.

For many people the outdoor life and the sight of nature in the variations produced in scenery during the course of the days and the seasons are satisfying enough to be helpful in making their cure of tuberculosis easy. They are extremely fortunate if they have this strong factor in their favor. It is very probable that we owe the discovery of the value of the Adirondacks and other such medium altitudes in the treatment of tuberculosis to the fact that Doctor Trudeau liked the outdoors so much and was indeed so charmed with the Adirondack region that when death from tuberculosis seemed {184} inevitable, he preferred the Saranac region as a place to die in, in spite of the hardships and the bitter cold from which at that time there was so little adequate protection, to the comforts of the city. He scarcely hoped for the miracle of cure from a disease which he as a doctor knew had carried off so many people, but if he were to die he felt that he would rather die in the face of nature with his beloved mountains all around him than in the shut-in spaces of the city.

His resolution to go to the Adirondacks seemed to many of those who heard of it scarcely more than the caprice of a man whom death had marked for itself. His physicians surely had no hope of his journey benefiting him but they felt very probably that in the conditions he might be allowed to have this last desire since there were so few other desires of life that he was likely to have fulfilled. His will to live outdoors in spite of the bitter cold of that first winter undoubtedly saved his life and then he evolved the system of outdoor treatment which has in the past fifty years saved so many lives and is now the recognized treatment for the disease. It is easy to understand, however, how much of firm determination was required {185} on his part forty years ago, when there were no comfortable ways of getting into the Adirondacks, when the last stage of the journey had to be made for forty miles on a mattress in a rough wagon, when water for washing had to be secured by breaking the ice in the pitcher or on the lake and when the bitter climate must have been the source of almost poignant torture to a man constantly running a slight temperature. He had the courage and the will power to do it and the result was not only his own survival but a great benefit secured for others.

Unfortunately many a consumptive patient who during his first period of treatment keeps to the letter the regulations for outdoor air and abundant food fails to do so if it is necessary to come back a second time. Persistency is here a jewel indeed and only the persistent win out. Many an arrested case fails to keep the rules of living that may be necessary for years afterwards and runs upon relapse. The will to do what is necessary is all-important. Trudeau himself, after securing the arrest of his disease in the Adirondacks, though he lived and worked successfully to almost seventy years of age, found it quite impossible to live out of them {186} and often had to hurry back from even comparatively brief visits to the lowlands. Besides, every now and then during some forty years he had the will power to take his own prescription of outdoor air and absolute rest. It was the faculty to do this that gave him length of life far beyond the average of humanity and the power to accomplish so much in spite of the invasion of the disease which had rendered large parts of both lungs inoperative. Not only did he live on, however, but he succeeded in doing so much valuable work that few men in the medical profession of America have stamped their name deeper on modern medical science than this consumptive who had constantly to use his will to keep himself from letting go.