Health Through Will Power

CHAPTER XII

THE WILL IN PNEUMONIA

What is true of tuberculosis and the influence of the will has proved to be still more true, if possible, of pneumonia. Clinical experience with the disease in recent years has not brought to us any remedy that is of special value, nor least of all of specific significance, but it has enabled us to understand how individual must be the treatment of patients suffering from pneumonia. We have recognized above all that mentally disturbing factors which lessen the patient's courage and will to live may prove extremely serious. We hesitate about letting an older person suffering from pneumonia learn any bad news and particularly any announcement of the death of a near relative, above all, a husband or wife. The shock and depression consequent upon any such announcement may {188} prove serious or even fatal. The heart needs all its power to accomplish its difficult task of forcing blood through the limited space left free in the unaffected lung tissue, and anything which lessens that, that is anything which disheartens the patient, to use our expressive English phrase, must be avoided as far as possible.

When a man of fifty or beyond, one or more of whose friends has died of pneumonia about his age, comes down with the disease and learns, as he often will in spite of the best directed effort to the contrary, that he is suffering from the affection, if he is seriously disturbed by the knowledge, we realize that it bodes ill for the course of the disease. If a pneumonia patient, especially beyond middle life, early in the case expresses the thought that perhaps this may be the end and clings at all insistently to that idea, the physician is almost sure to feel little confidence of pulling him through the illness. In probably no disease is it more important that the patient's courage should be kept up and that his will should help rather than hamper.

Courage is above all necessary in pneumonia because the organs that are most affected and have most to do with his recovery are so much {189} under the control of the emotions. Any emotional disturbance will cause the heart to be affected to some extent and the respiration to be altered in some way. When a pneumonia patient has to lie for days watching his respirations at forty to the minute, though probably he has never noticed them before, and feels how his heart is laboring, no wonder that he gets scared, and yet his scare is the very worst thing that can happen to him. It will further disturb both his heart and his respiration and leave him with less energy to overcome the affection. He may be tempted to make conscious efforts to help his lungs in their work, though any such attempt will almost surely do more harm than good. He must just face the inevitable for some five to nine days, hope for the best all the time and keep up his courage so as not to disturb his heart. After middle life only the patients who are capable of doing that will survive the trial that pneumonia gives. The super-abounding energy of the young man will carry him through it much better; and besides, the young man usually has much less solicitude as to the future and much less depending on his recovery.

A generation ago or even less, whiskey or {190} brandy or some form of strong, alcoholic stimulant, as it was called, was looked upon as the sheet anchor in pneumonia. For a generation or more at that time, the same remedy had been looked upon by a great many physicians as an extremely precious resource in the treatment of tuberculosis. The therapeutic theory behind the practice was that in affections of the lungs a particular strain was placed upon the heart and therefore this organ needed to be stimulated just as far as could be done with safety. As alcohol increases the rapidity of the heart beat, it was considered to be surely a stimulant and came to be looked upon as the safest of heart stimulants, because, except when used over very long periods, direct bad effects had not been noticed. In pneumonia, above all, the heart needed to be stimulated because it had to pump blood through the portion of the lungs unaffected by the pneumonia, usually congested and offering special hindrances to the circulation; besides, a much larger amount of blood than usual had to be pumped through these portions of the lungs in order to compensate for the solidified portions.

A number of very experienced physicians came to be quite sure that alcoholic stimulants {191} were the most valuable remedy that we had for this special purpose of cardiac stimulation; some of them went so far as to say, with a well known New York clinician, that if they were to be offered all the drugs of the pharmacopeia without alcoholic stimulant for the treatment of pneumonia on the one hand, or whiskey or brandy on the other without all the pharmacals, they would prefer to take the alcohol, confident that it would save more patients for them. They were quite sure that they had made observations which justified them in this conclusion.

We know at the present time that alcohol is not a stimulant but always a narcotic. It increases the rapidity of the heart beat, though not by direct stimulation, but by disturbing the inhibitory nerve apparatus of the heart and thus permitting the heart to beat faster. Just as there is a governor on a steam engine, to keep it from going too fast and regulate its speed to a definite range, so there is a similar governing apparatus or mechanism in connection with the heart. It is by affecting this that alcohol makes the heart go faster. Blood pressure is not raised, but on the contrary lowered, and the effect of alcohol is depression and not stimulation. {192} In spite of this, good observers seemed to note favorable effects from the use of alcohol in both pneumonia and tuberculosis. This appears to be a paradox until one analyzes the psychic effects of alcohol and places them alongside the physical, in order to determine the ultimate equation of the influence of the substance.

Alcohol has a very definite tendency to produce a state of euphoria, that is, of well-being. The patient's mind is brought to where it dismisses solicitude with regard to himself. This neutralizes directly the anxiety which so often acts as a definite brake upon resistive vitality. The alcoholic stimulant, in so far as it has any physical effect, probably does a little harm, but its influence on the mind of the patient not only serves to neutralize this, but adds distinctly to the patient's prospects of recovery. Without it, the dread which comes over him paralyzes to some extent at least his heart activity and interferes with lung action. Under the influence of alcohol, he gains courage—artificial, it is true—but still enough to put heart in him, and this is the stimulation that the older clinical observers noted. The patient can, with the scare lifted, use his will to be well {193} ever so much more effectively and psychic factors are neutralized that were hampering his resistive vitality.

This illustrates very well indeed the place of dilute alcohol in some of the usual forms in therapeutics about the middle of the nineteenth century. Practically all the textbooks of medicine at that time recommended alcohol for many of the continued fevers. In sepsis, in child-bed fever, in typhoid, in typhus, as well as in tuberculosis and pneumonia and other less common affections, whiskey or brandy was recommended highly and usually given in considerable quantities. All of these affections are likely to be accompanied by considerable anxiety and solicitude with a series of recurring dreads that sadly interfere with nature's efforts toward recovery. Under certain circumstances, the scare, to use the plain, simple word, was sufficient to turn the scale against the patient. The giving of whiskey at least lifted the scare [Footnote 5] {194} and enabled the patient to use his vital resources to best advantage.

[Footnote 5: The use of whiskey for snake-bite probably has no other significance than this lifting of the scare. It used to be said that the alcoholic stimulation neutralized the depressant effect of snake poisoning on the heart. Now we know that this is not true, and in addition, we know of no effect that alcohol in the system might have in neutralizing the presence of the toxic albumin which constitutes the danger in snake poisoning. It is only rarely that the bite of a rattlesnake will be fatal. Experts declare that the snake must be a large one, its sting must be inflicted on the bare skin, it must not have stung any one so as to empty its poison glands for more than twenty-four hours, and the full dose of the poison must be injected beneath the skin for the bite to be fatal. Very rarely are all these conditions fulfilled. When a person is bitten by a snake, however, the terror which ensues is quite sufficient of itself to hurt the patient seriously and he may scare himself to death, though the snake poison would not have killed him. The whiskey lifts the scare and gives nature a chance to neutralize the poison which she can usually do successfully.]

It is extremely important, then, first to be sure that the patient's will to be well is not hampered by unfortunate psychic factors and secondly, that his courage shall be stimulated to the greatest possible degree. Fresh air is the most important adjuvant for this that we have. The outdoor air gives a man the courage to dissipate dreads and makes him feel that he can accomplish what seemed impossible before. Undoubtedly this is one of the favorable effects of the fresh-air treatment of pneumonia, for it makes people mentally ever so much less morbid. The patient's surroundings must be made as encouraging as possible and there must be no signs of anxious solicitude, no long faces, no weeping, and as far as possible, no disturbance about business affairs that might make him think that a fatal termination was {195} feared. His will to get well must be fostered in every possible way and obstacles removed. This is why it has been so well said in recent years that good nursing is the most important part of the treatment of pneumonia. This does not mean that a good nurse can replace a physician, but that both must coordinate their efforts to making the patient just as comfortable as possible, so that he will feel assured that everything that should be, is being done for him, and that it is only a question of being somewhat uncomfortable for a few days and he will surely get well.

Sunny rooms, smiling faces, flowers at his bedside, cheerful greetings, all these, by adding to the patient's euphoria, bolster up his will and make him feel that after all, thousands of people have suffered from pneumonia and recovered from it, and there is no reason why he should not, provided that he will not interfere with his own recovery.

CHAPTER XIII

COUGHS AND COLDS

It might seem as though the will had nothing to do with such very material ailments as coughs and colds, and yet the more one knows about them, the clearer it becomes that their symptoms can be lessened, their duration shortened, their tendencies to complications modified, and to some extent at least, they can be almost literally thrown off by the will to be well. The idea of a little more than a generation ago that coughs and colds would be most benefited by confinement to the house and as far as possible to a room of an absolutely equable temperature has gradually given way before the success of the open-air treatment for tuberculosis and the meaning of fresh air in the management of pneumonia cases. Fresh, cold air is always beneficial to the lungs, no matter what the conditions present in them, though it requires {197} no little courage and will power to face the practical application of that conclusion in many cases. When it is bravely faced, however, the results are most satisfactory, and the respiratory condition, if amenable to therapeutics, is relieved or proceeds to get better. Of course it is well understood that any and every patient who has a rise in temperature, that is whose temperature is above 100° F. in the later afternoon hours, should be in bed. Under no circumstances must a person with any degree of fever move around. This does not mean, however, that such patients should not be subjected to fresh, cold air. The windows in their room or the ward in which they are treated should be open, and if the condition is at all prolonged, arrangements should be made for wheeling their beds out on the balcony or placing them close to a window. The cold air gives them distinctly chilly feelings and sometimes they complain of this, but they must be asked to stand it. Of course if the cold disturbs their circulation, if the feet and hands get cold and the lips blue, the patients are not capable of properly reacting against the cold and must not be subjected to it. Their subjective feelings of chilliness, however, must {198} not be sufficient to keep them from the ordeal of cold, fresh air; on the contrary, they must be told of the benefit they will receive from it and asked to exert their wills to stand the discomfort with just as little disturbance as possible.

People suffering from coughs, no matter how severe, should get out into the air regularly, if they have no fever, and should go on with their regular occupation unless that occupation is very confining or is necessarily conducted in dusty air. Keeping to the house only prolongs the affection and makes it much more liable to complications than would otherwise be the case. Sufferers from these affections should not go into crowds, should avoid the theaters and crowded cars, partly for the sake of others—because they can readily convey their affection to them—but also for their own sake, because they are more susceptible to other forms of bacteria than those already implanted in their own systems and they are much more liable to pick up foreign bacteria in crowds than anywhere else. They should be out in the open air, particularly in the sunlight, and this will do more to shorten the course of a cough and cold than anything else.

They need more sleep than before and should be in bed at least ten or eleven hours in the day, though if they should not sleep during all of that time, they need not feel disturbed but may read or knit or do something else that will occupy them while they retain a recumbent position. They should not indulge in long, tiresome walks and in special exertion, but should postpone these until the cough has given definite signs of beginning to remit.

With regard to the cough itself, it must not be forgotten that the action of coughing is for the special purpose of removing material that needs to be cleared from the lungs and the throat and larynx. It should not be indulged in except for that purpose. It requires a special effort, and while the lungs and other respiratory passages are the subject of a cold, these extra efforts should not be demanded of them unless they are absolutely necessary. Almost needless to say, people indulge in a great deal of unnecessary coughing. Some of this is a sort of habit and some of it is due to that tendency to imitate, so common in mankind. Every one has surely heard during religious services, in a pause just after heads have been bowed in prayer or for a {200} benediction, a single cough from a distant part of the church which seemed to be almost the signal for a whole battery of coughs that followed immediately from every portion of the edifice. If some one begins coughing during a sermon or discourse, others will almost inevitably follow. Coughing, like yawning, is very liable to imitation.

The famous rule of an old-time German physician was that no one was justified in coughing or scratching the head unless these activities were productive. Unless you get something as the result of the coughing, it should not be indulged in. There are a great many people who cough much more than necessary and who delay the progress of their betterment in that way. Whenever material is present to be coughed up, coughing is not only proper but almost indispensable. It is the imitative cough, the coughs which indicate overconsciousness of one's affection, the coughs that so often almost unconsciously are meant to catch the sympathy of those around, which must be repressed by the will, and when the patient finds that he really has to cough less than he thinks, he will be quite sure that he is getting better and will actually improve as a consequence of this feeling.

Coughs need an abundance of fluid much more than medicine, and warm fluids are better than cold; the will must be exercised so as to secure the taking of these regularly. At least a quart of warm liquid, milk if one is not already overweight, should be taken between meals during the existence of a cough. Hot milk taken at night will very often secure much better rest with ever so much less coughing than would otherwise be the case. The tendency to take cough remedies which lessen the cough by their narcotic effect always does harm. Coughing is a necessary evil in connection with coughs, and whatever suppression there is should be accomplished by means of the will. Remedies that lessen the coughing also lock up the secretions and disturb the system generally and therefore prolong the affection and do the patient harm. Most of the remedies that are supposed to choke off a cough have the same effect. Quinine and whiskey have been very popular in this regard but always do harm rather than good. Their use is a relic of the time when whiskey was employed for almost every form of continued fever and when quinine was supposed to be good for every febrile affection. We know now that quinine has no effect {202} except upon malarial fevers, and then only by killing the malarial organism, and that whiskey is a narcotic and not a stimulant and does harm rather than good. Those who did not take the familiar Q. and W. have in recent years had the habit of administering to themselves or to their friends various laxative or anodyne or antiphlogistic remedies that are supposed to abort a cough or cold and above all, prevent complications. All of these remedies do harm. Every single one of them, even if it makes the patient a little more comfortable for the time, produces a condition that prevents the system from throwing off the infection which the cold represents as well and as promptly as it otherwise would.

It requires a good deal of will power to keep from taking the many remedies which friends and sometimes relatives insist on offering us whenever a cold is developing, but the thing to do is to summon the will power and bravely refuse them. Medicine knows no remedies that will abort a cold. The use of brisk purgatives, sometimes to an extent which weakens the patient very much the next day, is simply a relic of the time when every patient was treated with antimony {203} or calomel and free purgation was supposed to be almost as much of a cure-all as blood-letting. There is no reason in the world to think that the emptying of food out of the bowels will do any particular good, unless there is some definite indication that the food material present there should be removed because it is producing some deleterious effect.

The longer a physician is in the practice of medicine the less he tries to abort infectious diseases, and coughs and colds are, of course, just infections. They must run their course, and the one thing essential is to put the patient in as good condition as possible so that his resistive vitality will enable him to throw off the infection as quickly as possible. It requires a good deal of exercise of will power on the part of the physician to keep from running after the many will-o'-the-wisps of treatment that are supposed to be so effective in shortening the course of disease, but any physician who looks back at the end of twenty years will know that his patients have reason to be thankful to him just in proportion as he has avoided running after the fads and fancies of current medicine and conservatively tried to treat his patients rather than cure their diseases. The patient is ever so much {204} more important than his disease, no matter what the disease may be.

Above all, for the cure and prevention of coughs and colds people must not be afraid of cold, fresh air. A good many seem to fear that any exposure to cold air while one has a cough may bring about pneumonia or some other serious complication. It must not be forgotten, however, that the pneumonia months in the year occur in the fall and the spring, October and November and March and April producing most deaths from the disease, and not December, January and February. The large city in this country which may be said to have the fewest deaths from pneumonia is Montreal, where the temperature during December and January is often almost continuously below zero for weeks at a time and where there is snow on the ground for three or four months in succession. The highest death rate from pneumonia is to be found in some of our southern cities which have rather mild winters and rather equable temperature,—that is, no considerable variation in the daily temperature range. Cold air is bracing and tonic for the lungs and enables them to resist the microbe of pneumonia, and it is now recognized {205} by physicians that personal immunity is a much more important factor in the prevention of the disease than anything else.

Coughs and colds and bronchitis and pneumonia, the respiratory diseases generally, are much less frequent in very cold climates than in variable regions. Arctic explorers are but rarely troubled by them, even though they may be exposed to extremely low temperatures for months. Men subjected to blizzards at thirty and forty degrees below zero may have fingers and toes frozen but do not have respiratory affections. Some years ago, it was noted that one of these Arctic expeditions had spent nearly two years within the Arctic Circle without suffering from bronchial or throat disease and within a month after their return in the spring most of them had had colds. Nansen and his men actually returned from the Arctic regions where they had been in excellent health during two severe winters to be confined to their beds with grippy colds within a week of their restoration to civilization, with its warm comfortable homes and that absolute absence of chill which is connected in so many people's minds with the thought of coughs and colds.

The principal reason why colds are so {206} frequent in the winter time in our cities and that pneumonia has increased so much is mainly because people are afraid of standing a little cold. Office buildings are now heated up to seventy degrees to make the personnel absolutely comfortable even on the coldest days, and as a consequence the air is so dry that it is more arid—that is more lacking in water vapor, as the United States Public Health Service pointed out—than Death Valley, Arizona, in summer. People dress too warmly, anticipating wintry days and often getting milder weather and thus making themselves susceptible to chilling because the skin is so warm that the blood is attracted to the surface. Will power to stand cold, even though at a little cost of discomfort, is the best preventive of coughs and colds and their complications and the best remedy for them, once the acute febrile stage has passed.

CHAPTER XIV

NEUROTIC ASTHMA AND THE WILL

In closing a clinical lecture on bronchial asthma at the University of Marburg some years ago, Professor Friedrich Müller, who afterwards became professor at Berlin, said, "Each asthmatic patient is a problem by himself and must be studied as such; meantime, it must not be forgotten what an important rôle suggestion plays in the treatment of the disease." This represents very probably the reason why so many remedies have been recommended for asthma and have proved very successful in the hands of their inventors or discoverers as regards the first certain number of patients who use them, and yet on subsequent investigation have turned out to be of no special therapeutic value and sometimes indeed to have no physical effect of any significance.

Of course this is said with regard to neurotic asthma only, and must not be applied too particularly to other forms of the affection, though there is no doubt at all that the symptoms of even the most severe cases of organic asthma can be very much modified and often very favorably, by suggestive methods.

The principal feature of asthma is a special form of severe difficulty in breathing. It is known now that the beginning of the affection is always as Strumpell said, "an extensive and quite rapid contraction of the smaller and smallest bronchial branches, that is the terminal twigs of the bronchial tubes." It is not so much air hunger, though there is, of course, an element of that because the lungs are not functioning properly, as an inability to empty the lungs of air already there and get more for respiratory purposes. The spasm in asthma has a tendency to hold the lungs too full of air and produce the feeling of their getting ever fuller and fuller. What the old sea captain said in the midst of his attack of asthma, when somebody sympathized with him because he had so much difficulty in getting his breath, was that he had lots of breath and would like to get rid of some of it. {209} He added, "If I ever get all this breath that's in me now out of me, I'll never draw another breath so long as I live, so help me." The respiration spasm is usually at full inspiration and the effort is mainly directed toward expiration and expulsion of air present using the accessory respiratory muscles for that purpose.

The picture of a man suffering from asthma is that of a patient so severely ill as to be very disturbing to one not accustomed to seeing it. It would be almost impossible for any one not used to the attacks to think that in an hour or two at the most the patient would be quite comfortable and if he is accustomed to the attacks, that he will be walking around the next day almost as if nothing had happened. All that the affection consists in is a spasm of the bronchioles and as soon as that lets up, the patient will be himself again. Some material may have accumulated during the time when the spasm was on which will still need to be disposed of, and there will be, of course, tiredness of muscles unaccustomed to be used in that special way, but that will be all.

We are still in the dark as to what causes the spasms but undoubtedly psychic factors {210} play an important etiological rôle. For a good many people, there is a distinct element of dread as the immediate cause of their asthmatic attacks. Some people have it only when they have gone through some disturbing neurotic experience. Occasionally it is the result of physical factors combined with some psychic element. Cat asthma is not very uncommon and occurs as a consequence of some contact by the individual with a specimen of the cat tribe though usually the large cats, the lions and tigers, do not cause it. There is nearly always, in those who are liable to this form of asthma, a special detestation of cats. There is probably some emanation from the animal which produces the asthmatic fever, just as is true also of horses in those cases where horse asthma occurs. In a few of these latter cases, however, it was noted that the horse asthma did not begin until after there had been some terrifying experience in connection with the horse, as a runaway, a collision, or something of that kind.

Any one who sees many asthmatic cases inevitably gets the impression after a time that their very dread of the attacks has not a little to do with predisposing them. {211} Occasionally the dread is associated with some other organic disturbance, either of heart or kidneys, or oftener still, with some solicitude with regard to these organs and the persuasion that there is something serious the matter with them, though there is at most only some functional disturbance. This is particularly true of cases of palpitation of the heart where there has been considerable dread of organic heart disease. In a certain number of these cases, there is some emphysema present, that is, overdistention of the lungs, such as is seen in high-chested people. Owing to the long anterio-posterior diameter of the chest and the fact that as a consequence it is nearly as thick through as it is wide, this form of chest is sometimes spoken of as barrel-chest. Patients who have it are particularly likely to suffer from asthma if they have any dread of heart trouble or if they are of a nervous constitution.

I have known people with the dread of the dark to get an attack of asthma if they were asked to sleep alone after having been accustomed for years to sleep with somebody in the room. I have known even a physician to have attacks of asthma of quite typical character as the result of a dread of being {212} out after dark which had gradually come over him. I have had a physician patient who was very uncomfortable if alone on the streets of New York, even during the day, and whose symptoms at their worst were distinctly dyspneic or asthmatic. He used to have to bring his wife with him whenever he came to see me for he lived out in one of the neighboring towns, because he was so afraid that he might get an asthmatic attack that would overcome him and he would feel helpless without some one to aid him.

In practically all these cases, the treatment of asthma becomes largely that of treating the accompanying dread. Once the acute symptoms of the attack itself manifest themselves, they have to be treated in any way that experience has shown will relieve the patient. The general condition, however, needs very often an awakening of the will to regulate the life, to get out into the air more than before, to avoid disturbing neurotic elements, and worrying conditions of various kinds. Thin people need to be made to gain in weight, using their will for that purpose; stout people who eat too much and take too little exercise need to have their lives {213} regulated in the opposite direction. In the meantime, anything that arouses the patient to believe firmly that his condition will be improved by some remedy or mode of treatment, will help him to make the intervals between attacks longer and the attacks themselves less disturbing. The will undoubtedly plays a distinct role in this matter which patients who have been through a series of asthmatic attacks recognize very clearly.

The many remedies for asthma which have been lauded highly even by physicians, and that have cured or relieved a great many patients and yet after a while have proved to be without much beneficial effect, make it very clear how much the affection depends on the will power to face it and throw it off. Nothing will be curative in asthma unless the patient has confidence in his power and uses his own will energy to help it. He must overcome the element of dread which occurs in connection with all asthmatic attacks, even those due to organic disease of heart or kidneys. No matter how frequent the attacks have been, there is always an element of fright that enters into an affection which interferes with the respiration. This must {214} be overcome by psychic means to help out the physical remedies that are employed. Sometimes the psychic remedies will succeed of themselves where more material means have failed completely.

CHAPTER XV

THE WILL IN INTESTINAL FUNCTION

During the past generation, the appreciation of the relative part played by the stomach and intestines in digestion has completely changed. Our forefathers considered the stomach the all-important organ of digestion and the intestines as scarcely more than a long tube to facilitate absorption and deal properly with waste materials. Their relative values are now exactly reversed in our estimation. The stomach has come to be looked upon as scarcely more than a thin-walled bag meant to hold the food that we take at each meal and then pass it on by degrees to be digested, prepared for absorption and finally absorbed in the intestines. It has comparatively little to do with such alteration of the food as prepares it to be absorbed. Its motor function is much more important than its secretory function and serious stomach troubles are {216} dependent on disturbances of stomach motility. Contractions at the pyloric orifice, that is the passageway from the stomach into the intestines, will cause the retention of food and seriously interfere with health. The dilatation of the stomach for any reason may produce a like result and these are the stomach affections that need special care.

If the stomach will only pass the food on properly, the intestines will do the rest. A number of people have been found in the course of routine stomach examinations who proved to have no secretory function of the stomach and yet suffered no symptoms at all attributable to this fact. The condition is well known and is called achylia gastrica, that is, failure of the stomach to manufacture chyle, the scientific term for food changed by stomach secretions. Our stomachs are only meant, apparently, to provide a reservoir for food that will save us the necessity of eating frequently during the day, as the herbivorous and graminivorous animals have to do, and enable us to store away enough food to provide nutrition for five or six hours. We thus have the leisure to occupy ourselves with other things besides eating and drinking.

This conclusion as to the relative {217} significance of the stomach and digestion is confirmed by the fact that removal of the whole stomach or practically all of it for cancer has in a number of well known cases been followed by gain in weight and general improvement in health. Schlatter's case, the very first one in which nearly the whole stomach was removed, proved a typical instance of this, for the patient proceeded to gain some forty pounds in weight. She had lost this during the course of the growth of a cancer and its interference with stomach motility. It was necessary, however, for her to be fed, rather carefully, well-chosen foods usually in liquid form, and every hour and a half instead of at longer intervals. Her intestines were thus spared from overloading and proceeded to do the work of digestion for which they are so well provided by abundant secretion poured into them from the large glands, the liver and the pancreas, as well as the series of small glands in their own walls all of which were manifestly meant to do extremely important work.

In the increased estimation of the significance of the digestive functions of the intestines which has come in recent years, there has been a tendency, as always in human {218} affairs, for the pendulum to swing too far. Above all, certain phases of intestinal function have come to occupy too much attention and to be the subject of oversolicitude. Whenever this happens, whatever function it concerns is sure to be interfered with. Attention has been concentrated to a great extent on evacuation of the bowels and the consequences have been rather serious. A great many people whose intestinal functions were proceeding quite regularly have had their attention called to the fact that any sluggishness of the intestines may be the source of disturbing symptoms and the beginning of even serious morbid conditions. As a consequence, they pay a great deal of attention to the matter and before long become so solicitous that the elimination of waste materials from the intestines is interfered with. Above all, they may be led to pick and choose their foods so delicately that there is not the necessary waste material left to encourage peristalsis.

The result is that to some extent at least, intestinal function would almost seem to have broken down in our day. Everywhere one sees advertisements of medicines and remedies and treatments of various kinds that will aid in the evacuation of the bowels. {219} Most of them are guaranteed to be perfectly harmless and all of them are pleasant to take, they work while you are doing nothing else and are just engaged in saving mankind not only suffering but complications of various kinds that may lead to serious results. Some years ago, when Matthew Arnold was in this country, he declared in one of his lectures that what the world needed was "leading and light," but a well known American physician who is closely in touch with American life declared not long since that what we needed in America manifestly, if advertisements were any index of the needs of a people, was laxatives and more laxatives. Advertisements cost money; it is said that at least four times as much as the advertising costs must be spent by the public on any object advertised in order to make it pay, so that very probably nearly a billion of dollars a year is spent in this country on laxatives. Only whiskey and tobacco present a higher bill to the American people annually.

Practically all of the laxative medicines do harm if taken over a prolonged period. Over and over again physicians have found that laxative remedies introduced even by scientists, with the assurance that they were quite {220} harmless and had no undesirable after effects proved the source of annoying or even serious symptoms after a while. It is true that when constipation has become habitual, it may be necessary to give laxative medicines for a prolonged period, but this is only another instance of the necessity that is often presented to the physician of choosing between two evils and trying to find the lesser one. Even the heavy oil that has become so popular in recent years has been found on careful investigation and prolonged observation to have certain undesirable effects and it must not be forgotten that it has not been used generally for a sufficiently long time for us to be absolutely sure what its sequelae may be.

This breakdown of intestinal activity is not the fault of nature but of men and women who have been thinking to improve on the natural laws of living. As the result of improvements in diet and refinements in cooking and the preparation of foods, less and less of their roughage is left in our articles of food when sent to the table. It is on this roughage or waste material that intestinal movement or peristalsis depends. If we eat perfectly white bread, cut all the gristle and fatty materials from our meat, carefully eliminating {221} the connective tissue bundles that may occur in it, eat our vegetables mainly in the shape of purees and avoid to a great extent all the coarser varieties, such as parsnips and carrots and beets, we provide very little material for the intestines to carry on and aid them in the elimination of other wastes. If, besides, we always ride and do not walk, and so have none of that precious jolting which occurs every time the heel comes down, and if we have no bending movements in our lives, no wonder that intestinal movement becomes sluggish and we have to supply stimulants and irritants to get it to do its work.

Intestinal evacuation is very largely a matter of will. There are very few people so constituted by nature that they will not have regular movements sufficient to maintain their digestive tracts in excellent health, if they form the right habits. They must, however, make up their minds, that is their wills, to restore coarse materials to their diet. They must eat whole wheat or graham bread, must eat fruit regularly and usually eat the skins of the fruit with it, that is as far as apples, pears, peaches, apricots, plums and the like are concerned. Even as regards oranges, it is probable that the eating of occasional {222} pieces of orange peel is an excellent means of helping intestinal functions and providing waste material. [Footnote 6 ]

[Footnote 6: A curious discovery has been made in recent years that orange skin contains a very precious element essential for bodily health, belonging to the class of substances known as the vitamines and contains more of it than any other food material that we have. The instinct which tempted so many of us as children to eat orange skin, in spite of the fact that we were discouraged from the practice, was founded on something much more than mere childish caprice. Orange skin is after all the basis of marmalade which has been so commonly used by the English people at breakfast and which is at once a tasty and healthful material.]

When baked potatoes are taken, the skin should be eaten, mainly because of the waste material it provides, but also because just underneath the skin and sure to be removed with it if it is taken off, there are certain salts and other substances that are excellent for health and particularly for digestion. Besides, the carbonized material which so often occurs on baked potatoes is of itself a good thing. It represents some of that charcoal which in recent years French physicians particularly have found very valuable as a remedy for certain disturbances of intestinal digestion. The removal of parings from fruit and vegetables and the careful trimming of meat, have taken out of human diet the materials which meant most for intestinal movements for former generations, and they {223} have to be supplied artificially by means of irritant drugs, salts, oils and the like, to the detriment of function.

The other element in the modern situation as regards the failure of intestinal function is the lack of fluids. People who live indoors are not tempted to take so much water as those who work outside and yet in our modern, steam-heated houses they often need more. Our heating systems take much more water from us than the former methods of heating. The result is seen in our furniture that comes apart from dryness and in our books and other things which crack and deteriorate. Something of the same thing happens to human beings unless they supply sufficient fluids. For this it is necessary deliberately to make up the mind, which always means the will, to consume five or six glasses of water between meals and especially to take one on rising in the morning and another on going to bed. This should not be hot and above all not lukewarm water, but fresh cold water which stimulates peristalsis. The creation of a habit is needed in the matter or it will be neglected. I have sometimes given patients some harmless drug, like a lithium salt, that was to be taken three or four times a day in a full glass of {224} water, in order to be sure that they would take the water. They were willing to take the medicine but I could not be assured that without it they would drink the amount of water that I counselled.

Above all, a regular habit of going to the toilet at a definite time every day must be created. Nothing is so important. In little children, even from their very early years, such a habit can be established; it is only necessary to put them on their chairs at certain times in the day and the desired result will follow. Adults are merely children of a larger growth in this matter, and the habit of going regularly is all-important. A little patience is needed, though there should be no forcing, and after a time, a very satisfactory habit can be established in this manner. It seems almost impossible to many people that anything so simple should prove to be remedial for what to them for a time seemed so serious a disturbance of health, but only a comparatively short trial of the method will be sufficient to demonstrate its value. A book or newspaper may be taken with one, or Lord Chesterfield's advice to learn a page of Horace which may afterwards be sent down as an offering to Libitina, the goddess of secret {225} places, may be followed, but the mind must not be diverted too much from the business in hand, and the will must be afforded an opportunity to exert its power.

It is true that the muscular elements of the intestines consist of unstriped muscles and that they are involuntary, and yet experience and observation have shown that the will has a certain indirect influence even over involuntary muscle. The heart, though entirely involuntary in its regular activities, can be deeply influenced by the will and the emotions, as the words encouraging and discouraging, or the equivalent Saxon words heartening and disheartening, make very clear. Undoubtedly the peristaltic functions of the intestines can be encouraged by a favorable attitude of the will towards them.

Above all, it is important that the anxious solicitude which a great many people have and foster sedulously with regard to the effect of even slight disturbances of intestinal functions should be overcome. We have discussed this question in the chapter on dreads and need only say here that the delay of a few hours in the evacuation of the bowels or even the missing entirely of an intestinal movement for a full day occasionally, will {226} usually not disturb the general health to any notable extent, and that the symptoms so often attributed to these slight disturbances of intestinal function are much more due to the solicitude about them than to any physical effect. There are a great many people whose intestinal functions are quite sluggish and whose movements occur only every second day or so, who are in perfectly good health and strength and have no symptoms attributable to any absorption of supposed toxic materials from the intestines. Indeed, in recent years, the idea of intestinal auto-toxemia has lost more and more in popularity for it has come to be recognized that the symptoms attributed to this condition are due in a number of cases to serious organic disease in other parts of the body, and in a great many cases to functional nervous troubles and to the psycho-neuroses, especially the oversolicitude with regard to the intestines. The will is needed then for intestinal function to regulate the diet, to increase the quantity of fluid, to secure regular habits and to eliminate worry and anxiety which interferes with intestinal peristalsis. There are but very few cases that will not yield to this discipline of the will when properly and persistently tried.

CHAPTER XVI

THE WILL AND THE HEART

The heart is the primum movens, the first tissue of the body that moves of itself in the animal organism, doing so rhythmically and of course continuously before the nervous system develops in the embryo. This spontaneous activity would seem to place it quite beyond the control of the will, as of course it is, so far as the continuance of its essential activity goes, but there is probably no organ that is so much influenced by the emotions and comes indirectly under the influence of the will as the heart. There are a series of expressions in practically all languages which chronicle this fact. We talk about the encouragement and discouragement or in Saxon terms that are exactly equivalent to the French words, heartening and disheartening of the individual. At moments of panic the {228} heart can be felt to be depressed, while at times when resolve is high there is a sense of well-being in connection with the firm action of the heart that flows over into the organism and makes everything seem easy of accomplishment.

There are a number of heart conditions that depend for their existence and continuance on a sense of discouragement, that is oversolicitude with regard to the heart. If something calls attention to that organ, the fact that it is so important for life and health and that anything the matter with it may easily prove serious, will sometimes precipitate a feeling of panic that is reflected in the heart and adds to the symptoms noted. The original disturbing heart sensation may be due to nothing more than some slight distention of the stomach by gas, or by a rather heavy meal, but once the dread of the presence of a heart condition of some kind comes over the individual, all the subjective feelings in the cardiac region are emphasized and the discouragement that results further disturbs both heart and patient.

Palpitation of the heart is scarcely more than a solicitous noting of the fact that the heart is beating. In certain cases, under the {229} stress of emotion, the heart beat-rate may be faster than normal, but in a number of people who complain of palpitation, no rapid heart action is noted. What has happened is that something having called particular attention to the heart, the beating of the organ gets above the threshold of consciousness and then continues to be noted whenever attention is given it. This is of itself quite sufficient to cause a sense of discomfort in the heart region and there may be, owing to the solicitude about the organ, a great deal of complaint.

Just one thing is absolutely necessary in the treatment of these cases, once it is found that there is no organic condition present. The patient's will must be stimulated to divert the attention from the heart and to keep solicitude from disturbing both that organ and the patient himself. It is not always easy to accomplish this, but where the patient has confidence in the diagnosis and the assurance that nothing serious is the matter, a contrary habit that will overcome the worry with regard to the heart can be formed. For it must not be forgotten that in these cases a series of acts of solicitous attention has been performed which has created a habit that can only be overcome by the opposite habit. {230} It is surprising how much discomfort this simple affection, due to a functional disturbance of the heart and overattention to it, may produce and how much it may interfere with the usual occupation. It is a case, however, simply of willing to be better, and nothing else will accomplish the desired result. At times the mistake is made of giving such patients a heart remedy, perhaps digitalis, but this only emphasizes the unfavorable suggestion and besides, by stimulating heart action, sometimes brings it more into the sphere of consciousness than before and actually does harm.

There is a form of this functional disturbance of the heart which reaches a climax of power to disturb and then is sometimes spoken of as spurious angina pectoris. In these cases the patient complains not only of a sense of discomfort but of actual pain over the heart region and this pain is sometimes spoken of as excruciating. Occasionally the pain will be reflected down the left arm which used to be considered the pathognomic sign of true angina pectoris but is not. Sometimes the pain is reflected in the neck on the left side or at times is noted at the angle of the scapula behind. When these symptoms occur {231} in young persons and particularly in young women, there is no reason to think for a moment of their being due to true angina pectoris, which is a spasm of the heart muscle consequent upon the degeneration of the coronary arteries, the blood vessels which feed the heart itself, and occurs almost exclusively in the old, and much more commonly in old men.

The pain of true angina pectoris is often said to be perhaps the worst torture that humanity has to bear. As a rule, however, it is very prostrating and so genuine sufferers from it are not loud in their complaints. Their suffering is more evident in their faces than in their voices. Indeed, it has come to be looked upon as a rule by the English clinicians and heart experts that the more fuss there is made, the less likelihood there is of the affection being true angina pectoris. When there is pain in the heart region then, especially in young or comparatively young women, of which great complaint is made, it is almost surely to be considered spurious angina, even though there may be reflex pain down the arm as well as the impending sense of death which used to be considered distinctive of the genuine angina pectoris.