Amusement and the Mind.—The theater, as it is at the present time, affords very little opportunity for mental relaxation. Most of our theatricals are mere show that occupies the eye but does not seriously catch the attention, especially after a certain number of types of these performances have been attended. The humor of the comedians of our musical comedy may, for {228} a certain number of people, mean something as a diversion of mind, but it does not last. Unfortunately, practically all their humor runs along the same line, most of it is extremely superficial, much of it is borrowed and wears signs of its origin, not a little of it is mere horse-play, which may divert children but not grown men, and so the theater as a mental relaxation has lost nearly all of its effect. Other diversions are sometimes more hopeful. For baseball enthusiasts, attendance at a game may be such a complete occupation of mind as to furnish thorough relaxation.
The kind of work that provides mental relaxation for others often proves exhausting to those who do it. Humorists, especially those who have to grind out paragraphs or columns of humor every day or every week, are usually melancholy men. The story of Grimaldi illustrates how serious may be the effect of work that seems mere play if pursued too singly. This humorist on one occasion consulted a specialist in mental diseases, for certain symptoms of nervous breakdown and depression that were causing him much annoyance and even more solicitude. The specialist believed in diversion of mind, and, having been to see Grimaldi the night before and enjoyed him hugely, though he did not recognize him off the stage, counseled him to go and see that humorist and have his "blue devils" banished for good. "If Grimaldi won't cure you of your depression," he added, "I don't know anything that will." "My God!" the humorist said, "then don't leave me in despair. Man, I am Grimaldi!"
Sports.—Unfortunately in our modern life we have to a great extent lost the idea of sport. The conventional make-shifts of life in a camp that is really a luxurious country house, or on a luxurious yacht, do not replace the complete diversions that came with real camping, hunting, fishing, sailing and the like. People now go to the country, but take the city with them. They live in country hotels and make five changes of clothing in the day, if not more. If men are interested in hunting and fishing and can go into the forest (unfortunately even the Adirondacks can scarcely be so designated now and we have to go into the Canadian wilderness to get away from the pall of regular life and civilization), complete recreation is secured. This makes a real vacation which does not mean absolute freedom of mind, but freedom from other cares so that one may with complete absorption apply himself to something different. During the year sports for grown-ups are difficult to obtain. Some men continue well on in middle life to play tennis, hand-ball, and certain other games, O fortunati nimium, that make the best kind of diversion. Fortunately, in recent years golf has become a favorite and for many makes a genuine diversion.
Children's Diversions.—In recent years we have so interfered with the normal natural development of the child that there is need to emphasize certain details in this matter. The modern child is apt to be precociously occupied with books and adult interests, because he is brought so much into the foreground of family interests. True play for some city-bred children is almost an anomaly. Exercise and air they get. They are conducted solemnly to the park by a nursemaid, who is instructed to see that they do not play with other children unless quite as well dressed as they are themselves, and their dress is often so elaborate that it is quite impossible for them to think of any real play. There is absolutely no recreation for the child in this procedure: on {229} the contrary, a new effort of will is required to walk with the stately propriety that is expected of it. Then the child is preoccupied with the thought of its clothes. Relaxation of mind is often quite out of the question, and yet we wonder why children are nervous and do not sleep well, why they have night terrors and do not digest their food properly, while all the time they are living unnatural lives that give no proper outlet for their energies and little diversion for their mind.
Games are important, but their true spirit has gone out in recent years. There are still a few young people who play for the sake of the sport, but everything now seems to be a preparation for some sort of contest. Only those are engaged in these contests and the preparation for them whose muscular development is such as to suggest that they will help to win. Winning, and not sport, has become the purpose of our games. This makes the participants worry about the games and associate them with dread of errors and ill chances. It is true that the interest for the contestants during the game is sufficient to make up for this and make the game valuable as relaxation; but those who need such relaxation most—the boys and girls who are underdeveloped muscularly—must sit and watch the contests, and this, after one has become accustomed to it, like newspaper reading and the theater, constitutes a poor apology for the complete relaxation of mind and diversion of brain-cell energy that used to come with sports when they were freely indulged, for the sake of the sport and not for the sake of winning.
Few people realize how powerful a factor for physical, as well as moral, good and evil is habit. The old expression that habit is second nature is amply illustrated in the most familiar experiences. The child, unable at the beginning to make any but the most ill-directed movements, learns during its first two years to make the most complex co-ordinated movements—first with difficulty, then with ease, and finally with such facility that there is no need for it to pay any but the most perfunctory attention to their execution. Walking requires the co-ordination of a large number of muscles so that the absolute position of every muscle in both the legs and in the trunk, at least as far as the shoulders, must be definitely known and their activity properly directed. Perhaps nothing brings out more clearly the difficulty of walking, though it depends on only one factor, the co-ordination of the two sides of the body, than the story of the Italian Tozzi twins. They were born with two heads and shoulders and with only one pair of legs. It was found that each head ruled the leg on its own side of the body. It was impossible for the creatures to walk. They lived to adolescent life, yet never succeeded in walking. The intimate association of the lower parts of their trunk and the long years of companionship of their brains, did not enable them to accomplish what seems to us so commonplace a co-ordination of movement as walking.
Formation of Habits.—The co-ordination of the two limbs is after all only a small portion of walking. The body must be held erect, the curve of {230} the spine must be managed so that the center of gravity is kept well within the base, and gluteal and femoral and calf muscles must all be co-ordinated with one another. In a few months a child learns to do all this, and in a couple of years it executes all the co-ordinate motions with such certainty that walking becomes not only an easy matter but an absolutely unconscious accomplishment that can be carried on while the mind is occupied with something else or while it becomes so abstracted that surrounding objects are not noticed.
A far more difficult co-ordination is required for talking. It is only when we analyze how nicely adjusted must be every movement, in order to pronounce consonants and vowels properly and to combine them in various ways, that we realize how complex is the mechanism of talking. A difference of a hundredth of an inch in the movement of the tongue, or less than that in the movements of various muscles of the larynx, makes all the differences between clear articulation and a defect of speech. In the course of the years up to seven, the child learns this wonderful co-ordination apparently without difficulty, but really at the cost of constant well-directed effort. There is no time in human existence when the child really learns so much as during the first four years of its existence, even if it learns nothing else except to walk and to talk. The foolishness of obtruding other things, information and study of various kinds, on the child's attention at this time should be manifest.
Unconscious Regulation of Muscles.—What is thus prefigured in early life invades every activity in later years. The boy who learns to ride a bicycle must at first devote all his attention to it, but after a while rides it quite unconsciously, his muscles having learned by habit to accommodate themselves automatically to all the varying positions of his machine. Anything well learned by habit is never forgotten. How hard it is to learn to swim, yet, after years away from the practice of it, the art comes back at once. The same is true of skating, and of the nice adjustments of muscles required in various games. Such is the influence of habit in forming a second nature. It is no wonder that Reid, the Scotch philosopher, should have written:
As without instinct the infant could not live to become a man, so without habit man would remain an infant through life, and would be as helpless, as unhandy, as speechless, and as much a child in understanding at threescore as at three.
Commenting on this Prof. J. P. Gordy, in his "New Psychology," [Footnote 26] says:
[Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.]
Strong as this statement seems, it is probably an understatement of the truth. Without habit, we should rather say, a man would be as helpless, as speechless, as unhandy at three-score as at birth. Habit is the architect that builds the feeble rudimentary powers of the child into the strong, developed powers of the full-grown man. If a child's vague, purposeless movements give place to definite movements performed for definite purposes, if his sensations become more definite, if his perceptions become clearer, if his memory becomes more accurate, if he reasons more and more correctly and logically, it is because of habit.
Law of Habit.—The law of habit is that every time we perform any action, mental or physical, or allow ourselves to be affected in any way, we have more proneness to, and greater facility in the performance of that action or in {231} experiencing that affection under similar circumstances, than we had before. In the chapter on Tics, I call attention to the fact that all the curious gestures by which we are individualized, are due to the law of habit. It is infinitely amusing to watch a group of people and note the endlessly different habits of which they have become the victims. There are tricks of speech and tricks of gesture eminently characteristic and often quite laughably individualistic. We imitate, especially those of whom we think much. Sometimes it is only when a father's attention is called to them in his sons that he realizes the ludicrousness, or at least laughableness, of some of the things he does, and he proceeds to correct both generations of their faults.
Habit and Food.—Most of our likes and dislikes for food are neither physical nor physiological, but simply habitual. We have become accustomed to certain things, and so we like them. We are unaccustomed to them, and do not care for them. It is amusing when people put forward these lacks of habituation as if they were physiological idiosyncracies. Many thin people do not like butter and milk. The real reason for this is not any peculiarity of digestion, or any gastric incompatibility, at least in 99 cases out of every 100, but the mere fact that they are not habituated to their use. That is one of the reasons why they are thin. Our tastes for curious foreign foods are nearly all deliberately acquired. Not one in ten ordinary Americans likes olives or caviar when first tasted. Nearly every curious article of food is "caviar to the general" at first trial. Later it becomes impossible to understand how we could have had any objection to them. At times, even an actual craving for them asserts itself as a consequence of the habitual use, and then deprivation means positive discomfort.
Slow Eating.—One of the most valuable habits that a man can cultivate, but one of the most difficult to acquire in our time, is that of eating slowly. Most Americans bolt their food to a degree that would be quite appalling to them if they realized what they were doing. Pieces of potatoe as large as the end of the thumb are swallowed. Bread and milk may be eaten so hurriedly as to be as potent a source of digestive disturbance as fried onions. There seems no doubt from what we know of Fletcher's experience and Chittendan and Follin's studies that a man derives more nutrition from food that is masticated properly, that he can get along and do his work on less material and that, above all, there is not the same tendency for him to put on weight that is so common among people after reaching middle age.
Sir Andrew Clarke used to have his patients chew a definite number ol times on each bite—say thirty times. Even so great a man as Gladstone submitted to this rule and gradually learned to accustom himself to eating very slowly. Fletcher's system of chewing the food until it passes down the esophagus of itself without any swallowing effort is a better rule. It is a surprise to most people how unconsciously swallowing can be accomplished in this way and how little liquid is needed in order to prepare food to be swallowed. The formation of the habit, however, is not an easy one. Persistence and frequent reminders are needed, or else the beginnings of the habit are soon dissipated and old bolting habits reassert themselves.
Water Drinking.—In drinking, habit is as supreme as in eating. The majority of people who work outside and perform muscular labor crave and take an abundance of water. Many of those who live indoors, especially in steam-heated houses, may need it quite as much if not more, but get out of the habit of drinking water. As we need about three quarts of water per day for use in our economy, this no water habit often becomes a serious factor in the production of physiological disturbances. We have replaced water drinking and the milk drinking of the olden times by tea and coffee, and as these are stimulants, habits form very readily with regard to them. I have known people who were sure they would be miserable without their half-dozen cups of tea or coffee each day, and who actually would be miserable for a few days, when deprived of it. They were seriously impairing the efficiency of their nervous system by so much stimulation. Unfortunately, it is just those whose nervous systems have least stability, and are already the subjects of more stimulation by conscious introspection than is good for them, that are most likely to form the tea and coffee habits, and who are most harmed by them, though they find it hard to understand the reason therefor.
Air and Exercise Habits.—Habits with regard to exercise and fresh air are particularly important. In this matter it is only habit that can be really helpful. To work at high pressure indoors for several days, and then, when one is quite on edge, to take a lot of severe physical exercise is not good. Every human being should go out between meals. I am not one of those who believe much in exercise for exercise's sake—what is needed is fresh air. Our sanatorium patients who sit out-doors all day have fine appetites. The advice to a busy man that he must form the habit of being out between every two meals for from half an hour to an hour would usually evoke a strenuous protest, but all he needs to do is to get up half an hour earlier and walk down to his office, and if he will walk back in the evening he will have plenty of air and exercise between his meals.
Change of Habits.—Patients do not want to change their habits. They come to a doctor to be treated. They want some medicine that will, without further inconvenience, rid them of certain discomforting symptoms. At the beginning, at least, patients resent interference with their habits. They are quite satisfied, and to modify them requires an effort that must be continued for some time. The changing of old habits and the formation of new habits are most important for the ordinary ills to which mankind is prone. Modifications of habit constitute real hygiene and are not mere corrections of symptoms, permitting the habits that have led up to them to go on.
Patients may conclude that it is too much trouble to change their habits. We all know persons who feel that they can not give up their coffee. As to whether or not the modification of a habit is worth the trouble it involves, the patient must be the judge after the case is put properly before him. It is possible that he may learn to endure the inconvenience given him by his symptoms rather than to stand the inconvenience of changing a nicely settled habit, and forming a new one. The reward should be put very plainly before him, however, and besides, the consequences of his habit in the future should be suggested so that he may realize just what it will lead to.
It is evident from the foregoing that physical habits have much to do with making life easier and saving expenditure of nervous energy, but just this same thing holds good for mental states. With care, a proper habit of mind and of the mental attitude towards difficulties in life, can be so cultivated as to ward off many of the discouragements, and most of the causes of depression that weigh heavily on some people. The natural disposition can not be entirely overcome, but habit, as a second nature, can modify the personality so as to make conditions much better than before.
With this wonderful power in habit, it is too bad that its force for good is not used. It is especially important that its force for evil shall not allowed to dominate human actions so as to make them harder of accomplishment. Many people, who are greatly troubled by the inconveniences and discomforts necessarily associated with human life, worry over it to such a degree as to make themselves sick. The expression I have quoted elsewhere of the old man who said, "I have had many troubles but most of them never happened," is a typical example of what the habit of looking at things from a wrong standpoint means to many people. They are confirmed pessimists. Their one consolation, when a small evil happens to them, is that perhaps this may be sufficient to ward off the greater evil that fate surely has in store.
Pessimism.—Pessimism has been defined as sticking one's nose in a dungheap and then asking, "How is it that it smells bad around here?" Some people are always nursing a grievance. No matter how many times they may happen to have been undeceived, still the next time the opportunity occurs they are sure that fate or friends or someone has it in for them and that the worst may happen at any time. In the expressive words of a recent slang phrase, they have a "perennial grouch." This state of mind toward the environment not only prevents the physical and mental good that cheerfulness brings with it, but it unfavorably influences physical conditions within the body. People suffering from indigestion are usually morbid, petulant, and hard to get along with. Many a dyspeptic makes this an excuse for his bad temper. Anyone who has had to study these cases much soon comes to the conclusion that the beginning of the digestive disturbance was the gloomy outlook on life, which flowed inward to disturb the digestion and all the other animal functions.
Depression of Mind and Body.—Patients suffering from melancholia nearly always lose in weight. As a result of their lowered vitality, there is a suppression of the nervous impulses which rule over nutrition, with a consequent loss of weight. In cases where there are only tendencies to depression and gloom, the effect upon the digestive system is not so marked but there is no doubt that there is some effect, and that the indigestion in these cases is more often than not a result of the depressed state of mind, rather than the depression of mind the result of the indigestion.
Moodiness.—The habit of looking at the gloomy side of things is easily formed and, once acquired, it becomes very forceful. Many a man who was quite cheerful when young, becomes moody as he grows older. Nearly everyone permits moods more than is good for him. The attitude of mind that should be cultivated is one in which it is realized that, though there may be {234} many sources of evil in the world there is a preponderance of good even in the worst environment, and that opportunities for making the best of things will be found by any cheerful disposition. Mrs. Wiggs of the Cabbage Patch is a typical example in fiction of the optimism that counts. Miss Helen Keller in real life is a typical example of how the most untoward circumstances can not crush the spirit of man if he only wishes to be cheerful—if he only tries to lift himself above his surroundings, no matter how discouraging they may seem to be. No one is without discouragement and causes for unhappiness. "Happy he who has least," the Greek dramatist said.
The difference between the optimistic and the pessimistic point of view is much more a matter of habit than is usually thought to be the case. Indeed, there is good reason for assuming that it is so largely a matter of habit, that other factors count for little. We all know individuals who, after having, been cheery, bright, hopeful and helpful, have had some incident sour them and then they have been just the opposite. This did not come all at once; it was a growth. They felt hurt and aggrieved, and then began to look at things through dark glasses, and after a time could see nothing on its brighter side. Not infrequently, as doctors well know, the growth of such a moody disposition has been the signal for the development of a series of complaints, if not of actual symptoms, and men and women who have not been in the doctor's hands before now become valetudinarians. This new physical condition is often attributed by their friends, by themselves, and even by complacent physicians, to the effect upon them of the trial or disappointment that struck them. Only too often it is wholly due to the cultivation of a habit of pessimism consequent upon a shock that for the moment pushed their cheerfulness into the background. Strong characters will not be thus easily affected, but weaker characters need not suffer such a change of disposition and with it a deterioration of health or well-being unless they so will it.
Habit can modify nature so much as to make what is practically another man. We all know how the dancing master can transform a country gawk into a refined, courteous society man (not gentleman, for that is something else) of graceful carriage and even handsome bearing. He cannot do this for all the pupils that come to him, for it is impossible to make a silk purse out of a sow's ear, but for anyone that comes with good will the revolution in manners is often a revelation to those who have known the man before. When the exterior can be changed so much, the interior attitude toward other people certainly can be greatly modified.
Persons of a melancholic disposition may be surprisingly cheerful, and even gay, with comparative strangers when they make the effort to be so. For many people, meeting with strangers is an excellent remedial measure. It stirs them up to present the best side, and it occupies attention to the exclusion of themselves in a way that is extremely beneficial. If people would only form the habit of being as courteous to their own folks as they are to others, the disposition involved in this would often save them from certain symptoms, and save their physicians from many complaints.
Happiness is the basis of good health. The phrase is often put the other way: Good health is the basis of happiness. Without health there is no happiness. But every physician knows that many a patient suffering from real organic ills, and having much physical pain to bear, still has many hours of happiness in working for others. This happiness reflected back upon his physical life is not able to cure his ailments, but does so lessen the significance of the symptoms as to make the ailment more bearable.
The most important therapeutic element in the formation of good habits, mental and physical, is that habit does away with the necessity for conscious regulation of many details of life. Without habits of doing things, we have to make numerous decisions and keep on making them under conditions that require special effort and waste of energy. When habit asserts itself, there is little or no difficulty. Habits of living in airy rooms, of taking exercise, of food regulation as to quantity and quality, of methods of taking food as regards mastication, the quantity of fluid ingested, the hours of meals and the like, can all be formed and then followed without effort. Just inasmuch as life can be ruled by habit, nerve force is conserved. This is as true for our attitude towards life, our disposition and consequently our satisfaction with life, as for anything else that we do. Habitual cheerfulness, habitual readiness to make allowance for others and to be helpful to them, habitual self-control—all of these things can be cultivated. Properly cultivated, they save much of the wear and tear of life, and make for contentment and happiness much more than many of the things for which men strive so anxiously because they seem to promise happiness.
Pain, while always a dreaded symptom of disease, seems, with the increase of comfort and the gradual abolition that has come in our time of many of the trials of existence, to have had its terrors increased. Even a slight pain or ache is dreaded, and if continuous or frequently repeated, becomes for many people a trial that is almost impossible to bear. This is all the more to be deplored because ability to stand a certain amount of pain, with reasonable equanimity, is almost a necessary condition of rapid recovery from disease or injury. Placidity of mind favors the flow of nerve impulses for reconstructive purposes, while over-reaction to pain inhibits the natural processes of repair. According to Shakespeare's heroine: "There was never yet philosopher that could endure the toothache patiently." Pain is usually supposed to be an essentially physical phenomena for which mental influence can be of little, if any, benefit. As a matter of fact, however, the mental attitude towards pain modifies it to a considerable degree. I have quoted Hippocrates' declaration that a greater pain drives out a lesser pain. Any strong preoccupation of mind will greatly lessen pain at any time.
Pain is not, after all, in the nerves, nor in the central nervous system, but in the consciousness. Just as there is no sound unless the waves in the air arouse recognition in the consciousness, so there is no pain unless the disturbance of nerves finds its way above the threshold of consciousness. Nerves may be racked, yet no sensation may be felt. There may be pain in the mind apart from the nerves, and slight nervous affections may produce severe pains. The whole question of the treatment of pain involves the individual much more than it does the affliction which causes the pain. What seems unbearable pain to many may be little more than a passing annoyance to others. What would be, under ordinary circumstances, intolerable torture, especially to sensitive people, may, because of intense preoccupation of mind, remain absolutely unnoticed. Maniacal patients sometimes inflict what would normally be extremely severe pain on themselves by burning or mutilation without any manifestation of pain. In the excitement of a panic men may suffer what would, under other circumstances, be excruciating agony, and yet not know that they are hurt.
To a mind that is without serious interest, even slight pain, if continuous, soon becomes unbearable. The course of pain, where there is no diversion of mind, is an interesting study. While suffering, we seem always able to bear the pain of the present moment, and it is only the cumulative effect of the pain that is past and the anticipation of the discomfort to come, that make the pain unbearable. Nearly, always it is much more the dread of what the pain may mean, and the lack of power to endure which gradually develops as a consequence of suffering, that constitute the worst features of pain. At the beginning of a period of pain we stand it well, as a rule, but its continual nagging debilitates us and heightens our susceptibility until we cannot nerve ourselves to further endurance. If our power of endurance were not thus gradually lessened the pain would not seem severe. There are many neurotic people whose susceptibility to pain has been so much increased by their lack of self-control and their tendency to react easily to pain, that even slight pain becomes a torment. Psychotherapy should gradually train these people to a power of endurance.
Pain from Over-Attention.—Much of what is called pain is really due to such concentration of mind on a particular portion of the body that the ordinary sensations of that part, usually accomplished quite unconsciously, become first a source of uneasy discomfort and then an ache or pain. There may be some slight physical disturbance which calls attention to the part, but there is no really serious pathological condition. While such pains are spoken of as imaginary it must be remembered that this does not mean that they are non-existent. On the contrary they may be much more real to the patient than physical ailments. A pain in the mind is a much more serious condition than having it in the body.
While pain may be thus created by concentration of attention, it must not be forgotten that what the mind can do in increasing pain is even more important than in originating it. Slight discomforts by concentration of attention on them may be made insupportable. It is this element in pain, above all, that the physician requires skill to alleviate. Habits of introspection and the lack of serious occupation of mind of many people leave them the victims of over attention to themselves. In trying to relieve their pain it may be {237} comparatively easy to alleviate their physical condition, but the mental condition, once aroused, may remain, and may easily tempt to the use of habit-forming drugs or others that may do serious harm. The story of the evil effects of headache powders in recent years, and of the opium habits formed in olden times, are a significant commentary on this fact. It is probable that in most of these cases, the discomfort for which remedies were frequently taken was of a kind that should have been treated only partly, if at all, by drugs. It is more important to lessen susceptibility than to try to cure the pain.
The relation of the mind to what is often considered severe physical pain, has come to be generally recognized in recent years. Neuralgias, for instance, have often been reported as recurring after fright, or strong emotion, or worry. It is at moments when patients are much run down in health that pains are particularly likely to be unrelievable, and during periods of emotional strain that anodyne drugs are most called for and are most likely to be abused.
Rest and Pain.—In any study of pain and its relief, one must always recur to that classical contribution to medicine, now in the fiftieth year of its publication and still as important as when it was written, Hilton's "Rest and Pain." He calls attention to the fact that what he wrote was only a development of what many practical physicians had thought long before his time. He quotes a prize essay of the French surgeon, David, written in 1778. Hilton's development of the idea that pain is usually a signal on the part of nature for rest, and that rest will usually enable her to overcome the pathological condition and so relieve the pain without recourse to drugs, is, and ever must be, the basic element in the therapeutics of pain. How many forms rest may take can only be judged by a careful reading of Hilton's book. The oftener one reads it, the better one realizes how much of precious common sense and acute clinical observation there is in it. It is essentially a book of psychotherapy. It treats the patient's mind first and then through that changes his habits, persuades him of the need of rest, directs how that rest should be taken and so leads up to his natural cure.
Every treatment of pain must include rest of mind as well as body. Hilton has particularly dwelt on the rest of body. Rest of mind is just as important. Many pains could be easily borne were it not for the worry that accompanies them. A slight pain becomes greatly annoying because the patient's general condition makes it impossible to stand discomfort with equanimity, and there has been no training in self-control. In spite of all our advance in medicine, we are not likely ever to make life so free from pain that people can go through it without needing self-control. Training in self-control is an important psychotherapeutic prophylactic. If, with a certain amount of capacity to bear discomfort, there goes such rest of mind as does not exaggerate or emphasize the condition, then many of the pains of life lose their power to annoy, all of them are distinctly lessened and the relief of them by accessory physical methods becomes easier.
Pain in Its Relation to Life.—There is an unfortunate tendency to exaggerate the significance of pain. We have cultivated irritability in the physical sense, rather than the power of endurance. Patients should, as far as possible, be lifted out of this condition of over-delicate sensitiveness and put into a state where the idea of pain is not so serious. Only in this way can {238} the more or less inevitable discomforts of life be borne without such reactions as seriously interfere with health. It may be said to be other than the physician's business to secure this magnanimity, but as magnanimity is needed in our patients, and there is no one else to respond, physicians must start its cultivation. The necessity for learning to bear minor discomforts, at least without exaggerated reaction, need not be presented to the patient directly, but can be gradually made a part of the system of treatment. By absorption in other interests, the consciousness of these discomforts disappears without the necessity for recourse to drugs.
Self-Denial.—Many thoughtful people are sure that what is needed to make a large number of our generation more happy, or at least less miserable, is training in self-denial and in self-control. The word self-denial has come to have a very distant sound for most of our generation. From early childhood anything that is unpleasant is shunned and anything that is difficult is likely to be shirked. The head-master of Eton College has recently insisted that too much is being done to please young folks and too little to stimulate them to activity. He declares that, as a rule, any undertaking begins to be useful just where it ceases to be simply pleasant. Unpleasantness is avoided to such a degree that the habit of thinking that it has no part in life comes to be a second nature. As a consequence, the reaction to any continued unpleasantness is likely to be exaggerated and make the subject very miserable, and sometimes disturbs and discourages, whereas it should have the effect of stimulating to reactive efforts, to bring out the best that is in us.
Hinton emphasizes the fact that an ingredient of pain is necessary to all health or pleasure. The fatigue and the hardship associated with mountain climbing is a portion of the essence of the pleasure in it. All healthy, pleasant exercise has an accompaniment of fatigue and some aches and pains. What is needed, then, in our time is the training to do things for the sake of doing them. We should be neglectful of the discomfort that may be associated with them, or we should even consciously rejoice in the fact that this very discomfort is of itself a sign that functions are being used to such an extent, that their limits are being expanded, their limitations overcome.
It may well be said that it is not the physician who, as a rule, should do this; it should be accomplished in the early years by the teachers and trainers of the young. True enough. But physicians can at least help in reforming the tradition in this matter so as to neutralize the present state of mind which seems to look upon pain as an evil. Pain is always either a conservative sensation or an actual stimulus to function. Besides, many of the present generation who come to us, having had no training in the precious qualities of self-denial and self-control under difficulties and discomforts, must have this knowledge supplied for them as far as possible by suggestions of various kinds. It is more difficult to accomplish much in this matter for the adult, but even in apparently hopeless cases of over-attention to self and incapacity to bear discomfort, much can be accomplished by patience and persistence.
The common dread of suffering is quite unwarranted by what we know about the effect of pain. There are many motives that may be adduced to make it seem less terrifying than it now is to many people. The effect of pain upon character is always excellent. The difference between two brothers, as we have said, one of whom has had the discipline of pain or suffering and {239} the development of sympathy that comes with it, and the other who has not had the advantage of this great human experience, is likely to be marked. In the one there is a depth of human nature that enables him to appreciate and even to express the meaning of life better than his apparently more fortunate brother. Practically all the men who have ever got close to the heart of the mystery of life, and expressed it in poetry or other form of literature or art, have gone through suffering as a portion of their training. Even the suffering that comes from ill health is never wasted. Men have gone through it who have thought that the ecstasy of relief following it made the experience worth while.
Men are not deterred from action by the prospect of even severe pain. Probably no greater physical suffering can possibly be invited than is sure to come to those who go on Arctic expeditions, or who undertake prospecting in Alaska. Of course, many of the prospectors find themselves in the bitter cold of the North without having realized what they would have to stand. But Arctic explorers, as a rule, know exactly what they have to expect. Most of of them have been through it all before, yet they deliberately choose to go again for rewards that, to an average man's eyes, seem trivial. The memory of past pain is rather pleasant. Virgil's "Perhaps it will be pleasant to recall these trials at some future time" is not poetic exaggeration.
The Discipline of Pain.—There is only one way to learn how to bear pain, and that is by practice in it. There might be no necessity for this in case life were arranged differently. But all men must die, and death inevitably involves a painful process. Suffering is practically unavoidable for the majority of men. Even in the midst of every possible material comfort, cancer may come with all its hideous connotations. It is important, then, that everyone should be prepared to stand some pain. Certain suggestions help in bearing special pains.
Pain Diffusion.—Pain along one nerve may readily become diffused. This diffusion will sometimes cause discomfort, and even tenderness, at a distance from the original seat of the pain. Such diffusion tends to produce in the patient's mind the idea that the underlying pathological condition is spreading, though it is only a sign that the nervous system is becoming irritable and easily responding to sensory disturbance. Dr. Head's investigations ("Brain," 1893), should be known to physicians, and the conclusions that flow from them should be presented to patients who are sometimes suffering quite as much from their apprehension of the spread of pain, and its significance, as from the discomfort itself. Dr. Head says:
If I have an aching tooth, the pain is at first localized to the tooth affected. The longer the toothache continues the more I become worn out, and the pain is rapidly accentuated by a "neuralgia," that is, a pain in the face. The neuralgia is soon accompanied by distinct cutaneous tenderness over a definite area on the face corresponding to the tooth affected. If I am anemic, or if the pain remains untreated until my bodily health is affected, I no longer have a localized area of tenderness, but the pain, and with it the tenderness, spreads until the whole of one-half of the head and even the neck may be intensely tender. Thus at last the pain of an aching tooth has produced tenderness over areas which bear no relation to the affected organ.
As pain can be suppressed by diversion of mind, or concentration of thought on something that creates great preoccupation, it must not be {240} forgotten that pain may almost be created by concentration of attention on certain areas of the body, or certain nerve tracts. Over-attention will actually make sensations intolerable that are at first quite indifferent, or at least very easy to bear. Sensitive people, in the ordinary meaning of that term, are those who are much given to paying attention to their sensations, and who therefore have much to complain of them. There is much in modern life that has the tendency to produce this sybaritic condition in which even slight discomforts become the sources of almost unbearable annoyance.
Even where there is no good physical reason for the occurrence of pain, thinking may produce discomfort. The one thing that Freud's work has made clear is that in neurotic persons the memory of a mental shock or strain may be transferred to some portion of the body related in some way to the shock, and then prove to be the source of hysterical pains and also of hysterical palsy. The case told by him in which the young woman massaging her father's limbs allows them always to rest on her own lap during the process, and after his death suffers from an hysterical, painful condition in this region, is a typical illustration. Her sympathy for her father, accentuated by his subsequent death, and her sorrow at a time when her nursing efforts made her particularly susceptible, led to an explosion of nervous energy along those nerves which had always felt the impress of his legs. The hysterical condition resulted. This is an extreme case. In milder forms it would be possible to explain many otherwise inexplicable pains and aches in sensitive young people along these same lines.
More than once I have seen young women, who had been asked to rub father or mother with liniment, complain of tingling pains in their fingers which were followed by some redness so that one would be tempted to think of Weir Mitchell's disease, though evidently the pathological cause at work was the slight disturbance of the vasomotor system due to the liniment and the rubbing, emphasized by the sympathetic feelings, and by the over-attention which this brought about. Whenever women have, for a prolonged period, to nurse others in whom they are deeply interested, and have to perform some habitual action that is somewhat fatiguing for them, after the death of the patient there will not infrequently be the development of hysterical or neurotic over-sensitiveness in the parts employed. This may give rise even to an hysterical joint, or to severe neurotic pains. Once these cases are recognized, the attention can be diverted from themselves and they can be made to understand that their grief and sympathy are being concentrated on the part and by transfer are producing physical manifestations. The pain is not imaginary, but the condition will improve as soon as the mind is diverted from it.
Neurotic and Organic Pain.—The distinction between pain due to a neurosis and to a definite lesion is often difficult to make. If there is a definite localization of pain, it is almost surely not neurotic, but organic. If there are certain positions in which pain is felt while it disappears in others, there is some local inflammatory or congestive condition and not mere hypersensitiveness of nerves at the bottom of it. These positions of maximum pain are important. When pain radiates a great deal, even though there may be complaint of a particular region, it is usually neurotic. If patients are asked to tell exactly where their pain is, and they indicate its location by a wave of the hand, it is probable that the condition is neurotic. When there is a definite {241} localized point of tenderness with the pain, even though there may be radiations, usually the condition is based upon some organic trouble. It must not be forgotten, however, that slight local troubles may by concentration of mind on them, become exaggerated and that, in spite of the fact that there is or was at the beginning a definite localization of pain with some tenderness, the neurotic elements may, after a time, become manifest and prove to be much more important than the others.
Pain that is definitely influenced by motion, as by the jarring effect of walking, or by bending and stooping, is practically always organic. The best differential diagnosis between neurotic abdominal conditions and organic trouble can be made by the help of information obtained in this way. If the appendix is inflamed, or the gall bladder infected, or contains a calculus, or if the kidney has a calculus, these are all made worse by movements, by jarring, by stooping as in tying the shoes, by riding on rough roads, and the like. If patients who suffer from obscure abdominal conditions associated with pain of which they complain much, can, at certain times, indulge with impunity in these exercises and motions, it is probable that their attacks are neurotic in character. Especially is this true if the indulgence in these rides and motions is without effect when they are in pleasant, agreeable company, though there may be some complaints when they have to ride alone, or under conditions that are less pleasant. If a hint of this distinction by which the physician differentiates one form of pain from another is given a neurotic patient, the suggestion will serve the purpose of producing complaints whenever the opportunity presents itself. Such patients take such suggestions, as a rule, without wishing to deceive, but they become persuaded that their sufferings are of the character asked for.