THERAPEUTIC IMPORTANCE OF HABIT
The most important therapeutic element in the formation of good habits, mental and physical, is that habit does away with the necessity for conscious regulation of many details of life. Without habits of doing things, we have to make numerous decisions and keep on making them under conditions that require special effort and waste of energy. When habit asserts itself, there is little or no difficulty. Habits of living in airy rooms, of taking exercise, of food regulation as to quantity and quality, of methods of taking food as regards mastication, the quantity of fluid ingested, the hours of meals and the like, can all be formed and then followed without effort. Just inasmuch as life can be ruled by habit, nerve force is conserved. This is as true for our attitude towards life, our disposition and consequently our satisfaction with life, as for anything else that we do. Habitual cheerfulness, habitual readiness to make allowance for others and to be helpful to them, habitual self-control—all of these things can be cultivated. Properly cultivated, they save much of the wear and tear of life, and make for contentment and happiness much more than many of the things for which men strive so anxiously because they seem to promise happiness.
CHAPTER VIII
PAIN
Pain, while always a dreaded symptom of disease, seems, with the increase of comfort and the gradual abolition that has come in our time of many of the trials of existence, to have had its terrors increased. Even a slight pain or ache is dreaded, and if continuous or frequently repeated, becomes for many people a trial that is almost impossible to bear. This is all the more to be deplored because ability to stand a certain amount of pain, with reasonable equanimity, is almost a necessary condition of rapid recovery from disease or injury. Placidity of mind favors the flow of nerve impulses for reconstructive purposes, while over-reaction to pain inhibits the natural processes of repair. According to Shakespeare's heroine: "There was never yet philosopher that could endure the toothache patiently." Pain is usually supposed to be an essentially physical phenomena for which mental influence can be of little, if any, benefit. As a matter of fact, however, the mental attitude towards pain modifies it to a considerable degree. I have quoted Hippocrates' declaration that a greater pain drives out a lesser pain. Any strong preoccupation of mind will greatly lessen pain at any time.
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.
SPECIAL PSYCHOTHERAPY
SECTION VI
THE DIGESTIVE TRACT
CHAPTER I
INFLUENCE OF MIND ON FOOD DIGESTION
With the progress of biological chemistry, digestion came to be considered a purely chemical process. Now we realize that even more important than the chemical factors of digestion is the individual liking for particular kinds of food, and the mental attitude of the patient toward digestion.
Not only may mental factors interrupt or hamper digestive processes generally but, as the investigations of Pawlow at the Imperial Institute of St. Petersburg show, they may modify very materially the chemical processes within the stomach. If, for investigation purposes, a stomach pouch be experimentally segregated in a dog from the rest of the stomach, and the dog be fed food that he has a particular liking for, the gastric juice manufactured will be especially strong and effective. If the food given be less to the dog's liking, the gastric juice is not nearly so efficient in its activity. Finally, if food be consumed for which the dog does not care, but which he takes because hunger compels him, the gastric juice manufactured for its digestion is quite weak and the process of digestion is slow. If this is true for an animal like the dog, whose psyche is comparatively of much less importance than that of human beings, the corresponding influences in men and women will be even more emphasized. This is only what common experience has always shown us. The human stomach is not a test-tube in which mere chemical processes are carried on, but its vital activity is of great importance. That vital activity depends to a large extent on the state of mind, on the relish with which food is eaten, on the individual likes and dislikes, and on the emotional condition during digestion.
Prejudices and Digestion.—Perfectly good food materials may become difficult or impossible of digestion as the result of learning something about their mode of preparation. In the country this is often noted, with regard to butter, milk, and even eggs. The story of the farmer's wife who wanted to trade her own butter for an equivalent amount made by someone else illustrates the influence of mind over relish for food. She was candid enough to say that the reason she wanted to exchange the butter was that a mouse had been seen in the cream, and her children could not, therefore, eat it. She took [{243}] back home with her exactly the same butter in another crock, and there was no further difficulty, though before this the children would have been actually sick if compelled to eat the butter. I once saw a family of three women who had vomited because they heard that the dishes had been washed in a slop pan, though this proved to be a mistake. Such occurrences emphasize the necessity for properly predisposing the mind, and for removing unfavorable suggestion, if digestion is to proceed properly.
Mental States and the Stomach.—The typical example of the influence of the mind on the digestive tract is to be found in the experiences of Flaubert, the French novelist, while writing "Madame Bovary." When he was writing the scene in which he describes the effects of the arsenic which Madame Bovary takes, he himself suffered from practically all the symptoms due to the drug. In order to describe it faithfully he had studied it carefully. He had the pains, the vomiting, the burning feeling and even the garlicky, metallic taste in his mouth. Such an incident is extremely exceptional, yet its possibility is recognized, and it illustrates how sensitive some people are to the action of mental states upon the body, and how large a role a strongly excited imagination can play in producing definite physical symptoms. There are many more such realistic imaginations than we have, perhaps, been inclined to suspect. It is over these particularly that the psychotherapeutist can exert his influence by helping to modify the cause of their symptoms, the mental attitude which exists, rather than by trying to change the symptoms which are only effects, for diseases must, as far as possible, be treated in their causes.
Disgust and Disturbance of Digestion.—Max Müller's story, told in his book on "Language," to show how language might have been a human invention from imitation of natural sounds, illustrates the influence of an unfavorable state of mind in disturbing digestion. An Englishman, traveling in China, fearful lest he should not be able to obtain food that he cared for, because of his lack of knowledge of the language of the country, was rather surprised on his first day's journey into the interior, to be served with a stew made of some kind of dark meat that tasted very well indeed and with which he was so much pleased that he asked for a second helping. Just as he was about to eat the second portion, he thought it well to ask the waiter what sort of meat it was, as he wished to be able to obtain the same kind at other places. Calling the waiter to him, he said, pointing to the dish of meat with a questioning tone, "Quack, quack?" The waiter at once shook his head and said, "Ugh! bow wow!" The Englishman pushed the second portion away and got up from the table.
Under the same circumstances nearly everybody would feel the same qualmishness—at least all who had been brought up according to our Western notions. Reason has little or nothing to do with it. It is a question of feeling. The dog is much more cleanly in its habits than the hog, but we in the West are used to the idea of eating hog-meat just as they in the East are used to eating dog-meat. The objection, of course, might be urged that the difference between the hog and the dog is that we do not eat carnivorous but only herbivorous animals. But the slop-fed hogs from the neighborhood of our large cities, constituting a goodly portion of those brought to market, eat meat quite ravenously. They certainly are not exclusively herbivorous. There is no [{244}] principle behind our objection to dog meal then—only the unfamiliarity of the idea of eating it.
The treatment of patients with digestive disturbances requires a careful analysis of the conditions of mind towards foods. If prejudice exists with regard to certain foods, there will be no relish for them, and unless these prejudices can be removed, the foods either will not be taken, though they represent important nutritional elements, or else they must be taken in such small quantities and digested with so much consciousness of their presence and such difficulty as to be a disturbing factor for health. Persuasion, the custom of the country, habit, training, mean much for this modification of mental attitude.
Custom and Food.—In recent years many parts of animals, not generally eaten before, have come to be consumed with a relish because of the removal of prejudices against them. It might be thought that organs like the kidney, the essential function of which is excretory, and through which so much of the offensive waste products of the body pass, could not be a relished article of food. But it has become quite a dainty. The liver, owing to the peculiar nature of its function, its very special flavor, and the staining with bile, might be expected to be objectionable. It is not, but, strange to say, a third organ of the abdominal cavity, the spleen, which has none of the external objectionable features of kidney or liver, is not yet eaten, and most people would probably find it rather difficult to eat it. This difficulty would result, not because of anything in the organic substance itself, but because of the lack of accustomedness to it. There are a number of people who now have trained themselves to eat it. Such apparently impossible portions of the animal as the intestines, even those of the hog, are eaten with relish by a great many people, though there are others who have never been able to get used to them. The dainties of some peoples are utterly repulsive to others. The French like brains and other special portions of animals that are not much eaten by Anglo-Saxons. Fried brains in black butter sauce are enough to turn the stomach of some people by the very thought of it, though it is a highly prized dish in the south of France.
In Italy most visitors eat snail soup with relish before they know what it is. It seems to be a special kind of gumbo soup. Down at Marseilles, gourmets occasionally eat angle-worms and find them to be a very appetizing dish. In all of these things the question of relish and peaceful, happy digestion depends entirely on the attitude of mind. The first men who ate eels must have been looked upon with considerable suspicion by their neighbors as viper eaters, and probably they themselves were not comfortable over the feat. It has been said that the first man who ever swallowed an oyster performed as great a feat as any of our important inventors or discoverers.
Gastric Antipathies.—To the great majority of mankind the idea of eating horseflesh is repulsive. Numbers of people in various parts of Europe have found, however, that after the initial repugnance is conquered, it is quite as pleasant to eat as cow's meat. To my taste, at least, it is much more palatable than venison or bear meat. At the beginning, its sweetish taste has a curious reflex effect. Taken in connection with the thought that this is horse meat, the taste is apt to produce a sensation of nausea. This is readily overcome, though the first time it is necessary to keep constantly inhibiting [{245}] the mind from acting unfavorably upon the stomach during the course of eating and digestion. Custom, I learned from many, soon made it quite as savory as beef.
Food Varieties and the Mind.—How easy it may be to overcome many prejudices in the matter of food digestion under the stress of necessity and the influence of example, was well illustrated during the siege of Paris. The Parisians, though a most delicate people in the matter of eating, were able to accommodate themselves to the conditions, and practically every kind of animal was eaten with a relish. Before the siege, to most of them it would have seemed quite impossible, that they should sit down with complacency to the dishes which afterwards were so appetizing. At the beginning there was a definite attempt to conceal the eating of rats, mice, cats and dogs under various names, and by various modes of preparation. But it was not long before there was an end of this pretense. The animals in the zoological garden proved a veritable life-saving store of meat. Every one of them was eaten, people were glad to get them, and paid high prices for them. Camel steaks, elephant cutlets, lion and tiger stews, appeared under their own names, even at the banquets of the wealthy.
What is true of the mental attitude for meats influencing not only the relish for them, but their digestion, is also true for many vegetables. There are unfavorable suggestions in the minds of many with regard to the supposed indigestibility of potatoes, turnips, carrots, beans and occasionally with regard to tomatoes, lettuce, or the like. A few definite physiological idiosyncrasies against these vegetables, or certain of them, do actually exist. The attitude of mind, however, is largely responsible for the discomfort that occurs after the consumption of most of them. Patients who ought to consume more starchy substances, or whose bowels need the residual materials that are contained in these vegetables, for the sake of their effect upon peristalsis, should be persuaded to take these vegetables, first in small quantities and then in gradually increasing amounts. Many of them can thus be brought to a diet at once more nutritious and more likely to help out intestinal function. Their objection to them is usually but a fancy.
Genuine Food Idiosyncrasies.—There are certain genuine idiosyncrasies with a physiological basis which prevent the taking of certain kinds of food, or cause disturbance if they are taken, but these are rare. Their presence should never be considered as demonstrated by subjective signs alone for these are eminently fallacious. In certain cases, however, so rare as to be almost always curiosities in medical practice, there are definite objective symptoms of the idiosyncrasy. These consist of urticarial rashes, tendencies to vomiting, or diarrhea, or both. Sometimes these result from the most bland and nutritious of foods. I have notes of the cases of two children—whose father could not eat eggs without vomiting—and to whom fresh eggs fed at the age of two and three years, always produced this same effect. Even small portions of egg would cause it. It mattered not how the egg was prepared, nor even whether it was carefully concealed in custard or in cake provided there was a certain amount of it, the food eaten with it would be vomited. There are many such idiosyncrasies for shell fish, cheese, and such fruits as strawberries, pineapples, pomegranates and the like, but they are demonstrated by objective signs. But by far the greater number of food dislikes are entirely [{246}] subjective and the subjective feelings can probably always be overcome by habit and training.
Food Dislikes.—Milk.—Nothing makes more clear the absolute dominion of the mind over the stomach than the likes and dislikes of people for various kinds of milk. Most Americans can take cow's milk with good relish, though there are a few to whom it is distasteful. In this country we have not had much experience with the milk of other animals. Even goat's milk is not commonly used. The very thought of taking it disturbs many people, and to take it with other food would almost surely produce disturbance of digestion. I have seen people while traveling quite upset over the discovery that goat's milk had been put into their tea or coffee. Mare's milk is commonly used in some parts of Europe and in many parts of Asia, but it would be quite impossible to most of our people. Sheep's milk is used in some places. Ass's milk is commonly used in parts of Asia and may be obtained in Spain and is said to be less likely to disagree with children in summer than cow's milk. Most American mothers would rather not hear of it.
The same thing is true of the milk products. Some people find certain kinds of cheese quite out of the question though other people relish them. It requires special training, not of stomach but of mind, to enable one to eat certain cheese, though once the habit has been acquired such articles are delicious. It is only in recent years that some forms of cheese with greenish tints have become popular in America. To serve them at a dinner a generation ago disgusted many people. Now a dinner does not seem complete without them.
The beverages of various countries illustrate this same principle. The wines the Spaniards care for are not palatable to the Italians, and vice versa. Beer, as the result of familiarity, is now drunk everywhere in Europe, but when it was first introduced into Italy from Germany, it was considered impossible to understand how anybody could take it and pretend that its taste was pleasant. The question is said to have been once asked of one of the Congregations at Rome whether it was permissible to take beer on fast days. The Cardinals who tasted it declared that not only did it seem to them permissible but that it was a mortification to drink it and therefore it was proper Lenten exercise.
Eggs.—Many people have a supposed natural repugnance for eggs which they are sure indicates that these are not good for them. As a result, the physician gets all sorts of stories with regard to the supposed effects of eggs. One person tells you that more than two eggs a day makes him bilious. Another will tell you that they are too heavy for him. A third will tell you that they are distinctly constipating. A fourth will tell you that they produce a tendency to diarrhea. Here, as with regard to milk, the experience of the tuberculosis sanatoria has shown that there are but few people who cannot, when properly persuaded and when eggs are given in various forms, take from four to six eggs in the day without injury, and even without inconvenience. In these cases, it is largely a matter of mental attitude towards the food. In many instances, it will be found that the disinclination began in some experience in childhood when an egg was not very good, or when it was served insufficiently cooked, or when, perhaps, eggs always cooked one way were made a staple of the diet for a considerable period. There are over one hundred [{247}] ways of cooking eggs and this variety of preparation will often make them palatable, and nearly always digestible.
Over and over again I have seen people who had thought that eggs made them bilious, and who accordingly had for long refused to eat them, put in circumstances (from tuberculosis, diabetes, or obesity) where eggs had to form a considerable portion of the diet. Then there was no difficulty about eating and digesting eggs. In three cases in my experience patients with an objection they thought constitutional, developed glycosuria, and then nearly all their desserts were custards, and eggs became a standing dish in their daily diet. In every case not only was there no trouble, but they got to like the eggs and wondered why they should ever have had any prejudice against them. Two of the patients were women, the third a man who had not touched eggs for many years. His wife's comment was: "Eggs always made him bilious when he did not take them, but now that he is taking them freely they no longer make him bilious."
Mental Changes and Digestion.—The change that has come over the public mind with regard to sour milk is a typical illustration of how much a difference in the mental attitude towards a food product may mean for its satisfactory consumption by many people. Sour milk, though many farmers and working people thought it a pleasant acid beverage, was for long looked upon as a product fit at most to be fed to the pigs, if, indeed, there might not be question even of the advisability of this. Only the very poor who craved the nutritious value there was in it, continued to take it to any extent. Even if the milk still tasted sweet, but broke when it went into the tea, that was enough to make it quite impossible for many sensitive stomachs.
Lactic Acid as a Bactericide.—Then came Metchnikoff's announcement that his studies showed sour milk to be an extremely valuable food material, but much more than that, an important auxiliary for the lessening of microbic life in the intestines. He seemed to be able to demonstrate that a great many bacteria, whose products, absorbed from the intestines, hastened that process of deterioration in the tissues that we call old age, were inhibited when sour milk or lactic acid bacteria were present. The general health of the person who took sour milk was, as a consequence, much better. Not only this, but processes of deterioration being lessened, prolonged life and even old age could be promised to those who drank sour milk in sufficient quantities. Metchnikoff had been brought to the study of this question by what he had seen on the Steppes of Russia. Among the nomad tribes a principal part of whose diet consists of soured mare's milk, he found a large proportion of very old people. In looking for the reason for this disproportionate longevity, he came to the conclusion that the sour milk had something to do with it. Then laboratory observations and experiments as to the influence of the bacillus, that causes the souring of the milk, on the growth of other bacteria, and especially such bacteria as are usually found in the human digestive tract, seemed to show that the lactic bacteria had a strong inhibitory effect on nearly all the pathologic flora of the intestines.
As the result of these studies, all the world is now quite willing to take its share of sour milk. We no longer hear the complaint that uncomfortable feelings in the digestive tract are the result of taking milk that was a little sour.
Since this doctrine of Metchnikoff's has come to be popularly known, fewer patients have insisted that they could not take milk in such quantities as the physician thought desirable for them. Before that, a persuasion with regard to the ease with which milk becomes contaminated with microbes, and the dread that it might thus be a source of disease, or at least of disturbance of digestion, made it very difficult of digestion for many people. Now that they have a good authority who insists that, even if it should become somewhat soured in the ordinary way, this, far from making it a pathological article of diet, rather adds to its value from a therapeutic standpoint, has changed the attitude of mind of these people.
We need a similar feeling with regard to eggs in order that they may be eaten by many people who now refuse them because they fear the possible evil results of taking even a slightly tainted egg. Our recent pure food investigations have shown that the bakers in our large cities have been for many years using canned eggs, and that these would be quite impossible of consumption except disguised as they are in the midst of baker's products. Sometimes these eggs have been kept for several months before being canned. All the cold storage eggs that cannot be disposed of otherwise are thus treated. In spite of the common use of these canned eggs by a large proportion of the city population no serious results have come from them. The change that comes over eggs in time does not apparently spoil their nutritive quality, but only disturbs their taste. The main element in the change is the production of hydrogen sulphide. This gas has a very unpleasing odor, but its presence is not of pathological significance. This gas is a common ingredient in those mineral waters that are known as sulphur waters, and that have a reputation for curing many forms of digestive disturbance, especially chronic cases of nervous indigestion. What is true of sour milk, then, would seem to be true of eggs that have been, to some degree, spoiled, and at least no serious results may be expected from them. If serious results were to be expected, we should have had many evil reports of them in recent years. Whether considerations of this kind will help patients, who need to get over qualminess with regard to eggs, because they are always suspicious lest they should not be fresh, will depend a good deal on the suggestive value of such information as presented by the physician.
Another Organic Acid.—Sauerkraut has shared the fate of sour milk, and because of its acid bacteria has been accepted by Metchnikoff as an ally. Yet sauerkraut used to be thought quite out of the question for invalids, especially those suffering from digestive disturbances. I recall the case of an old German shoemaker who had lived very much on sauerkraut when he was a young man and then, having made money in the manufacture of shoes, had not had much of it for thirty years, pleading with me, when he was old and it was rather hard to get anything to stay on his stomach, that he should be allowed to have sauerkraut. On the principle that what a man craves is usually what does him good, I allowed it. The physician with whom I was in consultation was perfectly sure there would be trouble, and the family were confident that his physicians evidently had given up all hope and were quite ready to yield to his caprices and let him take anything that he cared for. He not only took the sauerkraut without any trouble, though I must confess to some misgivings myself (for I am of those who unfortunately do not care for it and, therefore, [{249}] was prejudiced), but after having eaten a large plateful of sauerkraut twice a day for several days, he began to crave other things that would not stay down before, retained them well, digested them without difficulty, and got over that attack of indigestion and lived for several years afterwards. His own mental attitude was a better index than our supposed knowledge, though science has now come to confirm his state of mind.
Bacon and a Change in Suggestion,—Another food material with regard to which there has been a complete change of view in recent years, is bacon and hog products generally. Pork in all forms used to be considered quite indigestible, and was one of the first things that people suffering from indigestion—or the fear of it—eliminated from their diet. Now we know how valuable a food product it is, especially for those inclined to suffer from constipation, or who are under weight. Many people still look surprised when advised to eat it regularly. Here we have a typical example of the change in the mental attitude toward a particular article of food bringing about a corresponding difference as regards not only the appetite for it, but also its digestibility. Many persons, who used to have no appetite for breakfast, now find that after eating a crisp piece or two of bacon, they develop an appetite for other foods. Bacon has become a fetish for some people and is considered a help, not a detriment to digestion.
I recall a case in which I had very nearly the same experience with bacon as I related with regard to sauerkraut. The patient was an elderly woman, probably nearly ninety years of age, who, because of a crippling deformity, had not been able to get outside of the house for many years. She sat in a wheel chair, transported herself from one end of an apartment to another, spent most of her time by the window, but was very helpful in many little things about the house and occupied her hands with knitting and sewing. In spite of her condition, she was cheerful, pleasant, happy, and all her life had had a good digestion, her only trouble being a tendency to asthma as she grew old. I came back to the city after a summer vacation to find that she was not expected to live because nothing would stay on her stomach. She was sinking, and the end seemed not far off. I was asked to see her more because I had been her regular physician for some years, and it was thought that it would console her to see me than with any real hope of betterment. It had been extremely hot weather and this seemed to be an unfortunate circumstance. At my visit, I asked her if there was anything that she cared for. She shook her head and yet there seemed a hesitancy. I urged her to tell me if there was anything that she wanted, but only after considerable urging did she venture to say that there was something, only that she knew that she could not have it. Putting her thumb on the top of her little finger, she said, "Oh, I would like so much to have just a teenie-weenie bit of bacon." I said that she should certainly have it. Then taking courage, she asked if she could not have a little cabbage with it. I said, "Certainly." Her friends thought that it was just a yielding to one of the last wishes of an invalid with the idea that nothing could much harm her, since she was so near the end. She had eaten cabbage and bacon all her life; she ate it again with a relish, and in spite of the heat kept it down and digested it well. She had bacon and cabbage next day, and for several days; she gradually got strong and lived several more years of her happy contented life.
CHAPTER II
INDIGESTION AND UNFAVORABLE STATES OF MIND
Indigestion is the characteristic disease of our time. There are few men or women over thirty who have not suffered from it. The working classes are spared the most, but with the frequent suggestions in the newspapers and the introspection which has become so common, indigestion is often complained of even among them. Sedentary occupations, involving mental work and little physical effort, seem especially to predispose to some form of indigestion. Few of those who live what is called the intellectual life escape suffering from some of its symptoms. Not infrequently men have been hale and hearty specimens of muscular manhood when they took up some profession which compels them to be indoors, yet before long, they begin to complain of discomfort after eating, of tendencies to constipation, of headaches, of depression, of incapacity for mental effort after meals, and all these symptoms are attributed to the almost universal disease, indigestion.
It is possible for the general attitude of mind to have a great effect on digestive processes, and the symptom-complex which is called indigestion, or dyspepsia, is probably much more dependent on the mind than on any other factor. In many cases it is primarily due to over-concentration of attention on digestion. In others it is due to over-occupation with business, worry, or serious thought at times when the digestive processes need all the energy. In many cases so-called dyspepsia is due to an unfavorable state of mind toward digestive processes in general, because of unfavorable auto-suggestion. Normally, stomachic sensations reach our consciousness only under special circumstances. When, however, much attention is paid to them, even the slight sensations that occur with normal digestion may rise above the threshold of consciousness and become subjects of solicitude. If they do so, then the increased attention likely to be paid to them surely interferes with function and changes what may be merely physiological into pathological processes.
Disease Suggestions.—An unfortunate state of the public mind with regard to indigestion in general has been cultivated by many publications on the subject. People dread its occurrence, and fear that the first sign of discomfort in their gastric region is a signal of the beginning of a progressive affection. They fear the worst, and the consequence is a reaction quite out of proportion to the gravity of the ailment. So much has been said particularly of mistakes in diet that just as soon as they feel, or often rather think they feel, the first symptom of beginning dyspepsia they begin to study how to modify their diet so as to prevent its progress. They begin to eliminate various supposedly indigestible foods. Usually among the first things that are greatly reduced in quantity, or are entirely eliminated, are the fats and certain of the starchy vegetables. Because of expressions heard and read as to its harmfulness, the fearful ones also are usually timorous about taking fluid at meal times. As this is about the only time when they are likely to take fluid, unless it be summer, they soon suffer for lack of it. Eating only food that [{251}] leaves little residue and taking insufficient fluid leads to constipation. This reacts still further to disturb digestion, and to interfere with appetite.
This leads to further reduction in the amount and variety of food, with the consequence that insufficient nutrition to supply energy for bodily needs is taken. The digestive system gives up to the body as much as it possibly can, not only of the food materials to be consumed, but of its own substance. Thus it weakens its own vitality, with a lessening of appetite and of digestive power. Hence, a vicious circle of change is instituted, the consequences of which are easy to see. After a time the patient is taking only the blandest foods, constipation has become an important element in the case, and the mind is constantly occupied with solicitude over the digestion and the choice of materials at meals.
Contrary Suggestion and Digestion.—Hudson, in "The Law of Mental Medicine," insisted on the necessity for not suggesting to children the possibility of indigestion of various substances, for that is almost sure to disturb digestive functions. Children sometimes hear the remark that father or mother cannot take a certain article of food because it disagrees with them. The imitative faculty of the child is sure to be aroused, with the consequence that this particular food is not eaten with relish nor given a fair show for digestion, and will be the source of some stomach disturbance. Not infrequently substances thus spoken of are among those that are especially likely to do children good, such as milk or eggs, or occasionally butter. The harm done by the remark may, therefore, even be serious, for these foods should constitute a large proportion of the child's diet. Indeed, an excellent prophylactic in the matter of indigestion is to prevent as far as possible all conversation at table about the indigestibility of food. Unfortunately, this has, in late years particularly, become a favorite subject of table conversation.
Transferred Feelings.—Professor Cohnheim called attention to the fact that many uncomfortable feelings are likely to be mistranslated because they are referred to organs with which there is nothing wrong. Whenever this function is hampered in any way, there are many uncomfortable feelings associated with the digestion of food. The custom has been to refer the origin of all these to the stomach. Cohnheim thinks that it is much more likely that they really originate in the intestines, though the rule has been to take the patient's feelings as an indication and to treat the stomach. It is not an unreasonable thing for patients to be deceived as to the exact location of discomfort. Even in so acute a process as toothache it is possible to mistake the particular tooth that is giving trouble, and, as dentists know, a perfectly quiescent tooth is sometimes blamed for pain that is coming from another. Fillings have been removed, teeth have been treated, good teeth have been extracted, because patients insisted on the significance of their feelings in such cases. The stomach must not always be blamed. Sometimes the only source of supposed gastric discomfort is the constipation present which is usually easy to relieve.
Gastric Reflexes.—While the mind may serve to disturb digestion and produce gastric discomfort by over-attention, there are many reflexes that center in the digestive tract, the origin of which may be in distant organs. Fright often produces a sensation as of cold at the pit of the stomach. Looking down from a height has the same effect in some persons. Discordant noises [{252}] have the same effect on people of sensitive hearing and certain reactions to touch may be similarly reflected. There are a number of affections which produce uncomfortable reflex sensations in the gastric region. This is the hypochondrium of the olden time. Whenever feelings were complained of, for which there was no actual basis in the hypochondriac region, it came to be spoken of as hypochondriasis, a word that has an innuendo of imaginativeness about it. Dr. Head's studies with regard to the transfer of sensations from one portion of the body to the other, show us that there is a good physical reason in reflexes for many of these complaints. An explanation of this to patients will often relieve their minds greatly and make their discomfort seem much less serious. Dr. Head said:
With orchitis or prostatitis, we also occasionally find that the patient complains of a pain at the epigastrium, representing the stomach area. This is put down to hypochondriasis and if it occurs in a woman as a consequence of ovaritis, she is said to be hysterical. But this phenomena is no more "hysterical," whatever that may mean, than is the reference of the pain and the tenderness of an aching tooth to the back of the head or the shoulder. [Transfers which have been observed actually to take place.]
This is the phenomenon I have been accustomed to call "generalization" of visceral pain and tenderness, and is of such common occurrence as to form a very important factor in the clinical picture of many diseases.
The order in which generalization takes place, leads one to speak of the relative "specific resistance" of the centers for the sensory impulses from various organs. No very definite rule can be laid down to govern every case, but each case must be considered on its merits. However, the area which appears most easily on a woman, as a secondary affection, is the tenth dorsal; then, perhaps the sixth dorsal, or inframammary, and then the various gastric areas, beginning first with the ensiform or seventh dorsal. In a man the tenth dorsal appears rather less readily while the ensiform appears with great ease.
Affections of other organs within the abdomen may produce like reflexes. A chronic appendicitis, for instance, will often be reflected in the stomach area. So will the presence of gallstones, or of disturbances of the biliary mucosa. Loose kidney often produces stomach reflexes. Any disturbance of the intestinal function will produce gastric irritation and inhibition of digestion. Most of the other primary conditions are more serious. Often the patient is aware of their existence, and it is a relief to him to find that the stomach symptoms are not the index of further pathological development, but only reflex conditions. This of itself does much to make the condition more bearable.
Patients who are suffering from symptoms of indigestion often have areas of their skin surface that are at least very sensitive, if not actually tender. They feel the pressure of their clothing over a particular portion of the body, usually on the left side of the abdomen somewhat above, though at times also below the umbilicus. Though not painful, as a rule, it is decidedly uncomfortable and produces a constant desire to loosen the clothing, or lift it from the part. Mere loosening, it is soon found, does no good, because the clothing continues to touch the skin and it is not the constriction or pressure but the contact that produces the discomfort. Sometimes there is a distinct lesion of the stomach. This cutaneous hyperasthesia may, indeed, rise to the height of extreme tenderness in cases of gastric ulcer, or the like. But there is no [{253}] doubt that a certain amount of this sensation is present with all functional disturbances of the stomach and that the reflex sensitiveness of superficial nerves is only what might be expected from what we now know of this subject.
Discomfort and Digestion.—Just as certain food materials disagree because of the state of mind, so certain feelings in the gastric region, even in the skin surface, sometimes disturb digestion and lead to changes of the diet unwarranted by the condition. Patients conclude that, if the skin is so tender, then the underlying organs, the disturbance of which causes this tenderness, must be in a serious condition. For these patients the explanation of the present state of our knowledge as to reflex disturbance of sensory nerves will be of therapeutic value. They must be taught that pain is reflected from one nerve branch to another, and is not communicated by continuity of tissue, or by sympathetic affection from the stomach mucous membrane through the stomach wall, and then from the abdominal wall to the skin surface. This knowledge will prove reassuring.
Division of Energy.—After this mental occupation with digestion itself, which by consuming nervous energy lessens the amount available for digestive purposes, probably the most common factor in the production of indigestion is the concentration of mind on serious subjects, while digestion is proceeding. An old English maxim is that some people have not enough brains to run their liver and their business. The liver in old-time pathology was considered the most important of the abdominal organs and was taken by metathesis for them all. Most of us have only a limited amount of vital energy and, usually, we can accomplish only one thing well at a time. If we try to do intellectual work while digestion is going on, both the intellectual work and the digestion suffer. If we persist in attempting to do both, we will surely disturb the digestive organs and we may bring about grave neurotic disturbances in the central nervous system. We may be able for a time to accomplish the two things at the same time, but it will not be long before evil results will be seen. Nervous, high-strung people should be reminded of Lincoln's anecdote of the little steamboat on the Mississippi which had not steam enough to blow its whistle and run its paddle wheels at the same time, so that whenever the engineer wanted to blow the whistle he stopped the boat.
Indeed, much of the indigestion that we see is due to this dissipation of energy through the attempt to do two things at the same time. Those who live the intellectual life are the most frequent sufferers. Worries and anxieties that are allowed to trouble the mind during digestion time are sure to disturb digestion eventually because they use up energy that is needed for physical purposes.
A change of environment that takes us away from the ordinary cares of life, is often sufficient to make all the difference between ease of digestion and extremely uncomfortable dyspepsia. By worry the mind apparently becomes short-circuited on itself and uses up a large amount of the available energy in nervous impulses that do not find their way outside the central nervous system at all, but are used in disturbing associated nerve cells. Just as soon as a change of scene and occupation calls for a different set of thoughts and other feelings, energy is released for work outside the central nervous system itself, digestion begins to improve, and in a comparatively short time what seemed to be a serious gastric disturbance, disappears almost completely.
Lack of Sleep Repair.—In my own experience one of the most characteristic stigmata of these cases of indigestion which are due to exhaustion through other channels of vital energy, is that they feel much better in the evening than in the morning. They are, therefore, tempted to stay up late and so do not get the necessary rest. Their excuse for late hours is that they need recreation. To that excuse I have no objection. They do need more recreation; they need more hours during which their minds are absolutely free from business cares; but these hours must not be taken from their sleep, for they need rest even more than recreation.
Worries and Irritations During Meals.—The presence of worries or irritation during meals or shortly after, as well as unfavorable states of mind towards digestion itself, and occupation of mind with serious affairs during digestion, are likely to be sources of serious disturbance of digestion. A fright, a fit of anger, nagging, irritation, or any disturbing emotions, may hamper digestion. An experiment that is sometimes performed in the physiological laboratory on the cat nicely illustrates this. If the laboratory cat is fed some dainty that it likes, mixed with bismuth in order that its stomach and intestines may be made opaque to the x-rays, and then be examined by means of the fluoroscope, the peristaltic processes of digestion by which food is mixed in the stomach, passed out into the intestines, and by which intestinal digestion is stimulated, may be seen to go on very interestingly. If, now, the cat is made to arch its back, and manifest the usual signs of extreme irritation, the process of digestion is interrupted, and will not be resumed till some time after the cat quiets down. The lesson is obvious.
CHAPTER III
PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS
If discouragement and solicitude make a healthy stomach digest imperfectly, the same mental factors will play an even more serious role with a diseased stomach. Certainly without the mind's aid, there can be little hope of such a reactive vital resistance as will enable the organ to recover from the organic ailment.
So many cases of indigestion are due to mental persuasion alone, that after a time there is danger that the physician may be over-confident in his diagnosis, and may occasionally overlook serious organic lesions. Before attempting psychotherapy in these cases, the physician must assure himself that no organic lesion is present. This is particularly true for cancer in the middle-aged and ulcer in young women. At times these lesions are latent except for certain vague digestive symptoms. After careful consideration it is generally possible to make a definite decision, and then the indications are clear. Even when an organic lesion is present, a modification of the mental attitude will often be of great service to the patient. Suggestion will even make a cancer patient gain in weight, though one must be careful of that very fact because the apparent improvement may occasion delay until the case becomes inoperable.
Once the presence of these serious organic lesions of the stomach can be [{255}] excluded, the bringing of influence to bear on the patient's mind for the improvement of his digestion is indicated. It is true that there are certain reflex disturbances of the digestive tract consequent upon affections of other abdominal organs. Chronic lesions of the appendix may produce stomach symptoms as will also pathological conditions of the biliary tract. A floating kidney, various affections of the pelvic organs, especially in women, and of the urinary organs in men are sometimes said to produce seriously depressing effects upon the stomach. Where this occurs, the first indications undoubtedly are to put the patient into as good condition as possible before making any decision. Where a lesion of the stomach itself exists suggestions with regard to the increase of diet may do harm. They will not do harm in the reflex conditions, and so patients can be brought into better physical condition. As a consequence of this, their symptoms in other organs will often disappear. In case the symptoms do not disappear the patients are in better condition to stand and react from operative intervention.
Before concluding as to the character of the stomach symptoms we must make sure that other important organs are not affected. Most cases of tuberculosis begin with stomach symptoms, which often make their appearance before there is cough or any definite localizing symptom of the disease. Often there is only a disturbance of pulse, and perhaps a slightly increased range of temperature. If the patient has been exposed to tuberculosis, a careful investigation of the lungs should be made. Any disturbance of the liver or pancreas (especially cancer) will almost surely give rise to stomach symptoms. Latent cancer in any part of the body, however, will, by its depressing toxemia, produce loss of appetite, consequent loss of weight, and a number of symptoms that are sure to be referred to the stomach. I have seen cancer of the prostate, without disturbing urination, produce such symptoms for months before it was recognized. I have seen cancer of the rectum in a comparatively young woman treated as piles, without an examination, the development of the piles being attributed to the gastro-intestinal symptoms which were consequent upon the presence of the cancer.